Salah Kaprah Pemahaman “Surat Rujukan” Dalam Pelayanan JKN

Dalam berbagai diskusi dan perdebatan di forum BPJS Kesehatan terkait sistem rujukan, kerap kali muncul kalimat “surat rujukan berlaku 30 hari” ada juga yang berpendapat bahwa “surat rujukan hanya berlaku 2 minggu” dan lain-lain informasi yang cukup beragam dan menimbulkan kebingungan diantara para petugas pemberi layanan kesehatan maupun di kalangan masyarakat yang mengeluh mendapat intruksi dan informasi yang berbeda-beda.

Benarkah terdapat ketentuan secara eksplisit yang mengatur “umur” surat rujukan tersebut ?. Berawal dari rasa penasaran, maka saya mulai menelusuri berbagai peraturan perundangan-undangan terkait pelayanan JKN ini dari mulai PMK Nomor 71/2013 tentang Pelayanan Kesehatan pada JKN, PMK Nomor 28/2014 tentang Pedoman Pelaksanaan (Manlak) Program JKN, SE Menkes Nomor 32/2014 tentang Pelaksanaan Pelayanan Kesehatan bagi Peserta BPJSK di FKTP dan FKRTL, Peraturan BPJS Nomor 01/2014tentang Penyelenggaraan Jaminan Kesehatan, SE Direkur Pelayanan BPJS Nomor 38/2014 tentang Juknis SE Menkes Nomor 32/2014 serta Buku Panduan Praktis Sistem Rujukan Berjenjang.

Namun sayangnya, saya tidak menemukan ketentuan tentang batasan waktu ataupun “umur” surat rujukan secara eksplisit didalam aturan-aturan yang saya pelajari di atas. Tidak juga terdapat kalimat atau kata-kata “30 hari” ataupun “2 minggu”. Lalu kenapa bisa muncul informasi tersebut ? Pemberi informasi tersebut mengacu kepada aturan yang mana ?

I. TINGKATAN PELAYANAN KESEHATAN

Pelayanan kesehatan perorangan di Indonesia terdiri dari 3 (tiga) tingkatan yaitu : 

  1. Pelayanan kesehatan tingkat pertama;
  2. Pelayanan kesehatan tingkat kedua; dan
  3. Pelayanan kesehatan tingkat ketiga.

Pelayanan kesehatan tingkat pertama merupakan pelayanan kesehatan DASAR yang diberikan oleh fasilitas kesehatan tingkat pertama. Pelayanan kesehatan tingkat keduamerupakan pelayanan kesehatan SPESIALISTIK yang dilakukan oleh dokter spesialis ataudokter gigi spesialis yang menggunakan pengetahuan dan teknologi kesehatan spesialistik. Pelayanan kesehatan tingkat ketiga merupakan pelayanan kesehatan SUB SPESIALISTIKyang dilakukan oleh dokter sub spesialis atau dokter gigi sub spesialis yang menggunakan pengetahuan dan teknologi kesehatan sub spesialistik.

Implementasi di lapangan terkait dengan program JKN ini adalah Puskesmas, Klinik Pratama, Praktik Dokter, Praktik Dokter Gigi, Klinik Pratama atau yang setara dan RS Kelas D Pratama atau yang setara adalah termasuk dalam Pelayanan Kesehatan Tingkat Pertama atau FKTP (Fasilitas Kesehatan Tingkat Pertama). Sementara Klinik Utama, Rumah Sakit Umum dan Rumah Sakit Khusus termasuk dalam Pelayanan Kesehatan Tingkat Kedua dan Ketiga atau FKRTL (Fasilitas Kesehatan Rujukan Tingkat Lanjut).

Berdasarkan klasifikasi rumah sakit, maka RS Umum/Khusus kelas C dan B dapat dikatagorikan sebagai Pelayanan Kesehatan Tingkat Kedua (Sekunder) dan RS Umum/Khusus Kelas A atau RS Umum/Khusus Kelas B yang menjadi pusat pendidikan kedokteran dapat dikatagorikan sebagai Pelayanan Kesehatan Tingkat Ketiga (tersier).

II. DEFINISI RUJUKAN

Sistem Rujukan adalah penyelenggaraan pelayanan kesehatan yang mengatur pelimpahan tugas dan tanggung jawab pelayanan kesehatan secara timbal balik baik vertikal maupun horizontal (PMK 71/2013 Psl 1 Butir 13). Pelayanan rujukan dapat dilakukan secara HORIZONTAL maupun VERTIKAL.

Rujukan horizontal adalah rujukan yang dilakukan antar pelayanan kesehatan dalam satu tingkatan apabila perujuk tidak dapat memberikan pelayanan kesehatan sesuai dengan kebutuhan pasien karena keterbatasan fasilitas, peralatan dan/atau ketenagaan yang sifatnya sementara atau menetap.

Rujukan vertikal adalah rujukan yang dilakukan antar pelayanan kesehatan yang berbeda tingkatan, dapat dilakukan dari tingkat pelayanan yang lebih rendah ke tingkat pelayanan yang lebih tinggi atau sebaliknya. Rujukan vertikal dari tingkatan pelayanan yang lebih rendah ke tingkatan pelayanan yang lebih tinggi dilakukan apabila :

  1. Pasien membutuhkan pelayanan kesehatan spesialistik atau subspesialistik;
  2. Perujuk tidak dapat memberikan pelayanan kesehatan sesuai dengan kebutuhan pasien karena keterbatasan fasilitas, peralatan dan/ atau ketenagaan.

III. KETENTUAN SISTEM RUJUKAN BERJENJANG

Dalam PMK Nomor 71 Tahun 2013 diatur ketentuan tentang Sistem Rujukan sebagaimana berikut ini :

  1. Pelayanan kesehatan tingkat kedua hanya dapat diberikan atas rujukan dari Pelayanan Kesehatan Tingkat Pertama (PMK 71/2013 Psl 15 Ayat 2).
  2. Apabila sesuai dengan indikasi medis Peserta memerlukan pelayanan kesehatan rujukan tingkat lanjutan, PesertaWAJIB membawa SURAT RUJUKAN dari Puskesmas atau Fasilitas Kesehatan tingkat pertama lain yang bekerjasama dengan BPJS Kesehatan, kecuali dalam keadaan gawat darurat, bencana, kekhususan permasalahan kesehatan pasien, dan pertimbangan geografis (Lampiran PMK 71/2013 Romawi A angka 6).
  3. Pelayanan Rawat Jalan Tingkat Lanjutan merupakan kelanjutan dari pelayanan tingkat pertama yang berdasarkan surat rujukan dari Fasilitas Kesehatan tingkat pertama kecuali dalam kondisi tertentu sehingga Peserta tidak perlu membawa surat rujukan sesuai dengan ketentuan yang berlaku (Lampiran PMK 71/2013 Romawi C angka 1a).
  4. Dokter di Fasilitas Kesehatan penerima rujukan berkewajiban memberikanjawaban surat rujukan kepada dokter yang merujuk disertai jawaban dan tindak lanjut yang harus dilakukan jika secara medis Peserta sudah dapat dilayani di Fasilitas Kesehatan yang merujuk (Lampiran PMK 71/2013 Romawi C angka 1b.2).

 

Sementara dalam PMK Nomor 28 Tahun 2014 tentang Pedoman Pelaksanaan (Manlak) Program JKN menerangkan secara lebih rinci terkait dengan sistem rujukan berjenjang ini dengan disertai alur pelayanan pasien ke FKRTL sebagai berikut :

  1. Peserta datang ke Rumah Sakit dengan menunjukkan nomor identitas peserta JKN dan surat rujukan, kecuali kasusemergency, tanpa surat rujukan.
  2. Peserta menerima Surat Eligibilitas Peserta (SEP) untuk mendapatkan pelayanan.
  3. Peserta dapat memperoleh pelayanan rawat jalan dan atau rawat inap sesuai dengan indikasi medis.
  4. Apabila dokter spesialis/subspesialis memberikan surat keterangan bahwa pasienmasih memerlukan perawatan di FKRTL tersebut, maka untuk kunjungan berikutnya pasienLANGSUNG DATANG ke FKRTL (tanpa harus ke FKTP terlebih dahulu) dengan membawa surat keterangan dari dokter tersebut.
  5. Apabila dokter spesialis/subspesialis memberikansurat keterangan rujuk balik, maka untuk perawatan selanjutnya pasien langsung ke FKTP membawa surat rujuk balik dari dokter spesialis/subspesialis.
  6. Apabila dokter spesialis/subspesialisTIDAK MEMBERIKAN surat keterangan sebagaimana dimaksud pada poin (d) dan (e), maka pada kunjungan berikutnya pasienHARUS MELALUI FKTP. (Lampiran PMK 28/2014 Huruf F poin 2).

 

Di lapangan ternyata masih adanya multitafsir terhadap aturan sistem rujukan berjenjang ini, maka Menkes mengeluarkan Surat Edaran Menkes Nomor 32 Tahun 2014 tentang Pelaksanaan Pelayanan Kesehatan bagi Peserta BPJSK di FKTP dan FKRTL yang pada halaman 3 yang berbunyi : “Surat rujukan dibutuhkan untuk PERTAMA KALI pengobatan ke FKRTL, dan selanjutnya selama masih dalam perawatan dan belum di rujuk balik ke FKTP TIDAK DIBUTUHKAN lagi surat rujukan. Dokter yang menangani memberi surat keterangan masih dalam perawatan”.

BPJS Kesehatan pun sebagai penyelenggara program JKN ini merasa perlu mengeluarkan surat edaran tentang petunjuk teknis terhadap SE Menkes tersebut sehingga diharapkan tidak lagi ada perbedaan pemahaman tentang sistem rujukan berjenjang ini. Terbitlah Surat Edaran (SE) Direkur Pelayanan BPJS Nomor 38/2014 tentang Juknis SE Menkes Nomor 32/2014. Pada poin 1 huruf (c) sampai huruf (e) disebutkan bahwa :

  1. Apabila pasien masih memerlukan pelayanan di Faskes tingkat lanjutan karena kondisiBELUM STABILsehingga belum dapat dirujuk balik ke FKTPP, maka dokter spesialias/sub spesialis membuat surat keterangan yang menyatakan bahwa pasien masih dalam perawatan.
  2. Apabila pasien sudah dalam kondisiSTABIL sehingga dapat dirujuk balik ke FKTP, maka dokter spesialis/sun spesialis akan membuat surat keterangan rujuk balik.
  1. Apabila dokter spesialis/sub spesialisTIDAK memberikan surat keterangan yang dimaksud huruf c dan d maka unutk kunjungan berikutnya pasien HARUS membawa surat rujukan yang baru dari FKTP.

IV. KESIMPULAN

Berdasarkan aturan-aturan yang telah disampaikan diatas, maka saya mencoba membuat kesimpulan ringkas terkait sistem rujukan berjenjang ini :

  1. Pelayanan kesehatan spesialistik dan sub spesialistik dibagi menjadi dua bagian yaitu : a). KasusNon-Kronis dan b). Kasus Kronis.
  2. Kasus Non-Kronis adalah kasus / penyakit yang sudah menjadi kompetensi spesialis atau sub spesialis tetapi TIDAK TERMASUK dalam 10 PENYAKIT KRONIS yang telah ditetapkan oleh Menkes.
  3. Kasus Kronis adalah kasus / penyakit yang sudah menjadi kompetensi klinis spesialis atau sub spesialis tetapi dan TERMASUK dalam 10 PENYAKIT KRONIS yang telah ditetapkan oleh Menkes yaitu : diabetes mellitus (DM), hipertensi, jantung, asma, Penyakit Paru Obstruktif Kronis (PPOK), epilepsy, skizofren, stroke, sirosis hepatis dan Sindroma Lupus Eritematosus (SLE).
  4. Untuk kasus Non-Kronis setelah pelayanan di RS ada 2 kemungkinan yaitu : a). Perlu kontrol ulang dan b). Tidak perlu kontrol ulang.
  5. Jika Kasus Non-Kronis perlu kontrol ulang, maka dokter HARUS membuat surat keterangan atau surat kontrol dan diserahkan kepada pasien sebelum pulang. Surat ini akan dibawa oleh pasien pada kunjungan berikutnya ke rumah sakit TANPA harus meminta surat rujukan lagi dari FKTP.
  6. Jika Kasus Non-Kronis TIDAK perlu kontrol ulang, maka dokter HARUS membuat surat rujuk balik (SRB) atau jawaban rujukan dan diserahkan kepada pasien sebelum pulang. Surat ini akan dibawa oleh pasien pada kunjungan berikutnya FKTP untuk melanjutkan pengobatan di FKTP.
  7. Untuk kasus Kronis setelah pelayanan di RS ada 2 kemungkinan yaitu : a). BELUM STABIL dan b). SUDAH STABIL.
  8. Jika kasus Kronis yang BELUM STABIL, maka dokter HARUS membuat SURAT KETERANGAN MASIH DALAM PERAWATAN dan diserahkan kepada pasien sebelum pulang. Surat ini akan dibawa oleh pasien pada kunjungan berikutnya ke rumah sakit TANPAharus meminta surat rujukan lagi dari FKTP.
  9. Jika kasus Kronis yang SUDAH STABIL, maka dokter HARUS membuat SURAT RUJUK BALIK (SRB) dan diserahkan kepada pasien sebelum pulang. Surat ini akan dibawa oleh pasien ke kantor BPJS Cabang untuk mendaftarkan diri sebagai peserta Program Rujuk Balik (PRB) dan kunjungan berikutnya pasien langsung menuju FKTP dengan menunjukkan Surat Rujuk Balik (SRB) dan buku kontrol peserta PRB.

Jadi berdasarkan aturan-aturan yang ada, sesungguhnya TIDAK ADA yang membatasi “UMUR” surat rujukan dari FKTP ke RS. Surat rujukan dari FKTP  ke rumah sakit HANYApada kunjungan PERTAMA KALI dan selanjutnya dilakukan penilaian apakah masuk dalam kriteria kasus Non-Kronis atau kasus Kronis. Tidak ada aturan ekspilist yang menentukan bahwa Surat Rujukan berlaku untuk 30 hari ataupun 2 minggu ataupun batasan hari yang lain.

Kejadian di lapangan yang paling sering adalah memang pasien seringkali HARUS membuat surat rujukan lagi dari FKTP. Mengapa hal ini bisa terjadi ? Karena sesuai dengan aturan bahwa “Apabila dokter spesialis/sub spesialis TIDAK memberikan Surat Keterangan Kontrol/Masih Dalam Perawatan atau Surat Rujuk Balik/Jawaban Rujukan, maka untuk kunjungan berikutnya pasien HARUS membawa surat rujukan yang baru dari FKTP”. Nah inilah yang menyebabkan pasien harus membuat surat rujukan lagi ke FKTP pada saat akan berkunjung lagi ke RS. Bagi para dokter dan petugas pemberi layanan kesehatan mungkin hal ini cukup sepele, namun bisa kita lihat dampaknya kepada pasien peserta program JKN yang akan mendapatkan pelayanan kesehatan di rumah sakit.

Yang perlu dipahami adalah bahwa alur sistem rujukan diatas hanya berlaku untuk kasus/diagnosa yang SAMA ataupun yang BERHUBUNGAN. Jika merupakan kasus/diagnosa yang baru dan berbeda, maka pasien tetap harus ke FKTP untuk mendapat surat rujukan yang baru dan berbeda dengan rujukan yang terdahulu. Berapapun EPISODEnya jika masih merupakan kasus/diagnosa yang sama dan berhubungan, maka TIDAK memerlukan surat rujukan baru kecuali dokter tidak membuat surat keterangan kontrol / masih dalam perawatan.

Terkait dengan Episode dapat dilihat dalam tulisan saya terdahulu ” MENYAMAKAN PERSEPSI TENTANG EPISODE “.

Tentang Program Rujuk Balik (PRB) dan ketentuan pemberian obat untuk kasus kronis juga dapat dibaca dalam tulisan saya sebelumnya ” PEMBERIAN OBAT PASIEN KRONIS PROGRAM JKN “.

Demikian, semoga sedikit memperjelas pemahaman kita bersama tentang ketentuan surat rujukan dalam sistem rujukan berjenjang. Mohon maaf bila banyak kekurangan dan kesalahan, semata-mata karena keterbatasan referensi saya.

Salam,

Tri Muhammad Hani
RSUD Bayu Asih Purwakarta
Jl. Veteran No. 39 Purwakarta – Jawa Barat

Bahan Bacaan :

  1. PMK Nomor 71/2013 tentang Pelayanan Kesehatan pada JKN
  2. PMK Nomor 28/2014 tentang Pedoman Pelaksanaan (Manlak) Program JKN
  3. SE Menkes Nomor 32/2014 tentang Pelaksanaan Pelayanan Kesehatan bagi Peserta BPJSK di FKTP dan FKRTL
  4. Peraturan BPJS Nomor 01/2014 tentang Penyelenggaraan Jaminan Kesehatan
  5. SE Direkur Pelayanan BPJS Nomor 38/2014 tentang Juknis SE Menkes Nomor 32/2014
  6. Buku Panduan Praktis Sistem Rujukan Berjenjang, BPJS Kesehatan Jakarta, 2014
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