PENERAPAN MANAGED CARE DALAM PROGRAM JAMINAN KESEHATAN SEPINTU SEDULANG KABUPATEN BANGKA PROVINSI KEPULAUAN BANGKA BELITUNG

Yochanan Indroyono, DR. Drg. Yulita Hendrartini M.Kes

2012 | Tesis | S2 Kesehatan Masyarakat/MAK

Latar belakang: Jaminan kesehatan di Kabupaten Bangka telah berjalan sejak tahun 2005 merupakan wujud komitmen Pemerintah Daerah dalam mengimplementasikan Undang-undang Sistem Jaminan Sosial Nasional (SJSN), tetapi selama ini belum pernah dilakukan evaluasi penerapannya, sehingga penelitian ini dianggap penting untuk dilakukan Tujuan: Untuk mengeksplorasi dan mengidentifikasi penerapan managed care dalam pelaksanaan jaminan kesehatan di Kabupaten Bangka. Metode Penelitian: Jenis penelitian deskriptif kualitatif dengan rancangan studi kasus. Subyek penelitian ; Bupati, Kepala Dinas Kesehatan, pengelola jaminan kesehatan dan Pemberi Pelayanan Kesehatan. Instrumen yang digunakan adalah pedoman wawancara, dokumen laporan dan petunjuk tehnis jaminan kesehatan di Kabupaten Bangka Hasil: Konsep managed care yang diterapkan jaminan kesehatan di Kabupaten Bangka adalah : melakukan kontrak kerjasama dengan PPK melalui mekanisme seleksi PPK / kredensialing dengan melakukan uji kelayakan dan penelusuran dokumen surat ijin praktek. Adapun sistem pembayaran yang diterapkan memakai pembayaran retrospektif dengan fee for service. Kajian utilisasi yang dilakukan melalui mekanisme kajian prospektif, kajian konkurens dan kajian retrospektif. Sedangkan pelayanan komprehensif yang dilakukan oleh provider lebih banyak berorientasi pada pelayanan kuratif dan implementasi risk profit sharing belum berjalan dengan semestinya Kesimpulan: Belum seluruh konsep managed care diterapkan oleh jaminan kesehatan di Kabupaten Bangka. Prinsip yang telah dilaksanakan adalah kerjasama kontrak dengan PPK melalui mekanisme seleksi PPK / kredensialing dan kajian utilisasi. Beberapa prinsip yang belum dilaksanakan adalah pola pembayaran prospektif dengan kapitasi, pelayanan komprehensif yang mengedepankan pelayanan promotif dan preventif serta implementasi risk profit sharing bagi provider dan peserta

Background: Health insurance at District of Bangka has started since 2005. It reflects commitment of local government in implementing National Social Insurance System Act (Sistem Jaminan Sosial Nasional/SSJN), but so far there is no evaluation on its implementation. Objective: To explore and identify the practice of managed care in the implementation of health insurance at District of Bangka. Method: The study was descriptive qualitative with case study design. Subject of the study consisted of the regent, head of health office, managers of health insurance and health service providers. Research instruments were interview guide, report and technical guideline of health insurance at District of Bangka. Result: The concept of managed care adopted in the implementation of health insurance at District of Bangka was building partnership contract with health service providers through selection mechanism/credentials by undertaking proper test and assessing documents of practice license. Payment system used retrospective method with fee for service. Utilization was assessed using prospective, concurrent, and retrospective mechanism. The comprehensive service offered by the provider was mostly oriented on curative aspect and the implementation of risk profit sharing had not been done accordingly. Conclusion: The concept of managed care had not been fully implemented in health insurance of District of Bangka. Method that had been implemented was establishing partnership contract with health service providers through the mechanism of selection/credentials and assessment on utilization. Some aspects that had not been implemented were prospective payment pattern through capitation, comprehensive service oriented on promotive and preventive aspect and the implementation of risk profit sharing for the provider and participants.

Kata Kunci : Jaminan Kesehatan Daerah, Managed care,