SUPPLY SIDE OF HEALTH INSURANCE SYSTEM IN INDONESIA

Transcription

1 SUPPLY SIDE OF HEALTH INSURANCE SYSTEM IN INDONESIA dr. I Gede Subawa, MKes President Director of PT Askes Indonesia Phrarmaceutical Sector Meeting on 8 November 2012 Nikko Bali Resort Spa, Nusa Dua, Bali

2 Overview Of Indonesia Total population : 237,641,326 (2010 National Census) Gross national income per capita (PPP international $): 3,600 Life expectancy at birth m/f (years): 66/71 Probability of dying under five (per live births) : 34 (2007) Probability of dying between 15 and 60 years m/f (per population) : 234/143 Total expenditure on health per capita (Intl $, 2009) : 99 Total expenditure on health as % of GDP (2009) : 2.4 Source; WHO (2012)

3 ECONOMIC GROWTH OF INDONESIA 10% Indonesia real GDP grow faster than ASEAN and emerging/developing economies % GDP growth (real) % 8% 7% 6% 5% 4% 3% 2% 1% 0% Indonesi a Emer ging/devel oping Economies ASEAN

4 % Growth PER CAPITA INCOME GROWTH & per capita income is also expected to grow faster % Per Capita income growth % ASEAN 60% Em erging/develop ing Economies 40% 20% 0%

5 Population (M) INDONESIAN POPULATION GROWTH INDONESIAN POPULATION GROWTH Growth at 6% to 2015 The elderly population increase in the next 5 years ,5 247,6 116,6 116,9 123,7 123, Female Population (m) Male Population (M) to to to to to to 19 0 to Increasing life expectancy will create demand for chronic therapies Source: BPS (Central Statistics Bureau)

6 Population Split by Urban/Rural (%) DISTRIBUTION OF POPULATION 100% 80% 60% 40% 20% 0% Indonesia population increasingly moving to urban area 58,0% 51,7% 45,8% 40,5% 42,0% 48,3% 54,2% 59,5% Rural Urban

7 HEALTHCARE SPENDING % GDP spent on healthcare growing 2.4% of GDP (USD 44 per capita) 3,5% 3,0% 2,5% 2,0% 1,5% 1,0% 0,5% 0,0% Source: 1 Worldbank report, WHO Global Atlas, Datamonitor 7 7

8 HEALTHCARE SPENDING % spend is low compared to peer countries % GDP Spent on Healthcare, comparative Vietnam World Avg Malaysia Philippines Thailand Singapore Indonesia Myanmar Source: 1 Worldbank report, WHO Global Atlas, Datamonitor

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10 Indonesia Healthcare Transformation Universal Healthcare Coverage in 2014 Indonesia Minister of Health has already set a target to start covering all people s health costs as early as Law No. 40/2004 on National Social Security System (SJSN) Law No. 36/2011 on Social Security Implementation BPJS I (Health Insurance Carrier) ASKES +JAMKESMAS merge 5 Committees are now working to set the Insurance System

11 PT ASKES MOH JAMKESMAS PT JAMSOSTEK PT TASPEN PT ASABRI Healthcare Transformation System Sistem Jaminan Sosial Nasional Universal Health Coverage 2014 MOH JAMKESMAS PT JAMSOSTEK Less fortunate/poor Employee Health, Accident & Pension fund Dewan Jaminan Sosial Nasional (National Social Security Council) BPJS 1 BPJS 2 PT ASKES Civil servants & Military Retirement PT TASPEN Pension for civil servants PT ASABRI Active Military Health Non-Health Current 2014

12 HISTORY PT ASKES (PERSERO) 1968: Minister of Health: as an embryo of Universal Coverage 1968: BPDPK Reimbursement 1984: PERUM HUSADA BHAKTI Managed care 1992: PT ASKES (PERSERO) Managed care 2014: Health Insurance Carrier ( BPJS)

13 BPJS-1 (Health UHC Organization) 2012 BPJS-2 (Pension Organization) 2013 Preparation ROAD MAP TO UHC FORMAL SECTOR BUMN/BUMD, SELF WORKER, POOR, DISTRICT FORMAL SECTOR (ASKES, JAMKESMAS, JAMSOSTEK, MILITARY/POLICE, BUMN/BUMD, SWASTA INFORMAL SECTOR SELF WORKER, PBI 2019? UC Preparation

14 MANAGED CARE Integration between quality and cost control Gatekeeper concept Primary care Quality Assurances Credentialing & Recredentialing Comprehensive health care benefits Emphasizes on promotion and prevention Referral system Drugs Formularium DPHO Prospective payment system Utilization review Medical Advisory Board 14

15 Supply Side - UHC Health Insurance Specialist Supply Side 15

16 Health Insurance Specialist Legal Aspect UU 24/2011: 11 (d) (e) (d) Provider payment Regulator; (e) Provider contract BPJS; UU 40/ (1) (1) Benefit Delivery by BPJS Provider. 24 (1) (2) (3) (1) Payment Negotiation BPJS vs Provider Association (2) BPJS obligated to pay the provider at the latest 15 day (3) BPJS develop a healthcare system, quality control, provider payment mechanism (efficiency and effectiveness) 16

17 ASKES VS BPJS PROVIDER MANAGEMENT PT Askes (Persero) 1.Provider Mapping Primary provider Provider with catastrophic care 2. Cre/Recredentialing All Provider BPJS (proposed) 1.Provider Mapping Primary, Secondary, Tertiary Provider with catastrophic care Pharm, Optical, Laboratory 2. Cre/Recredentialing All Provider 3. Payment Nego & Provider Contract Nego & Contract to Provider 4. Updating Provider List Referensi Provider On Line (internal) 5. Performance of Provider Evaluation Utilization Review, customer satisfaction 3. Payment Nego & Provider Contract BPJS nego to Provider Assosciation BPJS contract to provider 4. Updating Provider List Referensi Provider On Line (public) 5. Performance of Provider Evaluation Utilization Review, customer satisfaction Medical Audit, Cost Effectiveness, Comprehensiveness 17

18 Health Insurance Specialist ROAD MAP HEALTH FACILITIES MANAGEMENT Alt.1: Qt I Year 2013 Year 2014 Qt II Qt III Qt IV Semester I Policy Synchronizat ion Finalization of guideline Qt I Socialization of health facilities Health Facilities Selection Negotiation Contract Perfomance Evalualuation of Health Facilities Implementati on of Regional Partnerships Alt.2: Year 2013 Year 2014 Qt II Semester II Semester I Policy Synchronizat ion Finalization of guideline Socialization of health facilities Negotiation Contract with Health Facilities: Askes, Jamsostek, TNI/POLRI, Jamkesmas, ) Perfomance Evalualuation of Health Facilities Implementati

19 Health Insurance Specialist Health Facilities Criteria Take Precedence Accredited If not accredited: Administrative Criteria Having a license from ministry of Health and local Government. Having a business license as a health Facilities. AMDAL Facilities Criteria Having facilities in accordance with the applicable regulation Having medical and administrative personnel according to regulations and the needs of the participants. Strategic location. Quality Criteria Having a quality accredited certification or other quality certification. Health Insurance Specialist

20 ASKES HEALTH CARE PROVIDERS 2011 Regional I Regional II Regional VIII Regional X Regional XII Regional III Regional IV Regional V Regional VI Regional VII Regional XI Regional IX Community Health Centers Family Physicians/24 hours Clinic 270 Laboratories, 231 Indonesian Red Cross Regional XI 952 Hospitals (506 Government hospitals; 109 TNI/POLRI hospitals; 263 private hospitals; 74 special hospitals) 162 providers for hemodialysis pharmacies dan 756 optical

21 DPHO (List of Drugs Items and Prices) As a drugs in Universal Health Coverage

22 Indonesia has an enormous number of drugs that are available on the market : 15,498 items (Ind. FDA 2012) 208 farmacies a problem of Askes to select an appropriate and qualified drugs for its members ASKES must ensure that the drugs are selected according to evidence based criteria (EBM) the problem of distribution is an issue to be overcome, and which creates drug price disparity among the islands A widely range of drug s price WHY SELECTION?

23 WITH THOSE CIRCUMSTANCES ASKES DESIGN A DRUGS POLICY FOR ITS MEMBERS EFFECTIVE, SAFE AND EFFICIENT List of Drug Items and Prices (DPHO, Since 1987) Annual update of the DPHO.

24 DPHO COMPOSEMENT PROCESS - Expert Team consist of : Pharmacologyst, Specialist, Health Ministry, and The National Agency of Food and Drug Control - Hospital Recomendation consists of National Essential Medicines List, Generic and Branded Generic that had not been included in the recent DPHO

25 DPHO & QUALITY OF SERVICES DPHO Board of Experts review the drug list by considering EBM and analyzing cost effectiveness. DPHO Board of Experts conducts a series of intensive discussions every week for 6 months every year. DPHO is composed based on the result of Board of experts recommendation to ensure all medical needs are accommodated for outpatient care (primary and specialist), and inpatient care. DPHO Board of Experts also recommends and specifies particular indications for certain drugs (restrictions), in order to ensure: Prescribing is in accordance with treatment guidelines. Improving patient compliance with chronic disease medicines. Decreasing overuse of antibiotics. Decreasing overuse of injections. Increasing use of generic medicines.

26 PRICING THE DRUGS The price negotiation is conducting after the quality of drugs is assured by certifying they fully meet of the following: Product Information, including meta analysis. Indonesia Food and Drugs Agency Register. Certificate of Analysis (COA). Good Manufacturing Practice (GMP) or Indonesian Certification of Good Manufacturing Practice. Price negotiation with pharmaceutical industries only at national level. By offering a large, fixed, captive market to the pharmaceutical industry, ASKES could obtain a significantly efficient price of up to 60% off the regular market price. The same price is implemented around the country

27 INDEPENDENCY OF DRUG FORMULARY 1. Selection process efektive dan efficient efficacy & safety aspect by Experts Team Price and distribution by ASKES Team 2. Label use defined DPHO Experts Team indications, restriction and maximum prescribe 3. Price based on negotiation between ASKES- Manufacturers including special arrangement 4. Askes Drug Formulary (DPHO) is designed for one year : The same policy and price around the country Evaluate and re-formulate every year

28 DPHO BENEFIT FOR STAKEHOLDER Members: Health care services availability Health care services quality Health Care Providers: More Choices and affailability Assurance of Drugs Quality and Availability Quality of Services Evidence-based practice Manufacturers : Captive Market, Less Marketing Cost Economies of Scales Government : Efficiency of Health Care Spending

29 OPTIMIZING DPHO IMPLEMENTATION Prescriber in government and private providers (primary, secondary, tertiary) should follow the drugs in DPHO for treating any ASKES patients. Communicating with ASKES members about the advantages of DPHO. Provide a scientific seminar or medicine workshop for prescribers at least four times each year at every ASKES branch office. Special analyses from the Medical Advisory Board (MAB) at every ASKES branch. The Medical Advisory Board recommends the medical judges and provides a second opinion in term of evidence based medicine drugs prescription. Review and evaluation of drug utilization, also prescribing drugs outside of DPHO.

30 EVALUATION OF DPHO DPHO CONTENT Number of Drugs in DPHO, Years Number of Therapy Class in DPHO vs DOEN, Years

31 EVALUATION OF DPHO Members trustworthiness of using DPHO medicine increase every year Outpatient Utilization

32 EVALUATION OF DPHO Members trustworthiness of using DPHO medicine increase every year Inpatient Utilization

33 DPHO CONTENT Sample description of the Indication Guide for prescribing Antineoplastic and Paliatif Treatment - Cytotoxic Indication: For gastrointestinal cancer Indication: For metastases breast cancer with Positive 3 (+++) HER2 of Positive FISH Indication: For Limfoma Non Hodgkins (LNH) Malignum with Positive CD20

34 Challenges Wide variety of kind and price available in the market potential to overuse, misuse Inefficient Over prescription and irrational prescription Provider Compliances moral hazards Commitment from Distributor/Manufacturer Effectiveness of the drug s prescription control

35 Divisi Jaminan Pelayanan Kesehatan