ABSTRACT

Calculation Analysis of Unit Cost On Tonsillectomy Service

with Activity Based Costing Method

(Case Study at PKU Muhammadiyah Hospital of Yogyakarta)

Elga Ria Vinensa1, Ietje Nazarudin2, Triyani Maryati 3

Fakultas Kedokteran dan Ilmu Kesehatan

Universitas Muhammadiyah Yogyakarta

Background : Private hospitals should strive to have the technical capability to manage and calculate costs based on the condition that both hospitals and facilities that can use the Indonesian Case Based Group (INA CBG) appropriately. RS PKU Muhammadiyah Yogyakarta as one of the private hospitals that participate and support the government's program of the Sistem Jaminan Sosial Nasional. Calculating the unit cost of a tonsillectomy was done as a study of the correspondence between the cost of services and a health claim

Methods :The study was a descriptive qualitative case study design. Tonsillectomy unit cost calculation using activity based costing (ABC) with the goal difference obtained unit costs plus a margin to claim CBG INA in 2012. Result : Based on the calculation, the unit cost of services tonsillectomy with activity-based costing method is Rp. 2.265.732. ABC unit cost calculations result in a greater cost than the claims of INA CBG so get the difference in cost of Rp. 785.034.

Conclusions : There is a negative difference between the calculation of service bi tonsillectomy ABC method with INA CBG claim. So that needs to be done by the hospital cost efficiency.

Key Word : Tonsillectomy, INA CBG, Activity Based Costing.

1

INTRODUCTION

Health care costs will increase continuously. Hospital as a health care

provider has the burden to be able to provide quality health services and for the

community fair. This encourages all elements of both the hospital and

stakeholders (providers or government ) to calculate exactly how much it costs

needed services .

There are two major forces in determining the cost of health care: 1.

related groups based on similarity of case ( cased -based groups ) and related

capitation and 2. opening of competitive pressures within the industry has

increased the major structural changes become manage care1.

The Birth of Law of Undang Undang Sistem Jaminan Sosial Nasional (UU SJSN)

Nomor 40 Tahun 2004 sourced fromUndang Undang Dasar (UUD) 1945 showed

that the government's plan to establish the national health insurance for all

indonesian citizens . The security system will come into force in 2014 . As per

Law Undang Undang Nomor 24 Tahun 2011 the program will be held by Badan

Penyelenggara Jaminan Sosial ( BPJS ) which represents the union of some of the

Badan Umum Milik Negara (BUMN)were appointed, namely:PT. Jamsostek, PT.

Askes, PT. Taspen, dan PT. Asabri2.

Health insurance refers to the quality control and cost control by applying

the principles of managed care is to enable the efficient financing with guaranteed

quality remains appropriate medical indication.Control financing is one of the

effective and efficient by using a pattern that is capitation and prospective

payment Indonesian Case Based Groups (INA CBG)3.

Analysis of the cost per unit ( unit cost) can be used to measure hospital

performance as the basis for preparing the budget, subsidies, and financing

negotiation tools to stakeholders. Calculation of unit cost by activity based costing

( ABC ) can accurately measure the cost out of each activity. This is because the

number of cost drivers used in imposition of overhead costs in order to improve

the accuracy and precision of the cost breakdown charging more accurate4.

2

Tonsillectomy is not free of morbidity and mortality that is necessary to

realize that the action is the same as the other surgery and should be done

optimally 5. In the United States classified tonsillectomy surgery because of fears

of major complications, whereas in Indonesia tonsillectomy surgery is classified

as being due to the short duration and not difficult enough 5,6.

Tonsillectomy is the case for most surgical services in the field of Telinga

Hidung dan Tenggoro (ENT) are handled by the hospital. Tonsillectomy is a

servant of action which ranks 15th on the amount of service equal to 67 actions in

2012 at the Hospital of the PKU Muhammadiyah Yogyakarta. PKU

Muhammadiyah Hospital is a private hospital in Yogyakarta that support the

Social Security program in the field of health. PKU Muhammadiyah Hospital

located at Jln. KHA Ahmad Dahlan Yogyakarta with 12 service areas of type B.

CBG INA package rates are applicable also regulate the rates of

tonsillectomy action. Rates INA act of CBG for tonsillectomy is Rp. 1.699.571

while the cost of real rates of tonsillectomy action at PKU Muhammadiyah

Hospital of Yogyakarta is Rp. 3.275.100, the difference that occurs between CBG

and real cost is Rp. 1.575.529 or by 93 % .

The issue of cost efficiency and important role in the health care process

and actions tonsillectomy procedure above lead researcher sees the need of

research on the calculation of unit cost analysis of the ABC method in

tonsillectomy at PKU Muhammadiyah Hospital of Yogyakarta. From the

background described above, it can be formulated:

1. How much the unit cost of tonsillectomy using the ABC method in RS PKU

Muhammadiyah Yogyakarta?

2. What is the difference between the ABC method of tonsillectomy rates in RS

PKU Muhammadiyah Yogyakarta with INA rates CBG?

3

MATERIALS AND METHODS

Types of Research

The study was conducted using qualitative descriptive method by

conducting case studies at PKU Muhammadiyah Hospital of Yogyakarta.

Calculation of unit costs were calculated using activity based costing (ABC).

Subject and Object Research

Subjects of this study was the Chief Financial Officer, Doctor Specialist of

ENT, Head of Medical Records, Nurse of ENT clinic, administration section,

Laboratory Chief Pharmacist, Head of Radiology, cashier, Physician Anesthesia

Specialist, Head of Surgery Central of Surgical Installation , Laundry to obtain

comprehensive data on the RS PKU Muhammadiyah Yogyakarta.

Object of this study is all activity that occurs when the patient entered the

hospital to go home. Tosilektomi in patients on government health insurance

Jamkesnas with a diagnosis of chronic tonsillitis and tonsillectomy in action

diagnosis of PKU Muhammadiyah Yogyakarta Hospital

Research Variables

The variables of this study is the unit cost and activity in the unit

tonsillectomy in ENT clinic, Arafah, Central of Surgical Installation , Admission.

Research Instruments

1. Studies of document that is to examine the documents that are related to cost

analysis of tonsillectomy actions

2. Interview guide: The interview is one method of data collection by asking

directly or communicate directly with the respondent.

3. Observation guide using clinical pathways by direct observation on the object

of research.

4. Stopwatch to count of length of time of each activity undertaken, ranging from

enrolling patients until the patient home.

4

Stages Of Research

Table 1 Stages of Analysis Research Unit Cost Calculation

Tonsillectomy Action in PKU Muhammadiyah Hospital of Yogyakarta

Name of Activity

Month

June 2013

July 2013

Ags 2013

Sep 2013

Okt 2013

Nov 2013

Des 2013

Jan 2014

Administering licensingPreparation of a research proposalResearch proposal examImplementation researchCalculating and analyzing dataExam results of research

Revision

The data collected is secondary data from the financial and medical

records of the period of January to December in 2012. Data collection was

conducted during the months of May to December 2013.

Data Analysis

Analysis of secondary data tonsillectomy action period January to

December 2012 in the RS PKU Muhammadiyah Yogyakarta.

1. Determine the activity centers and cost drivers related to the unit.

2. Direct charge consumed in the act of tonsillectomy.

3. Determining the cost of direct and indirect resource overhead of resource

overhead consumed each time the proportion of activity per ENT Clinic ,

Central Surgical Installation, Arafah.

4. Determine the activity centers associated actions contained in Tonsillectomy

Clinial Pathways.

5. Overhead charge into each activity centers Tonsillectomy Clinical Pathways.

6. Summing the direct and overhead costs are included in Tonsillectomy Clinical

Pathways.

5

7. Compare the unit cost of tonsillectomy rates with ABC method and payment

of INA CBG from government.

RESULTS

Picture of Research Subjects

Based on interviews with a number of parts of the medical record

tonsillectomy action during the year 2012 as many as 67 action. Tonsillectomy

action is divided into three major parts, namely: Actions in ENTClinic, Actions in

Arafah and Actions in Central of Surgical Installation.

Presentation of Data in Action Tonsillectomy

1. Determine the activity centers on the each unit and cost drivers of each cost

category

2. Direct charge consumed in the act of tonsillectomy

Table 2 Direct Costs Tonsilekomi PKU Muhammadiyah Yogyakarta in 2012

Kategori Biaya Satuan Jumlah Satuan(b)

Biaya Satuan(c)

(Rp)

Jumlah(a)

(Rp)

ENT ClinicRegistration Activity 1 12.500 12.500 Spesialist of ENT consultation Activity 1 27.500 27.500

Central of Surgical InstallationSpesialist of ENT Actions Activity 1 300.000 300.000 Spesialist of Anesthesia Actions Activity 1 120.000 120.000 Instruments Count 1 87.190 87.190 Instruments Sterilisation Count 1 108.000 108.000 Laundry Kg 6.3 5.000 31.500 Medicine and Consumable Thing

Braunol Sol Cc 50 110 5.520 Kasa Lipat 5 X 7 X 16ply Pcs 24 673 16.160 Handscoend St 6,5 Gamex Pcs 1 14.880 14.880 Handscoend St 7,5 Gamex Pcs 2 14.880 29.760 Catgut Pln 1 Resorba M 2 13.960 27.920 Aquadest Opls 25cc Flb 2 2.200 4.400 Spuit Terumo 2,5 Cc Pcs 1 2.960 2.960

6

Spuit Terumo 5 Cc Pcs 1 3.520 3.520 Ringer Lactate 500ml Flb 1 9.520 9.520 Ondansetron 4mg/2ml Inj Ampul 1 7.760 7.760 Ett Non Kingking 7 Rusch 0.3 Pcs 1 72.960 72.960 Fentanyl 0,05mg/Ml/2ml Ampul 1 32.400 32.400 Ketorolac 30mg Inj Vial 1 26.800 26.800 Recofol 20mg/Ml 0.65 Vial 1 63.680 63.680 Atracurium Hammeln 2,5mg/5ml Vial 1 75.920 75.920 Tramadol Inj Ampul 1 6.480 6.480 Forane 250 Ml Cc 1 144.000 144.000 N2o 25 Kg Cc 200 97 19.360 O2 Kap 6 Cc 200 11 2.160 Cefotaxime 1 G Ampul 4 7.700 30.800 Ketorolac 30mg Inj Vial 5 13.376 66.880 Aquadest Opls 25cc# 2Flb Flb 2 2.200 4.400

ArafahMaterai count 1 12.500 12.500Spesiailist of ENT Visite visite 2 35.000 70.000 Spesialist of Anesthesia Visite visite 2 35.000 70.000 Nutritions Eat 2 25.200 50.400 Laundry Kg 2 5.000 10.000 Administration of Arafah Activity 1 58.500 58.500Supporting

Blood test Activity 1 44.000 44,000 Ppt Activity 1 45.600 45.600 Aptt Activity 1 45.600 45.600 Strip Glucose Activity 1 14.400 14.400 Hbsag (Rapid) Test Activity 1 40.000 40.000 Thorax Examanation Activity 1 64.000 64.000

Medicine Ringer Lactate 500ml Flb 3 9.493 28.480 Cefixime Tab 100mg Tab 10 2.880 28.800 Tramadol Cap 50mg Tab 10 336 3.360

Total 1.934.070 Information: a=bxc, a= total cost, b= unit, c= unit price

source: RS PKU Muhammadiyah Yogyakarta In 2012

7

1. Determining the cost of direct and indirect resource overhead consumed

resource overhead per each time the ENTClinic, Central of Surgical

Installation, and Arafah.

2. Determine the activity centers of tonsillectomy actions contained in clinial

pathways and overhead charge into each activity centers in clinical pathway

Table 3 Indirect Resource Overhead Cost Of Activity

in Tonsilectomi Service at ENT Clinic

Activity at ENT ClinicTotal

Trasac-tion(a)

Cost DriverTime

(Minute)

Indirect Resource

OverheadCost Per Activity

Unit Cost(b)

Total Cost (c)

Patient acceptance 1 3 650 650Vital sign examinations 1 5 1.084 1.084Anamnesis, physical examination, diagnosis, medical explanation, doctor instructions 1 30 6.504 6.504Doctor prescription 1 5 1.084 1.084Charging administration hospitalized patients who will be 1 15 3.252 3.252Consultations to other part spesialist 1 15 3.252 3.252Escort patient undergoing inpatient 1 20 4.336 4.336Total Overhead Cost 20.162Informations : c=a*b, a= Total transaction, b= unit cost, c= Tota cost

Table 4Direct Resource Overhead Cost of Activity in Tonsillektomy at ENT Clinic

Activity in ENT ClinicTotal Tran

saction(a)

Cost Driver

Direct Resource Overhead Cost Per

ActivityUnit

Cost(b)Total Cost(c)

Patient acceptance 1 3 127 127Vital sign examination 1 5 212 212Anamnesis, physica Examination, diagnosis, medical explanation, Doctor Instruction 1 30 1.273 1.273

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Doctor Prescription 1 5 212 212Charging Administration Hospitalized patient who will be 1 15 637 637Consultation to the other spesialist 1 15 637 637Escort patient undergoing inpatient 1 20 849 849Total overhead cost 3.947Information : c=a*b, a= Totaltransactions, b= unit cost, c= total cost

T

Table 5Indirect Resource OverheadCost Activity

in Tonsellectomy Service at Arafah

Activity at Arafah Total Tran

saction(a)

Indirect Resource Overhead Cost Per Activity

Cost Driver

Unit Cost (b) Total(c)

Preparation room 1 15 6.426 6.426Patient Acceptance 1 5 2.142 2.142Handover medica record 1 3 1.285 1.285Room orientation 1 15 6.426 6.426Mounting identity bracelet 1 5 2.142 2.142Vital sign examination 5 5 2.142 10.710Assesment of patient history of pain score, risk of fall, and allergy 5 15 6.426 32.130Intra vena line 1 15 6.426 6.426Filling medical record (nursing care) 5 5 2.142 10.710Pre operation preparation 1 20 8.568 8.568Preparation and administration of drugs 3 15 6.426 19.278Bleeding observation 3 5 2.142 6.426Wound care 3 15 6.426 19.278Fluid Balance 4 5 2.142 8.568Assesment of gastrointestinal function 3 5 2.142 6.426Personal hygiene 5 20 8.568 42.839Remove the identity bracelet and intravena line 1 5 2.142 2.142Return the excess drug to the pharmaceutical 1 15 6.426 6.426Preraration of patient to go home 1 10 4.284 4.284Providing cover letter administrative settlement 1 5 2.142 2.142Delivering patient 1 15 6.426 6.426

9

Total 221.908Informations: c=a*b, a= Total Transactions, b= unit cost, c= total cost

Tabel 6 Direct Resource OverheadCost Of Activity

in Tonsilectomi Service at Arafah

Activity Arafah Total Tran-

sactiona)

Direct Resource OverheadCost Peraktivity

Second Sage Cost

Driver

Unit Cost(b)

(Rp)

Total(c)

(Rp)

Preparation room 1 15 634 634Patient acceptance 1 5 211 211Handover of medial record 1 3 127 127Room orientation 1 15 634 634Mounting identity bracelet 1 5 211 211Vital sign examination 5 5 211 1.056Assessment of patient history of allergy, risk of fall, pain score 5 15 634 3.168Intra vena line 1 15 634 634Medical Record filling (nursing care) 5 5 211 1.056Pre operation preparation 1 20 845 845Preparation and administration of drug 3 15 634 1.901Bleeding observation 3 5 211 634Wound care 3 15 634 1.901Fluid balance observation 4 5 211 845Assesment of gastrointestinal fungtions 5 20 845 4.224Preparation of medical drugs 5 5 211 1.056Personal hygiene 1 5 211 211Remove the identity bracelet 1 10 422 422Return the excess drug to the pharmaceutical 1 5 211 211Preraration of patient to go home 1 15 634 634Providing cover letter administrative settlement 1 3 194 194Delivering patient 1 10 581 581Total 22.654

Informations: c=a*b, a= Total Transactions, b= unit cost, c= total cost

10

Table 7Indirect Resource Overhead Cost Of Activity

in Tonsilectomi Service at Central of Surgical Installation

ActivityCentral of Surgical Installation

Total Tran-

saction(a)

Indirect Resource Overhead Cost Per activity

Cost Driver

Unit Cost (b) Total (c)

Patient identification 1 5 1.004 1.004Medical record handover 1 5 1.004 1.004Checks surgery tools and materials 1 5 1.004 1.004Pre operation check 1 3 602 602Checks anesthesia equipment and materials 1 15 3.011 3.011Do time in,durante, time out 1 15 3.011 3.011Implement anesthetic by a specialist anesthetist 1 15 3.011 3.011Carry out operations 1 30 6.022 6.022Write operation report 1 5 1.004 1.004Writing instruction postoperative 1 5 1.004 1.004Monitoring patients after surgery 1 30 6.022 6.022Decision permission to get out of recovery room by anesthesia specialists 1 5 1.004 1.004To call into the inpatient room to pick up patient 1 2 401 401Medical record handover 1 5 1004 1004Total 29.106

Informations: c=a*b, a= Total Transactions, b= unit cost, c= total cost

Table 8 Direct Resource Overhead Cost Of Activity

in Tonsilectomi Service at Central of Surgical Installation

ActivityCentral of Surgical Installation

Jumah Tran-saksi(a)

Direct Resource Overhead Cost Per activity

Cost Driver

Unit Cost(b) Total(c)

Patient identification 1 5 1.168 1.168Medical record handover 1 5 1.168 1.168Checks surgery tools and materials 1 5 1.168 1.168Pre operation check 1 3 701 701Checks anesthesia equipment and 1 15 3.505 3.505

11

materialsDo time in,durante, time out 1 15 3.505 3.505Implement anesthetic by a specialist anesthetist 1 15 3.505 3.505Carry out operations 1 30 7.011 7.011Write operation report 1 5 1.168 1.168Writing instruction postoperative 1 5 1.168 1.168Monitoring patients after surgery 1 30 7.011 7.011Decision permission to get out of recovery room by anesthesia specialists 1 5 1.168 1.168To call into the inpatient room to pick up patient 1 2 467 467Medical record handover 1 5 1.168 1.168Total 33.885

Informations: c=a*b, a= Total Transactions, b= unit cost, c= total cost

3. Summing the direct and overhead costs are included in clinical pathway

Table9 Unit Cost of Tonsillectomy Service on 2012

Kind of Cost Cost (Rp)Direct Cost 1.934.070

Overhead CostIndirect

Resource Overhead

Direct Resource Overhead

Overheadcost at ENT Clinic 20.162 3.947Overhead cost at Arafah 221.908 22.654Overheadcost at Central of Surgical Installation 29.106 33.885

Total cost 2.265.732

DISCUSSION

1. Expanses in the calculation of the unit cost of tonsillectomy service

From above calculations to obtain unit cost of tonsillectomy with ABC

Methot is Rp. 2.265.732. Tonsellectomy cost consist of :

a. Direct Cost in Unit Cost ofTonsillektomy service

12

Direct cost in unit cost of tonsillectomy service is Rp. 1.934.070

or 85 % total tonsillectomy cost .Cost of medicine and consumable thing

Rp. 686.804 (36% of total direct cost), the cost of medica service specialist

is Rp 767.500 (40% of total direct cost), the cost of other facilities is Rp.

479.766 (24% of total direct cost).

The cost of drugs and the cost of consumable materials are the

biggest cost in tonsillectomy services, yet when traced the use of drugs

and consumables materials are in accordance with formulary Jamkesnas

that the use of generic drugs. In this case can not be done to more

efficiency because drug should right dose, right time, right quantity.

Physicians in providing medication compliance in accordance with

formulary Jamkesnas influence on the quality and cost-efficiency

measures in the hospital 7.

Salary of ENT specialist and anesthetist also consume a

considerable cost burden that medical services in outpatient, like

otolaryngology consultation, preoperative visite, visite post surgery,

tonsillectomy surgery and anesthesia procedures inCentral of Surgical

Installation. Hospitals only provide physician salary for Jamkesmas

service by 50% of patients other general medical services. So it can not be

done in terms of the magnitude of the efficiency of medical services.

b. Overhead costs in the calculation of unit cost of tonsillectomy service.

The overhead on tonsillectomy service is Rp. 331.662 or 15% of total

costs of tonsillectomy service . The costs are divided into, the overhead

tonsillectomy at ENT Clinic is Rp. 24.109 or 1%, at Arafah is Rp. 144

562 or by 11%, and at Central of Surgical Installation is Rp. 62.991 or 3%

of the total cost of tonsillectomy.

Overhead costs for each unit is divided into indirect and direct

resource overhead. At the ENT clinic unit of indirect resource overhead

costs in the amount of Rp. 20.162 greater than the direct resourceoverhead

13

that is Rp. 3.947. In Arafah, indirect resource overhead costs in the

amount of Rp. 221. 908 greater than the direct resource overhead that is

Rp. 22.654. In Central of Surgical Installation unit of indirect resource

overhead costs in the amount of Rp. 29.106 is smaller than the direct

resource overhead that is Rp. 33.885. The small overhead costs than direct

costs on consumption due to depreciation expense tonsillectomy medical

devices, non-medical, and buildings which are already depleted in

economic value.

Direct resource overhead costs in tonsillectomy service greater than

indirect overhead costs, mean that are non functional unit consume

expanse more. Costs of indirect resource overhead to maintance non

functional, they are directors, training, support, procurement, security, etc.

The consumption cost in nonfunctional caused by a number of

nonfunctional employees is equal to 264 employees of 581 employees or

45% of total employees in PKU Muhammadiyah Hospital of Yogyakarta.

The cost of direct overhead resources consumed largely reflect the

employee directly in contact with patients such as nurses. In calculating

the unit cost of the direct costs of resource overhead is smaller than the

indirect resource overhead in the ENT clinic and Arafah. If traced further

then the number of nurses compared to the number of beds has been 1:1,

with details of the number of nurses is 215 and number of beds is 207.

This is in accordance with government regulations is the ratio of nurses

and hospital beds for type B is 1:18.

2. Tonsillectomy service prices with the ABC method and price INA CBG

The results of the calculation of unit cost measures tonsillectomy using the

ABC is Rp. 2.265.732 and from the rate calculation ( unit cost + margin ) use

management policy with a profit of approximately 10 % was Rp. 2.484.605 .

While claims of Jamkesmas is Rp . 1.699.571 in 2012 . In 2014 Jamkesnas

claim to tonsillectomy service is Rp . 2.301.4639 .

14

Unit cost of tonsillectomy service with the ABC method is Rp. 2.265.732

with direct costs in the amount of Rp. 1.934.070 and overhead of Rp.

331.662. While the rate INA Claims CBG is Rp. 1.699.571 which means only

able to finance the operational costs ( direct costs ), while the overhead

expenses of Rp . 331.662 is very small due to the cost of building and medical

and non-medical equipment has run out, which means that the economic value

of its large CBG INA rates can not be used for investment in private hospitals

In the calculation of cost are not all originators cost margin of 10% , it is

a kind of stamp duty and registration . Stamp duty and registration does not

calculate a margin at all.

Table 10 Comparison Between Rate Method of Activity Based Costing (ABC) + gain with ± 10% and INA CBG Real Cost Claims

Cost Type Unit Cost ABC ± Margin 10%

Real Cost INA CBG

ENTClinicIndirect Resource Overhead 22.178 - -Direct Resource Overhead 4.342 - -Direct Cost

Registration 12.500 12.500 -Medical salary 30.250 55.000 -Stamp duty 6.000 6.000 -

Central of Surgical InstallationIndirect Resource Overhead 32.017 - -Indirect Resource Overhead 37.274 - -Direct Cost

Drugs and Consumables Thing 735.064 35.300 -Tonsillectomy payment - 1.560.000 -Salaries of doctors for surgery Tonsillectomy 330.000 - -

salaries of doctors for anesthesia 132.000 - -

Laundry 34.650 - -sterilization of instruments 118.800 - -Equipment 95.909 - -

Arafah

15

Indirect resource overhead 244.099 - -Indirect resource overhead 24.919 - -Direct cost

Arafah price - 75.000 -Administrative inpatient 58.500 58.500 -Drugs ang consumable thing 66.704 75.800 -ENT Spesialist salary for visite 77.000 140.000 -Anesthesia Spesialist salary for visite 77.000 140.000 -

Laundry 11.000 - -Nutritions (food and snack) 55.440 -Supportings -

Routine blood checks 48.400 55.000 - Ppt 50.160 57.000 - Aptt 50.160 57.000 -Glucose checks strip 15.840 18.000 - Hbsag (Rapid) Test 44.000 50.000 -Thorax x ray 70.400 80.000 -

Total cost 2.484.605 3.275.100 1.699.571

Table 11 Differences Between ABC Unit Cost + Margin ± 10% with cost INA CBG (Jamkesnas) Tonsilektom Claims In 2012

Unit Cost ABC± 10%(Rupiah)(a)

INA CBG Claim (Jamkesmas)

(Rupiah)(b)

Differences (Rupiah)(c)

Differences (%)(d)

2.484.605 1.699.571 785.034 32%information: c=a-b, d=c:a*100%, a= unit cost abc± 10%, b= jamkesmas claim c=

differences in rupiah , d= differences in percentage

It is also in accordance with previous studies conducted. Based on the

results of research on the suitability of the cost of medical operative action

Mohammad Hussein Hospital in Palembang isn’t appropriate with INA CBG

claim (Jamkesmas claim). it is concluded that the cost of medical action

operative measures undertaken in Mohammad Hussein Hospital Palembang

98.6% do not fit and greater than the rate INA DRG10.

Difference that arises between the unit cost is calculated by using the

method of activity based costing (ABC) with the amount of claims due

Jamkesnas calculation method used is not the same. The amount of claims

16

fare price Jamkesnas given by the government obtained from the calculation

of some hospitals according to hospital type, Calculation of Jamkesmas claim

is influenced by factors such as BOR, hospital base rate, extreme tariffs,

adjusting the level of severity, type B Hospital Education and non-education,

and regionalization region 11.

Determination of cost of health measures such as hospitals are

complex. This is due to the number of variables or factors that need to be

considered so difficult to find a practical formula to calculate it, even to some

extent, the tariff determination hospitals also use the "trial and error" 11. How

many actions that has only a minimal profit or even not have a profit in

hospital , but because of the actions at the hospital is very complex and the

products are sold diverse services so that hospitals always apply a system of

cross-subsidies to cover some kind of action is minimal profits, such as for

example is the action tonsillectomy operations that keep the hospital running.

Under these conditions, it is necessary to efficiency costs. Efficiency in

economics is used to refer to a number of concepts related to usability and

maximizing the utilization of all resources in the production process of goods

and services. Under these conditions, the RS PKU Muhammadiyah need to

know what the cost structure is not efficiency so as to reduce their costs.

Badan Penyelenggara Jaminan Sosial (BPJS) membership maps

illustrate the framework that the new 2014 will be the start of diversion

participants Jamkesmas, Jamsostek, Askes PNS. Askes Sosial, Jaminan TNI

dan POLRI into SJSN where 148.2 million participants have secured a range

of insurance and 90.4 million have not been guaranteed by any insurance.

257.5 million in 2019 as many participants (all of Indonesia's population) will

be managed by BPJS kesehatan2. To face BPJS, hospital must be readiness to

manage the action as possible if they do not want to defisit.

Implementation of the national security system in private hospitals,

especially RS PKU Muhammadiyah Yogyakarta is not run expected because

of differences between the private and government management cost. The

17

presence incongruity between the unit cost of PKU Muhammadiyah Hospital

and INA CBG cost to Tonsillectomy Rp. 706 866 (31%) requiring hospitals

to re-evaluate the waiter tonsillectomy. The evaluation is based on clinical

pathways in order to be able to clearly see the non-value added so as to reduce

costs.

CONCLUSION

Unit cost tonsillectomy service at RS PKU Muhammadiyah Yogyakarta by

using activitybased costing method is Rp. 2265732

Value unit cost calculated by the method of activity based costing RSU PKU

Muhammadiyah Yogyakarta plus a margin (profit 10%) smaller than the cost of

INA CBG claim (Jamkesmas) for tonsillectomy service. The difference is Rp.

785 034 (32%).

DAFTAR PUSTAKA

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Jamkesmas rawat inap di Rumah Sakit Umum Daerah Banyumas.

8. Depkes, RI 2013, Surat Keputusan Menteri Kesehatan Republik Indonesia

Nomer 340/Menkes/SK/IX/2013 tentang Klasifikasi Rumah Sakit,

Departemen Republik Indonesia, Jakarta.

9. Peraturan Menteri Kesehatan Republik Indonesia Nomor 69 Tahun 2013

Tentang Standar Tarif Pelayanan Kesehatan Pada Fasilitas Kesehatan Tingkat

Pertama Dan Fasilitas Kesehatan Tingkat Lanjutan Dalam Penyelenggaraan

Program Jaminan Kesehatan

10. Septianis, Dwi. Alwi, Masnir. Misnaniarti, 2009, Perbandinga Biaya

Pelayanan Tindakan Medik Operatif Terhadap Tarif INA DRG pada Program

Jamkesmas di Rumah Sakit Mohammad Husein Palembang.

11. Chriswardani Suryawati, 2002, Dimensi kepuasan Pasien Dalam Mutu

Pelayanan Rumah Sakit, Persi Jateng Edisi 02, Semarang.

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