Menagih Komitmen Penyedia Obat Dalam Layanan Program JKN

BPJS Kesehatan saat ini sedang gencar-gencarnya mengingatkan kepada seluruh Fasilitas Kesehatan (Faskes) yang bekerjasama dalam pelayanan program JKN tentang substansi dari PMK Nomor 28 Tahun 2014 BAB V Huruf A Poin 7 yang menyatakan bahwa fasilitas kesehatan TIDAK DIPERBOLEHKAN meminta IUR BIAYA kepada peserta selama mendapatkan manfaat pelayanan kesehatan sesuai dengan haknya. Muncul surat edaran yang meminta faskes menunjukkan komitmen terhadap kesepakatan yang telah ditandatangani dalam bentuk spanduk dan banner berisi pernyataan pemberian pelayanan TANPA iur biaya.

Dalam survei kepuasan konsumen yang rutin dilakukan oleh BPJS centre seminggu sekali di RS kami ternyata masih muncul keluhan pasien terkait dengan adanya “tambah bayar” pasien atau iur biaya, padahal pelayanan kesehatan yang diberikan sudah diupayakan semaksimal mungkin tidak membebani pasien dengan iur biaya kecuali naik kelas perawatan atas permintaan sendiri. Hasil penelusuran informasi didapatkan fakta bahwa memang pasien masih harus mengeluarkan uang ketika mengambil obat. Ternyata persoalannya adalah terletak pada mekanisme pelayanan obat di Apotek jejaring BPJS Kesehatan yang masih menarik iur biaya dari pasien dengan alasan bahwa apotek membeli obat dengan harga REGULER (bukan harga e-katalog), namun dibayar oleh BPJS Kesehatan dengan harga e-katalog ditambah komponen perhitungan lain sebagaimana diatur dalam SE Menkes Nomor 31 Tahun 2014.

Benarkan Apotek jejaring BPJS dan Faskes Swasta TIDAK BOLEH membeli obat dengan harga e-katalog ? Mari kita analisa aturan hukum dan persoalan-persoalan yang timbul di lapangan. Menyambut pelaksanaan program JKN pada awal tahun 2014, Kemenkes sudah mengatur tentang ketersediaan, distribusi dan mekanisme pembelian obat-obatan dalam pelayanan peserta BPJS Kesehatan.

Pengaturan pengadaan obat berdasarkan Katalog Elektronik (E-Catalogue) bertujuan untuk menjamin transparansi/keterbukaan, efektifitas dan efisiensi proses pengadaan obat dalam rangka memenuhi kebutuhan pelayanan kesehatan yang hasilnya dapat dipertanggungjawabkan. Dalam PMK Nomor 28 Tahun 2014 tentang Manlak JKN Halaman 25 sudah sangat jelas disebutkan bahwa pelayanan obat untuk peserta JKN pada fasilitas kesehatan mengacu pada daftar obat yang tercantum dalam Fornas dan harga obat yang tercantum dalam e-katalog obat.

Pengadaan obat menggunakan mekanisme e-purchasing berdasarkan e-katalog atau bila terdapat kendala operasional dapat dilakukan secara manual. Sementara dalam PMK Nomor 63 Tahun 2014 Pasal 3 Ayat 1 mengamanatkan seluruh Satuan Kerja di bidang kesehatan baik Pusat maupun Daerah dan FKTP atau FKRTL Pemerintah melaksanakan pengadaan obat melalui E-Purchasing berdasarkan Katalog Elektronik (E-Catalogue) sesuai ketentuan peraturan perundang-undangan.

Dalam peraturan yang sama yaitu PMK Nomor 63 Tahun 2014 Pasal 3 Ayat 2 khusus mengatur untuk FKTP atau FKRTL SWASTA yang bekerjasama dengan BPJS Kesehatan DAPAT melaksanakan pengadaan obat berdasarkan Katalog Elektronik (E-Catalogue). Jadi kesimpulannya adalah tidak benar bahwa faskes swasta (termasuk apotek jejaring BPJS) yang telah bekerjasama dengan BPJS tidak boleh membeli obat dengan harga e-katalog. Bahkan semakin ditegaskan lagi pada PMK Nomor 63 Tahun 2014 Pasal 5 Ayat 1 bahwa PBF yang ditunjuk oleh Industri Farmasi yang tercantum dalam Katalog Elektronik (E-Catalogue) WAJIB memenuhi permintaan obat dari FKTP atau FKRTL SWASTA yang bekerjasama dengan BPJS Kesehatan dalam rangka pengadaan obat sebagaimana dimaksud dalam Pasal 3 ayat (2).

Kewajiban Indsutri Farmasi ditegaskan dalam PMK Nomor 63 Tahun 2014 Pasal 5 Ayat 2 yang menyatakan bahwa Industri Farmasi yang tercantum dalam Katalog Elektronik (E-Catalogue) WAJIB melaporkan realisasi pemenuhan permintaan obat dari FKTP atau FKRTL yang bekerjasama dengan BPJS Kesehatan yang telah dilakukan oleh PBF yang ditunjuk kepada Direktur Jenderal Bina Kefarmasian dan Alat Kesehatan dengan menggunakan contoh Formulir yang telah disediakan.

Lalu muncul pertanyaan, jika sudah terdapat payung hukum bahwa faskes swasta yang bekerjasama dengan BPJS dan apotek jejaring BPJS boleh membeli obat dengan harga e-katalog namun ternyata masih muncul fakta di lapangan bahwa mereka kesulitan untuk membeli obat dengan harga e-katalog, maka dimanakah letak persoalannya? Dalam sebuah diskusi di group BPJS Kesehatan ada informasi yang menyatakan bahwa adanya kebijakan internal perusahaan distributor obat yang tidak mau melayani pembelian obat dengan harga e-katalog dari faskes swasta dan apotek jejaring. Tentu saja “kebijakan internal” ini (jika memang benar adanya) sangat bertentangan dengan ketentuan yang berlaku. Persoalan penyediaan obat memang cukup rumit bahkan sebelum era JKN sudah terjadi karena menyangkut industri farmasi dan distributor obat yang sangat dipengaruhi oleh mekanisme pasar.

Sesungguhnya pemerintah telah menjamin ketersediaan obat dalam program JKN dengan mengeluarkan ketentuan seperti tercantum dalam PMK Nomor 28 Tahun 2014 tentang Manlak JKN bahwa dalam hal faskes mengalami kendala ketersediaan obat sebagaimana yang tercantum pada e-katalog maka dapat menghubungi Direktorat Bina Obat Publik dengan alamat email: e_katalog@kemkes.go.id atau 081281753081 dan (021) 5214872. Namun ternyata persoalan tidak selesai sampai disini. Seringkali ditemui kesulitan dalam proses pengaduan dan pelaporan kepada Direktorat Bina Obat Publik Kemenkes RI melalui berbagai alamat dan nomer kontak diatas.

PABRIK OBAT DAN DISTRIBUTOR OBAT

Dalam PMK Nomor 1799 Tahun 2010 Tentang Industri Farmasi Pasal 1 Angka 3 juncto PMK Nomor 63 Tahun 2014 Pasal 1 Angka 7 disebutkan bahwa Industri Farmasi adalah badan usaha yang memiliki izin dari Menteri Kesehatan untuk melakukan kegiatan pembuatan obat atau bahan obat. Indonesia memilik banyak sekali perusahaan Industri Farmasi, baik itu yang merupakan BUMN seperti Kimia Farma, Indofarma dan Biofarma atau sektor swasta yang sebagian juga dikuasai oleh Penanaman Modal Asing (PMA). Dalam keseharian seringkali industri farmasi ini secara sederhana kita sebut dengan “pabrik obat”.

Sementara pengertian tentang “distributor obat” terdapat dalamPMK Nomor 1148 Tahun 2011 Tentang Pedagang Besar Farmasi Pasal 1 Angka 1 juncto PMK Nomor 63 Tahun 2014 Pasal 1 Angka 8 yang mendefinisikan bahwa Pedagang Besar Farmasi, yang selanjutnya disingkat PBF adalah perusahaan berbentuk badan hukum yang memiliki izin untuk pengadaan, penyimpanan, penyaluran obat dan/atau bahan obat dalam jumlah besar sesuai ketentuan peraturan perundang-undangan.

Dalam praktik sehari-hari, PBF ini sering disebut dengan DISTRIBUTOR OBAT. Begitu banyak PBF yang ada di Indonesia saat ini dan salah satu PBF yang merupakan BUMN yaitu PT. Rajawali Nusindo (RNI) telah secara tegas menyatakan komitmen penuh mendukung pemerintah menjalankan program JKN khususnya yang menjadi ranah tanggungjawabnya yaitu pengadaan, penyimpanan dan penyaluran obat-obatan dari Industri Farmasi kepada fasilitas kesehatan pemerintah dan swasta. Terdapat pula beberapa PBF dengan status badan hukum BUMN yang merupakan anak perusahaan Industri Farmasi BUMN seperti PT. Indofarma Global Mandiri (IGM) yang merupakan anak perusahaan PT. Indofarma dengan sektor usaha khusus sebagai distributor obat atau PBF.

PERMASALAHAN

Persoalan pertama adalah PBF atau distributor obat tidak mau menyediakan obat dengan harga e-katalog kepada faskes swasta dan apotek jejaring BPJS karena kebijakan perusahaan. Kenapa demikian ? Ada kabar yang menyatakan bahwa PBF mulai hati-hati dan cukup ketat dalam penjualan obat kepada faskes swasta dan apotek jejaring BPJS setelah sempat didapati kasus di sebuah faskes swasta yang membeli obat dengan harga e-katalog namun kemudian dijual dengan harga reguler (sesuai tarif RS) kepada pasien non peserta BPJS.

Pertanyaan menariknya adalah, benarkah hanya terjadi di faskes swasta? Apakah tidak mungkin hal ini juga terjadi faskes milik pemerintah yang nota bene sampai dengan saat ini BELUM semua penduduk menjadi peserta BPJS Kesehatan sehingga masih terdapat ruang untuk penyalahgunaan dengan menjual obat dengan harga RS kepada pasien umum? Permasalahan kedua adalah penyediaan obat oleh PBF yang sudah ditunjuk untuk obat-obatan dengan harga e-katalog sangat lambat dan terkesan tidak mau melayani dengan komitmen tinggi. PBF cenderung mengutamakan distribusi obat-obatan berdasarkan pemesanan dengan harga reguler dibanding permintaan obat-obatan dengan harga e-katalog. Alasan paling logis terkait hal ini tentu saja tentang besarnya profit margin PBF tersebut yang mungkin memang sangat kecil sekali untuk obat-obatan yang harganya sudah dipangkas dalam e-katalog. Seperti kita pahami bahwa harga obat-obatan e-katalog memang jauh berada dibawah harga obat non e-katalog karena adanya pemangkasan secara signifikans biaya produksi dan biaya jalur distribusi.

Masalah yang lebih ke hulu adalah terkait ketersediaan obat-obatan yang masuk dalam e-katalog di industri farmasi seringkali minim atau malah kosong. Mungkin PBF sangat komitmen untuk melayani pemesanan obat e-katalog, namun seringkali jawaban PBF adalah “kosong pabrik”. Nah jika persoalan ini benar adanya, maka dapat kita simpulkan bahwa masalah bukan terletak pada proses penyimpanan dan pendistribusian akan tetapi persoalan terletak kepada komitmen Industri Farmasi untuk memproduksi obat-obatan e-katalog.

Setiap Industri Farmasi memiliki beberapa PBF yang bekerjasama dalam proses storage (Penyimpanan) dan distribusi. Ada PBF yang sudah ditunjuk sebagai distributor obat-obatan e-katalog dan ada juga PBF yang tidak ditunjuk sebagai distributor e-katalog. Mungkinkah ada kecenderungan Industri Farmasi lebih mengutamakan melayanai permintaan PBF yang tidak ditunjuk sebagai distributor obat e-katalog ? Sangat mungkin dan secara perhitungan profit oriented tentu saja kembali kita harus berfikir bahwasanya ada upaya dari Industri Farmasi untuk mempertahankan atau bahkan meningkatkan laba perusahaan dengan tetap mengutamakan pelayanan obat-obatan non e-katalog dengan “mengesampingkan” permintaan obat-obatan dengan harga e-katalog.

Saya pernah punya pengalaman ketika ditunjuk sebagai penanggungjawab pengadaan obat-obatan e-katalog pada Tahun 2014. Kesulitan yang dihadapi adalah ketersediaan obat-obatan e-katalog di PBF karena “kosong pabrik”. Obat-obatan yang ready stock di PBF atau masih di Industri Farmasi lebih banyak didistribusikan untuk permintaan dengan harga non e-katalog. Sehingga ketika ada permintaan obat dengan harga e-katalog, maka barulah Industri Farmasi tersebut memulai proses produksinya yang tentu memakan waktu. Pengalaman pahitnya adalah dari sejak bulan Juni 2014 sudah dipesan, namun PBF baru sanggup melayani paling cepat akhir Desember 2014 sehingga akhirnya diputuskan untuk membatalkan proses pembelian tersebut.

Sungguh persoalan ini sangat menyedihkan ketika melihat kenyataan di lapangan bahwa setiap hari ada jutaan nyawa yang hidup dan keselamatannya sangat tergantung kepada obat-obatan tersebut. Memang kembali harus diakui bahwa lemahnya pengawasan terhadap faskes menjadi salah satu faktor penyebab utama persoalan ini. Sangat sulit memang mengawasi faskes dalam pelayanan obat-obatan kepada pasien dengan membedakan pasien BPJS dan bukan peserta BPJS. Siapa yang mampu menjamin bahwasanya semua obat yang dibeli dengan harga e-katalog HANYA akan diberikan kepada pasien peserta BPJS ? Siapa yang dapat memastikan bahwa obat-obatan yang dibeli oleh faskes (pemerintah dan swasta) TIDAK dijual kepada pasien bukan peserta BPJS dengan tarif RS ? Ditekankan disini bahwa peluang moral hazzard ini tidak hanya terjadi di faskes swasta, namun faskes pemerintah pun tetap memiliki kemungkinan yang sama sampai Universal Health Coverage (UHC) di Indonesia dapat tercapai. Dan lagi-lagi menurut saya adalah peran Badan Pengawas Rumah Sakit (BPRS) yang belum berjalan optimal dan maksimal seperti dalam tulisan saya terdahulu tentang BPRS (Kompasianan Tanggal 14 April 2015).

KESIMPULAN

  1. Komponen pembiayan kesehatan terutama Rawat Jalan yang terbesar adalah pembiayan obat dan Bahan Habis Pakai (BHP). Sekitar 70% – 75% biaya pelayanan kesehatan pasien RJTL adalah dari obat-obatan dan BHP.
  2. Persoalan penyediaan obat adalah permasalah yag sangat rumit karena menyangkut banyak pihak dan sektor. Ada industri farmasi dan perusaah distributor yang berperan dominan di sini dengan segala bentuk kepentingan dan komitmennya. Ada Kemenkes yang menjadi “eksekutor” dan tempat “pengaduan” ketika persoalan penyediaan obat di faskes terdapat kendala. Ada BPRS dan Dinkes yang harus mengawasi kinerja faskes terutama RS dalam pelayanan obat-obatan kepada pasien peserta BPJS.
  3. Dalam konteks persoalan ini maka BPJS Kesehatan diharapkan berperan aktif tidak hanya sekedar menerima komplain, akan tetapi ikut berperan dalam meng-investigasi persoalan terutama di apotek jejaring BPJS yang memberlakukan iur biaya obat-obatan kepada pasien. Melakukan kredensialing ulang dan evaluasi penunjukan apotek jejaring jika memang persoalan penyalahgunaan atau penyelewengan aturan dilakukan oleh apotek jejaring tersebut.
  4. Perlu adanya law enforcement (penegakan aturan) kepada industri farmasi dan PBF yang dengan sengaja “melawan” ketentuan yang berlaku. Latar belakang adanya kebijakan sepihak dari industri farmasi dan PBF harus dianalisa dan dicarikan solusi atas persoalan-persoalan tersebut. Oleh siapa? Jika adanya upaya melawan hukum dari industri farmasi dan PBF, maka Kemenkes harus melakukan penegakan aturan dari yang paling ringan (teguran) sampai yang paling berat (pencabutan izin). Jika adanya moral hazzard dari faskes, maka Kemenkes, Dinkes dan juga BPRS harus melakukan upaya pencegahan dan penindakan sesuai ketentuan yang berlaku.

Terakhir, adanya temuan kasus moral hazzard di sebuah/beberapa faskes TIDAK BOLEH menjadi alasan pembenaran oleh industri farmasi dan PBF tidak mau melayani pembelian obat-obatan dengan harga e-katalog oleh faskes swasta dan apotek jejaring BPJS. Yang melakukan penyalahgunaan silahkan ditindak, tapi saya yakin masih banyak faskes swasta dan apotek jejaring yang masih tetap menjalankan pelayanan dengan baik dan benar sesuai ketentuan yang berlaku. Tidak adil bagi faskes swasta dan apotek jejaring BPJS yang memiliki komitmen tinggi terhadap program JKN ini jika harus terkena “getahnya”.

Melakukan pemecahan masalah yang sangat rumit terkait penyedian obat-obatan dan BHP bagi peserta program JKN sembari terus berupaya memperbaiki sistem pengadaan, penyaluran (distibusi) juga pengawasan merupakan salah satu faktor kunci utama keberhasilan program JKN menuju Universal Health Coverage (UHC) Indonesia tahun 2019. Selama masalah “complicated” ini tidak diatasi, maka rasanya sangat sulit bagi faskes untuk memenuhi komitmen tidak boleh ada iur biaya terhadap pasien peserta BPJS Kesehatan.

Wallahu’alam.

Sekian,

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

 

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