Pembagian Jasa Pelayanan Di Rumah Sakit Pada Era JKN : Fee For Services Atau Konversi ?

Diskusi tentang layanan kesehatan JKN selalu menjadi sebuah perdebatan hangat jika sudah merambah ke ranah reward atau salary. Pro dan kontra selalu terjadi, perbedaan cara pandang dan konsep kerap mewarnai diskusi. Sebenarnya bagaimanakah sistem pembagian jasa pelayanan yang ideal di RS pada era JKN ini ? Bagaimana nasib dan masa depan sistem remunerasi jika dikaitkan dengan sistem layanan ala JKN di Indonesia saat ini ?

Prinsip dasarnya sebenarnya adalah sistem pembagian jasa pelayanan itu hanya ada 2 yaitu dihitung berdasarkan pendapatan (bukan penerimaan) atau dihitung berdasarkan penerimaan. Apakah bedanya PENDAPATAN dan PENERIMAAN ?

PENDAPATAN dari sisi akuntansi adalah pendapatan Rumah Sakit secara Accrual yang dihitung berdasarkan tarif rumah sakit yang ditetapkan melalui Peraturan Daerah atau Peraturan Kepala Daerah (Perda, Pergub, Perwalkot atau Perbup). Berbicara pendapatan maka kita mengesampingkan besarnya klaim atau pembayaran klaim kepada BPJSK.

Pendapatan akan diakui sebagai PENERIMAAN ketika nilai atau nominal rupiah sudah diterima oleh RS dari pembayaran klaim oleh BPJSK berdasarkan nilai klaim yang tercantum dalam berita acara klaim. Jadi apabila pendapatan berdasarkan accrual, maka penerimaan berdasarkan cash based. Dari dua terminologi keuangan ini muncul istilah TAGIHAN dan JAMINAN. Tagihan adalah jumlah nominal tagihan yang dihitung berdasarkan tarif rumah sakit sebagaimana tercantum dalam billing pasien, sedangkan Jaminan adalah jumlah nominal jaminan yang dihitung berdasarkan hasil grouping menggunakan aplikasi INA CBGs. Nilai jaminan akan menjadi dasar nilai klaim RS kepada BPJS Kesehatan. Mudah-mudahan tidak membingungkan, secara sederhana adalah PENDAPATAN itu berdasarkan nilai TAGIHAN sementara PENERIMAAN adalah berdasarkan nilai JAMINAN.

Karena ada perbedaan antara tarif rumah sakit dan tarif paket INA CBGs maka akan muncul satu istilah lagi yaitu SELISIH JAMINAN. Selisih Jaminan adalah perbedaan (deviasi) antara tarif rumah sakit dengan tarif paket INA CBGs atau secara gampangnya adalah selisih antara TAGIHAN dan JAMINAN atau selisih antara PENDAPATAN dengan PENERIMAAN. Nah selisih jaminan ini ada dua kemungkinan, yaitu SELISIH JAMINAN POSITIF (SJP) dan SELISIH JAMINAN NEGATIF (SJN). Selisih Jaminan Positif akan terjadi manakala tarif paket INA CBGs LEBIH BESAR dibandingkan dengan TOTAL BILLING pasien berdasarkan tarif Rumah Sakit. Sedangkan Selisih Jaminan Negatif akan terjadi ketika tarif paket INA CBGs LEBIH KECIL dibandingkan dengan TOTAL BILLING pasien berdasarkan tarif Rumah Sakit.

Mengapa Total Billing ? Karena membandingkannya memang seperti itu. Tarif INA CBGs adalah tarif PAKET yang terdiri dari akomodasi, obat dan BHP, jasa sarana dan jasa pelayanan. Sedangkan tarif rumah sakit berdasarkan per jenis layanan, sehingga tidak bisa membandingkan tarif INA CBGs dengan per item jenis layanan, akan tetapi yang bisa dilakukan adalah menyandingkan tarif INA CBGs dengan Total Tagihan (Billing) pasien berdasarkan tarif rumah sakit.

Pada titik ini banyak yang masih keliru memahami tarif INA CBGs yang dikira masih seperti tarif RS berdasarkan per jenis layanan. Muncullah istilah Fee For Services dan Package System. Fee For Services pada hakikatnya adalah berbasis pada tarif per jenis layanan dan ini lazim digunakan oleh seluruh rumah sakit dalam penetapan tarif mereka. Coba kita buka buku tarif sebuah Rumah Sakit, pasti akan muncul tarif pemeriksaan dokter, tarif visite dokter, tarif operasi besar, tarif pemeriksaan laboratorium, radiologi dan lain sebagainya. Itu artinya bahwa tarif rumah sakit berdasarkan per jenis layanan atau tindakan.

Sedangkan Package System yang digunakan dalam sistem JKN adalah berdasarkan penggabungan antara jenis-jenis layanan tersebut ditambah biaya obat-obatan dan BHP menjadi SATU TARIF (Single Price) dalam sistem paket INA CBGs.

Adanya perbedaan sistem dan nilai tarif antara INA CBGs dengan tarif rumah sakit diatas memunculkan istilah KONVERSI. Menjelaskan konversi agak sulit dan berbelit, akan lebih baik menjelaskan konversi dengan contoh kasus.

Nah sekarang kita melangkah pada sistem pembagian jasa pelayanan yang selalu menimbulkan polemik dan debat panjang juga seru. Sampai pada poin diatas, maka RS sudah memiliki dua nilai, yaitu nilai PENDAPATAN dan nilai PENERIMAAN. Tergantung kebijakan internal RS yang tentu saja harus merupakan kesepakatan dan persetujuan para pemberi layanan langsung (dokter, paramedis dan sebagainya), apakah mau membagi jasa pelayanan berdasarkan nilai PENDAPATAN atau berdasarkan nilai PENERIMAAN. Jika membagi jasa pelayanan berdasarkan jumlah pendapatan maka artinya berdasarkan tarif rumah sakit dengan mengesampingkan jumlah pembayaran klaim BPJSK. Namun apabila mau membagi berdasarkan jumlah penerimaan maka artinya berdasarkan jumlah pembayaran klaim dari BPJSK yang menggunakan tarif paket INA CBGs. Lha mana bisa membagi jasa pelayanan dari tarif INA CBGs ? Khan tarif INA CBGs itu sudah paket sementara tarif RS per jenis layanan ?? Nah disitulah perlunya proses konversi dari tarif paket INA CBGs menjadi tarif rumah sakit per jenis layanan. Artinya ada proses MEMECAH-MECAH tarif INA CBGs dari bentuk PAKET (gelondongan) menjadi per jenis layanan sebagaimana tarif rumah sakit lalu menghitung PROPORSI tiap-tiap jenis layanan tersebut.

Kesimpulannya, tarif rumah sakit adalah berbasis pada per jenis item layanan atau tindakan sehingga menganut paham fee for services sehingga mekanisme distribusi jasa pelayanan nya pun menggunakan sistem fee for services juga dengan nilai yang tetap (fixed) berdasarkan ketentuan yang berlaku di rumah sakit. Sedangkan tarif CBGs adalah paket sehingga TIDAK BISA langsung dipergunakan untuk dasar membagi jasa pelayanan secara fee for services. Jika ingin membagi jasa pelayanan berdasarkan tarif paket CBGs maka pilihannya hanyalah dengan metode KONVERSI dari tarif PAKET CBGs menjadi tarif per item layanan rumah sakit. Belakangan mulai berkembang metode yang lebih fleksibel yaitu metode campuran (MIXED) antara metode fee for services dengan metode konversi. Secara singkat metode campuran ini yaitu metode fee for services dengan menghitung selisih jaminan positif (setelah konversi) dan besar selisih jaminan ini akan didistribusikan lagi kepada para pemberi layanan langsung terutama dokter. Metode MIXED mulai berkembang dan dianggap sebagai sistem pembagian jasa yang paling ideal dan adil.

A. METODE FEE FOR SERVICES

Pembagian jasa pelayanan secara Fee For Services artinya adalah berdasarkan pada pendapatan rumah sakit yang dihitung dari tarif rumah sakit. Karena tarif rumah sakit memang sudah berbasis pada per jenis layanan, maka sangat mudah menggunakan sistem ini. Besaran jasa pelayanan bersifat tetap (fixed) untuk tiap jenis layanan berdasarkan ketentuan yang berlaku di rumah sakit tersebut. Sifat tetap (fixed) ini berlaku mutlak dan tanpa melihat besaran nilai jaminan atau pembayaran klaim dari BPJSK ke rumah sakit. Kemungkinan nilai jaminan lebih tinggi atau lebih rendah dari total tagihan berdasar tarif rumah sakit dikesampingkan. Intinya adalah para pemberi layanan mendapat jasa pelayanan tanpa melihat jenis pembayaran pasien, apakah pasien umum atau pasien jaminan asuransi semuanya diberlakukan sama yaitu menggunakan tarif rumah sakit. Artinya para pemberi layanan tidak perlu tahu apakah manajemen keuangan rumah sakit mendapat selisih jaminan positif atau negatif dari pembayaran klaim BPJSK.

Apabila ternyata penerimaan total rumah sakit dari nilai jaminan dari pembayaran klaim BPJSK masih lebih rendah dibanding dengan pendapatan jika dihitung berdasar tarif rumah sakit, maka itu menjadi resiko internal manajemen rumah sakit karena akan menjadi subsidi rumah sakit. Kemampuan dan kecerdikan pimpinan rumah sakit sangat diperlukan untuk mengatasi kondisi ini, perlu dilakukan analisa penyebabnya. Apakah terjadi over billing atau karena belum optimal nya koding yang menjadi penyebab dari timbulnya selisih jaminan negatif ini.

Kondisi sebaliknya adalah jika ternyata penerimaan total rumah sakit lebih tinggi dari nilai jaminan dari pembayaran klaim oleh BPJSK, maka selisih jaminan positif tersebut akan menjadi pendapatan fungsional rumah sakit dan dimasukkan dalam pos jasa sarana untuk operasional dan maintenance serta untuk pengembangan rumah sakit.

B. METODE KONVERSI (DIRECT PROPORSIONAL)

Metode Konversi atau proporsional langsung (direct proprotional) digunakan apabila rumah sakit akan menjadikan penerimaan jaminan dari pembayaran klaim oleh BPJSK sebagai sumber pembagian atau distribusi jasa pelayanan. Mengapa harus dilakukan konversi ? Karena pembayaran klaim dari BPJSK berdasarkan PAKET atau gelondongan. Sesuai dengan Permenkes nomor 28 tahun 2014, maka tarif CBGs adalah tarif paket yang terdiri dari komponen akomodasi, sarana, obat dan BHP serta jasa pelayanan. Besar proporsi jasa pelayanan setinggi-tingginya adalah sebesar 44 % (PMK 28 / 2014).

Ada dua tahap pada metode ini yaitu :

  1. Tahap pertama adalah SPLIT PRICE yaitu melakukan PEMECAHAN tarif CBGs yang paket (gelondongan) tersebut menjadi per jenis layanan. Darimana kita mengetahui komponen-komponen jenis layanan yang ikut ber-kontribusi ? tentu saja dari tarif rumah sakit. Nah inilah yang disebut dengan proses melakukan KONVERSI tersebut. Jadi tujuan melakukan KONVERSI adalah untuk melakukan SPLIT PRICE.
  2. Tahap kedua adalah setelah dilakukan pemecahan per jenis layanan maka kita melakukan penghitungan proporsi untuk tiap jenis layanan. Proporsi dilakukan dengan menghitung prosentase kontribusi per jenis layanan dari tarif rumah sakit. Jumlah total prosentase per jenis layanan tersebut harus 100 %. Setelah mendapatkan proporsi masing-masing jenis layanan, maka selanjutnya kita menggunakan proporsi tersebut untuk menghitung nominal rupiah tarif paket CBGs yang sudah dipecah-pecah sebelumnya (split price). Setelah mendapatkan nominal rupiah per jenis layanan dari tarif paket CBGs tersebut, maka langkah selanjutnya adalah sama dengan fee for services yaitu melihat ketentuan distribusi jasa pelayanan nya. Berapakah untuk jasa sarana dan berapakah untuk jasa pelayanan nya sehingga diperolah besar nominal jasa pelayanan yang bisa didistribusikan kepada para pemberi jasa layanan.

Dapat dilihat bahwa metode ini memberikan peluang dinamika perolehan jasa pelayanan yang diterima untuk setiap bulan nya. Bisa lebih tinggi atau lebih rendah jika dibandingkan dengan perolehan jasa pelayanan yang dihitung berdasarkan tarif rumah sakit. Karena berubah-ubah maka tidak bisa disebut dengan fixed salary seperti hal nya metode fee for services. Pertanyaannya, apakah yang berubah-ubah hanya jasa pelayanan ? Jawabannya adalah tentu saja TIDAK. Karena semua item jenis layanan diproporsi, maka ketika nilai jaminan lebih rendah akan terjadi penurunan pada semua komponen termasuk akomodasi, sarana bahkan porsi obat dan BHP pun tentu akan lebih rendah daripada biaya rumah sakit untuk membeli obat dan BHP tersebut. Hal ini yang sering disalah artikan oleh para pemberi layanan yang mengira bahwa hanya jasa pelayanan saja yang turun padahal kenyataanya semua akan terkena imbas nya. Pun demikian jika nilai jaminan lebih tinggi daripada tarif rumah sakit, maka tidak hanya nominal jasa pelayanan yang meningkat namun semua komponen mendapatkan manfaat peningkatan nominal termasuk untuk sarana, akomodasi, obat dan BHP. Disinilah peluang rumah sakit untuk melakukan subsidi silang tergantung pada kepandaian dan kecerdasan pimpinan rumah sakit.

Memang cukup rumit dan agak panjang penjelasannya tentang metode ini karena selama berpuluh-puluh tahun kita terbiasa dengan metode fee for services. Sebagian dokter menyukai metode ini, tapi sangat banyak juga yang tidak menginginkan metode ini.

C. METODE CAMPURAN (MIXED)

Secara prinsip dasar metode campuran atau mixed ini tetap menggunakan pendapatan (berdasar tarif rumah sakit) sebagai sumber untuk melakukan pembagian jasa pelayanan yang artinya menggunakan metode fee for services dan bersifat tetap atau fixed. Namun jika pada metode fee for services tidak memperhatikan jumlah penerimaan jaminan dari pembayaran klaim BPJSK apakah lebih besar atau lebih tinggi, maka pada metode campuran ini tetap memperhatikan besar penerimaan jaminan tersebut.  Artinya bahwa harus dilakukan penghitungan terhadap besaran nilai SELISIH JAMINAN dari total pendapatan rumah sakit dan total penerimaan rumah sakit. Sekali lagi kita menekankan pada kata kunci TOTAL atau SELURUH (BRUTO) dan BUKAN pada per pasien. Nah menghitung selisih jaminan tersebut harus menggunakan metode konversi, makanya metode ini disebut dengan metode campuran atau mixed.

Untuk apa menghitung selisih jaminan ? Yaitu untuk menghitung jika terdapat SELISIH JAMINAN POSITIF (nilai jaminan lebih besar dari pada pendapatan), maka jumlah selisih jaminan tersebut khususnya untuk KOMPONEN JASA PELAYANAN akan dilakukan distribusi lagi kepada para pemberi layanan langsung (dokter) sebagai JASA PELAYANAN TAMBAHAN setelah dikurangi proporsi untuk jasa sarana berdasarkan ketentuan yang berlaku di rumah sakit tersebut. Jasa Pelayanan Tambahan tersebut diserahkan kepada Komite Profesi (Komite Medik) atau tim yang dibentuk oleh Komite Medik tersebut dengan mekanisme yang diatur dan disepakati secara internal oleh para dokter tersebut.

Pemberian jasa pelayanan tambahan ini dilakukan setelah pembagian jasa pelayanan utama (fee for services) karena tentu memerlukan waktu untuk menghitung selisih jaminan tersebut. Jika biasanya di sebuah RS pembagian jasa pelayanan utama pada tanggal 15 atau tanggal 20 tiap bulan nya, maka pembagian jasa pelayanan tambahan bisa dilakukan pada akhir bulan (tanggal 30 atau 31).

Andaikan terdapat kesepakatan di seluruh pegawai rumah sakit, bahwa selisih jaminan positif tersebut khususnya pada komponen jasa pelayanan TIDAK dibagikan menjadi jasa pelayanan tambahan namun akan dikumpulkan setiap bulannya dan akan dibagikan pada akhir tahun sebagai Bonus Akhir Tahun atau Jasa Produksi (meminjam istilah perusahaan swasta atau BUMN) dan sebagian dipergunakan untuk biaya kesejahteraan pegawai seperti family gathering, piknik dan sebagainya sehingga bisa dirasakan manfaatnya oleh seluruh pegawai. Termasuk juga jika ada sistem reward bagi pegawai terbaik tiap bulan bisa diambilkan dari alokasi dana ini.

Bagi para dokter, adanya peluang mendapatkan jasa pelayanan tambahan yang bersumber dari selisih jaminan positif tersebut akan secara tidak langsung memotivasi mereka melakukan efisiensi dan cost containment terhadap biaya layanan rumah sakit. Tanpa ada paksaan atau instruksi dari pimpinan rumah sakit, maka secara sadar dan sukarela para dokter akan melakukan penghematan penggunan obat-obatan, BHP dan utiliasi penunjang rumah sakit seperti pemeriksaan laboratorium dan radiologi menjadi sangat efisien yang dilakukan hanya berdasar pada indikasi medis. Mengapa mau dengan sukarela ? Ya…tentu saja karena para dokter sadar bahwa jika pelayanan mereka efektif maka akan menekan biaya rumah sakit sehingga terdapat selisih jaminan positif dan pada akhirnya akan mendapat manfaat yaitu memperoleh jasa pelayanan tambahan.

Metode ini akan menjawab pertanyaan dokter selama ini, jika para dokter dituntut oleh manajemen rumah sakit untuk menghemat obat dan BHP, untuk efisien dalam pemeriksaan laboratorium, radilogi dan lain sebagainya….sebetulnya manfaat atau benefit apa yang diterima oleh para dokter tersebut andaikan mereka mengikuti instruksi pimpinan rumah sakit tersebut ? Ternyata inilah jawabannya, bahwa ketika mereka efisien dan hemat tanpa meninggalkan SOP atau Protap Medis maka benefit langsung nya adalah akan mendapatkan jasa pelayanan tambahan selain jasa pelayanan utama.

Akan tercipta kondisi saling mengingatkan, para dokter spesialis akan mengingatkan para junior nya dokter jaga di IGD agar melakukan efisiensi utilisasi layanan rumah sakit. Budaya saling mengingatkan yang pada awalnya tercipta karena motivasi benefit tambahan maka akan secara tidak sadar akan menciptakan kendali biaya yang sangat efektif tanpa meninggalkan mutu layanan rumah sakit, artinya tercipta pelayanan standar (bukan sub standar) dengan tetap melakukan kendali biaya. Inilah mengapa metode mixed atau campuran ini dianggap metode paling ideal dan paling adil (fair).

Bagaimana jika terjadi selisih jaminan negatif ? Ya…itu menjadi resiko beban subsidi karena jasa pelayanan utama diberikan berdasarkan tarif rumah sakit. Namun, secara pribadi saya punya keyakinan bahwa potensi untuk terjadi selisih jaminan negatif akan dapat ditekan semaksimal mungkin karena bagaimanapun secara manusiawi tentu saja para dokter ingin mendapatkan jasa pelayanan tambahan diluar jasa pelayanan utama. Tuntutan situasi ini akan mendorong seluruh komponen di rumah sakit untuk bahu membahu mencegah terjadinya selisih jaminan negatif dan malah akan memiliki motivasi mehasilkan selisih jaminn positif dengan cara memperbaiki kualitas diagnosa, diagnosa tindakan, catatan medik, resume medik dan laporan operasi disamping terus berupaya menekan biaya rumah sakit dengan melakukan efisiensi penggunaan obat, BHP dan utilisasi pemeriksaan penunjang. Semua komponen rumah sakit memiliki tujuan yang sama yaitu akan secara sinergi berupaya semaksimal mungkin menciptaka selisih jaminan positif karena manfaat dari timbulnya selisih jaminan positif itu akan dirasakan secara bersama-sama.

Demikian tiga metode pembagian jasa pelayanan di RS pada era JKN ini. Semua metode ada sisi kelebihan dan kekurangannya. Jika dianggap metode ketiga adalah yang paling ideal dan adil, maka silahkan memilih metode itu. Terkait sisi kelebihan dan kekurangan metode fee for service dan metode konversi dapat dibaca pada tulisan saya terdahulu di “Remunerasi RS Pemerintah di Era JKN“.

Akhirul kata, pada akhir tulisan ini saya tetap berpendapat bahwa JKN ini tetap harus kita dukung, kita kawal dan kita kritisi secara cerdas dengan niat yang baik. Masih banyak sisi lemah dari program JKN ini, perihal yang terkait dengan tulisan ini tentu saja adalah persoalan besaran tarif CBGs yang masih belum ideal dan perlu dilakukan evaluasi juga revisi secepatnya. Saya tetap berharap bahwa perbaikan tarif CBGs bisa terlaksana bersamaan dengan naiknya versi CBGs (biasanya pada bulan April – Juni).

Banyak sekali kelemahan-kelemahan tarif CBGs sebagaimana yang sudah pernah saya sampaikan pada tulisan-tulisan terdahulu. Kelemahan tarif CBGs ini secara tidak disadari akan mendorong layanan yang tidak sesuai standar, mungkin kendali biaya tercapai namun kendali mutu tidak akan tercapai.

Ada persoalan yang juga harus mendesak dan harus secepatnya diselesaikan, yaitu terkait dengan obat-obatan dan BHP dengan terbitnya ketentuan baru tentang Fornas yang semakin banyak restriksi-restriksi nya. Persoalan obat dan BHP adalah lintas sektoral, tidak mungkin bisa diselesaikan oleh Kemenkes dan BPJSK saja namun ada sektor-sektor lain yang berperan dominan seperti LKPP terkait penetapan E-KATALOG yang sampai hari ini belum terbit E-KATALOG Tahun 2016 untuk obat-obatan dan BHP. InsyaAllah akan saya coba paparkan pada tulisan selanjutnya. Sekian.

Salam

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

 

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