Masalah JKN Dalam Debat Cawapres

Pertanyaan Panelis :

Masalah mendasar dalam Sistem Jaminan Nasional adalah Ketimpangan antara tuntutan kualitas layanan yang tinggi dan pembiayaan yang rendah. Apa kebijakan dan strategi yang akan dilakukan untuk mengatasi permasalah tersebut agar masayarakt mendapat pelayanan yang optimal ?

Jawaban dan Tanggapan Kyai Ma’ruf Amin (KMA) :

  1. Pemerintah telah melakukan langkah-langkah besar dalam rangka memberikan pelayanan kesehatan dengan memberikan harga yang murah.
  2. Akan melakukan Maximize Utility, memaksimalkan manfaat, memperbesar, menyempurnakan dan menambah dengan cara mendirikan pusat pusat kesehatan yang dapat dijangkau masyarakat dengan layanan lebih baik, Dokter yang siap dan redistribusi tenaga medis serta penyediaan obat yang cukup.
  3. Mendorong upaya preventif dan preventif melalui GERMAS, PISPK dan tidak mengkonsumi makanan yang kurang sehat, KIA dan mencegah stunting sehingga jumlah orang sakit makin berkurang.

Jawaban dan Tanggapan Sandiaga Salahuddin Uno (SSA) :

  1. JKN akan diteruskan, BPJS akan disempurnakan dengan pembenahan dan jangan saling menyalahkan, JKN BPJS Akan lebih baik karena akar masalahnya diketahui, dalam 200 hari pertama dicari akar permasalahan, hitung jumlahnya berapa yang dibutuhkan.
    b. Memanggil aktuaria-aktuaria terbaik dari Hongkong, putera puteri terbaik bangsa untuk menghitung betul-betul jumlahnya berapa dibutuhkan, untuk pelayanan prima negara tidak boleh absen dan tidak boleh pelit.
  2. Memberikan layanan prima, obat tersedia, tenaga medis harus dibayar tepat waktu tidak boleh dihutangi, rumah sakit-rumah sakit jangan sampai layanana turun karena tidak dibayar tepat waktu dan membenahi sistem rujukan.
  3. Kebiajakan Preventif dan promotif : gerakan 22 menit tiap hari berolah raga, Posyandu ditambah anggaran dan kesejahteraan dan Gizi anak-anak akan lebih baik dengan diberikan susu atau tablet susu juga kacang hijau sehingga masalah stunting dapat diturunkan

Secara objektif kita harus mengakui bahwa tingkat kesesuaian jawaban dengan masalah yang menjadi pokok pertanyaan, maka jawaban dan tanggapan Pak Sandiaga Salahuddin Uno (SSA) lebih nyambung dibandingkan dengan Kyai Ma’ruf Amin (KMA) meskipun tetap perlu pendalaman dan penajaman lebih lanjut.

Permasalahan ketimpangan antara tuntutan layanan yang bermutu dengan ketersediaan dana itu adalah nyata dan dihadapai saat ini. Kita anggaplah ini adalah sebuah penyakit atau diagnosa kerja yang biasa disimpulkan oleh para dokter setelah melakukan serangkaian pemeriksaan kepada pasien. Terdapat Diagnosa Kerja (Dx) yaitu Ketimpangan antara tuntutan layanan bermutu dengan ketersediaan dana.

Maka tugas pertama seorang dokter adalah mencari diagnosa pasti atau diagnosa utama terhadap diagnosa kerja tersebut sembari memberikan terapi-terapi simptomatik guna mengurangi penderitaan, kesakitan, mencegah kecacatan dan kematian.

Pencarian diagnosa pasti, tentu dengan tujuan mencari akar permasalahan atau causa nya sehingga dengan diketahui causa nya maka terapi yang diberikan akan lebih tepat sasaran. Jadi statemen SSA bahwa persoalan JKN akan lebih mudah diselesaikan jika kita mengetahui akar permasalahan sangat tepat.

Persoalan ketidakcukupan dana pada program JKN yang dikelola oleh BPJS Kesehatan sesungguhnya adalah masalah superfisial yang menjadi diagnosa kerja sehingga perlu dicarikan diagnosa pasti yang akan menunjukkan faktor penyebabnya.

Memanggil aktuaria terbaik adalah dalam rangka penghitungan kebutuhan dana yang diperlukan secara lebih tepat (presisi), namun ini sifatnya baru sekedar simptomatik. Ada persoalan causatif yang harus dicari dan segera diberika penatalaksanaan atau terapinya.

Mencari akar persoalan dari sebuah sistem penjaminan yang sangat besar dengan jumlah peserta terbanyak dan terbesar di dunia, yang sudah berjalan hampir 5 tahun dengan saut sengkarut masalah seperti benang kusut tentu memerlukan kehati-hatian, ketelitian dan kerja keras sehingga waktu 200 (dua ratus) hari adalah sangat realistis.

Sebagian orang mencibir kalau 200 hari itu hampir 1 tahun (365 hari) hanya untuk mencari akar permasalahan, iya benar. Namun jika semakin mendalami dan memasuki permasalahan program JKN, sebuah program penjaminan terbesar sedunia maka mereka akan paham mengapa target waktu tersebut cukup realistis.

IRONISME DEFISIT

Jika kembali pada sejarah pada tahun 2014 lalu, sesungguhnya program JKN ini merupakan penggabungan dari 3 (tiga) program asuransi yaitu : 

  1. ASKES yang terdiri dari ASKES SOSIAL bagi PNS/TNI/POLRI dan ASKES KOMERSIAL bagi pegawai swasta yang mendaftar.
  2. JAMKESMAS (sebelumnya ASKESKIN) bagi masyarakat miskin dan tidak mampu yang terdaftar dan iurannya dibayar oleh negara melalui APBN.
  3. JPK atau Jaminan Pemeliharaan Kesehatan yang dikelolah oleh PT. JAMSOSTEK bagi pekerja swasta yang mendaftar secara paket bersama dengan Jaminan Kecelakaan Kerja (JKK) melalui program ASTEK (Asuransi Tenaga Kerja).

Ketiga program penjaminan tersebut lalu dilebur menjadi satu program dan ditambah dengan peserta mandiri yang sebelumnya tidak memiliki ketiga program penjaminan diatas menjadi program Jaminan Kesehatan Nasional (JKN) dengan pengelolanya adalah BPJS Kesehatan.

Namun, meskipun terjadi peleburan dan penambahan menjadi satu program, pada kenyataannya berdasarkan pembiayaan iuran, maka terdapat 3 (tiga) segmentasi peserta JKN, yaitu :

  1. Peserta Penerima Upah (PPU) yang terdiri dari PPU Pemerintah (dari peserta ASKES Sosial) dan PPU Swasta (dari peserta ASKES KOMERSIAL ditambah peserta JPK JAMSOSTEK).
  2. Peserta Penerima Bantuan Iuran (PBI) yang sebelumnya adalah JAMKESMAS dan sekarang diperluas menjadi PBI Negara dan PBI Daerah.
  3. Peserta Mandiri atau Peserta Bukan Penerima Upah (PBPU) adalah masyarakat umum yang mendaftarn secara sukarela dan membayar iuran secara mandiri.

Tulisan guru saya Prof. dr. Laksono Trisnantoro, MSc., PhD dari PMPK FK UGM Yogyakarta di harian Kompas pada 31 Oktober 2018 lalu telah membuka tabir salah satu persoalan mendasar JKN yang saya pribadi menyebutnya dengan “Ironisme Defisit”.

Apa itu Ironisme Defisit ?

Berdasarkan tulisan beliau, bahwasanya terdapat situasi dimana peserta JKN Segmen Ke-3 (Mandiri atau PBPU) MENIKMATI iuran yang dibayarkan oleh Negara bagi peserta PBI dan PPU Pemerintah dan juga menikmati iuran yang dibayarkan oleh Badan Usaha (BU) bagi peserta PPU Swasta.

Lho… kok bisa ?

Tahukah kita semua bahwasanya data dari Kementerian Keuangan menyebutkan dana yang terkumpul dari iuran negara untuk peserta JKN segmen PBI masih TERSISA ? Angkanya pun cukup mencengangkan, sampai dengan tahun 2017 (sejak tahun 2014), jumlah dana “nganggur” dari segmen peserta PBI adalah sebesar 23,3 T.

Tahukah kita semua Wakil Menteri Keuangan menyampaikan data bahwa dana yang terkumpul dari iuran peserta JKN segmen PPU (Baik PPU Pemerintah maupun PPU Swasta) juga masih TERSISA ? Angkanya juga cukup membuat kaget, yaitu sampai dengan tahun 2017 (sejak tahun 2014), jumlah dana “tidak terpakai” dari segmen peserta PPU Pemerintah dan PPU Swasta adalah sebesar 12,1 T.

Lha kalau masih ada dana “idle” sekitar 35,4 T lalu mengapa BPJS Kesehatan malah defisit ? 
Inilah masalah utamanya, ternyata pada segmen peserta Mandiri atau PBPU mengalami defisit sampai tahun 2017 adalah sebesar 47,3 T.

Sejalan dengan data dari Kementerian Keuangan diatas, terdapat data terkait Rasio Klaim dari BPJS Kesehatan yang memberikan data bahwa Rasio Klaim segmen peserta PBI ternyata DIBAWAH 80 %, begitupula segmen peserta PPU juga masih dibawah 100 %. Namun, Rasio Klaim peserta Mandiri atau PBPU MENCAPAI 1300 % !!! Inilah problemnya.

Artinya bahwa terjadi subsidi silang dana yang dibayarkan oleh APBN, APBD dan dari Badan Usaha (BU) untuk membiaya masyarakat umum peserta mandiri.

Ironisme adalah ketika ada fakta bahwa dana yang terkumpul untuk membiayai peserta PBI yang nota bene adalah masyarakat tidak mampu ternyata malah terpakai sebagian untuk membiaya peserta Mandiri atau PBPU yang relatif lebih mampu. DISITULAH LETAK IRONINYA.

Itulah mengapa Prof. Laksono mengatakan bahwa keputusan pemerintah TIDAK menaikkan iuran PBI adalah sudah tepat, karena ketika ditambah pos pembiayaan JKN dari APBN ternyata yang menikmati malah masyarakat yang relatif lebih mampu dan ini tidak sesuai dengan UU Nomor 40 Tahun 2004 tentang SJSN Pasal 14 yang menyatakan bahwa Penerima Bantuan Iuran (PBI) adalah fakir miskin dan orang tidak mampu.

Jika dianggap bahwa hal ini terjadi karena pendataan jumlah dan penerima PBI yang masih kacau, itu hal yang berbeda karena harus diseselaikan oleh sektor lain yang menjadi tugas pokok dan fungsinya sebagai lembaga penyedia data.

Meskipun, pada akhirnya pemerintah harus merogoh kocek APBN dengan mekanisme menutup defisit pada akhir tahun 2018 lalu karena adanya resiko BPJS mengalami gagal bayar kepada sejumlah Rumah Sakit (RS) sehingga RS terancam kolaps dan tidak mampu lagi memberikan pelayanan kepada masyarakat peserta program JKN juga mengancam kualitas pelayanan RS. Tentu saja ini juga merupakan isu kesehatan yang sangat tidak populis serta merugikan secara elektoral.

Mengapa hal itu bisa terjadi ? Banyak faktor, salah satunya adalah tidak adanya seleksi peserta mandiri terhadap kemungkinan adanya “Adverse Selection”. Artinya, peserta yang mendaftar hanyalah yang sudah memiliki resiko tinggi terhadap kesehatan sehingga pasti akan membutuhkan biaya yang lebih tinggi ketika sakit.

Ingatkah dulu ketika kita sering ditawari asuransi swasta komersial ? Selalu khan kita diminta data usia, Berat Badan, Tinggi Badan dan riwayat penyakit yang pernah diderita sampai pada riwayat pernah atau tidaknya dirawat inap. Itu semua dilakukan oleh mereka dalam rangka melakukan seleksi dan meminimalkan resiko “Adverse Selection”.

Program JKN tidak melakukan itu semua, karena memang sejak awal dirancang sebagai Asuransi Sosial dan BUKAN sebagai Asuransi Komersial dengan tujuan menjangkau seluruh rakyat Indonesia melaluai Penjaminan Kesehatan Semesta atau Universal Health Coverage (UHC).

JKN dirancang sebagai program penjaminan sosial dan bukan penjaminan komersial adalah benar ketika tidak adanya segmen peserta mandiri (PBPU). Nyatanya, secara praktis di lapangan dengan adanya segmen peserta mandiri (PBPU) dan adanya fakta subsidi silang pembiayaan ke PBPU maka sesungguhnya praktik pendekatan penjaminan komersial itu terjadi.

Persoalan ketidakpatuhan pembayaran iuran, serta mendaftar ketika sudah sakit atau menjelang sakit dengan resiko biaya yang tinggi menjadi persoalan lainnya disamping masalah paket manfaat kesehatan yang luas dan “unlimited services“ yang memicu tingginya ekspektasi atau harapan terhadap kualitas pelayanan seperti pertanyaan panelis kepada kedua Cawapres.

MULTI SKEMA BERDASAR SEGMENTASI

Berdasarkan paparan diatas, sudah semakin jelas khan ya bahwasanya persoalan JKN itu tidak sesederhana atau simple yang terlihat di permukaan. Ada banyak faktor, banyak sektor dan memerlukan banyak kebijakan serta strategi yang harus terlibat dan harus dilakukan. Semua itu ibaratnya adalah obat atau antibiotik terhadap diagnosa penyakit yang sudah pasti, bukanlah sekedar diagnosa kerja saja yang cukup memberikan terapi simptomatik sementara belaka.

Dalam rangka mencari akar masalah yang akan menjadi diagnosa pasti, tentu memerlukan waktu, ketelitian dan kehati-hatian jangan sampai salah mendiagnosa yang menyebabkan salah terapi.

Jika melihat kedalam bahwa ternyata terdapat segmentasi peserta berdasarkan sumber pembiayaan iuran yang pada tataran praktikal akhirnya BPJS Kesehatan menggunakan pendekatan penjaminan komersial (saya setuju dengan Prof. Laksono), maka sudah saatnya memikirkan kemungkinan perubahan skema penjaminan yang bersifat multiple.

Dalam draft rencana proposal riset Disertasi saya (insyaAllah, mudah-mudahan dapat disetujui dan diterima) adalah terkait Pengembangan Sistem Penjaminan JKN yang Ideal, Adil (Fair) dan Menjamin Keberlangsungan (Sustainable). Topik ini membuka ruang diskusi, riset dan analisa secara mendalam, detail dan komprehensif terhadap masalah sistem penjaminan JKN saat ini dan juga memberikan pilihan solusi ke depan dalam rangka membangun Sistem Penjaminan yang Ideal, Adil (sesuai dengan proporsioanlitasnya) dan Menjamin Keberlangsungan atau Sustainabel terkait ketersediaan dananya.

Salah satu pokok pemikirannya adalah membuka kemungkinan adanya model sistem penjaminan yang saya sebut dengan “Multi Scheme Health Insurance” atau Penjaminan Kesehatan Multi Skema berdasarkan segmentasi kepesertaan. Adanya perbedaan skema penjaminan berdasarkan segmen peserta, sehingga minimal terdapat 3 skema penjaminan yaitu Skema Penjaminan PPU, Skema Penjaminan PBI dan Skema Penjaminan PBPU. Setiap skema dikelola dan dijalankan oleh Divisi atau Departemen tersendiri dari mulai hulu sampai hilir. Sehingga sangat mungkin juga akan adanya reformasi atau restrukturisasi badan penyelenggaranya yaitu BPJS Kesehatan.

Sistem kelembagaan BPJS Kesehatan perlu diwacanakan untuk dievaluasi karena setiap skema harus dikelola dari hulu sampai hilir dari mulai aspek kepesertaan, mekanisme pembiayaan (iuran), pelayanan kesehatan sampai pada pembayaran klaim ke fasilitas kesehatan. Divisi perluasan kepesertaan dan divisi jaminan pelayanan kesehatan (Pelayanan Primer dan Pelayanan Rujukan) seperti yang ada saat ini harus ada di setiap skema.

Pada rekruitmen dan perluasan kepesertaan harus dipikirkan penjaringan “adverse selction” pada Skema JKN Mandiri (PBPU) sementara pada skema yang lain mungkin tidak diperlukan. Adanya pembatasan paket manfaat layanan mungkin juga perlu diterapkan pada Skema JKN Mandiri (PBPU) ketika pada skema yang lain tidak diperlukan.

Tentu hal ini bisa menjadi sesuatu yang kontroversial, namun spirit akademis memang harus terus membuka ruang dan wacana untuk diskusi, riset dan analisis dalam rangka perubahan ke arah yang lebih baik.

Setidaknya, menurut pendapat pribadi saya hal ini lebih rasional ketimbang rencana memberlakukan iur biaya tambahan untuk kasus-kasus tertentu yang sampai saat ini Juknis nya pun belum ada.

Itulah sebagian kecil dari pokok-pokok pemikiran dan rencana riset saya terhadap pengembangan model penjaminan JKN yang ideal, yang adil dan yang menjamin keberlangsungan serta kecukupan dana BPJS Kesehatan sebagai “Cost Pooling”.

PENUTUP
Akhirnya, siapapun pemenang kontestasi presidan nanti, sangat diharapkan segera mengambil langkah-langkah pencarian diagnosa pasti dengan faktor penyebab (kausal) nya karena tentu memerlukan waktu sehingga penetapan target waktu pada awal periode pemerintahan dan durasinya menjadi sangat penting.

Dan setelah ketemu maka seharusnya segera mengobatinya dengan terapi yang tepat sesuai dengan faktor penyebab pada diagnosa pasti. Mudah-mudahan terbangun sebuah sistem penjaminan yang ideal, yang berkeadilan dan yang menjamin keberlangsungan pembiayaan bagi seluruh rakyat Indonesia.

Tetap memberikan apresiasi, menaruh hormat dan takzim kepada Bapak KMA, beliau orang terhormat, ulama, sesepuh dan guru bangsa. Namun mohon maaf dengan sangat Pak Kyai, khusus untuk pertanyaan masalah kesehatan, saya melihat Pak SSA lebih mampu memaparkan rencana kedepan menjawab persoalan JKN saat ini. Meski masih relatif superfisial dan perlu penajaman serta pendalam lebih lanjut.

Saya tidak akan komentar segmen dan topik debat yang lain, karena saya merasa awam dalam hal-hal tersebut. Yang saya bahas adalah sedikit bidang kesehatan yang kebetulan saya berkecimpung dan aktif menjadi praktisi di dunia kesehatan. Saya khawatir ketika saya membahas tentang INFRASTRUKTUR LANGIT adalah PALAPA RING yang ternyata menurut para ahlinya bahwa Palapa Ring adalah jaringan serat optik yang menghubungkan antar pulau dan dibangun melalui jaringan kabel submarine dibawah laut dan daratan yang berbentuk cincin, makanya disebut ring.

Terlepas dari semua hal diatas, secara umum saya melihat ada harapan besar bangsa Indonesia ke depan. Minimal dengan kemunculan tokoh-tokoh dan pemimpin-pemimpin muda yang santun, cerdas, religius, optimis dan berkomitmen tinggi merawat republik ini. Andaikata… misalkan… Qadarullah…. ternyata Pak SSA belum ditakdirkan Allah menjadi salah satu pemimpin Republik Indonesia pada tahun ini, namun setidaknya dalam 5 tahun ke depan kita memiliki beberapa pemimpin muda yang kharismatik, santun, religius dan cerdas (juga “good looking” selera emak-emak) seperti Pak Anies Baswedan, Pak Sandiaga Salahuddin Uno dan Mas Agus Harimurti Yudhoyono (AHY) yang akan membawa Indonesia menjadi negara maju dan disegani dunia. Tetap jaga optimisme untuk Indonesia. Aamiin YRA.

Wasallam.

Tri Muhammad Hani

(Kerja di Rumah Sakit Pemerintah)

Komentar

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