supply side of health insurance system in indonesia

dr. I Gede Subawa, MKes

President Director of PT Askes Indonesia

Phrarmaceutical Sector Meeting on 8 November 2012 Nikko Bali Resort Spa, Nusa Dua, Bali

SUPPLY SIDE OF HEALTH INSURANCE SYSTEM IN INDONESIA

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Overview Of Indonesia

• Total population : 237,641,326 (2010 National Census) • Gross national income per capita (PPP international $):

3,600 • Life expectancy at birth m/f (years): 66/71 • Probability of dying under five (per 1 000 live births) : 34

(2007) • Probability of dying between 15 and 60 years m/f (per 1 000

population) : 234/143 • Total expenditure on health per capita (Intl $, 2009) : 99 • Total expenditure on health as % of GDP (2009) : 2.4

Source; WHO (2012)

ECONOMIC GROWTH OF INDONESIA

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2007 2008 2009 2010 2011 2012 2013 2014

Indonesia Emerging/Developing Economies ASEAN

Indonesia real GDP grow faster than ASEAN and emerging/developing economies … % GDP growth (real) 2007 - 2014

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PER CAPITA INCOME GROWTH

0%

20%

40%

60%

80%

2008 2010 2012 2014

% Gr

owth

ASEAN

Emerging/Developing

Economies

…& per capita income is also expected to grow faster % Per Capita income growth 2007 - 2014

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INDONESIAN POPULATION GROWTH

116,9 123,8116,6 123,7233,5 247,6

050100150200250300

2010 2015

Po

pu

la

tio

n (M

) Female Population (m)

Male Population (M)

Source: BPS (Central Statistics Bureau)

INDONESIAN POPULATION GROWTH Growth at 6% to 2015

Increasing life expectancy will create demand for chronic therapies

The elderly population increase in the next 5 years

0 to 1010 to 1920 to 2930 to 3940 to 4950 to 5960 to 69

70+2010 2015

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DISTRIBUTION OF POPULATION

42,0% 48,3% 54,2% 59,5%

58,0% 51,7% 45,8% 40,5%

0%

20%

40%

60%

80%

100%

2000 2005 2010 2015

Po

pu

latio

n S

plit b

y

Urb

an

/Ru

ra

l (%

)

Rural

Urban

Indonesia population increasingly moving to urban area

2000 2010 2005 2015

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7

HEALTHCARE SPENDING

Source: 1Worldbank report, WHO Global Atlas, Datamonitor

0,0%

0,5%

1,0%

1,5%

2,0%

2,5%

3,0%

3,5%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

% GDP spent on healthcare growing 2.4% of GDP (USD 44 per capita)

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Source: 1Worldbank report, WHO Global Atlas, Datamonitor

…% spend is low compared to peer countries % GDP Spent on Healthcare, comparative

0

2

4

6

8

Vie

tnam

Wor

ld A

vg

Mal

aysi

a

Phi

lippi

nes

Thai

land

Sin

gapo

re

Indo

nesi

a

Mya

nmar

HEALTHCARE SPENDING

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Indonesia Healthcare Transformation Universal Healthcare Coverage in 2014

• Indonesia Minister of Health has already set a target to start covering all people’s health costs as early as 2014.

• Law No. 40/2004 on National Social Security System (SJSN)

• Law No. 36/2011 on Social Security Implementation – BPJS I (Health Insurance Carrier)

• ASKES +JAMKESMAS merge

• 5 Committees are now working to set the Insurance System

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Healthcare Transformation System Sistem Jaminan Sosial Nasional – Universal Health Coverage 2014

PT JAMSOSTEK

PT ASKES

PT TASPEN

PT ASABRI

Dewan Jaminan Sosial Nasional (National Social Security Council)

BPJS 1 BPJS 2

PT

JAM

SOST

EK

PT

ASK

ES

PT

TASP

EN

PT

ASA

BR

I

MOH JAMKESMAS

MO

H J

AM

KES

MA

S

Less fortunate/Poor

Employee – Health, Accident & Pension fund

Civil servants & Military Retirement

Pension for civil servants

Active Military Health Non-Health

Current

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2014

HISTORY PT ASKES (PERSERO)

1968: BPDPK

1984: PERUM HUSADA BHAKTI

1992: PT ASKES (PERSERO)

2014: Health Insurance Carrier ( BPJS)

Reimbursement

Managed care

Managed care

1968: Minister of Health: as an embryo of Universal Coverage

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ROAD MAP TO UHC

Preparation

Preparation

FORMAL SECTOR (ASKES, JAMKESMAS, JAMSOSTEK,

MILITARY/POLICE, BUMN/BUMD, SWASTA

FORMAL SECTOR BUMN/BUMD, SELF WORKER,

POOR, DISTRICT

INFORMAL SECTOR SELF WORKER, PBI

UC

2013

2014

2015

2019 ?

2012

2016

BPJS-1 (Health UHC Organization)

BPJS-2 (Pension Organization)

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Integration between quality and cost control

• Gatekeeper concept Primary care • Quality Assurances Credentialing & Recredentialing • Comprehensive health care benefits • Emphasizes on promotion and prevention • Referral system • Drugs Formularium DPHO • Prospective payment system • Utilization review • Medical Advisory Board

MANAGED CARE

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Supply Side - UHC Health Insurance Specialist

Supply Side

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Legal Aspect

UU 40/2004

• 23 (1)

(1) Benefit Delivery by BPJS Provider.

• 24 (1) (2) (3)

(1) Payment Negotiation BPJS vs Provider Association

(2) BPJS obligated to pay the provider at the latest 15 day

(3) BPJS develop a healthcare system, quality control, provider payment mechanism (efficiency and effectiveness)

• UU 24/2011: 11 (d) (e)

(d) Provider payment Regulator;

(e) Provider contract BPJS;

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Health Insurance Specialist

17

PROVIDER MANAGEMENT

BPJS (proposed)

1.Provider Mapping

• Primary, Secondary, Tertiary

• Provider with catastrophic care

• Pharm, Optical, Laboratory

2. Cre/Recredentialing

• All Provider

3. Payment Nego & Provider Contract

• BPJS nego to Provider Assosciation

• BPJS contract to provider

4. Updating Provider List

• Referensi Provider On Line (public)

5. Performance of Provider Evaluation

• Utilization Review, customer satisfaction

• Medical Audit, Cost Effectiveness, Comprehensiveness

PT Askes (Persero)

1.Provider Mapping

• Primary provider

• Provider with catastrophic care

2. Cre/Recredentialing

• All Provider

3. Payment Nego & Provider Contract

• Nego & Contract to Provider

4. Updating Provider List

• Referensi Provider On Line (internal)

5. Performance of Provider Evaluation

• Utilization Review, customer satisfaction

ASKES VS BPJS

Health Insurance Specialist

ROAD MAP HEALTH FACILITIES MANAGEMENT

Qt I

• Policy

Synchronizat

ion

• Finalization

of guideline

Qt II

• Socialization

of health

facilities

Qt III

• Health

Facilities

Selection

Qt IV

• Negotiation

• Contract

Semester I

• Perfomance

Evalualuation

of Health

Facilities

• Implementati

on of

Regional

Partnerships

Year 2013 Year 2014 Alt.1:

Qt I

• Policy

Synchronizat

ion

• Finalization

of guideline

Qt II

• Socialization

of health

facilities

Semester II

• Negotiation

• Contract with Health

Facilities:

Askes, Jamsostek,

TNI/POLRI, Jamkesmas, )

Semester I

• Perfomance

Evalualuation

of Health

Facilities

• Implementati

on of

Regional

Partnerships

Alt.2: Year 2013 Year 2014

Health Insurance Specialist

Take Precedence Accredited

If not accredited: • Administrative Criteria

• Having a license from ministry of Health and local Government. • Having a business license as a health Facilities. • AMDAL

• Facilities Criteria • Having facilities in accordance with the applicable regulation • Having medical and administrative personnel according to

regulations and the needs of the participants. • Strategic location.

• Quality Criteria • Having a quality accredited certification or other quality

certification.

Health Insurance Specialist Health Facilities Criteria

ASKES HEALTH CARE PROVIDERS 2011 Regional I

Regional II

Regional III

Regional IV

Regional V

Regional VI

Regional VII

Regional VIII

Regional IX

Regional X

Regional XI

Regional XII

• 8.774 Community Health Centers

• 3.753 Family Physicians/24 hours Clinic

• 270 Laboratories, 231 Indonesian Red Cross

• 952 Hospitals (506 Government hospitals; 109 TNI/POLRI hospitals; 263 private hospitals; 74 special hospitals)

• 162 providers for hemodialysis

• 1.184 pharmacies dan 756 optical

Regional XI

DPHO (List of Drugs Items and Prices) As a drugs in Universal Health Coverage

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• Indonesia has an enormous number of drugs that are available on the market :

15,498 items (Ind. FDA 2012)

208 farmacies

• a problem of Askes to select an appropriate and qualified drugs for its members

• ASKES must ensure that the drugs are selected according to evidence based criteria (EBM)

• the problem of distribution is an issue to be overcome, and which creates drug price disparity among the islands

• A widely range of drug’s price

WHY SELECTION?

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WITH THOSE CIRCUMSTANCES ASKES

DESIGN A DRUGS POLICY FOR ITS MEMBERS

EFFECTIVE, SAFE AND EFFICIENT List of Drug Items and Prices

(DPHO, Since 1987)

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Annual update of the DPHO.

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- Expert Team consist of : Pharmacologyst, Specialist, Health Ministry, and The National Agency of Food and Drug Control

- Hospital Recomendation consists of National Essential Medicines List, Generic and Branded Generic that had not been included in the recent DPHO

DPHO COMPOSEMENT PROCESS

DPHO & QUALITY OF SERVICES

• DPHO Board of Experts review the drug list by considering EBM and analyzing cost effectiveness.

• DPHO Board of Experts conducts a series of intensive discussions every week for 6 months every year.

• DPHO is composed based on the result of Board of experts recommendation to ensure all medical needs are accommodated for outpatient care (primary and specialist), and inpatient care.

• DPHO Board of Experts also recommends and specifies particular indications for certain drugs (restrictions), in order to ensure:

Prescribing is in accordance with treatment guidelines. Improving patient compliance with chronic disease medicines. Decreasing overuse of antibiotics. Decreasing overuse of injections. Increasing use of generic medicines.

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PRICING THE DRUGS

• The price negotiation is conducting after the quality of drugs is assured by certifying they fully meet of the following: Product Information, including meta analysis. Indonesia Food and Drugs Agency Register. Certificate of Analysis (COA). Good Manufacturing Practice (GMP) or Indonesian

Certification of Good Manufacturing Practice. • Price negotiation with pharmaceutical industries only at national

level. • By offering a large, fixed, captive market to the pharmaceutical

industry, ASKES could obtain a significantly efficient price of up to 60% off the regular market price.

• The same price is implemented around the country

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INDEPENDENCY OF DRUG FORMULARY

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1. Selection process efektive dan efficient

• efficacy & safety aspect by Experts Team

• Price and distribution by ASKES Team

2. Label use defined DPHO Experts Team

indications, restriction and maximum prescribe

3. Price based on negotiation between ASKES- Manufacturers including special arrangement

4. Askes Drug Formulary (DPHO) is designed for one year :

• The same policy and price around the country

• Evaluate and re-formulate every year

Members: – Health care services availability – Health care services quality

Health Care Providers: – More Choices and affailability – Assurance of Drugs Quality and Availability – Quality of Services Evidence-based practice

Manufacturers : – Captive Market, – Less Marketing Cost – Economies of Scales

Government : – Efficiency of Health Care Spending

DPHO BENEFIT FOR STAKEHOLDER

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OPTIMIZING DPHO IMPLEMENTATION

• Prescriber in government and private providers (primary, secondary, tertiary) should follow the drugs in DPHO for treating any ASKES patients.

• Communicating with ASKES members about the advantages of DPHO.

• Provide a scientific seminar or medicine workshop for prescribers at least four times each year at every ASKES branch office.

• Special analyses from the Medical Advisory Board (MAB) at every ASKES branch. The Medical Advisory Board recommends the medical judges and provides a second opinion in term of evidence based medicine drugs prescription.

• Review and evaluation of drug utilization, also prescribing drugs outside of DPHO.

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•Number of Drugs in DPHO, Years 2007 – 2012

•Number of Therapy Class in DPHO vs DOEN, Years 2007 – 2012

DPHO CONTENT

EVALUATION OF DPHO

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Members trustworthiness of using DPHO medicine increase every year

Outpatient Utilization

EVALUATION OF DPHO

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Members trustworthiness of using DPHO medicine increase every year

Inpatient Utilization

EVALUATION OF DPHO

DPHO CONTENT

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Antineoplastic and Paliatif Treatment - Cytotoxic

Indication:

For

gastrointestinal

cancer

Indication:

For metastases

breast cancer

with Positive 3

(+++) HER2 of

Positive FISH

Indication:

For Limfoma

Non Hodgkins

(LNH) Malignum

with Positive

CD20

Sample description of the Indication Guide for prescribing

Challenges • Wide variety of kind and price available in the

market potential to overuse, misuse

Inefficient

• Over prescription and irrational prescription

• Provider Compliances moral hazards

• Commitment from Distributor/Manufacturer

• Effectiveness of the drug’s prescription control

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