Perhitungan
Perhitungan
Perhitungan
Kapitasi
14 February 2007
TOPIK DISKUSI
BIAYA &
ANALISIS BIAYA
UNIT COST
UTILIZATION REVIEW
PERHITUNGAN BIAYA KAPITASI
PENETAPAN PREMI
Ronnie Rivany
Pusat Kajian Kebijakan dan Ekonomi Kesehatan
FKMUI
2006
UNIT COST
Total cost
ATP/WTP
quantity
ANALISIS
BIAYA
CRR
PESAING
Distinguishing Characteristic of
Health Care Evaluation
2
o
r
NO
r
e
1A PARTIAL EVALUATION 1B
N Examine only
Consequences
m
O
o
Outcome
Description
YES
Examine only
Costs
2
PARTIAL EVALUATION
Cost
Description
A
l
3A PARTIAL EVALUATION 3B
t
e
r Y Efficacy or
Cost
n E Effectiveness
Analysis
a
Evaluation
t S
i
v
e
s
FULL ECONOMIC
EVALUATION
Cost-Minimization Analysis
Cost-Effectiveness Analysis
Cost-Utility Analysis
Cost-Benefit Analysis
Principle Characteristics of
Provider Payments Systems
(Normand & Weber, 1999)
Payment
System
Case payment
Daily charge
Patient day
Bonus payment
Flat rate
Capitation fee
Salary
Budget
WHAT (1)
WHAT (2)
CAPITATION COVERAGE
OUT
PATIENT
IN PATIENT
SUPPORTING SERVICES
DRUGS & SUPPLIES
COSMETIC (?)
EXTRA ORDINARY
CANCER
HIV/AIDS
Morale hazards (?)
WHO
MEMBER OF THE
POPULATION
DEMOGRAPHIC by
SEX
AGE
MARITAL STATUS
FAMILY STATUS
EMPLOYMENT
STATUS
BENEFIT PACKAGE
WHERE
LOCAL
INDUSTRY
HEALTH
EDUCATION
REGIONAL
NATIONAL
GLOBAL
CAPTIVE MARKET
WHEN
POPULATION AT RISK
EPIDEMIOLOGICAL
TRANSITION
HEALTH CARE COST
INFLATION
COST
HOW (1)
KEY WORDS
POPULATION
LAW OF LARGE NUMBER
POOLING RISK
BI PARTIT vs TRI PARTIT
UTILIZATION ~ PROBABILITY
(ACTUAL vs ALLOWED RISK)
UNIT COST
LOADING FACTOR
PREMIUM
HOW (2)
THEORY
PROBABILITY RATE
= UTILIZATION
NO OF POPULATION
CAPITATION
= UNIT COST X PROB. RATE
HOW (3)
Probability Rate & Capitation
Demographic
By Sex
By Age
By Marital status
By Employ status
HOW (4)
APLIKASI PT ASKES.1
Perhitungan Premi
1.
2.
HOW (5)
APLIKASI PT ASKES.2
Biaya Pelayanan Kesehatan
RJTP
RJTL
Rawat Inap
Khusus
Suplemen
Rumus : C = F x P
HOW (6)
APLIKASI PT ASKES.3
Contoh ( per member per month)
RJTP = 250/1000
RJTL = 25/1000
RI
= 5/1000
RJTP = Rp 20.000
RJTL = Rp 300.000
RI = Rp 2.000.000 (kls II)
Layanan Khusus = Rp 250.000
Layanan suplemen = Rp 1.000.000
HOW (7)
APLIKASI PT ASKES.4
Komponen
layanan
Prevalensi
Harga per
kasus (Rp)
Biaya (Rp)
RJTP
250/1000
20.000
5.000
RJTL
25/1000
300.000
7.500
RI
5/1000
4.000.000
20.000
Khusus
5/1000
2.000.000
10.000
Suplemen 5/1000
1.000.000
5.000
Total
(80%)
47.500
Premi
(100%)
59.375
Loading
(20%)
12.500
Average Cost
Utilisation Review
Internal Customer
Review
Penghitungan
Nilai Kapitasi
Analisis utilisasi
per jenis layanan
Kecenderungan utilisasi
Batasan Layanan
(Ekslusi - Inklusi)
Analisis Populasi
Scr Internal
Demografi Target
Analisis
Probabilitas
Riil / allowed risk
Kapitasi
VC
FC
% OP
UC
Poli
homo
Act/
norm
OK
Hetero/
RVU
Act/
norm
Lab
Hetero/
RVU
Act/
norm
Total
100
TC
+ dep
Poli.1
(650x20) / (500x20)=
130,00
Poli.2
(350x25) / (15.000)=
58,33
OK
Lab
O
P
UC
Tarif
CRR
(TR/TC x 100%)
Unit Cost
Actual Prob
Kapitasi
Rajal.1
6.000
0,0002
1,2
Penunjang
Medis.1
250.000
0,02
5.000
Ranap.1
150.000
0,006
900
Sub total
Loading factor
5.901,2
0,40
2.360,4
Premi per
orang
8.261,6
Faktor
keluarga 4 org
33.046,4
35.000
Rajal.1
6.000
0,0002
1,8
Penunjang
Medis.1
250.000
0,02
7.500
Ranap.1
150.000
0,006
1.050
Sub total
Loading factor
8.551,8
0,40
3.420,7
Premi per
orang
11.972,5
Faktor
keluarga 4 org
47.890
50.000
DISKUSI (1)
DITERMINAN TEKNIS
vs EVIDENCE
ACTUAL vs ALLOWED RISK
PROBABILITY
BIAYA LAYANAN / TARIF (?) vs
UNIT COST
GENERIC vs SPECIFIC
DEMOGRAPHIC / POPULATION
DISKUSI (2)
DITERMINAN
DEMAND for HEALTH INSURANCE
(Rivany,1988)
UTILITY
PROBABILITY OF LOSS
MAGNITUDE OF LOSS
INCOME
PREMIUM
SERVICES
DISKUSI (3)
DITERMINAN UNIT COST
METODE
SIMPLE DISTRIBUTION
STEP-DOWN DISTRIBUTION
DOUBLE DISTRIBUTION
MULTIPLE DISTRIBUTION
ACTIVITY BASED COSTING
ACTUAL vs NORMATIVE
HOMOGEN vs HETEROGEN
OUTPUT (RELATIVE VALUE UNIT)
DISKUSI (4)
DITERMINAN PREMIUM
UNIT COST
PRICE
COST RECOVERY RATE
(CRR)
CAPITATION
PROBABILITY RATE (ACTUAL
vs ALLOWED RISK)
POLICY
LOADING FACTOR
ATP / WTP (?)
DISKUSI (5)
DRG & CASEMIX, the answer
CASEMIX
CLINICAL PATHWAY
INA DRGs (?)
PPE Depkes
HEALTH vs ECONOMICS
INDONESIAN DRGs
10
11
12
13
14
15
Newborn and other neonates with conditions originating in the perinatal period
16
Disease and disorders of blood and blood forming organs and immunological disorders
17
18
19
20
21
22
Burns
23
Factors influencing health status and other contact with health services
INA - DRG
1.Konfirmasi DRG
2.Hitung Cost/DRG
1
DRG
DRG
COST
DRG
CASEMIX
TARIF
COST
TARIF
Clinical Pathway
Operasional
CLINICAL PATHWAY
Admission
Diagnostic
Pra
Therapy
Therapy
Follow Up
Discharge
Pra R.I
(Poliklinik
/
UGD)
Hari I
Tgl
Hari 2
Tgl
Komplika
si/
Comorbidity
Pendaftaran
Penetapan Diagnose
Pra-Perawatan
Perawatan
Tindak Lanjut
Operasional
UNIT COST
Total cost
ATP/WTP
quantity
ANALISIS
BIAYA
CRR
PESAING
Marjin
COST/DRGs
UNIT COST
TINDAKAN RI
Total cost
UNIT COST
UNIT COST
UNIT COST
TINDAKAN Obat TINDAKAN Lab TINDAKAN Alkes
UNIT COST
TINDAKAN OK
Admission
Biaya Admission
Diagnostic
Biaya Diagnostic
Pra Therapy
Therapy
Biaya Therapy
Follow Up
Biaya Follow Up
Discharge
Biaya Discharge
Total Biaya
MDC
Diseases
DRG
Casemix
2000
MDC.14
Abortion
DRG.380
DRG.381
2001
MDC.01
Head Injury
DRG.2
2002
MDC.18
Malaria
DRG.423
2003
MDC.06
Appendicitis
DRG.165
DRG.166
2004
MDC.18
Typhoid fever
DRG.423
2005
MDC.14
Pregnancy
DRG.O01D
DRG.O01A
DRG.O01B
DRG.O01C
2005
MDC.06
Gastro Enteritis
DRG.G68B
DRG.G68A
DRG.164
DRG.167
Australian Refined
Diagnosis Related Group
Classification, Version 4.1
DRG
ALOS
INA DRGs
COST /
Public Sector
CITO
kls 3
Direct
Overhead
Total
O01A
9,14
11
5,444
3.710.590
2,089
98.622
7,533
3.809.212
O01B
6,13
6
3,998
3.205.076
1,550
98.622
5,548
3.303.698
O01C
5,00
6
3,792
3.067259
1,373
98.622
5,166
3.165.881
O01D
4,63
5
3,327
2.721526
1,262
98.622
4,589
2.820.148
MDC
Diseases
DRG
Casemix
2006
MDC.1
Stroke
DRG.B.70C
DRG.B 70A
DRG.B70B
DRG.B70D
2006
MDC.
HIV / AIDS
DRG.
2006
MDC.
DBD
DRG.
2006/7
MDC.
Prostat
DRG.
DRG.
2006/7
MDC.
Mata
DRG.
DRG.
MEDICAL PARTITION
yes
B 70A
patient
yes
Stroke
yes
Sev or
Compl
Dx or
proc
yes
No
B 70B
CC
No
B 70C
No
No
B 70D
A
B1
B2+
B2
C
0%
20 %
50 %
65 %
80 %
AMOUNT OF SUBSIDY
INDONESIAN DRGs
KESIMPULAN
Pengembngan INA-DRG
ICD tetap
MDC untuk sementara tetap
Clinical Pathway bisa dibuat
DRG di konfirmasi + bisa dibuat
Casemix di konfirmasi + bisa dibuat
Costing dilakukan dengan pendekatan
Activity Based Costing + Simple
Distribution