Pelayanan Pasien BPJS Dengan Kasus Thalasemia, Hemofilia Dan Pemberian Khemoterapi : Merugikan RS ??

A. THALASEMIA

Pasien Thalasemia Mayor adalah pasien yang mempunyai diagnosis primer maupun sekunder mempunyai kode ICD-10 yaitu D56.1. Pasien selain Thalasemia Mayor tidak mendapatkan top-up special drug. Jika pasien Thalasemia Mayor pada saat kontrol tidak diberikan obat kelasi besi (Deferipone, Deferoksamin, dan Deferasirox) maka tetap diinputkan sebagai rawat jalan dengan menggunakan kode Z09.8 sebagai diagnosis utama. Jika pasien Thalasemia Mayor dirawat inap hanya untuk tranfusi darah tanpa diberikan obat kelasi besi maka tetap menggunakan kode D56.1 sebagai diagnosis utama dan tidak mendapatkan top-up special drug.

Ketentuan untuk pelayanan pasien dengan Thalasemia adalah berdasarkan Surat Edaran (SE) Menkes Nomor 32 Tahun 2014 dan ditindaklanjuti dengan Surat Edaran Direktur Pelayanan BPJS Nomor 38 Tahun 2014 tentang Petunjuk Teknis SE Menkes Nomor 32 Tahun 2014 tentang Pelaksanaan Pelayanan Kesehatan Bagi Peserta BPJS Kesehatan Pada Fasilitas Kesehatan Tingkat Pertama dan Pada Fasilitas Kesehatan Tingkat Lanjutan Dalam Program Jaminan Kesehatan Nasional (JKN) yaitu :

  1. Pelayanan pasien dengan Thalasemia meskipun dilakukan di Rawat Jalan Tingkat Lanjutan (RJTL) namun untuk klaimnya dilakukan input data sebagai pasien Rawat Inap Tingkat Lanjutan (RITL).
  2. Klaim untuk pelayanan pasien dengan Thalasemia dilakukan melalui Case Mix-INA CBG dan ditambahkan Top Up Spesial Drugsyang biasa disebut dengan obat chelatin (chelator) seperti Deferoksamin, Deferasirox atau Deferiprone. Top Up untuk spesial drug pada kasus ini langsung dilakukan di software Case Mix-INA CBG.
  3. Tarif yang dihasilkan terbagi menjadi 2, yaitu tarif hasil grouping untuk diagnosa Thalasemia ditambah dengan Tarif Top Up Spesial Drugs.

Simulasi :

Kondisi Faskes

Kelas RS            : Kelas B Regional 1

Kelas Rawat       : Kelas 1 (Rawat Jalan namun dimasukkan dalam Rawat Inap Kls 1)

Input Coding dan Grouping

Diagnosa             : Thalasemia Betha Mayor (Kode ICD 10 : D56.1)

Tindakan              : Transfusi PRC (Kode ICD 9 : 99.04)

Spesial Drugs      : Deferoksamin

Hasil Grouping

Kode INA CBG     : D-4-13-I

Deskripsi               : Gangguan Sel Darah Merah Selain Krisis Anemia Sel Sickle Ringan

Tarif                       : Rp 2.744.400,00

Spesial Drugs       : Rp 5.880.918,00

Total Tarif              : Rp 8.625.318,00

 

Jadi pihak Rumah Sakit akan mengklaim biaya pelayanan untuk kasus ini adalah sebesar Rp 8.625.318,00 ke BPJS Kesehatan.

 

B. HEMOFILIA

Hemofilia adalah penyakit gangguan pembekuan darah yang disebabkan karena terjadinya defisiensi (kekurangan) faktor-faktor pembekuan darah. Hemofilia yang paling sering terjadi adalah kekurangan faktor pembekuan VIII yang disebut dengan Hemofilia A dan kekurangan faktor pembekuan IX yang disebut dengan Hemofilia B. Tindakan khas untuk kasus hemofilia selain dengan terapi medikamentosa adalah juga dengan pemberian tambahan (transfusi) faktor-faktor pembekuan (coagulant factors) dan atau transfusi tromboist (platelet).

Untuk kasus Hemofilia, berdasarkan ketentuan surat edaran Menkes dan BPJS maka berlaku ketentuan sebagai berikut :

  1. Pasien Hemofilia yang dirawat inap dilakukan klaim pelayanan berdasarkan Case Mix-INA CBG.
  2. Berlaku penambahan pembayaran klaim DILUAR Case Mix-INA CBG yang besarannya sama untuk semua tingkat keparahan kasus serta semua kelas perawatan.
  3. Besaran penambahan pembayaran klaim disesuaikan dengan kelas RS dan regional dengan ketentuan sebagaimana tabel yang tercantum dalam surat edaran tersebut dan diajukan secara fee for services.

 

Simulasi :

Kondisi Faskes

Kelas RS           : Kelas B Regional 1

Kelas Rawat      : Kelas 1

Input Coding dan Grouping

Diagnosa           : Hemofilia A (Kode ICD 10 : D66)

Tindakan            : Transfusi Faktor Pembekuan (Kode ICD 9 : 99.06)

Spesial Drugs     : –

Hasil Grouping

Kode INA CBG    : D-4-11-I

Deskripsi              : Gangguan Pembekuan Darah Ringan

Tarif                      : Rp 3.409.200,00

Spesial Drugs       : Rp 00,00

Total Tarif              : Rp 3.409.200,00

 

Penambahan Pembayaran Klaim diluar INA CBG (Sesuai Tabel dalam SE Menkes)

Kelas RS             : Kelas B Regional 1

Jumlah                 : Rp  7.914.235,00

Total Klaim           : Rp 11.323.435,00

Jadi pihak Rumah Sakit akan mengklaim biaya pelayanan untuk kasus ini adalah sebesar Rp 11.323.435,00 ke BPJS Kesehatan.

C. PELAYANAN KEMOTERAPI

Pelayanan pemberian obat kemoterapi untuk kasus-kasus keganasan yang memerlukan kemoterapi sesuai indikasi medis dapat dilakukan di fasilitas kesehatan sekunder (Tingkat II) dengan mempertimbangkan kemampuan fasilitas kesehatan dan kompetensi sumber daya manusia kesehatan. Pemberian kemoterapi biasanya dilakukan dalam kondisi pasien di rawat inap, namun pada kondisi tertentu pemberian kemoterapi dapat dilaksanakan di pelayanan rawat jalan sesuai dengan indikasi medis.

Dalam SE Menkes dan SE BPJS yang sama juga telah mengatur ketentuan khusus untuk pelayanan pasien BPJS yang memerlukan kemoterapi, yaitu :

  1. Pelayanan kemoterapi baik di rawat jalan ataupun rawat inap ditagihkan dengan paket INA CBG dan obat kemoterapinya ditagihkan tersendiri di luar paket INA CBG secara fee for services.
  2. Pelayanan obat kemoterapi mengikuti ketentuan dalam Formularium Nasional (FORNAS), pedoman pelaksanaan Fornas serta ketentuan lain yang berlaku lainnya.
  3. Penagihan obat kemoterapi sesuai Fornas mengikuti ketentuan berdasarkan SE Menkes Nomor 31 Tahun 2014 tentang Pelaksanaan Standar Tarif Pelayanan Kesehatan Pada FKTP dan FKRTL dalam Program JKN dimana obat kemoterapi dibayar berdasarkan harga dalam e-katalog terakhir (2014) ditambah faktor pelayanan dan embalagesesuai dengan SE Menkes tersebut.

Berikut ini akan ditampilkan contoh simulasi klaim untuk pelayanan pasien BPJS dengan diagnosa salah satu jenis keganasan sel darah yaitu Leukimia yang membutuhkan kemoterapi.

Simulasi :

Kondisi Faskes

Kelas RS                    : Kelas B Regional 1

Kelas Rawat               : Kelas 1

Input Coding dan Grouping

Diagnosa Primer        : Leukimia Monositik Akut (Kode ICD 10 : C93.0)

Diagnosa Sekunder   : Kemoterapi Pada Keganasan (Kode ICD 10 : Z51.1)

Tindakan                    : Infus Obat Kemoterapi Keganasan (Kode ICD 9 : 99.25)

Spesial Drugs             : –

Hasil Grouping

Kode INA CBG          : C-4-10-II

Deskripsi                    : Leukimia Akut Sedang

Tarif                            : Rp 10.477.600,00

Spesial Drugs            : Rp 00,00

Total Tarif                   : Rp 10.477.600,00

 

Pembayaran Obat Kemoterapi diluar INA CBG (ditagih secara fee for services)

Nama Obat Generik               : Sitarabin Serb Inj. 1000 mg/ 10 mL

Nama Paten                           : DBL Cytarabun (PT. Tempo Scan Pacific)

Harga di E-Katalog 2014        : Rp      575.000,00

Faktor Pelayanan (0,05)         : Rp        28.750,00

Embalage (Obat Jadi 1 R)      : Rp             300,00

Total Klaim                              : Rp 11.081.650,00

Jadi pihak Rumah Sakit akan mengklaim biaya pelayanan untuk kasus ini adalah sebesar Rp 11.081.650,00 ke BPJS Kesehatan.

KESIMPULAN

Setelah melihat hasil simulasi dari ketiga kasus tersebut diatas, maka yang perlu dilakukan adalah membandingkan nilai klaim dengan real cost (tarif rumah sakit). Tentu saya tidak berani menyimpulkan bahwa kasus-kasus khusus ini “menguntungkan” atau “merugikan” sebelum dilakukan perbandingan dengan tarif RS. Sangat mungkin di beberapa rumah sakit ada yang “untung” namun saya berkeyakinan masih banyak juga RS yang secara nominal “rugi” dalam memberikan pelayanan terhadap ketiga kasus khusus diatas.

Yang paling penting untuk dilakukan adalah Utilitazion Review (UR) untuk melihat kasus-kasus yang menyerap sumber daya besar berdasarkan tarif rumah sakit dan kemudian disandingkan dengan besaran nilai klaim nya ke BPJS. Keuntungan melakukan UR ini adalah dapat diketahui komponen biaya mana yang tinggi dan yang efisien sehingga jajaran manajemen RS akan dapat menganalisa faktor penyebab dari tingginya komponen biaya tersebut serta dapat dilakukan langkah-langkah antisipatif untuk kasus-kasus yang sama ke depan nya. Perlunya rumah sakit melakukan efisiensi, cost containment dengan tetap berpijak pada prinsip dasar JKN dengan metode cas Mix-INA CBG yaitu melakukan kendali mutu dan kendali biaya.

Demikian sekilas ulasan dan simulasi dari saya terkait dengan tiga kasus khusus dalam pelayanan pasien BPJS Kesehatan pada program JKN. Mohon maaf jika banyak kekurangan dan kesalahan dalam penulisan terutama terkait dengan teknis medis yang bersifat spesialistik atau sub spesialistik karena keterbatasan kompetensi dan pengetahuan saya. Mohon maaf juga jika kasus dan simulasi yang saya berikan diatas kurang tepat dari sudut pandang sejawat yang ahli dalam bidang spesialisasi penyakit tersebut. Semata-mata karena keterbatasan saya dalam ilmu pengetahuan dan pengalaman klinis dibandingkan dengan sejawat klinisi sekalian yang ahli dalam bidang tersebut.

Terimakasih bagi yang sudah berkenan membacanya, kritik dan saran selalu saya harapkan dari rekan sejawat semua.

Salam,

Tri Muhammad Hani

RSUD Bayu Asih Purwakarta

Jl. Veteran No. 39 Kabupaten Purwakarta – Jawa Barat

Bahan Bacaan :

  1. Permenkes Nomor 28 Tahun 2014 tentang Pedoman Pelaksanaan (Manlak) JKN.
  2. Surat Edaran (SE) Menkes Nomor 031 Tahun 2014 tentang Pelaksanaan Standar Tarif Pelayanan Kesehatan Pada Fasilitas Kesehatan Tingkat Pertama dan Fasilitas Kesehatan Rujukan Tingkat Lanjutan dalam Program Jaminan Kesehatan Nasional.
  3. Surat Edaran (SE) Menkes Nomor 032 Tahun 2014 tentang Pelaksanaan Pelayanan Kesehatan bagi Peserta BPJS Kesehatan pada Fasilitas Kesehatan Tingkat Pertama dan Fasilitas Kesehatan Rujukan Tingkat Lanjutan dalam Penyelenggaran Program Jaminan Kesehatan.
  4. Surat Edaran (SE) Direktur Pelayanan BPJS Nomor 038 Tahun 2014 tentang Petunjuk Teknis Surat Edaran (SE) Menkes Nomor 032 Tahun 2014 tentang Pelaksanaan Pelayanan Kesehatan bagi Peserta BPJS Kesehatan pada Fasilitas Kesehatan Tingkat Pertama dan Fasilitas Kesehatan Rujukan Tingkat Lanjutan dalam Penyelenggaran Program Jaminan Kesehatan.
  5. E-Katalog obat dan BHP tahun 2014 yang dapat dilihat dari website https://katalog-obat.lkpp.go.id/e-katalog-obat/

 

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