Pengembangan Model Kebijakan Cost-Sharing Prescription Pembiayaan Jaminan Kesehatan Nasional Pada Penyakit Katastropik

Diesty Anita Nugraheni, Prof. Dr. apt. Satibi, S.Si., M.Si.; Prof. Dr. apt. Susi Ari Kristina, S.Farm., M.Kes.; Dr. apt. Diah Ayu Puspandari, MBA, Mkes.

2024 | Disertasi | S3 Ilmu Farmasi

Penyelenggaraan Jaminan Kesehatan Nasional (JKN) mengalami defisit pembiayaan dalam beberapa tahun terakhir ini. Pembiayaan kasus penyakit katastropik pada tahun 2018 sebesar 25?ri total biaya pelayanan kesehatan. Permasalahan ini memerlukan kebijakan cost-sharing yang tepat khususnya pada penyakit dengan pembiayaan terbesar. Tujuan penelitian adalah pengembangan model kebijakan cost-sharing prescrription pembiayaan jaminan kesehatan nasional pada penyakit katastropik.

Penelitian menggunakan metode mix method explanatory sequential design yang terdiri dari tiga tahap. Tahap I dan II menggunakan metode kuantitatif dengan rancangan cross-sectional. Penelitian dilakukan di tiga rumah sakit kelas A dan B (pemerintah dan swasta) provinsi DI Yogyakarta. Pengambilan data tahap I dengan teknik convenience sampling menggunakan kuesioner pada pasien penyakit katastropik (penyakit jantung, kanker dan stroke) peserta JKN sebanyak 1203 responden. Data dianalisis menggunakan regresi logistik. Penelitian tahap II, diambil data sekunder berupa biaya medis langsung penyakit jantung, kanker dan stroke sebanyak 52.591 kasus. Data dianalisis dengan perbandingan rata-rata secara deskriptif. Tahap III dilakukan penelitian kualitatif dengan rancangan case study untuk wawancara dan delphi. Pengambilan data dilakukan dengan teknik purposive sampling sebanyak 17 informan. Data dianalisis menggunakan concept map dan item cluster analysis serta analisis konsensus delphi.

Hasil penelitian menunjukkan rata-rata WTP rawat inap dan rawat jalan adalah 7,68±15,51?n 6,81±13,01%, yang dipengaruhi oleh jenis kelamin, jumlah keluarga, tempat perawatan, dan jenis penyakit. Biaya obat, alkes dan BMHP adalah komponen tinggi pada biaya medis layanan rawat inap dan jalan masing-masing antara 25%-34?n 60%-70%. Persepsi cost-sharing saat ini dibutuhkan karena biaya pengobatan sudah melebihi paket INA-CBGs, diharapkan berlaku untuk obat diluar formularium nasional disertai aturan legal. Kesimpulan penelitian adalah model cost-sharing pada penyakit katastropik dalam bentuk persentase copayment sebesar 10?ri total biaya obat, dengan pengecualian pada pasien penerima bantuan iuran, penerima obat life saving, dan di fasilitas kesehatan tingkat pertama. Obat diluar formularium nasional dapat dikenakan cost-sharing berdasarkan indikasi pasien dengan reimburstment.

The National Health Insurance program has encountered financing deficits in recent years. The catastrophic health spending in 2018 reached 25% of the total healthcare costs. This issue requires an appropriate cost-sharing policy, especially for diseases with the highest spending. The objective of this study was to develop a prescription drug cost-sharing policy model for catastrophic diseases under the national health insurance.

The research used a mix method explanatory sequential design which consists of three stages. Phases I and II used quantitative methods with a cross-sectional design. The research was conducted in three class A and B hospitals (government and private) in DI Yogyakarta province. Phase I data were collected using a convenience sampling technique using a questionnaire distributed to patients with catastrophic illnesses (heart disease, cancer, and stroke) who were JKN members, totaling 1203 respondents. The data were analyzed using logistic regression. In phase II research, secondary data were taken in the form of direct medical costs for 52,591 cases of heart disease, cancer, and stroke. The data were analyzed using descriptive average comparisons. In stage III, qualitative research was carried out with a case study design for interviews and Delphi. Data collection was carried out using a purposive sampling technique with 17 informants. The data were analyzed using concept maps and item cluster analysis as well as Delphi consensus analysis.

The results showed that the average WTP for inpatient and outpatient care was 7.68 ± 15.51% and 6.81 ± 13.01%, respectively, influenced by gender, family size, place of treatment, and type of disease. The costs of medicines, medical equipment, and BMHP are high components of the medical costs of inpatient and outpatient services, between 25%-34% and 60%-70%, respectively. The perception that cost-sharing is currently needed because treatment costs have exceeded the INA-CBGs package, is expected to apply to drugs outside the national formulary accompanied by legal regulations. The research concluded that a cost-sharing model for catastrophic illnesses in the form of a copayment percentage of 10% of the total drug costs. However, the prescription drug cost-sharing did not include recipients of premium subsidy (PBI), patients who received life-saving drugs, and patients at the primary healthcare.

Kata Kunci : cost-sharing, jaminan kesehatan nasional, katastropik, kebijakan publik, willingness to pay