Reform Needed at the BPJS Kesehatan

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  • TEMPO.CO, JakartaThe move by President Joko Widodo to increase the Health Care and Social Security Agency (BPJS Kesehatan) premiums at the beginning of May is mistaken.

    This decision will not solve the fundamental problems that have led to the BPJS Kesehatan deficit, namely the huge increase in health service claims resulting from chaotic data and fraud that has occurred from top to bottom.

    An investigation team from this magazine discovered potential losses to the BPJS Kesehatan totaling Rp47.6 trillion in 2019. These losses were the result of six main problem areas: the BPJS management itself, regional governments, hospitals and clinics, the health ministry, companies whose employees are registered as BPJS members and individual participants. If the problems with the system could be improved, last year’s BPJS deficit of Rp15.5 trillion could be covered without having to increase premiums.

    Of these six major problem areas, almost half of the total losses – around Rp16 trillion – are from hospitals and clinics. The Corruption Eradication Commission (KPK) calculates that payment for unnecessary treatment of patience costs the BPJS up to Rp10 trillion every year. Meanwhile, hospitals that claim payment for a class above their actual standard are estimated to have caused up to Rp6 trillion in BPJS losses.

    Another source of problems adding significantly to the losses is the chaotic state of the data of individual participants. The Development and Finance Comptroller (BPKP) discovered there were 27.44 million patients categorized as recipients of premium assistance (PBI) whose data was in a mess. The government says there are 30 million PBI participants whose data has not been synchronized with the Integrated Social Security Data, resulting in potential losses to the BPJS of Rp9 trillion.

    The solution to these problems is not simple, but it is not impossible. The problem is that the fault does not lie simply with the BPJS management, but also with the lack of coordination between agencies and ministries. President Joko Widodo must insist that putting the BPJS in order is a government priority.

    The potential losses originating from hospitals and clinics for example could be overcome if the health ministry were to issue National Medical Service Guidelines (PNPK). Without these guidelines, no legal action can be taken against fraud in the provision of medical services. The health ministry has only completed 40 PNPKs of a total of 74 needed by the BPJS. Sustained lobbying by professional medical associations and a number of lawsuits with the Constitutional Court have severely slowed down the process of producing these guidelines.

    Fraud by hospitals claiming for health services above the appropriate class could also be dealt with if the Hospital Accreditation Commission and the health ministry were consistent and meticulous in their auditing. There must be sanctions for hospitals proved to have used deception in their accreditation. During the term of the previous Minister of Health, Nila Moeloek, the government found 615 hospitals that appeared to have fraudulently increased their accreditation class. Conversely, the current Minister of Health, Terawan Agus Putranto has yet to respond to reports of 898 hospitals suspected of doing the same thing.

    As well as this, the chaotic state of data of BPJS patients receiving premium assistance could be overcome if the of home affairs ministry and the social affairs ministry synchronized their demographic data. However, the two ministries have been busy passing the buck back and forth between them. Once again clear direction from the country’s leadership is needed.

    Furthermore, the problems at the BPJS Kesehatan could be overcome more quickly if the oversight mechanism in the institution was working properly. At present, the BPJS has two oversight bodies, the National Social Security Council (DJSN) and its own internal oversight body. But they are mere paper tigers because they have no legal authority and only minimal funding. Improvements to the BPJS structure and management cannot be delayed any longer.

    There is no need for President Jokowi to wait for Presidential Regulation No. 64/2020, which governs the increase in the BPJS premiums, to be the subject of another lawsuit at the Supreme Court to correct the decision. In February, this highest court ruled in their decision number 7P/HUM/2020 that the increase of premiums could only be implemented if the government improved the quality of the health services paid for by the BPJS.

    Continuing to insist on an increase in premiums without dealing with the fundamental problem of the BPJS deficit will not only go against the Supreme Court ruling, but will make matters worse. It is certain that President Jokowi does not wish to be remembered as a head of state whose decisions were frequently overruled by the courts.

    Read the Complete Story in this Week's Edition of Tempo English Magazine