Indonesian National Health Insurance: Gaps in Communication with
Health-Care Providers
Susy K. Sebayang
1
, Ralalicia Limato
2
, Desak Ketut Ernawati
3
, Olivia Waworuntu
4
, Grace Monica
Halim
5
, Edwin Widodo
6
1
Faculty of Public Health, Universitas Airlangga, Banyuwangi, East Java, Indonesia
2
Eijkman Institute for Molecular Biology, Jakarta, Indonesia
3
Department of Pharmacology and Therapeutics, Faculty of Medicine, Udayana University, Bali, Indonesia
4
Faculty of Medicine, Sam Ratulangi University, Manado, North Sulawesi, Indonesia
5
International Labour Organization - Indonesia, Jakarta, Indonesia
6
Department of Human Physiology, Faculty of Medicine, Brawijaya University, Malang, Indonesia
sksebayang@fkm.unair.ac.id
Keywords: National health insurance, BPJS, Health-care providers, Corporate communication.
Abstract: The perspective of health-care provider on the implementation of the Indonesian national health insurance
scheme managed by Badan Penyelenggara Jaminan Sosial (BPJS) in 2014 has not been reported much.
This study aims to explore the gaps in communication between health-care providers and BPJS.
Quantitative data was collected prior to an Indonesian health insurance workshop held in Jakarta in
November 2015. Fifty health-care providers in Jakarta responded to a questionnaire. Two months later, a
random sample of 20 providers who responded to the initial questionnaire agreed to a follow-up phone
interview. Most of the respondents came to the workshop for more information on BPJS (69.6%) and
21.4% came to share their experience and to give feedback to BPJS. 72.7% of the respondents did not find
the BPJS operational manual to be helpful for their need of information. 41.2% of respondents wanted more
information on INA-CBG and tariff regulation, BPJS operational regulation (41.2%), and the verification
system and reasoning (11.8%). The respondents did not have any feedback from BPJS nor did they see any
changes in BPJS two months after the workshop. In conclusion: debates between health-care providers and
BPJS have continued, indicating the need and willingness for both sides to communicate but the gaps of
information persist. BPJS needs more innovation in relation to their communication system.
1 INTRODUCTION
Indonesian Law No 40/2014 established the national
social insurance scheme to ensure basic life needs
covering from health, work accidence, pension, and
life insurance. Indonesia started implementing the
national health insurance scheme or Jaminan
Kesehatan Nasional (JKN) in 2014 and has aimed
for universal coverage by 2019 (Mboi, 2015). In
Indonesia, JKN was mandated by law to be managed
by Badan Penyelenggara Jaminan Sosial (BPJS).
Concerns about JKN implementation, the people’s
perception of JKN implementation and the financing
system has been frequently assessed (Suprianto &
Mutiarin, 2017; Utami & Mutiarin, 2017). Concerns
about JKN implementation from the health-care
providers’ perspective, however, has not been
reported often. Issues such as the costs and the
payments received by the doctors and providers has
been only anecdotally reported. Studies on the gaps
of communication between the two institutions in
Indonesia are scarce.
It has been previously reported that 83% of
health-care providers in Jakarta found that the JKN
system was not beneficial for health-care providers.
The reasons mostly mentioned were unrealistic
costing in Indonesia Case Based Groups (INA-
CBGs), a suboptimal payment system and
complicated management (Sebayang et al., 2016). It
is also known that there is distrust between health-
care providers and insurers (Revive Health, 2017;
Xu, 2017). However, there may also be gaps in the
communication between BPJS and health-care
providers that can potentially be bridged in order to
improve the trust between BPJS and health-care
providers. This study, thus, aims to explore the gaps
10
Sebayang, S., Limato, R., Ernawati, D., Waworuntu, O., Halim, G. and Widodo, E.
Indonesian National Health Insurance: Gaps in Communication with Health-Care Providers.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 10-13
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
in communication between health-care providers and
BPJS in Jakarta, Indonesia. The study was funded
by the Alumni Grants Scheme No AG 1400075 of
Australia Awards, Indonesia.
2 METHODS
The data was collected using quantitative and
qualitative methods in a descriptive study from the
participants of a one-day JKN workshop held in
Jakarta in November 2015. This workshop provided
an open discussion between JKN, represented by
BPJS, the Ministry of Health, and health-care
providers from public and private sectors including
clinicians and management officers. The health-care
providers who attended the workshop were
represented by clinicians and managers from the
public and private health sectors.
Prior to the workshop, all 103 attendants of the
workshop, including health-care providers, were
offered to respond to a pre-workshop questionnaire.
The questionnaire obtained information on the
participant’s reason for attending, the information
that they expected to get by attending the workshop,
and their opinion on what part of BPJS
implementation they found useful and what part
made their work more difficult. Two months after
the workshop, a random sample of 33 health-care
providers who responded to the original
questionnaire were contacted for a follow-up phone
interview with open-ended questions to obtain
information on their perception of the updates from
BPJS.
The quantitative data was analysed using
STATA 14. Common themes were obtained from
the qualitative data from the phone interview.
3 RESULT
Sixty eight out of the 103 respondents returned the
pre-workshop questionnaire, 50 of which were
health-care providers. All health-care respondents
worked in hospitals, 66% were female and 78%
represented hospitals that were already BPJS
providers). Of the 33 health-care providers
randomly contacted two months later, 20 health-care
providers agreed to take a follow-up phone
interview. The pre-workshop questionnaire showed
that most health-care providers attended the
workshop to get new information about JKN or
BPJS (69.6%) and one fifth (21.7%) of the providers
wanted to share their experience and to provide
suggestions for the better implementation of the
insurance scheme (Table 1).
Table 1: Health-care providers’ motivation for attending
the workshop (N=46)
Motivation for Attending
N
%
Invited
4
8.7
To get new information
32
69.6
To share and give suggestion
10
21.7
For the question about whether or not the
participants found that the BPJS operational
guideline were helpful, 44 providers answered but
only 34 participants provided details of what
information they needed more. Out of the 44
providers who answered, 72.7% reported that they
did not find the BPJS operational guideline to be
helpful. Most providers wanted more information
on the INA-CBGs and tariff policy (41.2%) and
updates on the operational regulations including the
primary update (41.2%). Some providers also
wanted more information on the BPJS verification
system (11.8%). A smaller number of providers
wanted information on the health service (disease
prevention policy, service coverage, quality and
patient safety) after JKN implementation,
membership (how to be a BPJS provider, what
membership information is to be given to patients)
and other information (BPJS implication on medical
audits and sharing of the patients’ medical record,
BPJS success stories and government expectations
of private hospitals regarding BPJS) (Table 2).
Table 2: New information needed by health-care providers
(N=34)
Information Needed by Providers
N
%
INA-CBGs and tariff policy
14
41.2
Update on operational regulation
14
41.2
Verification System
4
11.8
Health Service
3
8.8
Membership
2
5.9
Other
3
8.8
Only 37 providers reported what they found to be
useful from BPJS implementation and what they
thought made their work more difficult. Health-care
providers found that the unrealistic INA-CBGS
(24.3%) made their work more difficult.
Interestingly, the referral system and the coding
system were perceived as being both positive and
negative. The verificators not having a medical
degree was reported to be a drawback (13.5%) and
was perceived as ‘trespassing doctor’s authority’,
followed by limited medical knowledge and a lack
of socialisation. Other drawbacks reported included
a lack of hemodialysis service, piles of paperwork,
Indonesian National Health Insurance: Gaps in Communication with Health-Care Providers
11
and limited allowable diagnostic checks.
Approximately 15% of providers did not find any
positive side of BPJS implementation that was
useful for their work. They reported other positive
aspects, albeit which was small in proportion,
including the availability of complete patient
information, the emergency unit service, BPJS
centres, and providers perceived by the community
as having good intentions. A provider also
perceived the BPJS verification system as positive
(Table 3).
Table 3: Providers’ answers on their perception of JKN
and it’s implementation
Perception
n
Perceived as negative (N=37)
Unrealistic INA-CBGS
9
Referral System
9
Coding System
8
Verificators are not doctors
5
Limited Medicine
4
Lack of Socialization
3
Other
5
Perceived as positive (N=37)
JKN is a Pro-poor Policy
7
Coding System
5
Referral System
5
Nothing positive
4
Other
5
In the follow up interview, the health-care
providers reported that they had not received any
more updates from BPJS since the workshop and
most providers reported not seeing any improvement
in the BPJS system (85%). Fifteen percent of the
providers reported that they were starting to become
BPJS providers after the workshop.
4 DISCUSSION
The study found gaps in the communication between
BPJS as JKN implementers and health-care
providers. Most of the providers found that the
information provided in the BPJS operational
manual was unsatisfactory and they needed to come
to the workshop to get more information and
clarification. In addition, the providers came to the
workshop to share their experiences to give
suggestions for the better implementation of BPJS,
indicating a willingness to open up communication.
Although literatures on communication
between patients and health-care providers are
abundant (Anderson, Wescom, & Carlos, 2016; Kee,
Khoo, Lim, & Koh, 2017; Sandu, Caras, & Nica,
2013), there is a lack of reports on communication
between health care providers and insurance
company, not only in Indonesia, but globally.
However, our finding was in-line with a review
study of publication on JKN reporting that
socialization of technical aspects of BPJS to both
hospitals and community health centres were limited
(Irwandy, 2016; Marlinae, Rahman, Saputra, &
Anhar, 2016).
The study previously reported that 83% of
health-care providers found that BPJS was not
beneficial to providers due to the unrealistic costing
in relation to INA-CBGS, the suboptimal payment
system and complicated management (Sebayang et
al., 2016). The current study has shown that health-
care providers found some positive sides to BPJS
although clarifications are urgently needed to close
the gaps in communication. The clarifications
mostly needed by the providers were for the INA-
CBGS and tariff policy and for updates on the new
regulations. The finding is in line with a study that
reported health care provider dissatisfaction on the
tariffs (Irwandy, 2016).
Participants during the workshop claimed that
the regulations changed too often and sometimes the
changes in the regulations were made effective
retrospectively, affecting past cases that
consequently brought more administrative burden to
the providers. Referrals and the coding system have
the potential for easy clarification as they were
perceived as being both positive and negative by the
participants. Having an effective referral and back-
referral system as well as case coding system will
help the providers in managing their workload.
Clarification on the verification system was also
needed. Providers, mostly having a medical
background, felt that having verificators without a
medical background made their work harder.
Although not opposing verification per-se, the
workshop discussion revealed that the participants
perceived the verificators as not understanding the
cases properly and trespassing doctor’s authority.
The opposition against non-medical personnel doing
the verification of a doctor’s work is a source of
distrust between BPJS and the health-care providers.
Another remaining important challenge for BPJS
was that 15% of the participants did not find any
benefits of BPJS. BPJS may need to design a
comprehensive communication strategy specifically
for providers.
Like other companies, BPJS will benefit from a
more active stance of corporate communication,
such as increase in market, long term reputational
risk management and better management (Eccles &
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
12
Vollbracht, 2006). As BPJS relies heavily on
health-care providers and their quality of care, good
communication between BPJS and providers will
build trust and benefit BPJS in long term
collaboration with health-care providers in providing
health access to all.
5 CONCLUSION
There are gaps in the communication between BPJS
and the health-care providers. Debates between
health-care providers and BPJS have continued,
indicating the need and willingness for both sides to
communicate but the gaps of information persist.
BPJS needs more innovation in their communication
system to bridge the gap with health-care providers
by providing the information that they need and
ensuring updates and socialisation immediately after
any changes in the regulations. Common
understanding needs to be reached for a better
accepted verification system.
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