Overcoming the Budget Deficit of the National Health

Insurance Implementing Agency to Improve Service,

Management and Financial Efficiency

Diana

, Anis Eliyana

, and Mukhtadi

Universitas Negeri Jakarta, Indonesia

Universitas Airlangga, Indonesia

Universitas Pertahanan, Indonesia

muhelharry@gmail.com

Abstract. Indonesia has established a universal insurance scheme, known as the

National Health Insurance (JKN) since January 2014 under the name BPJS

(Social Security Administering Agency). JKN is a merger of four pre-existing

public insurance schemes (Askes insurance for civil servants, Jamkesmas

insurance for the poor, Jamsostek as insurance for private sector workers and

Asabri as Insurance for the armed forces). JKN was designed under the National

Social Security law to meet the basic needs of the people and contribute to the

realization of a prosperous and just Indonesia. With this insurance, it is hoped

that people will not face financial barriers to access health care and hence

increase the use of their health services. After running for 5 years the JKN

program faces many obstacles that need to be corrected from various aspects,

ranging from service procedures, patient handling and payment from the JKN to

the Hospital facing obstacles, JKN's debt to the hospital reaches a very large

amount that affects the performance of the Hospital, both for the procurement of

consumables / medicines and payment for medical services to doctors and other

workers in the hospital. The current problems with the existence of JKN are: the

flow of referrals from health facilities 1 to the referral hospitals requires quite a

long time with a long queue because it is constrained by the administrative

readiness needed to be able to receive JKN services. Medical personnel who

provide services seem slow in providing action, because doctors do not come or

there are activities elsewhere. In addition, patients get drugs that are not

according to the control schedule, for example, a monthly control schedule, the

drugs that are obtained are only for 10 days due to the limited available drugs.

Less optimal services provided to service recipients due to unbalanced incentives

received by service providers / medical personnel also make their performance

diminished. For health service providers (Hospitals) in collaboration with JKN,

it is expected to improve the quality of JKN participant services by increasing the

performance of medical personnel working at the Hospital, so that medical staff

can provide good services to JKN patients by being given incentives in

accordance with their performance. For JKN itself, they must be able to keep the

payment time to hospital partners so that they can provide services to JKN

participants better, JKN is expected to be able to cover the current deficit by

increasing the number of JKN participants, increasing JKN contributions and

inviting JKN participants to pay their contributions on time.

Keyword: JKN

∙BPJS∙Hospital∙Financial∙Budget

838

Diana, ., Eliyana, A. and Mukhtadi, .

Overcoming the Budget Deﬁcit of the National Health Insurance Implementing Agency to Improve Service, Management and Financial Efﬁciency.

DOI: 10.5220/0010598900002900

In Proceedings of the 20th Malaysia Indonesia International Conference on Economics, Management and Accounting (MIICEMA 2019), pages 838-846

ISBN: 978-989-758-582-1; ISSN: 2655-9064

1 Introduction

WHO proposes that all member countries implement universal health coverage to help

people access high-quality health services without financial barriers. WHO

recommendations for universal health coverage are in line with the Alma Ata

declaration which aims to provide high quality services that can be accessed by people

in primary care. In response to these global recommendations, Indonesia has

established a universal insurance scheme, known as the National Health Insurance

(JKN) since January 2014 under the name BPJS (Social Security Administering

Agency).

JKN is a merger of four pre-existing public insurance schemes (Askes insurance for

civil servants, Jamkesmas insurance for the poor, Jamsostek as insurance for private

sector workers and Asabri as Insurance for the armed forces). JKN was designed under

the National Social Security law to meet the basic needs of the people and contribute

to the realization of a prosperous and just Indonesia. With this insurance, it is hoped

that people will not face financial barriers to access health care and hence increase the

use of their health services.

The role of primary care as a gatekeeper for secondary and tertiary care has been

strengthened in JKN implementation. It is hoped that primary care doctors can meet the

basic health needs of the community and must be able to manage most of the patient's

problems. In implementing JKN, this sector is supported by a capitation payment

system. This is a payment concept where private family doctors and Puskesmas

(Indonesia Public Care Clinic) as primary care providers are paid a set payment per

number of registered patients, whether patients come to seek medical assistance or not.

This payment scheme is intended to enable primary care services to focus on health

promotion and disease prevention in addition to healing measures. JKN also introduced

several new health system regulations compared to the previous insurance scheme.

Under the Askes and Jamkesmas schemes in the past, patients are free to access any

primary care services. They can also easily get referral letters from their general

practitioners to access secondary care at the hospital. However, under the JKN scheme,

patients must formally register at the JKN office or practice a designated family doctor

or Puskesmas. Conditions guidelines which can be appropriately managed by doctors

based on their competency standards have also been published. Referrals can only be

made based on appropriate clinical judgment. Therefore, patients must comply with the

procedures set by JKN, in which, JKN will not cover the costs of hospital treatment if

referrals are made outside the guidelines. On the other hand, the Indonesian government

also supports the utilization of primary care under JKN by disseminating information

about JKN procedures to the public and preparing practice guidelines for primary care

providers. This information was spread by large-scale media campaigns including

advertisements on TV and radio; while procedures were made to make registration with

JKN easier for patients.

Unfortunately, there is little evidence available about the factors underlying this

problem arising during the initial implementation of JKN in primary care settings. In

particular, little is known about patients' views and experiences during JKN

implementation, which may be an important factor influencing their decision about

Overcoming the Budget Deﬁcit of the National Health Insurance Implementing Agency to Improve Service, Management and Financial

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839

whether to choose JKN. Information about patient views is important because patients

are real users of health services, and their views and experiences represent actual

conditions in practice settings. The current evidence only shows that there is a different

level of satisfaction with the JKN program in Indonesian provinces (Ekawati et al.,

2017)

After running for 5 years the JKN program faces many obstacles that need to be

corrected from various aspects, ranging from service procedures, patient handling and

payment from the JKN to the Hospital facing obstacles, JKN's debt to the hospital

reaches a very large amount that affects the performance of the Hospital , both for the

procurement of consumables / medicines and payment for medical services to doctors

and other workers in the hospital. A number of hospital directors (RS) complained

about financial problems suffered due to JKN debt, Dr. Cipto Mangunkusumo Hospital

(RSCM), and Sari Asih Hospital Ciledug.

Due to payment arrears from JKN, the Hospital also made changes in the service

and amount of drug administration, this greatly affected the patient's satisfaction with

JKN services. In addition, it also disrupted the performance of the medical staff at the

hospital, because their medical services were also delayed by the arrears of payment

from JKN. Whereas in the industrial 4.0 era, the world of health was demanded to

improve health services and the completeness of a health service center to become a

one stop service. Patients demand to get fast and accurate services.

1.1 Theoretical Background and Discussion

The current problems with the existence of JKN are: the flow of referrals from health

facilities 1 to the referral hospitals requires quite a long time with a long queue because

it is constrained by the administrative readiness needed to be able to receive JKN

services. Medical personnel who provide services seem slow in providing action,

because doctors do not come or there are activities elsewhere. In addition, patients get

drugs that are not according to the control schedule, for example, a monthly control

schedule, the drugs that are obtained are only for 10 days due to the limited available

drugs. So that patients feel less satisfied with the services provided by JKN because the

system is too complicated. Less optimal services provided to service recipients due to

unbalanced incentives received by service providers / medical personnel also make

their performance diminished.

Many participants refer to the closeness between services and their homes and the

convenience of access to primary care services and choose them as their usual way of

health care. In addition, many participants complained that the long waiting times and

facilities at the clinic were less comfortable and limited the enjoyment of their services.

In some cases, participants chose to leave the clinic or choose to go to a private hospital

rather than continuing to queue. Another thing that participants complained about was

that they saw a lack of physical facilities in the clinic that affected their ease of seeing

a doctor. JKN participants felt that JKN had helped people with affordable medical

costs, it still did not resolve inequality and hampered access to high-quality medical

care for people living in the area.

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Hospital as a service industry, customer satisfaction is always influenced by the

quality of interaction between customers and employees who make contact services

(Kotler, 2000). Evidence of service quality appears in flawless or perfect performance

(Berry and Parasuraman, 1990), a concept similar to what is stated as zero defects in

manufacturing. Based on the customer's point of view, service contact (service

encounter or known as the moment of truth) occurs when the customer interacts with

the organization (company) to obtain the services it buys. Basically, there are two main

things related to service, namely hope customers to the quality of customers (expected

quality) and customer perceptions of service quality when receiving services

(experienced or perceive quality) Customers always assess a service received by

comparing it with what is expected or desired. Customer satisfaction in this case is the

patient becomes the key to the performance measure that is said to be perfect, in this

case does not mean meeting rigid standards, but performance that can give satisfaction

approaching 100% from the customer's point of view Customers always assess a service

received by comparing with what is expected or desired. n buying from companies that

offer the highest perceived value, consumers evaluate the benefits it receives with their

sacrifice to obtain the product. Loyal customers are customers who have the

characteristics of, among others, making repeated purchases of the same business

entity, notifying others of satisfaction that is obtained from the company, and showing

immunity to offers from offers from other competing companies. Greater customer

loyalty, in turn, can be determined by trust in the airline brand and by the feelings or

influences that an airline brand has. With the level of acceptance of product quality

(perceive quality) will provide a sense of satisfaction because consumer expectations

for company performance can be achieved properly. Impression or a good image of the

airline brand, for the experience gained by customers will be the key for airlines there

are loyal customers. So the Hospital must pay attention to the satisfaction of JKN

participants in getting services provided by medical personnel in the Hospital.

1.2 Perceived Service Quality

Good service quality arises because of the service strategy related to company policies.

Service strategies must be continuously developed to be maintained and improved,

especially to create customer loyalty. Service strategy must be able to provide the

perceive value received by its customers, such as services that must meet the

expectations of its customers, then this will motivate customers to remain loyal to the

company rather than having to move to a competing company. (Parasuraman 1996)

1.3 Customer Satisfaction

Satisfaction is the level of one's feelings after comparing the performance or results he

feels with his expectations. So, the level of satisfaction is a function of the difference

between perceived performance and expectations. (Kotler 2008)

Overcoming the Budget Deﬁcit of the National Health Insurance Implementing Agency to Improve Service, Management and Financial

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1.4 Corporate Image Corporate Image

Loyalty is the result and satisfaction relationship for good product quality. Selnes

(1993) suggests that the company's brand reputation can be explained together with

shared loyalty and satisfaction. Andreassen and Lindestad (1998) suggested that

intrinsic cues such as attitudes toward products are strongly influenced by products or

services. whereas extrinsic cues such as corporate image are only part of the product or

service.

1.5 Upcoming Customer Loyalty

This model is explaining future loyalty behavior. In the travel and tourism business,

loyalty cannot always be made effective in purchasing tickets. The definition of loyalty

according to Oliver (1999) is as follows: A deeply held commitment to rebuy or

repatronize a preferred product / service consistently in the future causing repetitive

same brand or same brand set purchasing, despite situational influence and marketing

efforts having the potential to cause switching behavior. (Chaudhuri & Holbrook, 200l).

It can be said, loyalty is a deep commitment to repurchase or become a regular customer

and a product / service that is favored consistently in the future, where that commitment

causes repeated purchases of the same flight services, even has the willingness to

recommend service providers to others which are conative aspects.

The Social Security Administering Body (BPJS) or JKN is a legal entity formed to

carry out the health insurance program with the aim of protecting the entire community

with affordable premiums and with wider coverage for the entire community.

Nationally, the number of people as well as the National Health Insurance in Indonesia

has been reached 128 million as of August 2014.

According to the Head of the Marketing and Membership Department of JKN

Regional Division of South West Sulawesi, Southeast Sulawesi and Maluku, Adi

Siswadi, said JKN participants in South Sulawesi who had registered until September

2014 had reached 4.18 million people. JKN health services focus on First Level Health

Services (FKTP) / primary health facilities, such as in Puskesmas. For this reason, the

quality of these primary health facilities must be maintained, bearing in mind the effects

of the implementation of the National Health Insurance going forward, which will result

in increased public demand for health services.

Patient satisfaction is an important element in evaluating service quality by

measuring patient response after receiving services. The existence of an assessment of

these services means the health service facilities are expected to remain standing and

growing. Improving the quality of health services for JKN participants, health services

are no longer concentrated in hospitals or health facilities (health facilities) advanced

level, but health services must be carried out in stages according to medical needs. This

principle will enforce the health services to be focused on

First Level Health Services (FKTP) / Primary health facilities such as in health

centers which will be the main gate for BPJS Health participants in accessing health

services. One of the efforts to strengthen primary health facilities, it is expected that

health workers who are at the level of primary health facilities, must have the ability

and must master the latest things about predictions, signs, symptoms, diagnosis and

comprehensive management of various diseases, because two important elements in

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842

efforts to improve health services are the level of patient satisfaction as a service user

and fulfillment of established service standards. Patient satisfaction is an important

element in evaluating service quality by measuring the extent of patient response after

receiving services.

With a good quality of service, will create satisfaction for patients. One assessment

of service quality, namely reliability, responsiveness, and empathy. Reliability, namely

the ability of health workers to provide promised services in a timely and satisfying

manner. Responsiveness, namely the ability of health workers to help patients and

provide responsive services. Empathy includes the ease of having good communication

relationships and understanding the needs of patients. Health Center has tried to

improve the quality of its services in terms of tangibles by providing clean health

facilities, neat care rooms and the appearance of health workers in uniform and neat, as

well as from insurance aspects by providing safe services, complete medical records

and able to provide information relating to action taken. So that the quality of service

that is the focus of research is reliability, responsiveness, and empathy influence

opatient satisfaction. With this assessment the health service facilities are expected to

continue to stand up and grow.

Patient satisfaction is the customer's response to the discrepancy between the level

of prior importance and the performance of the factual felt after use. Expectations are

directly proportional to the desire of patients to be able to enjoy the service

satisfactorily. If the services provided are as expected, the quality is interpreted as good

and satisfying, and so should.

Health services from health workers provided to patients who are JKN participants

are expected to provide satisfaction to these patients. The quality of health services

must be further improved. Thus, the researcher considers that this needs to be examined

regarding the effect of JKN service quality on patient satisfaction in health care. This

study aims to determine the effect of JKN service quality on patient satisfaction in

health care centers.

In addition to the importance of patient satisfaction in receiving hospital services,

care must also be paid to the performance of medical personnel who provide services

to JKN participants. Performance is certainly a function of individual performance on

specific tasks that consist of standard job descriptions but is also influenced by variables

such as success in maintaining good interpersonal relationships, absenteeism and

withdrawal behavior, substance abuse, and other behaviors that increase workplace

hazards (Murphy & Kroeker, 1988). As such, overall performance is a combined

variable that reflects the extent to which individuals engage in work behavior that

contributes to, or reduces, the achievement of goals related to their work (Astin et al.,

2003).

The government in an effort to improve the quality of human resources to provide

health services issued several regulations aimed at maintaining the quality and

competence of graduates of the health workforce, but this is not easy because getting a

registration certificate or recommendation issued by a collegiate requires a long time,

requirements the long one. In addition, the Government standardizes hospitals by

holding hospital accreditation that aims to equalize the standard of services provided to

patients, including the administrative requirements that must be carried out by nurses.

However, this makes nurses spend more time completing administrative data than

serving patients. Therefore, hospitals as a place for health services are demanded to

Overcoming the Budget Deﬁcit of the National Health Insurance Implementing Agency to Improve Service, Management and Financial

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843

have reliable nurses and high job performance. Here what is meant by Job Performance

refers to overall performance and not just the performance of single tasks. Job

Performance is a function of individual performance on specific tasks consisting of

standard job descriptions but is also influenced by variables such as success in

maintaining good interpersonal relationships, absentee and withdrawal behavior,

substance abuse, and other behaviors that increase harm in the workplace (Murphy &

Kroeker, 1988).

Conceptualization of performance has been expanded in recent years to include core

Task Performance, citizenship performance, and counterproductive performance. Core

Performance Task refers to the basic tasks required of a particular job. Citizenship

performance refers to the extra behavior carried out by employees (eg, assisting

coworkers), exceeding and above the requirements of their core tasks, which actively

promote and strengthen organizational effectiveness (Hunt, 1996; Organ, 1988).

Counter-productive performance refers to the behavior carried out by employees who

intentionally endanger the welfare of the organization (Bennett & Robinson, 2000).

Rotundo and Sackett (2002) find that each of these three behavioral categories

contribute to overall performance rankings, with the core Performance Task given the

greatest weighting, followed by counterproductive performance and citizenship

performance.

So based on the results of the concept study above, it can be synthesized that

performance is the behavior or actions of employees in their work at the individual level

which measures the achievement of employees in the organization and the process by

which the employee reaches the target given and even surpasses it. In addition to the

problem of satisfaction from JKN participants, there is news that has become JKN's

problem, arrears of payments to the hospital for months, amounting to approximately

Rp. 9.1 trillion in mid-2019, so this disrupts the performance of hospitals in providing

services to JKN participants , and also the hospital late to provide medical services to

its medical personnel.

Many efforts have been made to overcome all existing problems in various ways,

one of them to JKN stakeholders has been conveyed that the Health BPJS has signed

Memorandum of Understanding (MoU) with several banks to overcome short-term

liquidity problems through supply chain financing. The Social Security Administering

Body (BPJS) assesses the Minister of Finance Regulation (PMK) number 33 of 2019

regarding Amendments to PMK No.10 / PMK / 02/2018 concerning Procedures for

Provision, Disbursement and Accountability of Health Insurance Fund Contributions

Recipients of Contribution Aid to provide liquidity certainty for BPJS.

In PMK No33 / 2019 it is stated in article 7 that in the event of liquidity problems,

BPJS Health can submit bills for a maximum of the next three months. The bill was

intended for contribution funds for Recipient Assistance (PBI). PBI contribution funds

will be the responsibility of JKN in this case BPJS Health both formally and materially.

The use of funds will also be audited by an independent auditor. Disbursement of these

funds is expected to help the JKN partner hospitals to continue to operate to function

as a servant of JKN participants. What has been done to overcome the problems of debt

and BPJS Health deficits, the government has tried to finance the JKN-KIS program by

paying contributions for poor and disadvantaged people. In addition, the government

MIICEMA 2019 - Malaysia Indonesia International Conference on Economics Management and Accounting

844

also becomes an employer for the state apparatus and pays contributions in a timely

manner.

The government's commitment beyond those two obligations is to inject additional

state budget funds that have been done continuously as the government's commitment

to close the deficit so far while continuing to evaluate JKN. The government is looking

at whether there are other things that can still be done so that the process of increasing

fees becomes a last resort. So that it can be more understood by the community if the

choice to increase the fee is taken.

At this time the Presidential Regulation of The Republic of Indonesia Number

75/2019 Concerning Amendment to The Presidential Regulation Number 82/2018

Concerning Health Warranty which states the adjustment of JKN participant

contributions, which is expected to increase the contribution of these participants to

cover the deficit that has occurred so far, hope there will be no future health guarantees.

the delay in JKN payments to the Hospital, so that Hospitals that have collaborated with

JKN can provide maximum service to JKN participants.

2 Conclusion

With many obstacles experienced by JKN, both by JKN participants, health service

providers (Hospitals) and JKN as health funders, there must still be a lot of

improvements to the JKN service system so that JKN participants have the convenience

of receiving services without going through more efficient procedures , can get

treatment faster and get appropriate treatment so that the goal of JKN to improve the

health status of Indonesian people can be achieved and JKN participants are satisfied

with the services provided by JKN partner hospitals.

For health service providers (Hospitals) in collaboration with JKN, it is expected to

improve the quality of JKN participant services by increasing the performance of

medical personnel working at the Hospital, so that medical staff can provide good

services to JKN patients by being given incentives in accordance with their

performance.

For JKN itself, they must be able to keep the payment time to hospital partners so

that they can provide services to JKN participants better, JKN is expected to be able to

cover the current deficit by increasing the number of JKN participants, increasing JKN

contributions and inviting JKN participants to pay their contributions on time . Also if

possible JKN can look for donors outside the existing provisions with supporting

provisions. JKN is expected to improve the flow of JKN participant services to be more

efficient, more open about the financing of medical services provided to partner

hospitals, so that the medical staff understand the services provided by JKN whether it

is in accordance with the service rates set by the Hospital.

References

Andreassen TW, Lindestad B. (1998), “Customer Loyalty and Complex Services: The Impact of

Corporate Image on Quality, Customer Satisfaction and Loyalty for Customers with Varying

Overcoming the Budget Deﬁcit of the National Health Insurance Implementing Agency to Improve Service, Management and Financial

Efﬁciency

845

Degrees of Service Expertise. International Journal of Service Industri Management, Vol. 9,

No. 1, pp. 7–23.

Arjun Chaudhuri; Morris B Holbrook. (2001). “The Chain of Effect from Brand Trust and Brand

Effect to brand preformance : The Role of Brand Loyalty”. Journal of Market Focused

Management.

Astin, J. A., Shapiro, S. L, Eisenberg, D. M., & Forys, K. L. (2003). Mind-body medicine : States

of the science, implications for practice. Journal of the American Board of Family Practice,

16, 131-147.

Bennet, Rebecca J, Robinson, Sandra L. (2000). Development of a Measure of Workplace

Deviance. Journal of Applied Psychology 85(3):349-60. DOI: 10.1037/0021-9010.85.3.349.

Christine Novita Nababan, CNN Indonesia | Thursday, 04/18/2019 BPJS Health Pays Rp11

Trillion Through the State Budget 'Bail'

Ekawati, F. M., Claramita, M., Hort, K., Furler, J., Licqurish, S., & Gunn, J. (2017). Patients'

experience of using primary care services in the context of Indonesian universal health

coverage reforms. Asia Pacific Family Medicine, (January 2014), 1–10. https://doi.org/

10.1186/s12930-017-0034-6

Hunt, SD & Morgan, RM. (1996). The resource-advantage theory of competition: dynamics, path

dependencies, and evolutionary dimensions. Journal of marketing 60 (4), 107-114

Kotler, Philip. (2000). Prinsip – Prinsip Pemasaran Manajemen, Jakarta : Prenhalindo.

Kotler, Philip; Armstrong, Garry. (2008). Prinsip-prinsip Pemasaran, Jilid 1, Erlangga, Jakarta.

Murphy, K.R. and Kroeker, L.P. (1988). Dimensions of Job Performance. Colorado State

University, Fort Collins.

Oliver, Richard L. (1999). “Whence Consumer Loyalty”. Journal of Marketing.Volume 63

Special Issue, pp. 33-44.

Organ, D.W. (1988). Organizational Citizenship Behavior: The Good Soldier Syndrome.

Lexington, MA: Lexington Books.

Peraturan Presiden Republik Indonesia Nomor 25 Tahun 2019 Tentang Perubahan Atas

Peraturan Presiden Nomor 82 Tahun 2018 Tentang Jaminan Kesehatan.

Rotundo, M. and Sackett, P.R. (2002). The Relative Importance of Task, Citizenship, and

Counterproductive Performance to Global Aspects of Job Performance: A Policy-Capturing

Approach. Journal of Applied Psychology, 87, 66-80. http://dx.doi.org/10.1037/0021-

9010.87.1.660.

Selnes, F. (1993). "An Examination of Effect of Pruduct Performance on Brand Reputation,

Satisfacation and Loyalty". European Journal of Marketing, Vol. 27, No. 9, pg. 19.

Undang Undang Republik Indonesia Nomor 24 Tahun 2011 tentang Badan Penyelenggara

Jaminan Sosial

Yanurisa, Ananta. (2019). Hospital Complains of Bloody Financial Failure. BPJS Health. CNBC

Indonesia.

Zeithaml, Valerie A., Berry Leonard L. & Parasuraman, AV. (1996). The Behavioral

Consequences of Service Quality. Journal of Marketing 60(2). DOI: 10.2307/1251929.

MIICEMA 2019 - Malaysia Indonesia International Conference on Economics Management and Accounting

846