Analisis kemampuan dokter mengelola penyakit di layanan kesehatan primer dalam jaminan kesehatan nasional (studi di DIY)

ARAS UTAMI, dr. Mora Claramita, MPHE., PhD; Dr. Drg. Julita Hendrartini, M.Kes

2015 | Tesis | S2 Ilmu Kesehatan Masyarakat

INTISARI Latar Belakang: Dokter di layanan primer berperan sebagai gatekeeper untuk mengurangi biaya dengan membatasi rujukan ke pelayanan spesialis yang tidak tepat. Pembatasan rujukan antara lain dengan diberlakukannya 155 diagnosis penyakit yang harus dilayani di fasilitas kesehatan tingkat pertama (FKTP). Ada 13 kasus terbanyak dari 155 yang dirujuk ke rumah sakit berdasarkan hasil monitoring BPJS Kesehatan Jawa Tengah-DIY tahun 2014. Salah satu alasan rujukan ke rumah sakit dikaitkan dengan kompetensi dokter. Tujuan penelitian ini adalah mengidentifikasi persepsi dokter tentang kemampuan dokter dalam mengelola penyakit di FKTP BPJS Kesehatan cabang DIY; membandingkan kemampuan dokter praktik perorangan, klinik pratama, dan puskesmas; dan menjelaskan faktor-faktor yang mempengaruhi dokter merujuk penyakit tersebut. Metode: Penelitian ini merupakan studi komparatif dengan metode campuran dan rancangan cross-sectional study. Penelitian dilakukan pada Juli-September 2015 di DIY. Jumlah sampel 110 dokter FKTP. Pengumpulan data dengan kuesioner dan wawancara mendalam. Hasil: Nilai tengah persepsi dokter terhadap kemampuan dokter adalah 3,62 (skala 1-4). Hasil kualitatif menyebutkan kompetensi dokter dianggap cukup baik oleh sebagian besar dokter. Namun dokter mengakui memiliki kompetensi yang kurang pada penyakit Bell�s palsy, bronkopneumonia, dan presbiopia. Perbandingan kemampuan dokter puskesmas 3,69, dokter praktik 3,54, dan klinik pratama 3,38 dengan nilai signifikansi p<0,001. Masih adanya kasus penyakit yang dirujuk ke rumah sakit disebabkan oleh faktor eksternal dan faktor internal, Faktor eksternal merupakan faktor yang dirasa cukup dominan meliputi kurangnya kelengkapan obat, kurangnya kelengkapan alat medis, permintaan pasien, kebijakan BPJS, dan perilaku dokter spesialis rumah sakit yang tidak mengembalikan pasien rujuk balik ke FKTP. Faktor internal adalah penyulit penyakit dan kurangnya kompetensi pada penyakit Bell�s palsy. bronkopneumonia, dan presniopia. Kesimpulan: Persepsi dokter terhadap kemampuan diri dokter dalam mengelola penyakit cukup baik. Terdapat perbedaan kemampuan dokter yang bermakna dimana dokter puskesmas memiliki kemampuan yang lebih baik daripada dokter praktik perorangan dan dokter klinik pratama. Faktor-faktor yang mempengaruhi dokter merujuk penyakit adalah kurangnya alat medis, kurangnya ketersediaan obat, permintaan pasien, kebijakan BPJS, perilaku dokter spesialis, dan faktor penyulit penyakit, serta kompetensi dokter yang kurang pada beberapa penyakit tertentu. Kata kunci: kemampuan dokter, keputusan merujuk, pelayanan kesehatan primer, jaminan kesehatan nasional

ABSTRACT Background: Readiness of primary care physicians for the success of National Health Insurance Program (JKN) is very important, because primary care physician is gatekeeper to reduce costs by limiting improperly referrals to specialist. Referral restriction in JKN is by implementation 155 diagnoses of diseases that must be cared in first level health facilities (FKTP). There were 13 most diseases of the 155 who were referred to secondary health facilities (FKTL) based on the results of monitoring BPJS Health Central Java-Yogyakarta in 2014. One reason for referral to FKTL is associated with physician competence. The purpose of this study was to identify the physician perception of physician�s competence to care the disease in FKTP BPJS Health branch DIY ; to compare physician�s competence to caredisease among individual physician practices, clinics, and public health centers; and explain the factors influencing referral that disease. Methods: This study is a comparative study using mixed methods and a cross-sectional study. The study was conducted in July-September 2015 in DIY. The samples were 110 FKTP. Respondent was primary care pyhsician. Data was collected by questionnaires and in-depth interviews. Results: The median of primary care physicians�s competence according to their perception was 3.62 (minimum is 3.15 and maximum is 3.85). Qualitative results stated that most physician gave good perception in their competence to care disease. There were 10 from 17 physicians acknowleged that they had lack competence in Bell�s palsy and presbyopia. Physician�s competence in public health care was 3.69, individual physician practices was 3.54 and clinic�s was 3.38 with a significance value p <0.001. There were still cases of disease referred to hospital was caused byf external and internal factor. External factors being considered as dominant factors contributing the referral included incomplete medical drug, incomplete medical devices, patient requst, BPJS policy, and behavior specialist in hospital that did not refer the patient return back to FKTP. Internal factors were complication of disease and lack competence of physicians. Conclusion: Physician�s competence have an average of 3.62 which is good (competence level scale is 1-4). There are differences of physician�s self-evaluation competence between the types FKTP where physicians in public health care have a better competence than individual practice physicians and clinics. Factors that influence physicians refer the disease are incomplete medical drug, incomplete medical devices, patient demand, BPJS policy, behavior specialist in hospital that do not refer the patient returns back to FKTP, complication of disease, and lack physician�s competence. Keywords: physician�s self-assesment competence, referral, primary health care, national/social health insurance

Kata Kunci : Keywords: physicia's self-assesment competence, referral, primary health care, national/social health insurance