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Strategic Purchasing and Contracting in Universal Health Coverage Rp Rp Indonesian Case Rp Laksono Strategic Purchasing and Contracting in Universal Health Coverage Rp Rp Indonesian Case Rp Laksono Trisnantoro and Yulita Hendrartini Universitas Gadjah Mada 1

Content: Part I. Health Finance Functions • The Concept • The case of Indonesia Content: Part I. Health Finance Functions • The Concept • The case of Indonesia health financing • Group Work Part II. The Growth of Private Hospitals and Contracting Group Work Part III. Strategic Purchasing • The concept • What happened in strategic purchasing: Is there any good contract? The case of Indonesia • Group Work 2

Health Financing Functions and Objectives Functions Revenue Collection Objectives raise sufficient and sustainable revenues Health Financing Functions and Objectives Functions Revenue Collection Objectives raise sufficient and sustainable revenues in an efficient and equitable manner to provide individuals with both a basic package of essential services and financial protection against unpredictable catastrophic financial losses caused by illness and injury Pooling manage these revenues to equitably and efficiently pool health risks Purchasing & Payment assure the purchase and payment of health services in an allocatively and technically efficient manner Hsiao, 2010

Broad Definition of Financing Collect Fund Pool the Risk Allocate Resource Payment Hsiao, 2010 Broad Definition of Financing Collect Fund Pool the Risk Allocate Resource Payment Hsiao, 2010

The Indonesian Case 5 The Indonesian Case 5

Health Financing in Indonesia for SHI (2014) Resource collection Pooling Government contribution for poor Health Financing in Indonesia for SHI (2014) Resource collection Pooling Government contribution for poor and near poor: Rp. 19. 225 (USD 1. 5) PMPM contributions Civil servant and military 5% of monthly wages 2% from employee 3% from employer Contributions Laborers – 5% of monthly wages 1% from employee 4% from employer Self funded / informal sector From Rp 25. 500 – 59. 500 PMPM (2. 0 USD – 4. 5 USD) purchasing PHC public & private providers: capitation BPJS as single purchaser Public and private Hospitals : DRGs (INACBG) based payments vary according to region 3 rd class IP for poor 2 nd class IP for non poor 1 st class for non poor (depends on premium)

Tax Income Overall Health Financing Non-tax Income (simplified) Contribution from Workers (67, 5 T) Tax Income Overall Health Financing Non-tax Income (simplified) Contribution from Workers (67, 5 T) APBN (19. 93 T) 20 T PBI Mo. H Other Ministries 489 ( 72. 9 T) Pemda Local Gov Primary Care BPJS Self-Funded Private Insurance 4 T Referral Care Out of pocket NHA 2009 : (18 T) 7

Tax Income Non-tax Income Revenue Collection Contribution from Workers (67, 5 T) APBN PBI Tax Income Non-tax Income Revenue Collection Contribution from Workers (67, 5 T) APBN PBI Mo. H Other Ministries 489 ( 72. 9 T) Pemda Local Gov (19. 93 T) Primary Care BPJS +20 T Self Funded Private Insurance 4 T Referral Care Out of pocket NHA 2009 : (18 T) 8

Tax Income Two Big Pools: Mo. H BPJS: Insurer Body Non-tax Income APBN Contribution Tax Income Two Big Pools: Mo. H BPJS: Insurer Body Non-tax Income APBN Contribution from Workers (67, T) PBI Mo. H Other Ministries Pemda Local Gov Primary Care BPJS Self Funding Private Insuran ce Referral Care Out of pocket 9

Tax Income Purchasing by BPJS for UHC Non-tax Income APBN Contribution from Workers (67, Tax Income Purchasing by BPJS for UHC Non-tax Income APBN Contribution from Workers (67, 5 T) PBI Mo. H Other Ministries + Pemda Local SS Local Gov Primary Care BPJS Self Funding Private Insurance Referral Care Out of pocket 10

II • Trend of Indonesian Hospitals 11 II • Trend of Indonesian Hospitals 11

Trend of Hospital Growth 29 39 41 42 3 3 3 7 32 32 Trend of Hospital Growth 29 39 41 42 3 3 3 7 32 32 33 36 Kemkes Pemprov Pemkab Pemko 2012 Kementerian lain 2013 2014 TNI Non Proft Private H POLRI Swasta non profit Updated (Oct 2015) 77 75 67 63 105 118 125 86 88 92 94 85 89 96 112 237 RS 411 447 455 467 468 599 654 727 724 706 804 TREND JUMLAH RS DI INDONESIA BERDASAR KEPEMILIKAN For Proft Private H Swasta / lainnya BUMN

In the last 15 years: More public finance more private hospitals Private hospitals: partner In the last 15 years: More public finance more private hospitals Private hospitals: partner for government of Indonesia 13

Public-Private Mix Providers Budget Source Public Hospital Private Hospital Public source 1 2 Private Public-Private Mix Providers Budget Source Public Hospital Private Hospital Public source 1 2 Private source 4 3 14

Whether Government using Contractual Arrangement? Providers Budget Source Public Hospital Private Hospital Public source Whether Government using Contractual Arrangement? Providers Budget Source Public Hospital Private Hospital Public source 1 2 Private source 4 3 15

Whether Government using Contractual Arrangement? Providers Budget Source Public Hospital Private Hospital Public source Whether Government using Contractual Arrangement? Providers Budget Source Public Hospital Private Hospital Public source 1 2 Private source 4 3 Not an easy answer 16

A complex mechanism of fund channeling from government to private hospitals: Government budget for A complex mechanism of fund channeling from government to private hospitals: Government budget for poor family is channeled through BPJS pool BPJS purchase to private sector. 17

Tax Income Purchasing by BPJS Non-tax Income APBN Contribution from Workers (67, 5 T) Tax Income Purchasing by BPJS Non-tax Income APBN Contribution from Workers (67, 5 T) PBI Mo. H Other Ministries Pemda Local Gov Primary Care BPJS Referral Care Out of pocket Self Funding Private Insurance Public Providers: Compulsory Private Providers: by contract Is it by contract arrangement? 18

Contracting defined • Contracting is a purchasing mechanism used to acquire: ▫ ▫ ▫ Contracting defined • Contracting is a purchasing mechanism used to acquire: ▫ ▫ ▫ from a specific provider a specified service for an explicit quantity of a known quality at an agreed-on price for a given period of time • In contrast to a one-off exchange, the term Contracting implies an on-going relationship, supported by a contractual agreement. Ricardo Bitran and Ursula Giedion 19

Contracting defined Example of purchaser-provider split from the U. K. • In 1991: NHS Contracting defined Example of purchaser-provider split from the U. K. • In 1991: NHS introduced “internal markets” in public system. – District authorities & “GP fund-holders “ buy services for community from public hospitals (“NHS trusts”), which compete for contracts. • Results (Peacock, 1997) – Quality: Non conclusive evidence on waiting times, cleanliness, referral system, and clinical quality. – Efficiency. Limited impact due to: i. iii. iv. Existence of oligopolies (few providers with important market power) Competition focused more on marketing than on prices or quality Information asymmetries and Costs of contracting. – Equity: Concerns about potential risk selection by GP fund-holders. Ricardo Bitran and Ursula Giedion 20

Discussion: Is there a contracting scheme for UHC in Indonesia? Providers Budget Source Public Discussion: Is there a contracting scheme for UHC in Indonesia? Providers Budget Source Public Hospital Public source 1 Private source 3 ? ? Private Hospital 2 ? 4 21

Discussion: Is there a contracting scheme for UHC in Indonesia? Providers Budget Source Public Discussion: Is there a contracting scheme for UHC in Indonesia? Providers Budget Source Public Hospital Public source 1 Private source 3 ? ? Private Hospital 2 ? 4 Should be discussed using strategic purchasing concept 22

Part III. Strategic Purchasing From: Di Mc. Intyre and Viroj Tangcharoensathien et al. 23 Part III. Strategic Purchasing From: Di Mc. Intyre and Viroj Tangcharoensathien et al. 23

Passive vs. strategic examples Passive • “Passive” – resource allocation based on historical patterns Passive vs. strategic examples Passive • “Passive” – resource allocation based on historical patterns and means – little/no selectivity of providers – little/no quality monitoring – price and quality taker Strategic • “Strategic” – payment systems that create deliberate incentives – selective contracting – quality improvement efforts and rewards – price and quality maker Adapted from Cashin: WHO Advanced course on health financing for UHC, Tunisia, June 2014

Strategic purchasing responsibilities Know how much money they have and how much they (can) Strategic purchasing responsibilities Know how much money they have and how much they (can) spend Project and manage revenue and expenditures (including implications for service entitlements) Decide what to buy and from whom to buy Select providers and enter into contracts with them to deliver goods and service entitlements in line with population needs Decide how and how much to pay providers Develop and implement provider payment systems and calculate payment rates Know and make known how the money is being used Monitor provider performance, service utilization & quality, and publicly report on provider & purchaser performance Adapted from Cashin: WHO Advanced course on health financing for UHC, Tunisia, June 2014

Strategic Purchasing • Equity in resource distribution … to achieve • Access to and Strategic Purchasing • Equity in resource distribution … to achieve • Access to and utilisation of services on the basis of need • Efficiency in resource use • Quality services that are effective • Financial protection

Strategic purchasing actions • To fulfil responsibilities, purchaser must develop, manage and use information Strategic purchasing actions • To fulfil responsibilities, purchaser must develop, manage and use information systems: – Population health needs – Utilisation-related information, such as: • • • Patient demographics Diagnosis & treatment (tests, medicines, procedures) Referral Length of stay (if inpatient) Waiting list information etc. – Financial management: Revenue and expenditure

Strategic Purchasing Action Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 28 Strategic Purchasing Action Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 28

Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 29 Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 29

Strategic purchasing actions: Citizen - purchaser • Registration of beneficiaries (where required) • Active Strategic purchasing actions: Citizen - purchaser • Registration of beneficiaries (where required) • Active assessment of health needs of the population, updated regularly • Mechanisms for engaging with population to determine values and preferences • Using this information to assess if the services purchased adequately meet population needs Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Strategic purchasing actions: Citizen - purchaser • Making population aware of entitlements & responsibilities Strategic purchasing actions: Citizen - purchaser • Making population aware of entitlements & responsibilities (e. g. follow referral route) • Public reporting by purchaser(s) on its/their performance • Mechanisms for holding purchaser(s) accountable for performance (e. g. active civil society) Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 32 Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 32

Strategic purchasing actions: Purchaser - provider • Implies some ‘separation’ of purchasing & provision Strategic purchasing actions: Purchaser - provider • Implies some ‘separation’ of purchasing & provision responsibilities (even if done within same organisation, at least some ‘separate thought processes’/explicit ‘purchasing’ actions) • Active decision-making on which providers to purchase services from (e. g. accreditation): – Meets core structural quality of care requirements – Location relative to distribution of population – Range of services (in line with entitlements) Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Strategic purchasing actions: Purchaser - provider • Preparation of guidelines for providers (some evidence-based Strategic purchasing actions: Purchaser - provider • Preparation of guidelines for providers (some evidence-based decision-making capacity): – EDL/formulary – Standard treatment guidelines (STGs): • Diagnostic tests • Drug treatment • Supplies for surgical procedures (e. g. type of stent that can be used) • PHC gatekeeping and referral pathways Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Strategic purchasing actions: Purchaser - provider • Contracting with providers, specifying: – Range of Strategic purchasing actions: Purchaser - provider • Contracting with providers, specifying: – Range of services required – Compliance with STGs – Quality expectations – Payment issues – Requirements for information submission – Penalties for non-performance and rewards for good performance – No balance-billing permitted (financial protection) – Etc. Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Strategic purchasing actions: Purchaser - provider • Influencing drug prices (e. g. reference pricing) Strategic purchasing actions: Purchaser - provider • Influencing drug prices (e. g. reference pricing) • Determining provider payment mechanisms and setting payment rates: – Using mechanisms that create incentives for efficiency and quality – Assessment of how providers are responding to incentives and what refinements needed – Closed ended / budget neutral approaches important (e. g. DRGs with global budget) • Auditing of bills & timely payments to providers Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Strategic purchasing actions: Purchaser - provider • Monitoring provider performance: – Clinical quality of Strategic purchasing actions: Purchaser - provider • Monitoring provider performance: – Clinical quality of care (e. g. diagnosis and treatment in line with STGs, hospital infection rates, etc. ) – Efficiency (e. g. compliance with EDL/formulary and referral procedures; claims audits) • Taking action on performance: – Poor performance – e. g. quality improvement plan, accreditation not renewed – Good performance – nature of rewards • Financial management (ensuring expenditure in line with revenue) Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 38 Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 38

Strategic purchasing actions: Government - purchaser • Establishing clear policy and regulatory frameworks within Strategic purchasing actions: Government - purchaser • Establishing clear policy and regulatory frameworks within which purchaser(s) (and providers) will function, including: – Explicit expectations of purchaser(s) – Governance structures and mechanisms – Autonomy for purchaser in day-to-day management decision-making and operations – Requirements for reporting by purchaser(s) – Ability to take action on poor performance – Protection of population (e. g. balance billing) Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Strategic purchasing actions: Government - purchaser • Specifying service entitlements for population (e. g. Strategic purchasing actions: Government - purchaser • Specifying service entitlements for population (e. g. ‘itemised’ benefit package, or comprehensive services with some exclusions) • Influence over resource flows to purchaser(s) – e. g. contribution rates to insurance schemes; taxfunded allocations (including extent to which government engages with purchaser(s) over resource requirements to meet needs of population) Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015

Wheter Passive or strategic examples? Passive • “Passive” – resource allocation based on historical Wheter Passive or strategic examples? Passive • “Passive” – resource allocation based on historical patterns and means – little/no selectivity of providers – little/no quality monitoring – price and quality taker Strategic • “Strategic” – payment systems that create deliberate incentives – selective contracting – quality improvement efforts and rewards – price and quality maker Adapted from Cashin: WHO Advanced course on health financing for UHC, Tunisia, June 2014

A Critical Analysis of Purchasing Arrangements under BPJS in Indonesia Yulita Hendrartini Laksono Trisnantoro A Critical Analysis of Purchasing Arrangements under BPJS in Indonesia Yulita Hendrartini Laksono Trisnantoro Gadjah Mada University, Indonesia i. HEA, Milan; Tuesday 14 July, 2015 Gadjah Mada University

Tax Income Purchasing by BPJS Non-tax Income APBN Non-PBI ex PT Askes (67, 5 Tax Income Purchasing by BPJS Non-tax Income APBN Non-PBI ex PT Askes (67, 5 T) PBI Mo. H Other Ministries Pemda Local Gov Primary Care BPJS Non-PBI Mandiri Private Insuran ce Referral Care Out of pocket 43

Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 44 Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 44

Summary: Mechanism for strategic purchasing Principle agent relationship on going proccess Key Challenge Purchaser Summary: Mechanism for strategic purchasing Principle agent relationship on going proccess Key Challenge Purchaser government • Organizational structure • Capacity building for DHO • Negociated budget • • Unclear Role of stakeholder Lack of Data for monitoring Updating Lack of health facilities investment Purchaser - citizen • Review benefit package annualy • Patient satisfaction review • Lack of Citizen voice • Limitation of Custommer right Purchaser - provider • Prospective Payment • • Selection and credentialing • • Setting indicator • • • Capitation not effective DRG Tariff in adequate In equity provider distribution Lack of Quality control Lack of Fraud prevention

Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 46 Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 46

Purchaser-Government on going proccess • Organizational structure • Capacity building for DHO • Negociated Purchaser-Government on going proccess • Organizational structure • Capacity building for DHO • Negociated budget Key Challenge • Unclear Role of stakeholder • Lack of Data for monitoring • Updating • Lack of health facilities investment

Gaps in government actions to promote strategic purchasing • Unclear organizational roles • Accountability Gaps in government actions to promote strategic purchasing • Unclear organizational roles • Accountability lines between BPJS / purchaser and the Ministry of Health (and District Health Office) • Inadequte monitoring activities • Data limitation and lack of DHO capacity to monitor the program • Problems in reducing the inequity of services. • Limited budget to developing new health service infrastructure and deploy strategic human resources

49 49

Purchaser-Citizen on going proccess Key Challenge • Review benefit • Lack of Citizen voice Purchaser-Citizen on going proccess Key Challenge • Review benefit • Lack of Citizen voice package annualy • Limitation of • Patient satisfaction Custommer right review

Gaps in relation to role of citizens and population in strategic purchasing • The Gaps in relation to role of citizens and population in strategic purchasing • The needs, preferences and priorities of citizens in determining service entitlements is not clear in the policy design and implementation. v Many regions where community needs are not met indicates that there is no mechanism to ensure beneficiaries can access available services, especially the marginalized groups v Lack of evidence on health needs no evidence that citizens can participate in the process of determining health needs and priorities v No representation in purchasing boards v Limitation of patients’ rights legislation v Remote areas citizen is lost in the big data.

Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 52 Di Mc. Intyre and Viroj Tangcharoensathien et al. 2015 52

Purchaser-Provider on going proccess Key Challenge • Prospective Payment • Capitation not effective • Purchaser-Provider on going proccess Key Challenge • Prospective Payment • Capitation not effective • Selection and • DRG Tariff in adequate credentialing • In equity provider • Setting indicator distribution • Lack of Quality control • Lack of Fraud prevention

Gaps in relation to providers in strategic purchasing • Purchaser (BPJS) has inadequate credentials Gaps in relation to providers in strategic purchasing • Purchaser (BPJS) has inadequate credentials and capacity to contract especially in government providers. There is no clear Contractual Arrangement • Poor monitoring mechanisms to control health services moral hazard (potential fraud) • No fraud regulation • Provider response to prospective payment system (capitation and DRG payment) problems: Ø Provider ability/capacity to respond to incentives accept limitation Ø Lines of accountability detection potential Fraud

In Indonesian Case, the position: Passive • “Passive” – resource allocation based on historical In Indonesian Case, the position: Passive • “Passive” – resource allocation based on historical patterns and means – little/no selectivity of providers – little/no quality monitoring – price and quality taker Strategic • “Strategic” – payment systems that create deliberate incentives – selective contracting – quality improvement efforts and rewards – price and quality maker Adapted from Cashin: WHO Advanced course on health financing for UHC, Tunisia, June 2014

The Contractual arrangment is not clear Providers Budget Source Public Hospital Public source 1 The Contractual arrangment is not clear Providers Budget Source Public Hospital Public source 1 Private source 3 ? ? Private Hospital 2 ? 4 56

Can Indonesia achieve strategic purchasing in the context of UHC? • Equity in resource Can Indonesia achieve strategic purchasing in the context of UHC? • Equity in resource distribution (Difficult if there is no policy) • Efficiency in resource use (Probably No) • Access to and utilisation of services on the basis of need (No) • Quality services that are effective (No) • Financial protection (Yes in well developed areas)

Group Work 2: Describe the relationship between purchaser(s) and providers in your country? Citizen Group Work 2: Describe the relationship between purchaser(s) and providers in your country? Citizen Government Purchaser(s) Providers

Group Work 3: Is there any contractual arrangement for UHC in your country? Providers Group Work 3: Is there any contractual arrangement for UHC in your country? Providers Budget Source Public Hospital Public source 1 Private source 3 ? ? Private Hospital 2 ? 4 59