A Glimpse of BPJS

Tauhid Nur Azhar

Photo by Nappy on Unsplash

This morning, after briefly reading five essays submitted by LPDP scholarship applicants, my thoughts wandered to the concept of our national health insurance system, BPJS. Perhaps there were several triggers, such as one of the essays I read after dawn, which was written by a healthcare worker, a midwife at a community health center in Tolitoli Regency, Central Sulawesi. Or maybe it was because my wife was recently treated at a BPJS referral hospital due to respiratory issues caused by an infection (pneumonia) with the co-morbid factor of asthma.

From my experience with using BPJS, such as when my eldest child was treated at the same hospital as her mother some time ago, or when I took care of my father who was also treated at a hospital with health insurance facilities, I was quite impressed and had a good impression of the standard of service and insurance procedures used.

Of course, I have heard a lot of criticism, input, and even grumbles from various parties, both representing patients and their families, or from healthcare facilities at various levels; from primary to referral, healthcare workers, and various other related parties. I think this is reasonable and is part of the dynamics of the national health insurance system, which has a spectrum of elements and complex issues.

But allow me in this morning’s writing not to position myself with the perspective of a user or program manager in the field. On this occasion, I only want to educate about the national health insurance system, especially so that we can all learn about the system and how it works, hoping to gain an objective understanding of this national health insurance system. I write and try to elaborate on this theme not just because one of the current BPJS directors, specifically the Director of Health Service Insurance, is my mentor, senior, and friend since studying at the Faculty of Medicine, Diponegoro University, but simply because I want to convey information based on my knowledge related to the national health insurance system.

Let’s start this morning’s writing by trying to look at the national health insurance systems implemented in two countries that are often considered benchmarks or standards in various fields, including health. These two countries are the United Kingdom and the United States of America.

The UK, or as some of us know it as England, has a very famous health insurance system called the National Health Service (NHS). This system began operating in 1948 with the aim of providing comprehensive healthcare, free at the point of use, for all UK residents. The NHS is primarily funded by general taxation and national insurance contributions.

Most of the NHS funding comes from taxes and national insurance. Therefore, healthcare costs are collectively borne by society. All UK residents, including citizens and permanent residents, can access NHS healthcare services without paying directly at the point of service. This means that general practitioner (GP) services, inpatient care, surgery, and most prescription drugs can be obtained free of charge at the time of service.

The NHS emphasizes the importance of primary healthcare services through a strong GP network. GPs act as the gatekeepers of the healthcare system, providing preventive services, initial diagnosis, and referrals to specialist services if needed.

Although the NHS continues to face challenges such as waiting lists for elective procedures and cost pressures due to an aging population, the system is recognized as efficient due to relatively low administrative costs and is considered fair because access to services does not depend on the ability to pay.

Meanwhile, the health insurance system in the United States is very different from the UK because it is pluralistic, complex, and dominated by the private sector. The United States does not have a centralized universal health insurance system. The main characteristic of its health insurance system is mixed funding with various mechanisms.

Most of the population obtains health insurance through their employers (employer-sponsored insurance). The premiums for this insurance are partly paid by the employer and the employees.

It is called mixed because there are also government programs for specific groups, such as Medicare, a federally funded program for individuals aged 65 and over and some people with disabilities.

Then there is Medicaid, a joint federal and state program for low-income residents.

There is also the Children’s Health Insurance Program (CHIP), which is dedicated to children from middle- to low-income families who do not qualify for Medicaid.

Recently in the USA, the Affordable Care Act (ACA) has been implemented/enforced since 2010, aimed at expanding insurance coverage through subsidies for middle- to low-income individuals and expanding Medicaid in some states. The ACA also prohibits insurance companies from denying insurance due to pre-existing health conditions.

What about in our own country? Over the past few decades, as countries around the world race towards achieving universal health coverage (UHC), Indonesia has also been striving to realize this concretely through the implementation of the National Health Insurance (JKN) system managed by the Social Security Agency (BPJS) Kesehatan.

This system not only aims to provide comprehensive access to healthcare services for all Indonesian citizens but also serves as a crucial pillar in improving governance, efficiency, and equity in healthcare services.

The origins of the health insurance system in Indonesia can be traced back to the pre-reform era, when the government began providing health insurance for civil servants and TNI/Polri (Askes) and insurance for formal sector workers (Jamsostek). However, these programs did not cover the entire population. The idea of unifying these social insurance schemes gained strength post-reform, accompanied by a spirit of equality and social justice.

Law №40 of 2004 on the National Social Security System (SJSN) serves as the legal basis mandating the establishment of a single social security agency. As a follow-up, BPJS Kesehatan was officially established on January 1, 2014, merging PT Askes (Persero) into a single entity responsible for the health insurance of all Indonesian residents.

BPJS Kesehatan is tasked with implementing the JKN program based on the principle of mutual cooperation, where each participant pays affordable premiums according to their ability, while those who cannot afford it are subsidized by the government. The main functions of BPJS Kesehatan include, among others:

1. Fund Collection: Collecting premiums from participants, including wage earners, non-wage earners, and recipients of premium assistance (PBI) from the government.
2. Financial Risk Management: Spreading healthcare financing risks among a broad population, so individuals are not burdened with unaffordable healthcare costs.
3. Healthcare Service Financing: Paying for healthcare services to primary healthcare facilities (FKTP) and advanced referral healthcare facilities (FKRTL) through capitation and INA-CBG mechanisms.
4. Quality and Efficiency Improvement: Collaborating with the Ministry of Health and other stakeholders to ensure service quality and promote cost efficiency.

The main goal of JKN is to achieve universal health coverage, a condition where everyone receives quality healthcare without financial difficulties. Through JKN, the community, especially low-income individuals, can access healthcare services that were previously inaccessible. For poor families, the cost of treating catastrophic illnesses (such as heart disease, cancer, and kidney failure) can be covered by this system.

The existence of JKN also increases the health literacy of the community, as easier access encourages individuals to be more proactive in checking their health and preventing illness.

The governance process of the JKN system is designed considering efficiency, transparency, and accountability. Some key elements in this governance include:

1. Regulations and Policies: Regulations are issued through Laws, Presidential Regulations, and Ministerial Regulations. The National Social Security Council (DJSN) monitors and evaluates the program implementation.
2. Payment Mechanism:

• Capitation: Pre-payment per capita for FKTP, encouraging efficiency and enhancing the role of primary services.
• INA-CBG: Package payment per episode of care for inpatient and advanced outpatient cases, based on case classification (Case-Based Groups).

3. Information Technology: Implementation of an integrated information system, from the Mobile JKN application to the electronic claims system, improves administrative processes and minimizes fraud potential.

The stakeholders (stakeholders) involved in the implementation of JKN are very diverse, including:

1. Central and Regional Governments: The Ministry of Health, Ministry of Finance, and regional governments help register poor participants and support healthcare infrastructure.
2. BPJS Kesehatan: As the implementing agency, BPJS Kesehatan manages administrative processes, premium collection, claim verification, and payments to healthcare facilities.
3. Healthcare Facilities: Both primary healthcare facilities (community health centers, clinics, private practitioners) and advanced facilities (hospitals) provide services according to quality standards.
4. JKN Participants: The entire Indonesian population, including formal and informal workers and subsidized vulnerable groups by the government.
5. Supervisory and Audit Bodies: DJSN, Financial and Development Supervisory Agency (BPKP), and independent audits to ensure accountability in fund usage.

To gain a comprehensive understanding of the dynamics and development of JKN in Indonesia, let’s analyze the facts based on data from the 2016–2021 period, sourced from BPJS Kesehatan statistical reports.

This simple analysis is based on data commonly found in annual and statistical reports of JKN, including the number of participants, coverage, service utilization, financial burden, and service quality indicators. Please note that this analysis is generic and based on patterns and trends commonly reported by BPJS Kesehatan for that period. If there are specific figures, consider them as illustrative examples that approximate the data usually included in the official reports.

From 2016 to 2021, the number of JKN participants consistently increased. In 2016, the number of participants was around ±170 million, while in 2021, this number increased to ±220 million.

The increase in participants generally occurred across all segments of participation, such as Premium Assistance Recipients (PBI), Wage Earners (PPU), Non-Wage Earners (PBPU), and Non-Workers. However, the PBI segment showed significant growth due to government subsidy policies.

During this five-year period, the number of primary and advanced outpatient visits increased. This indicates an increase in access to healthcare services. For example, in 2016, the total number of primary outpatient visits was ±110 million, increasing to ±140 million visits in 2021. This increase was accompanied by an expansion of the healthcare facility network, both FKTP (Primary Healthcare Facilities) and FKRTL (Advanced Referral Healthcare Facilities).

The total expenditure incurred by JKN continued to increase with the growing number of participants and increased service utilization. For example, in 2016, the total healthcare service cost was around Rp. 60 trillion, increasing to over Rp. 100 trillion in 2021. Most of the funding was allocated for catastrophic illnesses such as heart disease, cancer, kidney failure, and stroke. This trend has been consistent from year to year, showing a dominant pattern of non-communicable disease burden.

Regarding capitation in healthcare facilities, including those under the Ministry of Home Affairs, the management of capitation funds has been regulated in the Minister of Home Affairs Regulation (Permendagri) №28 of 2021, which contains regulations on the recording and verification of capitation funds for the National Health Insurance (JKN) in primary healthcare facilities (FKTP) owned by regional governments.

Meanwhile, the standard tariffs and adjustments to the amount of capitation funds in line with the dynamics of various relevant economic indicators, among others, have been regulated in the Minister of Health Regulation №3 of 2023 on the Standard Tariffs for Healthcare Services in the Implementation of the Health Insurance Program, announced on January 9, 2023. This regulation is in line with efforts to increase promotive and preventive efforts in FKTP and the evaluation of FKTP performance in providing the best promotive and preventive services. Additionally, this regulation includes an increase in services that can be paid through BPJS and adjustments to the cost per unit for various medical procedures in FKTRL.

Data shows a significant increase in the number of participants, approaching Universal Health Coverage (UHC). According to the theory of universal coverage (Frenz & Vega, 2010), the increase in the number of participants reflects the government’s commitment to expanding access to healthcare.

The dominance of non-communicable diseases in the JKN financial burden is in line with the epidemiological transition occurring in Indonesia (Mboi et al., 2017). The aging population and lifestyle changes increase the incidence of chronic diseases, which in turn increases the financial burden on the JKN program.

The increase in the number of visits reflects increased accessibility. According to the Andersen Health Behavior Model (Andersen & Newman, 1973), increased access to healthcare services is reflected in the ease with which the community utilizes healthcare facilities when there is financial insurance. This indicates that JKN contributes to reducing financial barriers in accessing healthcare services.

The increase in claims and healthcare service costs puts pressure on the financial sustainability of JKN (Agustina et al., 2019). Experts emphasize the need for renewed financing strategies, increased efficiency in claim management, and strengthened promotive and preventive efforts to prevent cost escalation in the future.

It cannot be denied that, in line with health economics theory stating that increasing health insurance coverage will increase demand for services (demand) as financial barriers decrease (Cutler & Zeckhauser, 2000), the number of participant visits to healthcare facilities will continue to increase year by year.

And it cannot be denied that the trend of catastrophic diseases falling within the realm of degenerative metabolic conditions will dominate. This is in line with Omran’s Theory of Epidemiological Transition (1971), which states that developing countries will shift from infectious diseases to degenerative and chronic diseases as economic and social development progresses. The 2016–2021 JKN trend supports this theory, as seen from the expenditure dominated by non-communicable diseases.

For the following period, 2021–2023, since 2024 is still ongoing, the focus is on existing verified data.

After reaching ±220 million participants in 2021, JKN participant coverage continued to increase in 2022–2023. By the end of 2022, the number of participants was estimated to have reached ±225 million, and in 2023, it increased again to around ±230 million.

This growth indicates that Indonesia is approaching universal coverage (Universal Health Coverage/UHC). This increase is seen across all segments of participation, with consistent government support for the PBI group.

Post-COVID-19 pandemic, there has been an increase in visits to healthcare facilities as community mobility and economic activity recover. Outpatient visits to FKTP and FKRTL slightly decreased in early 2022 due to ongoing mobility restrictions but increased again in the second half of 2022 to 2023. For example, the total number of primary outpatient visits at the end of 2023 is estimated to have increased by around 5–10% compared to 2021. During this period, several telemedicine services and BPJS Kesehatan mobile applications have been optimized, making it easier for participants to obtain information and basic services without always having to physically visit healthcare facilities.

The financial burden in 2022–2023 is still on an increasing trend, with estimates exceeding Rp. 110–120 trillion in 2023. This increase is influenced by the cost of treating chronic cases that continue to dominate expenditures.

Catastrophic diseases such as kidney failure, cancer, and ischemic heart disease remain the largest contributors. Nevertheless, in 2022–2023, there have been intensified promotive-preventive efforts (such as through health screenings) to curb the increase in severe cases in the future.

Quality indicators such as waiting times, drug availability, and patient satisfaction have gradually improved. Online referral programs, queue system improvements, and the development of the JKN mobile application have contributed to improved access and participant comfort.

However, regional disparities remain a challenge. Remote areas still face infrastructure and medical personnel limitations, so service quality is not entirely uniform.

With approximately ±230 million participants by the end of 2023, this trend supports the UHC target. This is in line with the theory that expanding coverage increases accessibility and service utilization (Frenz & Vega, 2010). The dominance of non-communicable diseases (NCDs) continues. Omran’s theory of epidemiological transition (1971) remains relevant in this period. In the context of 2022–2023, increased screening and promotion of healthy lifestyles have begun to be implemented to control the long-term cost and burden of NCDs.

Now we come to a part that, in my opinion, is crucial in the context of implementing the JKN system, which is the identification of disease groups and the regulation of their financing patterns. Isn’t this the essence of any health insurance system? Although the focus and emphasis should now shift from curative to preventive and promotive aspects, shouldn’t it? For Indonesia, the system developed and adopted from global standards with innovative adaptive development according to national needs is INA-CBG.

INA-CBG (Indonesia Case-Based Groups) is a system for grouping healthcare services based on clinical characteristics (diagnosis, procedures) and resources used to treat patients. This approach is similar to the Diagnosis Related Groups (DRG) system used in many other countries. The main goal of INA-CBG is to simplify the claim and payment system to healthcare facilities so that it is no longer based on itemized billing (fee for service) but rather on bundled payments for an episode of care.

Briefly, the steps in calculating using the INA-CBG approach include:

1. Patient Data Collection: Patient data treated at healthcare facilities (hospitals) will be recorded in medical records. Important data includes:

• Primary and Secondary Diagnoses: Determined based on the doctor’s examination results and recorded with ICD-10 codes.
• Medical Procedures: Surgical procedures, diagnostic examinations, or other procedures performed during treatment, recorded with ICD-9-CM codes (or ICD-10-PCS depending on the system used).
• Length of Stay (LOS): How long the patient was hospitalized.
• Other Clinical Indicators: Such as complications or comorbidities that affect the severity of the case.

2. Coding of Diagnosis and Procedures:

• Medical coders will translate diagnoses and procedures into the appropriate ICD codes. Accuracy in coding is crucial because these codes will determine the appropriate INA-CBG group.

3. Case Grouping:

• Once the diagnosis and procedure codes are obtained, the data is entered into the INA-CBG grouper software. This software uses a specific algorithm to place the patient’s case into one of the INA-CBG groups.
• Each INA-CBG is designed to group cases with similar clinical characteristics and resource use. For example, all patients with a diagnosis of pneumonia without specific complications and a certain duration of treatment may fall into the same INA-CBG group.

4. Setting INA-CBG Tariffs:

• Each INA-CBG group has a predetermined tariff (package tariff) that is set nationally and can be adjusted based on the hospital class, region, or other relevant factors. This tariff reflects the average estimated cost of treating a condition with similar characteristics.
• The setting of this tariff is usually done by the healthcare financing management body (such as BPJS Kesehatan) in collaboration with the Ministry of Health. Tariffs are reviewed and updated periodically based on cost analysis, service utilization, and established quality standards.

5. Claim and Verification Process:

• Hospitals submit claims to BPJS Kesehatan or the relevant insurance based on the determined INA-CBG. The claim will be verified by the insurance party or BPJS Kesehatan. If the claim matches the clinical data and applicable standards, the hospital will be paid the amount of the INA-CBG package tariff.
• During the verification process, the insuring party has the right to check the consistency of clinical data with the coding performed. If there are inconsistencies, the claim may be rejected or require correction.

6. Evaluation and Monitoring:

• The INA-CBG system is monitored and evaluated periodically to ensure that the set tariffs align with clinical practices and actual costs. Adjustments can be made based on historical data analysis, healthcare cost inflation, changes in disease patterns, and feedback from healthcare facilities.

Of course, there is a specific reason why INA-CBG is applied in Indonesia, right? The benefits of the INA-CBG approach include:

• Efficient Financing: Reduces complex claim administration because the entire treatment for one episode of illness is paid in one package.
• Cost Control: Encourages healthcare facilities to provide efficient services because payment is package-based, not item-based.
• Standardization and Transparency: Clear classification helps compare efficiency and quality among healthcare facilities.

While some challenges and aspects open to criticism have been identified, including:

• Accuracy of Coding Needed: If coding is not accurate, claims may be misgrouped, potentially disadvantaging healthcare facilities or insurers.
• Periodic Tariff Adjustment: Tariffs must be reviewed periodically to continue reflecting real costs and encouraging quality.
• Risk of “Upcoding” and “Downcoding”: There is a potential moral hazard where healthcare facilities may be tempted to increase diagnosis/procedure codes to fall into higher tariff groups. Audit mechanisms are needed to minimize this.

For me personally, and perhaps also representing similar conditions from some colleagues struggling in the healthcare service field, or even the general public who actually have the right to know the processes occurring within the healthcare financing system, which is a mandatory obligation of the state that must have high accountability to be accountable to all its stakeholders, the mechanism for calculating and paying claims related to the application of INA-CBG still invites and contains questions and “mysteries” that seem to require objective explanations.

Therefore, allow me to try to make some assumptions using the following simulative approach. Disclaimer: this is just an example I use with fictional illustrations and formulated based on my very limited personal knowledge.

Case Example (allow me to use the condition of my wife when she was treated, with necessary modifications): A patient comes to the hospital with symptoms of cough, fever, and shortness of breath. After clinical and radiological examinations, the doctor diagnoses the patient with pneumonia. The patient is hospitalized for 4 days, given intravenous antibiotic therapy, symptomatic therapy, and strict monitoring of vital signs. No serious complications or co-morbidities that worsen the patient’s condition are found.

Step 1: Identification of Primary and Secondary Diagnoses Primary Diagnosis: Pneumonia, unspecified (J18.9) based on ICD-10 classification. Secondary Diagnosis: For example, essential hypertension (I10) if the patient has a history of hypertension, but in this case, assume the patient does not have significant co-morbidities. Therefore, there is no secondary diagnosis that affects grouping.

Step 2: Procedure Coding In cases of pneumonia, the procedures usually performed are medication and supportive treatment. If there are no major surgical procedures or specific invasive procedures, the major procedure may not be listed. However, if there is a diagnostic procedure such as bronchoscopy (for example), it can be recorded with the appropriate ICD-9-CM/ICD-10-PCS code.

For example, if the patient only receives IV antibiotic therapy and nebulization, these procedures generally do not result in a significant major procedure code in grouping, except for medication administration procedures (usually recorded but not a major procedure that significantly affects the INA-CBG group).

Step 3: Input Data into the INA-CBG Grouper System Data on diagnosis (J18.9) and procedures (if any) are entered into the INA-CBG grouper software. The grouper will ask for several variables such as:

• Primary diagnosis
• Secondary diagnosis (if any)
• Procedures performed
• Length of stay (LOS) In this case example: Primary Diagnosis: J18.9 (Pneumonia unspecified) No additional co-morbidities or complications affecting grouping Duration of hospitalization: 4 days No major procedures (e.g., surgery) recorded.

Step 4: Grouping into INA-CBG The grouper will group the case into one of the INA-CBG groups. For example, a case of pneumonia without complications may fall into a group representing “Inpatient — Lower Respiratory Tract Infection Without Complications.”

As a fictional example (since specific codes may vary depending on the version of INA-CBG used): INA-CBG Code: B-4–10-I (this is just an illustration, not an official code) This code, for example, represents a case of mild to moderate pneumonia without complications.

Step 5: Setting the Tariff Each INA-CBG has a predetermined tariff. The tariff depends on the hospital class, region, and type of service. For example, for a class B hospital in the Java region, the tariff for the pneumonia without complications group (B-4–10-I) may be set at around Rp3.5 million — Rp4.5 million per episode of care, depending on the latest regulations. (This figure is merely an illustrative example, not an official tariff).

Step 6: Claim Submission After the patient is discharged, the hospital submits a claim to BPJS Kesehatan by sending medical data, coding results, and the resulting INA-CBG. BPJS Kesehatan verifies whether the codes and tariffs are correct. If correct, BPJS Kesehatan pays the INA-CBG package tariff amount to the hospital.

Algorithmic Illustration of the Above Case:

• Diagnosis Code: J18.9 (Pneumonia unspecified)
• INA-CBG Code: B-4–10-I (for example)
• INA-CBG Tariff: Rp4.0 million (example) Thus, the payment received by the hospital from BPJS Kesehatan for this case is Rp4.0 million for the entire episode of care, regardless of the detailed costs of medications, laboratory tests, or medical procedures incurred.

Please note that the INA-CBG codes and tariff amounts above are fictional examples to illustrate the process. The official tariffs are those set by the Ministry of Health and BPJS Kesehatan and can be found in the relevant INA-CBG regulations.

In actual practice, INA-CBG grouping can be influenced by other factors such as co-morbidities, complications, types of procedures, and length of stay exceeding standards. The more complex the case, the higher the likelihood of falling into an INA-CBG group with a higher tariff.

Equally crucial is the determination of premium amounts and capitation calculation. From this, the balance between mandatory healthcare service approach and healthcare economics and national fiscal policy, in this case, subsidies, will be obtained.

The determination of premium amounts and capitation in the National Health Insurance System (JKN) operated by BPJS Kesehatan is basically based on actuarial principles and government regulations. Although in practice, premium values are often set through regulations (Presidential Regulation or Minister of Health) and consider economic conditions and fiscal policy, the concept of their calculation can be explained theoretically as follows.

1. Setting Participant Premiums Participant premiums (premiums) are intended to cover the cost of healthcare services (benefit cost), administrative costs, and reserve funds for future risks. Conceptually, the calculation of premiums can be formulated as: Premium per Participant per Month = (Benefit Cost + Administrative Cost + Risk Reserve) / Number of Participants Where Benefit Cost (Benefit Cost) is the average estimated cost of healthcare services that will be incurred for each participant over a certain period. This calculation involves analyzing epidemiological data, historical claims, projected disease trends, and treatment costs. Σ(pi * ci) where: pi = probability of a participant experiencing disease/health event i ci = average cost of treating disease i With: : Probability of a participant experiencing a type-i disease/health event Administrative Cost: Operational costs for running the program (e.g., claim system, verification, IT, human resources). Risk Reserve (Contingency Reserve): Additional funds to anticipate uncertainties, fluctuations in healthcare costs, and unforeseen risks. In the practice of JKN, tariffs for various segments of participants (e.g., Premium Assistance Recipients (PBI), Wage Earners (PPU), Non-Wage Earners (PBPU), etc.) have been regulated by the government. The initial calculation uses an actuarial approach, but the final setting considers social, economic, and national policy conditions.
2. Setting Capitation for Primary Healthcare Facilities (FKTP) Capitation is a payment system to primary healthcare facilities (e.g., community health centers, primary clinics, family doctors) based on the number of registered participants they handle, not based on the number of services provided. This concept aims to encourage efficiency, prevention, and better cost management.

In general, the capitation formula can be outlined as follows: Capitation per Participant per Month = (Average Frequency of Visits per Participant per Month x Average Cost per Visit) x Quality Factor Average Frequency of Visits per Participant per Month (Utilization Rate): Estimate of how often a participant uses FKTP services in a month. This is obtained from the analysis of historical utilization data. Average Cost per Visit: Estimated standard cost for one service at FKTP, including medical services, essential medications, and minor procedures. Quality Factor: Adjustment of tariffs based on service quality indicators, such as patient satisfaction levels, success of promotive-preventive programs, compliance in reporting, and achievement of priority health indicators. If FKTP performs well, they may receive a higher multiplier factor, thus increasing capitation.

Example Calculation: If Visit Frequency = 0.3 Average Cost per Visit = Rp50,000 Quality Factor = 1.05 Then: Capitation per participant per Month = (0.3 x 50,000) x 1.05 = (15,000) x 1.05 = 15,750 rupiah For 10,000 registered participants: Total Capitation per Month = 10,000 x 15,750 = 157,500,000 rupiah In practice, these figures are set by BPJS Kesehatan and are considered based on cost studies, financial capacity, and policy considerations.

In summary, the setting of premiums and capitation in the BPJS Kesehatan system can be outlined as follows: Premiums: Based on estimated benefit costs, administrative costs, and risk reserves, and set through government policies. Capitation: Based on the number of participants, average visit frequency, cost per visit, and quality factor, with the aim of creating incentives for efficiency and improving service quality at primary healthcare facilities.

That is the writing of this old man this morning, although it seems to contain many polemics and data collection inaccuracies, hopefully, this writing can be a mere companion in filling the weekend, accompanied by a cup of bitter Kapal Api coffee, of course 🙏🏾🇲🇨🩵

References

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