IMPLEMENTASI KENDALI BIAYA DAN KENDALI MUTU PELAYANAN KESEHATAN PROGRAM JAMINAN KESEHATAN DAERAH KUTAI KARTANEGARA DI RSUD PARIKESIT TENGGARONG

CHRISTINA MARIA ADEN, Dr.drg.Julita Hendrartini M.Kes., AAK

2012 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar Belakang : Penyelenggaraan jaminan kesehatan di daerah dengan menggunakan prinsip asuransi sosial dikenal dengan sistem Jaminan Kesehatan Daerah (Jamkesda). Sebagai suatu organisasi bercirikan managed care maka kendali biaya dan kendali mutu merupakan hal yang utama. Pelaksanaan Jamkesda di Kabupaten Kutai Kartanegara menunjukkan adanya kecenderungan peningkatan porsi anggaran terbesar untuk rawat inap di RSUD Parikesit. Oleh karena itu perlu diadakan evaluasi terhadap kendali biaya dan kendali mutu pada layanan rawat inap bagi peserta Jamkesda di RSUD Parikesit. Metode : Jenis penelitian deskriptif dengan rancangan penelitian campuran. Data kuantitatif didukung oleh data kualitatif. Data kuantitatif berdasarkan utilization review. Data kualitatif didapat dari wawancara mendalam terhadap Direktur RSUD Parikesit, dokter dan pasien serta kajian terhadap isi kontrak kerjasama. Hasil : Cakupan rawat inap peserta Jamkesda di RSUD Parikesit sebesar 0,15% per bulan. Mekanisme rujukan dan verifikasi klaim belum berjalan dengan baik. Terjadi kecenderungan penyalahgunaan kartu kepesertaan. Terdapat kecenderungan pemborosan dalam bentuk peresepan berlebih (overprescribing) dan peresepan boros (extravagant prescribing). Tingkat kepuasan pasien 52%. Kendali biaya dan kendali mutu belum berjalan sesuai dengan isi kontrak. Kesimpulan : Sosialisasi paket manfaat dan mekanisme alur rujukan pelayanan kesehatan perlu dilakukan kepada peserta. Bapel perlu mempersiapkan tenaga verifikator dan melakukan pengawasan distribusi kartu kepesertaan. Rumah sakit perlu mengadakan perbaikan kualitas pelayanan melalui pembenahan infrastruktur rumah sakit dan meningkatkan kesesuaian obat dengan formularium dan penggunaan obat generik.

Background: Implementation of health coverage in the region by using the principle of social insurance system known as the Local Health Insurance (Jaminan Kesehatan Daerah-Jamkesda). As an organization characterized by the managed care, both cost containment and quality control are priority. Implementation in the Kutai Kartanegara regency showed a trend increase in the portion of the largest budget for inpatient services at Local Public Hospital (LPH) Parikesit. Therefore it is necessary to evaluate the cost containment and quality control of Jamkesda’s participants inpatient services at LPH Parikesit. Method : The study was descriptive research with a mixed method of study design. Quantitative data will be supported by qualitative data. Quantitative data based on utilization review. The qualitative data obtained from depth interviews with the Director of LPH Parikesit, doctors and patients and review the contents of the contract. Result : The inpatient services coverage of Jamkesda’s participants at LPH Parikesit was 0,15% per month. The referral system and claim verification process was not running optimally and the tendency misused of Jamkesda’s participant card. There has been a tendency of waste on Jamkesda’s participants inpatient service at LPH Parikesit in the form of excess prescription (overprescribing) and wasteful prescribing (extravagant prescribing). The patient satisfaction rate is 52% satisfied. Implementation of cost containment and quality control has not consistent with the contract. Conclusion : Need socialization benefits and referral system to Jamkesda’s participants and control the distribution of participant card. Bapel must prepare for Jamkesda’s verificator at Parikesit hospital and control the distribution of Jamkesda’s participant card. Hospital need to hold a service quality through physical facilities improvement and enchance drugs’ accordance with formulary and generic drugs.

Kata Kunci : Jamkesda, managed care, kendali biaya dan kendali mutu