Ayo Perbaiki Tarif Ina CBGs Bersama-Sama

Belum lama ini muncul sebuah surat edaran dari Kementerian Kesehatan yang meminta masukan kepada Rumah Sakit yang bekerjasama dengan BPJS agar mengirimkan data-data keuangan (costing) dan kode INA CBGs (coding) Rumah Sakit dalam rangka perbaikan tarif INA CBGs pada tahun 2016. Berdasarkan Perpres 12 Tahun 2013 bahwasanya Tarif INA CBGs akan dilakukan evaluasi dan revisi setiap 2 tahun sekali. Meskipun pada kenyataannya pada tahun 2015 yang mana belum 2 tahun sejak dijalankannya program JKN telah dilakukan revisi secara parsial terhadap tarif INA CBGs.

Adanya surat edaran tersebut diyakini tidak terlepas dari dorongan para pemberi pelayanan dan pemerhati program JKN di lapangan selama ini kepada NCC Kemenkes agar lebih banyak melibatkan Rumah Sakit baik itu RS Publik atauun RS Privat (Swasta) yang bekerjasama dengan BPJSK serta organisasi profesi dan kolegium dalam penyusunan tarif INA CBGs, sehingga ini merupakan momentum yang sangat baik sekali dalam rangka mewujudkan tarif INA CBGs yang betul-betul mewakili biaya riil (real cost) pelayanan kesehatan baik di FKTP maupun di FKRTL.

SEKILAS TENTANG INA CBGs

INA CBGs adalah singkatan dari Indonesia Case Based Groups. CBGs merupakan salah satu metode pengelompokan kasus berdasarkan kesamaan penyerapan sumber daya. CBGs bersama-sama dengan Diagnose-Related Group (DRG) menggunakan sebuah instrumen atau tool yaitu Case Mix.

Case Mix adalah Sebuah alat untuk mengklasifikasikan jenis kondisi pasien menjadi kelompok-kelompok sesuai dengan sumber daya yang dikonsumsi dengan pendekatan terhadap Lama Hari Rawat (Length Of Stay; LOS), biaya episode perawatan atau biaya pelayanan harian. (Pof. Syed, UNU-IIGH).

MENGAPA HARUS CBGs DAN BUKAN DRG ?

Diagnose-Related Group (DRG) pertama kali dikembangkan oleh Prof. Robert Fetter dan Jane Thompson dari Univeristas Yale Amerika Serikat dan digunakan pertama kali pada Tahun 1983 oleh program Prospective Payment System (PPS) dalam Program JaminanMedicare. Metode DRG dikembangkan hanya berdasarkan kasus-kasus penyakit yang bersifat akut terutama pasien rawat inap dan hanya menggunakan sistem klasifikasi berdasarkan diagnosa utama serta prosedure (tindakan). Padahal kita memahami bahwaCost Drivers di pelayanan kesehatan bukan hanya diagnosa dan prosedur, namun juga ada fakor obat, investigasi dan prosthesa yang juga faktor penting sebagai layanan yang menimbulkan biaya (Cost Drivers). Selain itu tidak adanya peluang untuk melakukan Top Up Payment telah menimbulkan resiko finansial tersendiri bagi penyedia layanan kesehatan. Faktor-faktor tersebut menjadi sisi lemah metode DRG ini sehingga mulailah dikembangkan metode baru hasil modifikasi dari DRG yaitu yang disebur dengan Case Base Groups (CBGs).

CBGs merupakan hasil modifikasi dari DRG dengan beberapa keunggulan yaitu : 1). Sudah mencakup kasus-kasus yang bersifat akut, sub akut dan kronis. 2). Cost Drivers selain diagnosa utama dan prosedur, terdapat pula cost drivers yang bersifat unbundling (diluar paket) yaitu obat-obatan, prosedur khusus, investigasi dan prothesa. Sehingga CBGs pada saat ini terdiri dari 8 komponen utama yaitu Akut, Sub Akut, Kronis, Spesial Prosedur, Spesial Investigasi, Spesial Prothesa, Spesial Drugs, Paket Rawat Jalan serta 1 komponen lagi yang sedang pada tahap pengembangan yaitu Pelayanan Dokter Gigi (Dental).

BAGAIMANA TARIF CBGs DIBANGUN ?

Sistem pembayaran berdasarkan kasus mencakup minimal 2 komponen utama yaitu : 1). Perangkat parameter untuk menghitung tarif pembayaran pada setiap tipe kasus; dan 2). Sistem administrasi (Informasi dan Billing System) Rumah Sakit untuk melaporkan kasus-kasus yang ada dan harus dibayarkan oleh pasien.

Parameter untuk menghitung tarif pembayaran per kasus terdiri dari minimal : 1). Tarif Dasar atau Rerata Total Biaya Per Kasus (Based Rate; BR) dan 2). Bobot Kelompok Kasus (Case Group Weight, CGW) untuk membedakan antar kasus-kasus dengan intensitas penyerapan sumber daya (resources) yang berbeda-beda.

Persamaan umum secara komputerisasi untuk menghitung pembayaran rumah sakit berdasarkan kasus adalah sebagai berikut :

Tarif Per Kasus (i) = BR x CGW (i)

Ket :

(i)       : Merupakan kelompok kasus tertentu

BR     : Base Rate atau Tarif Dasar

CGW : Bobot Kelompok Kasus (i)

Sehingga kita bisa melihat bahwa komponen utama dalam penghitungan tarif per kasus adalah TARIF DASAR dan BOBOT KELOMPOK KASUS. Kedua komponen ini bisa dihitung apabila ada data-data yang diperoleh dari rumah sakit dalam bentuk data Costing dan data Coding.

Langkah pertama dalam menghitung tarif per kasus adalah dengan menghitung bobot kelompok kasus baru kemudian menghitung tarif dasar. Untuk menghitung bobot kelompok kasus tentu saja kita harus melakukan penyusunan kelompok kasus terlebih dahulu berdasarkan kriteria-kriteria yang harus ditetapkan sebelumnya.

A. MEMBANGUNG KELOMPOK KASUS (CASE GROUP)

Dalam membangun kelompok kasus dilakukan dengan berdasarkan 3 prinsip utama yaitu :

  1. Koherensi Klinis. Adalah kasus yang dikelompokkan harus sama berdasarkan sistem anatomi tubuh dan satu kelompok penyakit. Koherensi klinis penting agar sistem klasifikasi penyakit menjadi logis dari sudut pandang medis dan dipahami serta dapat diterima oleh penyedia layanan. Sebagai contoh membangun Koherensi Klinis adalah mengelompokka kasus berdasarkan : 1). Sistem Tubuh; 2). Pemisahan kasus medis dan klinis; dan 3). Tingkat prosedur, masalah medis dan faktor-faktor lain yang membedakan proses perawatan.
  2. Intensitas sumber daya yang sama (homogen secara ekonomis). Setiap diagnosis dalam kelompok kasus berdasarkan diagnosis harus memiliki kesamaan dalam hal intensitas penggunaan sumber daya dan biaya untuk berbagai layanan diagnostik dan pengobatan yang diperlukan untuk benar-benar mendiagnosa dan mengobati kasus atau menyelesaikan satu fase dalam manajemen kasus. Hal ini berarti bahwa akan ada distribusi biaya dalam setiap kelompok, tetapi distribusi harus relatif ketat. Intensitas pengunaan sumber daya, pada awalnya dilakukan dengan melakukan estimasi terhadap rata-rata lama perawatan (Length of Stay; LOS) dan biaya rata-rata per tempat tidur-hari di Instalasi dimana kasus terkait biasanya diobati, tanpa adanya perhitungan biaya yang keluar terhadap setiap layanan individual.
  3. Keterwakilan statistik. Setiap kelompok diagnosis terkait harus mengandung cukup banyak jumlah kasus-kasus di rumah sakit untuk mendapatkan perkiraan biaya agregat yang stabil per kasus dalam pengulangan sample (reliable).

B. MENGHITUNG BOBOT KELOMPOK KASUS

Bobot Kelompok Kasus atau CGW berasal dari rata-rata biaya per kasus pada setiap group yang sudah ditentukan pada langkah sebelumnya dan membagi biaya kelompok kasus dengan rata-rata biaya keseluruhan per kasus untuk mendapatkan bobot relatif seperti yang dilihat pada persamaan dibawah ini :

CGW(i) = Biaya Rata-Rata Per Kasus(i) / Rata-Rata Biaya Keseluruhan Per Kasus

 

Untuk menghitung rata-rata biaya keseluruhan per kasus, pertama-tama perlu untuk menentukan terlebih dahulu biaya rumah sakit yang akan dimasukkan dalam sistem pembayaran rumah sakit, dan menghapus semua biaya dari data pengeluaran rumah sakit yang tidak akan dimasukkan dalam biaya penggantian per kasus. Misalnya, jika rumah sakit memiliki Instalasi Rawat Jalan atau Poliklinik, maka beberapa pengeluaran yang berhubungan dengan layanan rawat jalan harus dihapus dari data jumlah pengeluaran rumah sakit sakit. Akan tetapi, pelayanan yang diberikan oleh Instalasi Rawat Jalan di Rumah Sakit dapat dimasukkan ke dalam pembayaran per kasus, sehingga perlu untuk memasukkan biaya-biaya tersebut dari Instalasi Rawat jalan. Kategori pengeluaran lainnya, seperti biaya modal atau pelayanan ambulan juga harus dikeluarkan jika biaya-biaya tersebut tidak ditagihkan melalui sistem pembayaran berdasarkan kasus.

C. MENGHITUNG TARIF DASAR (BASE RATE)

Tarif Dasar (Base Rate) adalah akumulasi rata-rata biaya per kasus rumah sakit yang merupakan titik awal untuk mengatur tarif per kasus yang dikembangkan dimana Tarif Dasar dikalikan dengan Bobot Kelompok Kasus. Base Rate adalah variabel kebijakan yang penting yang mempengaruhi alokasi sumberdaya pelayanan kesehatan antara sektor rumah sakit dan bagian-bagian lain dalam sistem pelayanan kesehatan. Base Rate dapat digunakan sebagai instrumen untuk mempromosikn keadilan, sebagai contoh, dengan meningkatkan Base Rate di daerah yang mengalami keterbelakangan finansial dalam proses penganggaran.

Dengan memasukkan atau mengeluarkan biaya investasi (capital cost), base rate juga mempengaruhi keputusan melakukan investasi rumah sakit, pembeli atau penyandang dana lainnya dan secara alokasi keseluruhan antara ekerja dan pemodal di dalam menghasilkan jasa pelayanan kesehatan. Oleh karena itu, penentuan base rate merupakan rentang kebijakan penting di dalam sistem pembayaran rumah sakit berdasarkan kasus.

D. KESIMPULAN

  1. Penentuan kelompok kasus (Case Group) yang menjadi cikal bakal terbentuknya kode CBGs sangat ditentukan olehinput (masukan) kode-kode dari rumah sakit-rumah sakit. Jumlah kode CBGs di Indonesia relatif masih jauh tertinggal dibandingkan dengan negara-negara lain. Saat ini di Indonesia terdapat 077 kode CBGs yang terdiri dari 798 kode rawat inap dan 288 kode rawat jalan. Jumlah ini masih kalah jauh dengan Thailand yang sudah memiliki 2.045 kode dan bahkan dengan negara tetangga Malaysia yang sudah memiliki 1.220 kode. Indonesia perlu mengembangkan kode-kode untuk perawatan di ruangan khusus seperti ICU, ICCU, CICU, NICU dan PICU yang saat ini masih disatukan dengan kode untuk perawatan di ruang rawat inap biasa. Kuncinya adalah data dan masukan dari RS.
  1. Perhitunganbobot kelompok kasus juga sangat bergantung kepada input data costing dan coding dari RS. Rata-rata biaya per kasus dalam sebuah kelompok ditentukan oleh data-data pembiayaan dari RS. Semakin banyak data yang terkumpul maka akan semakin valid dan memiliki level presisi yang tinggi karena metodologi untuk perhitungannya adalah dengan mencari nilai rerata (average). Artinya semakin tinggi tarif rumah sakit maka sesungguhnya akan menyumbangkan terhadap nilai tarif CBGs, semakin banyak RS yang memasukkan data tarif yang tinggi maka akan semakin tinggi pula tarif CBGs yang dhihitung berdasarkan nilai rata-rata yaitu jumlah biaya dibagi dengan jumlah kasus (mirip dengan perhitungan biaya satuan atau unit cost di rumah sakit).

Costing

  1. PerhitunganTarif Dasar RS (Base Rate) juga sangat ditentukan oleh data-data pembiayaan rumah sakit yang masuk. Artinya semakin tinggi data pembiayaan rumah sakit maka akan semakin tinggi pula hospital base rate ini. Biaya-biaya langsung dan tidak langsung, biaya overhead dan biaya pada pusat-pusat penghasil (Revenue Centre) akan menentukan besaran base rate.

costing1

Untuk memperbaiki tarif CBGs maka ada dua hal yang mutlak harus dilakukan oleh rumah sakit, yaitu : a). Perbaiki tarif RS dan data pembiayaan termasuk biaya satuan (Unit Cost)b). Memberikan data-data pembiayan (costing) dan coding kepada NCC Kemenkes. Jangan ada yag ditutup-tutupi, berikanlah data apa adanya, terutama RS Privat (Swasta) yang issue-nya agak enggan memberikan data costing karena konon menyangkut “rahasia dapur” mereka. Jka ingin tarif INA CBGs ini mengalami perbaikan dan “peningkatan” maka harus dihilangkan pemikiran seperti itu.

Mengkritik tarif CBGs tidak dengan berteriak-teriak nyinyir di luar dan menyindir para perumus tarif di NCC Kemenkes. Jangan lupa bahwasanya besar kecilnya tarif CBGs sebenarnya ada di “tangan” rumah sakit-rumah sakit tersebut. Sudahkah kita sanggup dan mau memberikan data tersebut? Apakah data tersebut sudah benar dan tidak ada yang ditutup-tutupi? Tahukah bahwa tarif CBGs yang ada sekarang ini juga “akibat” dari kontribusi data RS juga? Tahukah fakta sebenarnya bahwa dari sekian banyak RS yang diminta datanya namun hanya sebagian kecil saja yang mengirimkan kembali data-data ke NCC Kemenkes ? Dan kebetulan sebagian besar data tersebut berasal dari RS Pemerintah yang nota bene tarif nya lebih banyak ditentukan oleh kebijakan tarif (Pricing Policy) dan seringkali diwarnai kepentingan politis.

Ayo perbaiki tarif CBGs bersama-sama dengan cara kita perbaiki terlebih dahulu tarif rumah sakit, perbaiki dulu data-data biaya (costing) dan data-data coding. Selanjutnya kita sampaikan data-data tersebut kepada NCC Kemenkes berdasarkan template costing yang sudah ditentukan. Jangan mengkritik tarif CBGs sedangkan kita sendiri tidak bersedia memberikan data-data keuangan RS. Janganlah menjadi peri yang buruk muka cermin dibelah. Introspeksi dan refleksi diri jauh lebih bijaksana ketimbang mencaci. Mulailah dari yang kecil, mulailah dari diri sendiri dan mulailah dari sekarang (Quote AA Gym).

Sekian dan selamat menjalankan ibadah puasa.

Tri Muhammad Hani

RSUD Bayu Asih Purwakarta

Jl. Veteran No. 39 Kabupaten Purwakarta -Jawa Barat

Bahan Bacaan :

  1. USAID: Case-Based Hospital Payment Systems : A Step-By-Step Guide For Design And Implementation In Low- And Middle-Income Countries, December 2005. USA.
  2. Syed Mohammed Aljunid, MSc. PhD: INA-CBG For Sustainable Universal Coverage. International Institute For Global Health (UNU-IIGH). Malaysia.
  3. Syed Mohammed Aljunid, MSc. PhD: Universal Coverage and Development of Medical Industries in SEA. ITCC-UKMMC, Malaysia.

 

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  54. İnstagram kullanıcıları daha aktif ve etkin olmasını istiyorsanız takipçi
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    Bunun kendi imkanlarınızla kısa sürelerde hallediyor olmanız neredeyse imkansızdır.

    İnstagram takipçi satın al hizmeti ile hesaplarınızda istediğiniz sayılarda takipçi sahibi olabilirsiniz.

    Bu alanda hizmet veren ve takipçi satışı yapan platformları kullanabilirsiniz takipcisatinalin.org
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  63. Tiktok şüphesiz en iyi video izlenme uygulamaları arasına girmiştir hemde çok kısa
    bir sürede.. Bir çok kişi tarafından artık gelir kaynağı haline gelmiş durumda,
    Etkilişimlerini çoğaltmak amacıyla tiktok izlenme satın al işleminden faydalanmak istiyorlar.
    İzlenme satın alma işlemi, bireylerin her paylaşımını keşfet etkili hale getiriyor.

    Genellikle reklam vermek isteyen kişiler tiktokerları tercih ediyoralr.
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  64. Sosyal medya hayatımızın her anında kullanılan bir platformdur.

    Bu yüzden de farklı amaçlar güdülerek bu platformunun değerlendirilmeye
    çalışıldığı da bilinmektedir. Bu anlamda ise instagram türk takipçi satın al seçeneği
    en başta gelmektedir.
    Sosyal medya ile kişiler hem günlük hayatlarını sevdikleri kişiler ile video veya resim
    yoluyla paylaşabilmektedir hem de ürün satışları yapabilmektedirler.

    Kişilerin özellikle satış yapmak veya ürün tanıtmak gibi amaçlardan dolayı sosyal medyayı
    kullanmalarında önemli olan takipçi sayılarıdır.

    Bu anlamda ise kişilere kolaylık sağlanabilmesi için en ucuz takipçi
    fırsatları oluşturulmuştur.
    Kişiler söz konusu olan bu fırsatla istemiş
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    değerlendirmeleri tavsiye edilmektedir.

  65. Instagram Takipçi Sayısının Önemi
    Günümüzde neredeyse en çok kullanımının olduğu uygulama olan instagram uygulamasında kullanıcılar kendilerini daha
    yaygın ve daha yüksek etkileşimler almanın etkisine kaptırmış durumdadır.

    Bu nedenle kişiler daha fazla etkileşim alabilmek
    adına ve daha yaygın bir kitleye ulaşabilme imkanı elde etmek
    isterler.
    Bu kişilerin takipçi satın al
    gibi platformlar aracılığı ile gerçek takipçiye sahip olarak etkileşimleri en kısa zamanda en yüksek seviyelere taşıma imkanı
    elde ederler.

  66. HIZLI TAKİPÇİ SATAN SİTE

    Sosyal medyanın hayatımızda bir parça olmasından bir vakit sonra bireylerin değişik şekillerde
    kullanımlarına ideal olabilecek platformlar meydana getirilmiştir ve bu
    platformlarda da bireylerin amaçlarını yerine getirilebilmesi amacıyla takipçi adetlerini yükseltmek isterler.

    Bu sebeple de tabiki takipçi almak hedeflemekteler.

    bu işlemin de en hızlı takipçi sitesi arayarak bir
    an önce takipçilerine kavuşmak istemektedirler.
    Bu sebepten de hızlı takipçi satın al diyerek aramalar yaparlar..

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