health financing system & referral system Helvi Ramadhani 1908260083 -…
health financing system & referral system Helvi Ramadhani 1908260083
types of hospital
Class A must have medical service facilities and capabilities at least 4 Basic Specialist Medical Services, 5 Medical Support Specialist Services, 12 Other Specialist Medical Services and 13 Sub Specialist Medical Services
Class B must have medical service facilities and capabilities at least 4 Basic Specialist Medical Services, 4 Medical Support Specialist Services, 8 Other Specialist Medical Services and 2 Basic Subspecialist Medical Services.
Class C must have medical service facilities and capabilities at least 4 Basic Specialist Medical Services and 4 Medical Support Specialist Services
Class D includes General Medical Services, Emergency Services, Basic Specialist Medical Services, Nursing and Midwifery Services, Clinical Support Services and Non-Clinical Support Services.
According to WHO, the referral system (referral system) is a process in which health workers who have limited resources to treat clinical conditions (drugs, equipment, capabilities) at one level of the health system, seek help from better health facilities or have certain resources at a higher level. the same or above, or take over the handling of the patient's case
The general rules in the tiered referral mechanism are as follows:
Third-level health services can only be provided upon referral from
second-level or first-level health services.
Midwives and nurses can only make referrals to doctors and/or dentists
primary health care provider.
Second-level health services can only be provided upon referral from
first-rate health services.
The above provisions do not apply to emergencies, disasters, specialties
patient health problems, and geographic considerations
Health services are carried out in stages, according to medical needs
starting from the first level of health services.
difference between puskesmas and FKTP
FKTP : Health facilities that provide non-specialist individual health services for the purposes of observation, promotion, prevention, diagnosis, treatment, treatment, and/or other health services.
FKRTL : Health facilities that provide individual health services that are specialized or sub-specialized, which include advanced outpatient care, advanced inpatient care, and inpatient care in special care rooms.
health financing system in the SJSN system
BPJS Health in providing health insurance uses the Capitation financing system at the first level (primary) health facilities and INA CBG's for advanced health facilities.
The capitation payment system is a payment system that is implemented at the first level of health facilities, especially the First Level Outpatient services in collaboration with BPJS Health
The INA-CBGs application is one of the patient data entry devices used
to group rates based on data from medical resumes.
INA-CBGs have been installed in hospitals that serve JKN participants, which is used for JKN is INA-CBGs 4.0
types of JKN
JKN is part of the National Social Security System (SJSN)
JKN provides health services to the community through two health facilities
Advanced Referral Health (FKRTL).
First Level Health Facilities (FKTP)
the role and principles of insurance in general
Utmost good faith
Insurance ensures that a person who is sick will get the services he needs without having to consider his economic situation
JKN is a national social health insurance that is mandatory based on Law Number 40 of 2004 concerning SJSN, Law Number 36 of 2009 concerning Health and Law Number 24 of 2011 concerning BPJS
difference between BPJS and private health insurance
Private insurance membership is voluntary and is usually managed by a private business entity that aims to seek profit.
benefits of BPJS
The benefits provided by BPJS Health are also more complete than private health insurance
No Pre-Existing Condition
No ceiling limits
lack of BPJS
Not All Hospitals Cooperate with BPJS Health
The Process is Long and Less Flexible
Hospital fees that are not reimbursed
advantages of private insurance
The organizers are not limited
Have a Ceiling
The process is very simple
Can be used abroad
Disadvantages of Private Health Insurance
Has complicated administration
The requirements to have private health insurance are very difficult
The amount of the premium is high
health financing method
Direct Payments by Patients