Pengawasan Eksternal Rumah Sakit di Era JKN : Cukupkah Hanya oleh Badan Pengawas?

Penyelenggaraan program Jaminan Kesehatan Nasional (JKN) oleh BPJS Kesehatan hampir berjalan 1,5 tahun sejak resmi digulirkan pemerintah pada 1 Januari 2014. Dalam rentang waktu tersebut, berbagai kejadian, fenomena, data, fakta dan realita dapat kita lihat dan dengar dari berbagai sumber informasi yang ada saat ini. Persoalan kunjungan pasien yang melonjak drastis, pengakuan masyarakat bahwa RS sering “menolak” pasien dengan alasan Tempat Tidur penuh hampir setiap hari kita dengar. Korban dari adanya “tragedi” inipun sudah beberapa kali kita dengar.

Kasus Dara dan Dera adalah salah satu kasus yang sangat fenomenal dan menyita perhatian serta perbincangan publik secara nasional. Masyarakat memberikan penilaian negatif kepada sektor kesehatan, tudingan negatif diarahkan kepada Rumah Sakit dan stakeholder bidang kesehatan baik pusat maupun daerah. Masyarakat tidak peduli dan tidak mau tahu dengan kesulitan yang dihadapi oleh rumah sakit, sementara di sisi lain RS juga belum sepenuhnya menjalankan fungsi dan kewajiban sebagaimana sudah diatur dalam Undang-Undang Nomor 44 tentang Rumah Sakit. Keluhan Masyarakat Terhadap Pelayanan Rumah Sakit Berbagai keluhan masyarakat dan pasien terkait dengan program JKN oleh BPJS Kesehatan hampir tiap hari kita dengar dan kita baca.

Dengan menggunakan beragam gaya bahasa, kata-kata versi masyarakat, saya mencoba untuk menyimpulkan dari begitu banyak dan ragam nya keluhan tersebut terkait dengan pelayanan RS dalam program JKN ini menjadi 5 (lima) permasalahan utama, yaitu :

  1. Keluhan terhadap kekurangan jumlah tempat tidur di RS sehingga pasien merasa ditolak dan dipingpong kesana kemari untuk mencari sendiri rumah sakit yang masih memiliki tempat tidur kosong.
  2. Keluhan terhadap buruknya pelayanan, prosedur yang rumit dan bertele-tele dan harus melalui sistem rujukan yang berjenjang.
  3. Keluhan terhadap pelayanan yang bersifat gawat darurat (emergensi) karena adanya asimetris informasi tentang kriteria emergensi yang telah ditetapkan dengan kondisi emergensi menurut asumsi masyarakat.
  4. Keluhan terhadap keterbatasan sarana untuk pemeriksaan penunjang seperti pemeriksaan laboratorium dan radiologi khusus (MRI, CT Scan, Lab canggih).
  5. Keluhan terhadap keterbatasan obat-obatan yang belum ada di Formularium Nasional maupun yang sudah ada namun faskes yang belum mampu menyediakan obat-obatan tersebut.

 

Dari berbagai macam keluhan tersebut, pangkal persoalan sebenarnya adalah terletak pada dua hal yaitu, pertama karena kurangnya sosialisasi tentang program JKN kepada masyarakat. Dari berbagai keluhan yang disampaikan oleh masyarakat tersebut sebagian besar berawal dari kurang pahamnya masyarakat akan program JKN ini. Sesungguhnya keluhan pada poin (b) sampai poin (e) sudah diatur semuanya dalam ketentuan-ketentuan pelaksanaan JKN oleh BPJS Kesehatan dari mulai Perpres, Permenkes, Kepmenkes, Surat Edaran (SE) Menkes, Peraturan Direktur BPJS dan SE Direktur Pelayanan BPJS. Meskipun beberapa peraturan masih perlu dievaluasi dan direvisi, namun jika sosialisasi terhadap aturan-aturan ini yang memuat sistem, prosedur, hak, kewajiban dan manfaat JKN ini cukup optimal maka saya meyakini bahwa keluhan-keluhan tersebut akan berkurang secara signifikan.

Persoalan kedua adalah memang harus diakui oleh kita semua masih adanya beberapa rumah sakit yang dianggap oleh masyarakat “menutup-nutupi” hak-hak peserta BPJS Kesehatan baik dilakukan secara sadar ataupun tidak disadari. Contoh yang cukup transparan adalah masyarakat menganggap RS “tidak mau” memberikan pelayanan kepada peserta JKN, padahal ini sangat mungkin terkait dengan adanya kebijakan internal RS seperti pembatasan atau kuota jumlah tempat tidur yang disediakan. Hal-hal yang menjadi latar belakang RS melakukan hal ini cukup bervariasi, namun semuanya bermuara pada satu hal, yaitu ketidakpuasan RS terhadap rendahnya pembayaran klaim dengan tarif yang mengkuti sistem pembayarn prospektif dalam paket tarif sesuai Case Mix-INA CBG.

Dampak paling mudah untuk dilihat adalah ketika hospitas cost yang diserap terhadap pelayanan pasien peserta JKN lebih tinggi daripada jumlah yang dibayarkan oleh BPJS maka akan berbanding lurus terhadap rendahnya penerimaan jasa pelayanan tenaga kesehatan (dokter, perawat, bidan, nakes lainnnya) yang pasti akan berujung pada penurunan kualitas pelayanan.

Persoalan Sosialisasi JKN kepada Masyarakat Tugas dan Kewajiban siapakan yang harus mensosialisasikan JKN ini kepada masyarakat? Kita tidak bisa membebankan semua kewajiban kepada BPJS karena pada tahun pertama ini BPJS masih disibukkan dengan dua hal :

  1. Melayani pendaftaran peserta dari jalur mandiri karena ternyat “euforia” masyarakat untuk mendaftar sebagai peserta BPJS di luar dugaan. Kita bisa lihat di setiap kantor BPJS setiap hari selalu penuh sesak dengan msayarakat yang mau mendaftar.
  2. Melakukan sosialisasi kepada badan usaha yang berdasarkan Perpes 111 Tahun 2013 harus segera mendaftaran pekerjanya sebagai peserta BPJS selambat-lambatnya Juni tahun 2015 ini.

Sebagian besar keluhan masyarakat adalah terkait ketidakpahaman atau ketidaktahuan akan sistem, prosedur, hak, kewajiban serta manfaat program JKN ini. Pengawasan Terhadap Rumah Sakit Undang-Undang Nomor 44 Tahun 2009 tentang Rumah Sakit pada Pasl 55 Ayat (1) yang berbunyi : “Pembinaan dan pengawasan nonteknis perumahsakitan yang melibatkan unsur masyarakat dapat dilakukan secara internal dan eksternal”. Secara khusus terkait dengan pengawas eksternal rumah sakit diatur pada Pasal 55 Ayat (3) yang berbunyi : “Pembinaan dan pengawasan secara eksternal sebagaimana dimaksud pada ayat (1) dilakukan oleh Badan Pengawas Rumah Sakit Indonesia”. Ketentuan ini mengamanatkan kepada Menkes untuk membentuk Badan Pengawas Rumah Sakit Indonesia (BPRSI) dan kepada Gubernur untuk membentuk Badan Pengawas Rumah Sakit Propinsi (BPRS Propinsi).

Pengertian nonteknis perumahsakitan adalah terkait dengan mutu pelayanan rumah sakit (penjelasan Pasal 2 Ayat (1) PP 49/2013 tentang BPRS). Undang-undang ini juga mengamanatkan untuk menyusun peraturan teknis pembentukan BPRS lebih lanjut mengenai BPRS dengan Peraturan Pemerintah (PP) sebagaimana dalam Pasal 61 yang berbunyi : “Ketentuan lebih lanjut mengenai Badan Pengawas Rumah Sakit Indonesia dan Badan Pengawas Rumah Sakit Provinsi diatur dengan Peraturan Pemerintah”. Sehingga terbitlah PP Nomor 49 Tahun 2013 tentang Badan Pengawas Rumah Sakit. Dalam PP tersebut telah dijabarkan bahwasanya salah satu kewenangan BPRS (PP 49 Tahun 2013 Pasal 5 huruf h) adalah memberikan REKOMENDASI kepada Menteri dan Pemerintah Daerah untuk mengambil tindakan administratif terhadap Rumah Sakit yang melakukan pelanggaran.

Sedangkan salah satu kewenangan BPRS Propinsi (PP 49 Tahun 2013 Pasal 25 huruf f) adalah memberikan REKOMENDASI kepada Pemerintah Daerah untuk mengambil tindakan administratif terhadap Rumah Sakit yang melakukan pelanggaran. Kita dapat melihat dengan jelas bahwa kewenangan BPRS dan BPRS Propinsi “hanya” sekedar memberikan rekomendasi kepada Menkes dan Pemerintah Daerah. Artinya, keputusan pemberian sanksi atau tindakan administratif kembali diarahkan kepada eksekutif yang ada di pusat (Kemenkes) dan di Daerah melalui Dinas Kesehatan setempat sebagai eksekutor.

Permasalahnya, sudahkan dijalankan kewenangan ini? Atau sudahkan eksekutif pusat dan daerah melaksanakan rekomendasi dari BPRS jika memang ada rekomendasi tersebut. Perlu dikaji lagi seberapa efektifnya kewenangan ini berjalan di lapangan sehingga fungsi pengawasan rumah sakit berjalan optimal terutama menghadapai keluhan-keluhan masyarakat terhadap rumah sakit.

Persoalan lainnya adalah beberapa rumah sakit masih melakukan pembatasan atau kuota jumlah tempat tidur bagi peserta JKN. Hal ini terjadi bukan tanpa alasan, karena UU Rumah Sakit belum secara tegas melarang rumah sakit memberlakukan kuota atau pembatasan jumlah tempat tidur. Belum ada ketentuan setingkat menteri yang secara tegas dan eksplisit melarang pembatasan jumlah tempat tidur (kuota) pasien peserta JKN.

Dalam UU RS memang telah mengatur kewajiban RS menyediakan sarana dan pelayanan bagi masyarakat tidak mampu atau miskin (UU RS No. 44/2009 Pasal 29 Ayat (1) huruf e yang kemudian diatur lagi melalui Permenkes Nomor 69 Tahun 2014 tentang Kewajiban Rumah Sakit dan Kewajiban Pasien pada Pasal 4 terkait dengan penyediaan sarana dan pelayanan bagi pasien tidak mampu atau miskin dengan ketentuan RS harus menyediakan paling sedikit 40 % dari total tempat tidur untuk RS Pemerintah dan paling sedikit 20 % dari total tempat tidur untuk RS Swasta sebagai tempat tidur Kelas III bagi masyarakat tidak mampu atau miskin.

Yang menjadi masalah adalah saat ini peserta program JKN bukan hanya masyarakat tidak mampu sebagai peserta BPJS PBI, namun ada peserta BPJS sebagai Peserta Penerima Upah (PPU) dan Peserta Bukan Penerima Upah (PBPU) termasuk jalur mandiri. Selain peserta BPJS PBI, maka ada ketentuan hak kelas rawat inap di RS berdasarkan aturan (PPU Pemerintah) dan kerjasama masing-masing badan usaha (PPU Badan Usaha) dengan BPJS serta bagi peserta PBPU (mandiri) berdasarkan jumlah premi yang diambilnya. Satu-satunya “himbauan” terkait tentang hal ini hanya dapat kita temukan dalam Permenkes Nomor 27 Tahun 2014 tentang Petunjuk Teknis (Juknis) Sitem Indonesian Case Base Groups (INA-CBGs) pada halaman akhir terdapat himbauan dengan kalimat “Apa saja yang sebaiknya TIDAK dilakukan oleh rumah sakit” pada poin terakhir yaitu poin ke-7 : ” Memberikan pelayanan dengan mutu yang kurang baik. Misalnya : memperpendek jam pelayanan poliklinik, pelayanan yang bisa diselesaikan dalam waktu satu hari dilakukan pada hari yang berbeda, tidak melakukan pemeriksaan penunjang yang seharusnya dilakukan, tidak memberikan obat yang seharusnya diberikan, serta MEMBATASI JUMLAH TEMPAT TIDUR yang tersedia di rumah sakit untuk peserta JKN.

Meskipun Permenkes 71 Tahun 2013 tentang Pelayanan Kesehatan Pada JKN dan Permenkes 28 Tahun 2014 tentang Pedoman Pelaksanaan JK sudah diatur tata cara dan mekanisme naik kelas atas permintaan pasien ataupun dikarenakan keterbatasan sarana tempat tidur RS, namun tetap belum mampu menyelesaikan masalah terkait keluhan pasien yang merasa kerap “ditolak” oleh rumah sakit dengan alasan kamar penuh. Disinilah peran dan fungsi pengawasan oleh BPRS dan BPRS Propinsi dalam mengawasi berbagai “upaya” rumah sakit untuk tidak mengindahkan himbauan tersebut. Aturan yang bersifat kurang tegas dan gamang memang memicu untuk terjadinya pelanggaran meskipun terkadang tidak disadari oleh rumah sakit.Kelembagaan BPRS dan BPRS Propinsi belum mampu menjangkau seluruh rumah sakit di Indonesia sampai ke pelosok negeri.

BPRS dan BPRS Propinsi (bagi yang sudah terbentuk) baru mampu menyisir rumah sakit-rumah sakit di daerah perkotaan dan belum sampai menjangkau ke tingkat kabupaten apalagi daerah-daerah perbatasan yang jauh dari pusat pemerintahan. Hal ini menyebabkan peran dan fungsi BPRS dan BPRS Propinsi masih kurang dirasakan oleh masyarakat. Bahkan saya yakin bahwa masih banyak pihak yang berkecimpung di sektor kesehatan dan perumahsakitan yang belum tahu akan keberadaan lembaga ini apalagi masyarakat awam. Keluhan-keluhan masyarakat terkait dengan pelayanan RS belum mampu dijangkau, dipetakan, dikaji dan dianalisa oleh BPRS dan BPRS Propinsi.

Di sisi lain BPRS masih kurang kuat memiliki kewenangan sehingga bergaining position (posisi tawar) BPRS dan BPRS Propinsi terhadap rumah sakit masih lemah padahal jika menilik struktur dan keanggotaan BPRS ini sudah melibatkan unsur masyarakat dan organisasi profesi sehingga independensi nya akan terjaga. Sayangnya lembaga strategis ini ibarat pedang tajam yang tidak bisa ditarik dari sarungnya.

Permasalahan

  1. Wilayah geografis Indonesia yang berbentuk kepulauan, terdiri dari 17 ribu lebih pulau dengan jumlah penduduk lebih dari 240 juta jiwa tersebar dalam 492 kabupaten/kota yang sangat mustahil bisa dijangkau semuanya oleh BPJS dan BPJS Propinsi.
  2. Sosialisasi program JKN kepada masyarakat yang belum optimal. Sampai dengan saat ini BPJS masih disibukkan oleh persoalan pendaftaran peserta baru, pembayaran iuran dan sosialisasi kepada badan usaha yag harus mendaftarkan karyawannya sebagai peserta BPJS berdasarkan ketentuan Perpes Nomor 12 Tahun 2013 tentang JKN yang diperbaharui melalui Perpres Nomor 111 Tahun 2013 tentang Perubahan Atas Perpes Nomor 12 Tahun 2013.
  3. Jumlah Rumah Sakit di Indonesia baik RS Publik ataupun Privat yang berjumlah sangat banyak. Data Kemenkes terakhir melalui RS Online adalah terdapat sebanyak 2.397 RS Umum dan Khusus milik pemerintah dan swasta. Sedangkan data terkini dari BPJS, jumlah RS yang sudah bekerjasama adalah sebanyak 1.664 rumah sakit. Jumlah ini tentu saja sangat tidak mungkin bisa diawasi seluruhnya oleh sebuah lembaga yang hanya berkedudukan di tiap propinsi saja.
  4. Dinas Kesehatan memang sudah memiliki kewajiban untuk melakukan pembinaan dan pengawasan terhadap rumah sakit, namun seringkali fungsi pembinaan dan pengawasan tersebut belum berjalan optimal karena banyak kendala di lapangan juga termasuk adanya konflik kepentingan yang asimteris antara penyelenggara negara (aparatur) dengan masyarakat.

 

Usul dan Saran

  1. Pembentukan BPRS diseluruh propinsi di Indonesia dengan target selambat-lambatnya pada akhir 2015 seluruh propinsi di Indonesia harus sudah memiliki BPRS Propinsi.
  2. Pembentukan cabang-cabang BPRS Propinsi di setiap kabupaten/kota dalam wilayah rentang tanggung jawab di setiap propinsi dengan target selambat-lambatnya akhir tahun 2016 telah terbentuk BPRS Kabupaten di seluruh kabupaten dan kota di Indonesia.
  3. Penguatan fungsi dan peran BPRS Propinsi dan cabang-cabang nya dengan membekali dengan kewenangan melakukan tindakan yang bersifat teguran atupun sanksi administratif dan BUKAN hanya sekedar memberi rekomendasi kepada dinas kesehatan propinsi ataupun dinas kesehatan kabupaten/kota. Diperlukan badan pengawas yang bersifat independen dan melibatkan masyarakat sebagai pengguna layanan rumah sakit dengan dibekali kewenangan untuk melakukan “eksekusi administrasi” terhadap rumah sakit.
  4. Ketentuan terkait pelarangan pembatasan kuota jumlah tempat tidur di rumah sakit perlu dipertegas secara eksplisit dari sekedar “himbauan” pada tingkat peraturan menteri kesehatan, namun harus ditegaskan lagi dengan produk hukum yang lebih kuat seperti peraturan presiden (Perpres) ataupun setingkat intruksi presiden (Inpres).
  5. Membangun sinergisitas yang lebih kuat antara BPRS dengan Dewan Jaminan Sosial Nasional (DJSN) dalam melakukan fungsi pengawasan kepada rumah sakit yang sudah berkerjasama dengan BPJS guna menjamin keberlangsungan pelayanan dan peningkatan mutu layanan rumah sakit.
  6. Percepatan revisi tarif INA CBG dengan melibatkan setidaknya minimal 50% rumah sakit swasta, organisasi profesi dan sepeminatan, organisasi rumah sakit daerah (ARSADA), dan organisasi rumah sakit swasta (ARSSI). Proses perhitungan tarif didorong untuk dilakukan dengan berdasar pada real hospital cost dan bukan political cost.

Terimakasih,

Tri Muhammad Hani, dr. MARS
RSUD Bayu Asih Purwakarta
Jl. Veteran No. 39 Kabupaten Purwakarta – Jawa Barat
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