The Analysis of JKN-KIS Hospital Outpatient Referral System

Implementation Subsequent to Online Referral Application

Lisa Riati, Ade Heryana, Cut Alia Keumala Muda and Erlina Puspitaloka Mahadewi

Department of Public Health, Faculty of Health Sciences, Esa Unggul University, 9 Arjuna Utara, West Jakarta, Indonesia

Keywords: National Health Insurance, Vertical Referral System, Outpatient Services, Health Service System, Back

Referral System.

Abstract: National Health Insurance Program (JKN) carried out in referral system mandatory for members and health

care providers, that hadn’t optimum in the implementation caused mismatch in submit the selected specialist

and input the diagnoses, online reference numbers are not found, lack in giving the explanations for referral

agreements, and incomplete filling the referral letters. This research aims to studying the implementation of

hospital outpatient referral system in order to recommend various improvements. This research used

Qualitative-Quantitative approaches (Mixed Method) with primary and secondary data. Five informants

were included in this research, 114 participants for Quantitative study, and observed some relevant

documents. The results of the Qualitative research revealed that vertical referrals to hospital had been

implemented according to policy, but back referral system is still not running optimal. From survey study

showed that 91.2% participant had approved in referral services, but 94.7% had incomplete contents of

referral letter. It’s suggested to arrange cooperation and coordination between insurance operator (BPJS),

healthcare provider (Hospital Management, Specialist) and members (patients) to optimize referral system.

It is expected that the results of this research could give the insight for the Hospital and related institutions

in improving various aspects related to the optimized of referral system.

1 INTRODUCTION

The National Health Insurance Program (JKN)

began to be implemented from 1 January 2014. The

Program is the mandate of Undang-Undang Nomor

40 Tahun 2004 on SJSN, which is held with

mandatory health insurance mechanisms. JKN was

implemented gradually and was expected to reach

the Universal Health Coverage (UHC) in 2019.

Public legal entity that is assigned the task and

responsibility to conduct JKN program namely

Badan Penyelenggara Jaminan Sosial (BPJS)

Kesehatan (Mas'udin, 2017).

The referral system is organized with the aim of

providing good quality healthcare, so that the

purpose of service is achieved without having to use

expensive costs. It is called effective and efficient.

The referral system in Indonesia is governed in

Permenkes Nomor 001 Tahun 2012 on Sistem

Rujukan Pelayanan Kesehatan Perorangan.

On August 15th, 2018 BPJS Kesehatan has been

implementing an online referral system trial. Online

Referral System JKN-KIS is a digitizing referral

process for the ease and certainty of participants in

obtaining services in the hospital tailored to the

competence, distance and capacity of the hospital

referral purpose based on the need medical patients.

The reason for the reference for online referral is

because the implementation of a level of reference in

each region refers to local regulations, participants

who reside on the border area can’t access the

facility if not in accordance with the settings local

governments are concerned with regulatory referral

arrangements in the region. Participants referred to

the referral facility, do not obtain the necessary

services due to the limitation of information

regarding medical needs, infrastructure and human

resources (SDM) so as to cause the participants

should again be referred to Other health facilities.

The queue that accumulates in the hospital is due to

be a reference focus on the area. There is no

information system that can manage the

implementation of referrals online and real time

(BPJS Health, 2018).

Hospital X is a type B in the city of Tangerang

which is one of the private of the recipient of the

Riati, L., Heryana, A., Muda, C. and Mahadewi, E.

The Analysis of JKN-KIS Hospital Outpatient Referral System Implementation Subsequent to Online Referral Application.

DOI: 10.5220/0009562500290033

In Proceedings of the 1st International Conference on Health (ICOH 2019), pages 29-33

ISBN: 978-989-758-454-1

good referral from primary care and secondary care

Banten province. Since the online referral system

trial of August 2018 RS X has received an

introduction to online referrals from referrer facility.

Based on survey for data related to the

explanation provided by the health worker in terms

of approval given the reference of 15 respondents,

there are 2 (13.3%) the respondent who did not get

an explanation regarding referral approval. Related

to the completeness of the referral letter is obtained

that from 54 files there are 51 (94.4%) unsuitable

files. For patients who back referral to hospital X

have not reached the target. With the background of

the problem researchers are interested in Analysis of

JKN-KIS Hospital Outpatient Referral System

Implementation Subsequent to Online Referral

Application.

2 THEORY

Health Service system in accordance with Perpres

Nomor 72 Tahun 2012 on Sistem Kesehatan

Nasional (SKN) is the management of health

organized by all components of Indonesia in an

integrated and mutually supportive Ensuring the

degree of public health highest. According to SKN's

understanding, health efforts consist of two main

elements.

Upaya Kesehatan Masyarakat (UKM) and Upaya

Kesehatan Perorangan (UKP) must run

synergistically. Indonesia has established that the

UKM program with its community-related

promotive and preventive efforts is the responsibility

of the government (Kemenkes and Dinkes). The

UKP is a person who is managed by BPJS

Kesehatan. In the decentralized system, UKM

funding is now the responsibility of local

governments. Local government as a party to know

the health condition in the area is given a mandate

not only to organize, but also to develop and

strengthen UKM as complementary elements or a

strong companion in the health insurance

(Darmawan, 2016).

To achieve the optimal degree of public health

needs to be held various health efforts by collecting

all the potential of the Indonesian nation.

Maintenance of various health efforts requires the

support of funds, human resources, drug resources

and health supplies as input SKN. Based on the

concept of UKM and UKP in health efforts there is a

level of health care system that is: community,

primary services, secondary services, and tertiary

services.

A referral system is essentially aimed at

generating an efficient health service system. A level

referral system can reduce the waste of cost (patients

and facilities) because the patient's disease is

handled by the appropriate medical personnel and

technology. In this case there is no irrational health

service and that is not enough. The referral system

has a fairly long history since the system had not

existed in the early 1800 to 2005 in the form of

Gatekeeper. This history differs between developed

countries and developing Countries (Heryana, 2019).

According to (Bossyns, 2006) on the developed

world, the history of the referral system is initiated

by the medical information organization, then

followed the agreement between the medical

profession which ultimately provides

recommendations for creating the specifications of

the more common medical practitioners or General

Practitioner (GP). The history of the referral system

in the country ends with the application of

Gatekeeper and health care cost calculation. While

in the developing world, the history of the referral

system begins with the absence of access to most of

the population to hospital services, and is

recommended to form a primary facility with

inexpensive costs and quality in certain areas

(Heryana, 2019).

3 METHOD

This research used Qualitative - Quantitative

approaches (Mixed Method) with primary and

secondary data. Five informants were included in

this research, 114 participants for Quantitative study,

and observed some relevant documents.

4 RESULTS AND DISCUSSION

4.1 Vertical Referral Search

Based on the research results related to the vertical

reference to RS type B is obtained information that

the referral system from primary care is still that

hadn’t optimum in the implementation caused

mismatch in submit the selected specialist and input

the diagnoses, online reference numbers are not

found, lack in giving the explanations for referral

agreements, and incomplete filling the referral

letters. While the vertical reference of RS type C to

RS type B has been quite good with the spokes

occurring cases of errors such as in the primary care.

ICOH 2019 - 1st International Conference on Health

There are differences in the vertical reference system

before and after the online referral system is applied,

the patient must follow referral system. Constraints

that occur when make a vertical reference that does

not comply with the existing provisions is wrong the

destination that causes the patient to wait for service.

The lack of file requirements brought to the patient

would have to return back to the referrer facilities to

create or retrieve the corresponding file.

4.2 Referral Services Search

From the results of the study concluded for the

explanation of the reference process has been well

seen from the frequency distribution of 114

respondent that has been given to the outpatient day

with approval of 104 (91.2%) which the doctor has

given explanation related to the reasons for

referring, diagnosis, therapy, medical action

provided, explanation of the risk arising and 10

(8.8%) frequency distribution that is not given the

explanation of referral approval. In this case, the

doctor understands the importance of education

before the patient should be referred to in relation to

the diagnosis, action or treatment needed if not

available in the hospital. From 104 respondents

given the explanation of the referral agreement,

there are 33 (32%) respondent that does not obtain

any risk or complications that occur, in this case

may be due to communication from a physician who

is lacking, also related to the low level of patient

education leading to the communication given

Cannot be understood, and there are 27 (26%)

respondent who did not get an explanation related to

the diagnosis and therapy or medical action required

because when communicating with the patient, the

doctor uses medical terms that cause the patient

can’t understand the condition actually happened.

4.3 Referral Letter Search

Based on the results of the research related to the

accuracy of the reference cover letter judging from

the frequency distribution of 114 files in observation

obtained data that there is 108 (94.7%) which is still

incomplete and only 6 (5.3%) the completed filling.

The result of the observation of the reference file of

the referrer facilities is still a lot of inaccuracies in

the filing of a referral letter. From 114 to the

introduction of the referral letter, only 10 files that

have been filled with examination results

(anamneses, physical examination and supporting

examination) have been conducted, only 21 files

filled with therapy or actions that have been given,

and 79 file that is populated for subsequent

management.

The accuracy of manual reference filling is still

incomplete, in research at RS X get the referrer

facility there are still many that have not filled in the

complete contents in the referral letter. Based on the

results of the research of Hartini (2016) that the

completeness of the reference letter with clear

writing and can be read in the referral service of

BPJS patients in the Chatib Quzwain Sarolangun’s

hospital has qualified as the regulations that have

been Established, but nevertheless found one or two

filling columns in a less complete reference. Ideally,

the completeness of the reference letter field with

clear writing is one of the requirements in the

referral process in order to provide optimal

information for optimal patient handling as well.

4.4 Back Referral Search

By research it can be concluded that related to the

implementation of the reference program is still not

running optimally. There are some obstacles that

occur is less understanding of the specialist doctors

related to the program of the reverse reference,

diagnosis or condition of the patient who has not

stabilized according to the doctor, there are no

specific criteria for diagnosis that has been

expressed in the back referral program, the patient

does not want to be back referral, and the

availability of drugs are still lacking in primary care

or pharmacies that have been working with BPJS

Kesehatan that causes the patient to return to the

secondary care to get the therapy.

This is to be examined by Primasari (2015) The

reference provisions have not been properly

implemented in the Dr Adjidarmo’s hospital, this is

due to the understanding of some doctors about the

reference, limitation of the drug in primary facilities,

so that the patient is once back referred to the drug

to hospital to obtain the necessary medication. The

lack of information from BPJS Kesehatan to the

doctors about the referring system makes a

difference in perception that results in the unoptimal

referral activity in the hospital. The lack of a

reference system also occurs due to the way the drug

is assessed as less effective when the patient is

referred back to primary care and the less effective

way of communicating for participants to obtain

complete information relating to the provision of

Drug of the reference program in primary care and

pharmacies who have collaborated with BPJS

Kesehatan.

The Analysis of JKN-KIS Hospital Outpatient Referral System Implementation Subsequent to Online Referral Application

5 CONCLUSION

5.1 Referral

The vertical reference from primary care to RS X is

obtained information that the referral system from

primary care is still that hadn’t optimum in the

implementation caused mismatch in submit the

selected specialist and input the diagnoses, online

reference numbers are not found, lack in giving the

explanations for referral agreements, and incomplete

filling the referral letters. Weak coordination

between the agencies that caused the error.

Meanwhile the vertical reference for secondary care

is good enough. The vertical reference document in

RS X consists of: Handbook of BPJS Kesehatan,

Permenkes Nomor 001 Tahun 2012, Letter of

Commitment from BPJS Kesehatan, and hospital

memorandum.

5.2 Referral Services

Giving explanation of referral approval before the

patient is referred from primary care or secondary

care to RS X is good. Of the 114 respondents who

were treated to outpatient poly, there were 104

respondents (91.2%) which has been given

explanation of approval, meanwhile there are 10

respondents (8.8%) which is not given an

explanation of referral approval. In the case of a

referral letter, the doctor has explained the reasons

for referring, diagnosis, therapy, medical actions

provided, and the risk explanation arising.

5.3 Referral Letter

The accuracy of the contents of the reference letter

in RS X of primary care and secondary care is still

lacking. Of the 114 files in observation found that

there were 108 files (94.7%) which is still

incomplete. While the completed filling is only 6

files (5.3%). For charging a referral letter in RS X to

another facility is good.

5.4 Back Referral

The reference to RS X has not been running with

maximum. Still constrained by the lack of

understanding of doctors related to the referral

program, the specialist as a whole knows the

existence of the program, but not described the

specific criteria of patients who have been stabilized

to be referred back such as what, because the

patients referred to RS X are patients with

conditions that can’t be handled in the lower facility

and mostly with double diagnosis, so that the

specialist still struggling to run the program. Patients

who have been stable and should be back referral

expressed objections, because the drug therapy

prescribed by the doctor is not available in primary

care and pharmacies. Program BPJS Kesehatan

related to the reference in terms of the citation more

can control the cost of expenditure paid to primary

care than cost for advanced facility. For vertical

reference document in RS X consists of: Handbook

of BPJS Kesehatan, Permenkes No 001 Tahun 2012,

Letter of Commitment from BPJS Kesehatan, and

hospital memorandum.

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The Analysis of JKN-KIS Hospital Outpatient Referral System Implementation Subsequent to Online Referral Application