Perhitungan Biaya

Kapitasi

14 February 2007

DR.Ronnie Rivany, Drg, MSc

Pusat Kajian Kebijakan dan Ekonomi Kesehatan
FKMUI
2007

TOPIK DISKUSI
BIAYA &

ANALISIS BIAYA
UNIT COST
UTILIZATION REVIEW
PERHITUNGAN BIAYA KAPITASI
PENETAPAN PREMI

Konsep Biaya &

Analisis Biaya

Ronnie Rivany
Pusat Kajian Kebijakan dan Ekonomi Kesehatan
FKMUI
2006

KONSEP BIAYA & ANALISIS BIAYA

DUPLIKASI

dengan sesi sesi y.a.d

APLIKASI UNIT COST

Tarif
Premi
CLINICAL PATHWAY
Diagnostic Related Groups & CASEMIX
KONSEP Badan Layanan Umum

Bab IV Pasal 8 . Standar Pelayanan Minimum

Bab IV Pasal 9 . Perhitungan biaya per unit layanan

DITERMINAN TARIF per TINDAKAN

TARIF
margin

UNIT COST

Total cost

ATP/WTP

quantity

ANALISIS
BIAYA

CRR

PESAING

Distinguishing Characteristic of
Health Care Evaluation
2

Scope of Examination: Both Cost and Consequences

o
r

NO

r
e

1A PARTIAL EVALUATION 1B

N Examine only
Consequences
m
O
o
Outcome
Description

YES

Examine only
Costs
2

PARTIAL EVALUATION

Cost
Description

A
l
3A PARTIAL EVALUATION 3B
t
e
r Y Efficacy or
Cost
n E Effectiveness
Analysis
a
Evaluation
t S
i
v
e
s

FULL ECONOMIC
EVALUATION
Cost-Minimization Analysis
Cost-Effectiveness Analysis
Cost-Utility Analysis
Cost-Benefit Analysis

KONSEP BIAYA & ANALISIS BIAYA

DUPLIKASI
Contoh

dengan sesi sesi y.a.d

Analisis Biaya di RSUD 45 Kuningan

Jawa Barat tahun 2001, untuk menghitung Unit
Cost dengan mempergunakan metode Double
Distribution

Principle Characteristics of
Provider Payments Systems
(Normand & Weber, 1999)
Payment
System

Definition of basis for payment (unit)

Fee for services

Single act or product

Case payment

Single case diagnosis (DRGs &

Casemix)

Daily charge

Patient day

Bonus payment

For specific act (e.g. immunization)

Flat rate

For approved investments

Capitation fee

All services for one person in one

period

Salary

Period of work (one month)

Budget

All services for health fund members in one

period

WHAT (1)

CAPITATION (Normand &

Weber,1999)
KEPALA = CAPUT (?)
BIAYA PER KEPALA = CAPITATION
FEE

A CAPITATION FEE COVERS SERVICES

FOR ONE HEALTH FUND MEMBER OVER
A CERTAIN PERIOD (NORMALLY ONE
YEAR)
CAPITATION FEE ARE SUITABLE AS A
PAYMENT MECHANISM FOR PRIMARY
OR AND SECONDARY CARE
THE CAPITATION FEE IS BASED ON THE
POOLING OF RISK OF THE POPULATION

WHAT (2)

CAPITATION COVERAGE
OUT

PATIENT
IN PATIENT
SUPPORTING SERVICES
DRUGS & SUPPLIES
COSMETIC (?)
EXTRA ORDINARY
CANCER
HIV/AIDS
Morale hazards (?)

WHO

MEMBER OF THE
POPULATION
DEMOGRAPHIC by
SEX
AGE
MARITAL STATUS
FAMILY STATUS
EMPLOYMENT

STATUS
BENEFIT PACKAGE

WHERE

LOCAL
INDUSTRY

HEALTH
EDUCATION

REGIONAL
NATIONAL
GLOBAL

CAPTIVE MARKET

WHEN

POPULATION AT RISK
EPIDEMIOLOGICAL
TRANSITION
HEALTH CARE COST
INFLATION
COST

OF DRUGS & SUPPLIES

COST OF TECHNOLOGY

Including NON MEDICAL

COMPONENT
Including TERTIARY CARE

HOW (1)

KEY WORDS
POPULATION
LAW OF LARGE NUMBER
POOLING RISK
BI PARTIT vs TRI PARTIT
UTILIZATION ~ PROBABILITY
(ACTUAL vs ALLOWED RISK)
UNIT COST
LOADING FACTOR
PREMIUM

HOW (2)
THEORY

PROBABILITY RATE
= UTILIZATION
NO OF POPULATION

CAPITATION
= UNIT COST X PROB. RATE

HOW (3)
Probability Rate & Capitation
Demographic
By Sex
By Age
By Marital status
By Employ status

Utilization Unit cost Capitation

(1)
(2)
(2 X 3)

HOW (4)
APLIKASI PT ASKES.1
Perhitungan Premi
1.

2.

Biaya Pelayanan Kesehatan

(70 80 %)
Biaya Loading (20 30 %)
Cadangan ( 5 %)
Biaya operasi (5 10 %)
Profit (10 15%)

HOW (5)
APLIKASI PT ASKES.2
Biaya Pelayanan Kesehatan

Dihitung berdasarkan experience

(angka utilisasi & harga layanan
kesehatan rerata 2 tahun terakhir)
Pengelompokan layanan :

RJTP
RJTL
Rawat Inap
Khusus
Suplemen

Rumus : C = F x P

C = Biaya layanan setiap kompoonen

F = Angka utilisasi setiap komponen
P = Harga komponen layanan kesehatan

HOW (6)
APLIKASI PT ASKES.3
Contoh ( per member per month)

Angka utilisasi (per 1000 peserta per

bulan)

RJTP = 250/1000

RJTL = 25/1000

RI
= 5/1000

Layanan khusus = 5/1000

Layanan suplemen = 5/1000

Biaya per kasus

RJTP = Rp 20.000
RJTL = Rp 300.000
RI = Rp 2.000.000 (kls II)
Layanan Khusus = Rp 250.000
Layanan suplemen = Rp 1.000.000

HOW (7)
APLIKASI PT ASKES.4
Komponen
layanan

Prevalensi

Harga per
kasus (Rp)

Biaya (Rp)

RJTP

250/1000

20.000

5.000

RJTL

25/1000

300.000

7.500

RI

5/1000

4.000.000

20.000

Khusus

5/1000

2.000.000

10.000

Suplemen 5/1000

1.000.000

5.000

Total
(80%)

47.500

Premi
(100%)

59.375

Loading
(20%)

12.500

HOW (8) APLIKASI RS.1

Unit Cost Review

Review CRR dan Tarif

Average Cost

Utilisation Review

Internal Customer
Review

Penghitungan
Nilai Kapitasi

Analisis utilisasi
per jenis layanan

Unit cost / Average cost

Per Pasien

Kecenderungan utilisasi

Batasan Layanan
(Ekslusi - Inklusi)

Analisis Populasi
Scr Internal
Demografi Target

Analisis
Probabilitas
Riil / allowed risk

Kapitasi

HOW (9) APLIKASI RS.2

COST STRUCTURE
Jenis
TC %
layanan

VC

FC

% OP

UC

Poli

homo

Act/
norm

OK

Hetero/
RVU

Act/
norm

Lab

Hetero/
RVU

Act/
norm

Total

100

HOW (10) APLIKASI RS.3

Cost Recovery Rate
Jenis
layanan

TC
+ dep

Poli.1

10.000 20 500 650

(650x20) / (500x20)=
130,00

Poli.2

15.000 25 600 350

(350x25) / (15.000)=
58,33

OK
Lab

O
P

UC

Tarif

CRR
(TR/TC x 100%)

HOW (11) APLIKASI RS.4

Kapitasi + LF 40 % + Actual Prob
Jenis Layanan

Unit Cost

Actual Prob

Kapitasi

Rajal.1

6.000

0,0002

1,2

Penunjang
Medis.1

250.000

0,02

5.000

Ranap.1

150.000

0,006

900

Sub total
Loading factor

5.901,2
0,40

2.360,4

Premi per
orang

8.261,6

Faktor
keluarga 4 org

33.046,4
35.000

HOW (12) APLIKASI RS.5

Kapitasi + LF 40 % + Allowed
Risk
Jenis Layanan Unit Cost
Allowed
Kapitasi
Risk

Rajal.1

6.000

0,0002

1,8

Penunjang
Medis.1

250.000

0,02

7.500

Ranap.1

150.000

0,006

1.050

Sub total
Loading factor

8.551,8
0,40

3.420,7

Premi per
orang

11.972,5

Faktor
keluarga 4 org

47.890
50.000

DISKUSI (1)
DITERMINAN TEKNIS

SERUPA TAPI TAK SAMA

(Konsep sama, teknis beda)
EXPERIENCE

vs EVIDENCE
ACTUAL vs ALLOWED RISK
PROBABILITY
BIAYA LAYANAN / TARIF (?) vs
UNIT COST
GENERIC vs SPECIFIC
DEMOGRAPHIC / POPULATION

DISKUSI (2)
DITERMINAN
DEMAND for HEALTH INSURANCE
(Rivany,1988)

UTILITY
PROBABILITY OF LOSS
MAGNITUDE OF LOSS
INCOME
PREMIUM
SERVICES

DISKUSI (3)
DITERMINAN UNIT COST

METODE
SIMPLE DISTRIBUTION
STEP-DOWN DISTRIBUTION
DOUBLE DISTRIBUTION
MULTIPLE DISTRIBUTION
ACTIVITY BASED COSTING

ACTUAL vs NORMATIVE
HOMOGEN vs HETEROGEN
OUTPUT (RELATIVE VALUE UNIT)

DISKUSI (4)
DITERMINAN PREMIUM

UNIT COST
PRICE
COST RECOVERY RATE
(CRR)
CAPITATION
PROBABILITY RATE (ACTUAL
vs ALLOWED RISK)
POLICY
LOADING FACTOR
ATP / WTP (?)

DISKUSI (5)
DRG & CASEMIX, the answer

International Classification Disease

IX
X
Major Diagnostic Classification
Diagnostic Related Group
AN-DRGs, 3rd version, 1996
23 MDCs, 956 DRGs
4th version, 1999/2000

CASEMIX
CLINICAL PATHWAY
INA DRGs (?)
PPE Depkes

HEALTH vs ECONOMICS

INDONESIAN DRGs

Pengembangan Konsep Clinical Pathway

International Classification of Disease (ICD)
Major Diagnostic Categories (MDC)
Clinical
Pathway

Surgical / Other / Medical

Diagnosis Related Groups (DRGs)
Casemix

Major Diagnostic Categories

1

Diseases and disorders of the nervous system

Disease and disorders of the eye

Disease and disorders of the ear, nose, and throat

Disease and disorders of the respiratory system

Disease and disorders of the circulatory system

Disease and disorders of the digestive system

Disease and disorders of the hepatobiliiary system and pancreas

Disease and disorders of the musculoskeletal system and connective tissue

Disease and disorders of the skin, subcutaneous tissue, and breast

10

Endocrine, nutritional, and metabolic diseases and disorders

11

Disease and disorders of the kidney and the urinary tract

12

Disease and disorders of the male reproductive

13

Disease and disorders of the female reproductive system

14

Pregnancy, childbirth, and the purperium

15

Newborn and other neonates with conditions originating in the perinatal period

16

Disease and disorders of blood and blood forming organs and immunological disorders

17

Myeloproliferative disease and disorder, and poorly differentiated neoplasm

18

Infectious and parasitic disease (systemic or unspecified sites)

19

Mental diseases and disorders

20

Alcohol/drug use and alcohol/drug- induced organic mental disorders

21

Injuries, poisoning, and toxic effects of drugs

22

Burns

23

Factors influencing health status and other contact with health services

POLA PIKIR INDONESIAN DRGs (1)

INA - DRG
1.Konfirmasi DRG

2.Hitung Cost/DRG

Clinical Pathway & Casemix

Activity Based Costing

POLA PIKIR INDONESIAN DRGs (2)

ICD
MDC

1
DRG

DRG
COST

DRG
CASEMIX

TARIF

COST
TARIF

Clinical Pathway

Clinical pathway adalah suatu konsep

perencanaan pelayanan terpadu yang
merangkum setiap langkah yang
diberikan kepada pasien mulai masuk
sampai keluar rumah sakit
berdasarkan standar pelayanan
medis, standar asuhan keperawatan,
dan standar pelayanan tenaga
kesehatan lainnya, yang berbasis
bukti dengan hasil yang dapat diukur
dan dalam jangka tertentu selama di
rumah sakit.

Bab IV. Pasal 8

Standar Pelayanan Minimum (?????)
Definisi

Operasional

SPM diusulkan denan mempertimbangkan kualitas

layanan, pemerataan dan kesetaraan layanan, biaya
serta kemudahan untuk mendapatkan layanan
Specific, Measureable, Attainable, Reliable, Timely

PAKET PELAYANAN ESENSIAL (PPE) ???

CLINICAL PATHWAY

Tahapan Clinical Pathway & Activity

Based Costing

Admission

Diagnostic

Pra
Therapy

Therapy

Follow Up

Activities Based Costing + Simple Distribution

Discharge

Format dasar Clinical Pathway

Aktivitas
pelayanan

Pra R.I
(Poliklinik
/
UGD)

Hari I
Tgl

Hari 2
Tgl

Komplika
si/
Comorbidity

Pendaftaran
Penetapan Diagnose
Pra-Perawatan
Perawatan
Tindak Lanjut

Rawat Inap (R.I)

Bab IV. Pasal 9

Pola Tarif Layanan
Definisi

Operasional

Pola Tarif Layanan adalah imbalan atas barang/jasa

layanan yang diberikan / disesuaikan dengan jenis layanan
serta ditetapkan dalam bentuk tarif yang disusun atas
dasar perhitungan biaya per unit layanan atau hasil per
investasi dana, dengan mempertimbangkan kontinuitas
dan pengembangan layanan, daya beli masyarakat, asas
keadilan dan kepatutan serta kompetisi yang sehat

COST OF TREATMENT ( COST / DRG / CASEMIX)

DITERMINAN TARIF per TINDAKAN

TARIF
margin

UNIT COST

Total cost

ATP/WTP

quantity

ANALISIS
BIAYA

CRR

PESAING

DITERMINAN TARIF per DRGS

TARIF

Marjin
COST/DRGs
UNIT COST
TINDAKAN RI

Total cost

UNIT COST
UNIT COST
UNIT COST
TINDAKAN Obat TINDAKAN Lab TINDAKAN Alkes

UNIT COST
TINDAKAN OK

ACTIVITY BASED COSTING + SIMPLE DISTRIBUTION

Cost of Treatment (Cost/DRG/Casemix) &

Pola Tarif PK-BLU
No

Cost of Treatment / Activity Based

Costing

Pola Tarif PK-BLU

Admission

Biaya Admission

Diagnostic

Biaya Diagnostic

Pra Therapy

Biaya Pra Therapy

Therapy

Biaya Therapy

Follow Up

Biaya Follow Up

Discharge

Biaya Discharge

Total Biaya

Total Biaya per unit

layanan

Lesson Learnt (INA-DRGs 2000-2005)

Tahun

MDC

Diseases

DRG

Casemix

2000

MDC.14

Abortion

DRG.380

DRG.381

2001

MDC.01

Head Injury

DRG.2

2002

MDC.18

Malaria

DRG.423

2003

MDC.06

Appendicitis

DRG.165
DRG.166

2004

MDC.18

Typhoid fever

DRG.423

2005

MDC.14

Pregnancy

DRG.O01D

DRG.O01A
DRG.O01B
DRG.O01C

2005

MDC.06

Gastro Enteritis

DRG.G68B

DRG.G68A

DRG.164
DRG.167

Australian Refined
Diagnosis Related Group
Classification, Version 4.1

DRG

ALOS

INA DRGs
COST /

Public Sector

CITO
kls 3

Direct

Overhead

Total

O01A

9,14
11

5,444
3.710.590

2,089
98.622

7,533
3.809.212

O01B

6,13
6

3,998
3.205.076

1,550
98.622

5,548
3.303.698

O01C

5,00
6

3,792
3.067259

1,373
98.622

5,166
3.165.881

O01D

4,63
5

3,327
2.721526

1,262
98.622

4,589
2.820.148

Lesson Learnt (INA-DRGs 2006-2007)

Tahun

MDC

Diseases

DRG

Casemix

2006

MDC.1

Stroke

DRG.B.70C

DRG.B 70A
DRG.B70B
DRG.B70D

2006

MDC.

HIV / AIDS

DRG.

2006

MDC.

DBD

DRG.

2006/7

MDC.

Prostat

DRG.

DRG.

2006/7

MDC.

Mata

DRG.

DRG.

Aplikasi INA-DRG dalam Cost

of Treatment Stroke ( template )
MDC 1 dan DRG B70
Terdiri dari 4 kelompok
B70A:
Stroke dengan penyerta dan penyulit
B70B:
Stroke dengan penyerta atau
penyulit
B70C:
Stroke murni
B70D:
Stroke, meninggal atau dirujuk
dibawah 4 hari

MEDICAL PARTITION
yes
B 70A
patient
yes

Stroke

yes

Sev or
Compl
Dx or
proc

yes

No

LOS > 4 days

Or survived/
Not trasfered

B 70B

CC

No

B 70C

No

No

B 70D

KK WOMEN & Children Hospital

(Spore 2006)

Adopting Australian Version (667

codes)
Subsidy = Discount
Amount of charges (cost) to be
borne by Government
CLASS

A
B1
B2+
B2
C

0%
20 %
50 %
65 %
80 %

AMOUNT OF SUBSIDY

APLIKASI COST/DRG/Casemix dalam PK BLU(1)

INDONESIAN DRGs
KESIMPULAN

Pengembangan perhitungan Unit Cost per

Tindakan menjadi Unit Cost per Layanan /
Kinerja ( Cost per DRG/Casemix)

Pengembngan INA-DRG
ICD tetap
MDC untuk sementara tetap
Clinical Pathway bisa dibuat
DRG di konfirmasi + bisa dibuat
Casemix di konfirmasi + bisa dibuat
Costing dilakukan dengan pendekatan
Activity Based Costing + Simple
Distribution