Health Financing and Referral System

The World Health Organization (WHO) states that the ideal budget allocation for health is at least 6% of the state budget (APBN). Meanwhile in developed countries, the budget allocation for health reaches 6%-15%. In Indonesia the budget for the Ministry of Health is less than 5% of the state budget.

In the world of insurance there are 6 basic principles that must be met

Definition of Health Financing

Sources of funding for health costs differ in several countries

the health costs can be divided into two types

managed care is a system in which health services are implemented in an integrated manner with the health financing system, which has 5 (five) elements as follows:

Law of Large Numbers

The health service referral system

FINANCING SYSTEM MODEL

in stages according to medical needs, namely: Starting from the first level of health services by first level health facilities

If further services by specialists are required, the patient may be referred to a second-level health facility.

interval referral

collateral referral

cross referral

split referral

costs are the amount of funds that must be provided to organize and or utilize various health efforts needed by individuals, families, groups and communities.

Direct Payments by Patients

User payments

Saving based

Informal

Insurance Based

  1. Government budget.
  1. Community budget.
  1. Cost assistance from within and outside the country.
  1. Combined government and community budgets.

Medical service fee

Cost of public health services

Utmost good faith

Insurable interest

Indemnity

Proximate cause

Subrogation

Contribution

  1. Provision of health services by certain providers (select providers).
  1. There are special criteria for determining the provider.
  1. Have a quality control program and utilization management.
  1. Emphasis on promotive and preventive efforts.
  1. There are financial incentives for participants who carry out service according to procedure.

Insurance requires a large number of participants, so that risk can be distributed evenly and widely and effectively reduced.

This principle is a legal consequence of large numbers, the more participants, the greater the risk that can be reduced. According to analysts in the United States, the number of members of 50,000 per Health Maintenance Organization (HMO), is considered profitable.