Financial deficit in the Healthcare and Social Security Agency (BPJS Kesehatan) continues to grow and is feared to have an impact on public health services. The government is now looking for various ways to save the agency’s finances, from injecting funds to improving the management system.
The deficit reached Rp 10.4 trillion last year, while this year it grew to Rp 16.5 trillion. In September, the government provided additional funds of Rp 4.9 trillion to BPJS Kesehatan.
BPJS Kesehatan President Director Fahmi Idris said the funds had been used up within a day after being disbursed. It was distributed entirely to thousands of hospitals in Jakarta, Bogor, Depok, Tangerang, and Bekasi (Greater Jakarta). “A total of Rp 4.9 trillion has been absorbed as of 29 September 2018. It is currently in the process of entering a new bill,” Fahmi said during a meeting at the House of Representatives building on Monday (10/29).
The bailout from the government is indeed not enough to patch the deficit. There are still trillions of rupiah that must be paid for health facilities, such as hospitals. Not to mention the debts to pharmaceutical companies, which was recorded at Rp 3.5 trillion until July. Meanwhile, BPJS Kesehatan must also bear one percent penalty per month for late payment of bills to its partners.
BPJS Kesehatan is deemed not capable of managing government funding to cover its deficit, even though this state health agency and the Ministry of Health have already committed to immediately make some improvements. This made President Joko Widodo (Jokowi) furious because it forced him to take matters into his own hands.
Jokowi even reprimanded the Health Minister Nila F. Moeloek and Fahmi. “The [deficit problem] should’ve been solved by the minister and the BPJS director. [How can] a matter related to hospitals’ debts reach the president? This is outrageous,” Jokowi said in his speech on the opening of the Indonesian Hospital Association (PERSI) congress in Jakarta, Wednesday (10/17).
According to him, BPJS Kesehatan cannot casually ask for additional funding from the government. Jokowi also warned that this condition should not happen again next year, and urged BPJS to immediately improve the existing management system. If the system has been improved, its management becomes easier. Thus, Jokowi believes BPJS Kesehatan could be free of financial deficit.
The deficit occurs because the premium income and its managed funds are smaller than the claims that must be paid. There are several factors that lead to deficit, one of which is that BPJS Kesehatan’s premiums have been not increased since 2016, even though the Presidential Regulation No. 19 and 28/2016 concerning second amendment to the regulation No. 12/2013 on Health Insurance stated that the premium of health insurance programs must be evaluated within a maximum period of two years.
BPJS Kesehatan Membership and Marketing Director Andayani Budi Lestari said the agency spent an average of Rp 41,240 per person for hospital services last year. Meanwhile, the average premium per person is only Rp 34,766, meaning BPJS Kesehatan is forced to add fund of Rp 6,474 per person. The total participants in this year’s BPJS Health program were 203 million people, which are targeted to reach 250 million people next year.
The premium for the government-sponsored participants (PBI) is only Rp 23,000 per person. Based on actuarial calculations and recommendations from the National Social Security Board (DJSN) in 2016, it should be Rp 36,000 per person. The premium for non-PBI participants of second-class healthcare facilities is Rp 51,000 from the supposed amount of Rp 63,000. The problem is that BPJS Kesehatan cannot simply increase the premiums as the decision regarding its adjustment lies is in the hands of the president. Based on the Presidential Regulation (Perpres) No. 82/2018 issued last September, there is no increase in the PBI premiums.
BPJS Kesehatan recorded low income also because 54 percent of independent participants have not yet paid their premiums. Not to mention, the people who have just registered to become participants after being hospitalised. BPJS Kesehatan must cover the health cost, even though those participants have just paid premium one time.
Deficit occurs not only in terms of income. Claims that must be paid are also considered too large. BPJS Watch had revealed fraud from BPJS Kesehatan’s partner hospitals. They allegedly raised (mark-up) the hospital service costs and BPJS participant claims, causing an increase in the bills submitted to BPJS Kesehatan.
During a joint meeting with the House of Representatives Commission IX yesterday, Fahmi said the agency has been preparing special strategies to be free of financial deficit. BPJS Kesehatan will seek funding from banks through the supply chain financing program. This financing program is given specifically to health facilities from the partners of BPJS Kesehatan to help accelerate receipt of receivables. Up to now, the agency has cooperated with 13 banks and two multi-finance companies.
In addition, BPJS Kesehatan also prepares policies and programs targeted to save expenses of up to Rp 3 trillion, including improvement of referral systems. With this system, its participants will get hospital services that are tailored to the competence, distance and capacity of the referral hospital based on the patient’s medical needs.
Other programs include the efficiency of spending on treatment services for cataracts, physiotherapy, and healthy babies in sectio (labor) cases and optimization of claim and medical audits in suspected of fraud cases. “We also developed a method of implementing administrative sanctions for non-independent participants who have not paid premiums,” Fahmi said.
The government Regulation (PP) No. 87/2013 actually regulates the government to be able to take special actions in addressing the Health Social Security Fund with a negative value. There are three specific actions: adjustment of premiums, injection of funds, and adjustment of benefits.
The Indonesian Doctors Association (IDI) has proposed adjustment to premiums when their representatives were invited to meet Jokowi at the Presidential Palace last September. According to Jokowi, the government is still conducting an assessment and considering the premium adjustment. Regarding the injection of funds, the government has done it.
As for the adjustment of benefits, the Supreme Court (MA) has cancelled the regulation of Director of Healthcare Insurance (Dirjampelkes) related to health services for cataract patients, healthy newborns, and medical rehabilitation. Thus, there is no longer any limitation or arrangement of benefits for the three services.
However, the government is still trying to help BPJS Kesehatan to be free of its problems. Deputy Minister of Finance Mardiasmo said the ministry has prepared six policy mixes that could reduce BPJS Kesehatan’s financial deficit to Rp 2.9 trillion.
First is to intercept arrears in local government. This is regulated in the Minister of Finance Regulation (PMK) No. 183/2017 on Procedures for the Settlement of Arrears in Local Government Health Insurance Premiums through Deduction of General Allocation Funds and/or Profit Sharing Funds. From this policy, the funds that flow to BPJS Kesehatan are targeted to reach Rp 264 billion throughout 2018. Up to October, its realisation has reached Rp 29.57 billion.
Second, the use of at least 50 percent of the Revenue Sharing from Excise Tax on Tobacco Products (DBH CHT) through regulation No. 222/2017. Until 18 October 2018, the DBH CHT distribution reached Rp 2.22 trillion to 354 regions in 18 provinces. It is targeted to increase by another Rp 750 billion until the end of this year. The utilisation of these funds is expected to contribute in suppressing the nominal value of the claims.
Third, the efficiency of BPJS operational funds in accordance with regulation No. 209/2017. Based on the Ministry of Finance’s calculations, the efficiency can reach Rp 198 billion. Fourth, the acceleration of premium disbursement of the government-sponsored participants (PBI). This is in line with the enactment of regulation No. 10/2018 on Procedures for the Provision, Disbursement and Accountability of PBI health insurance premiums. As of 31 July, the premiums had been paid for 12 months amounting to Rp 25.5 trillion.
Fifth, deduction of cigarette tax that is sent directly to the account of Social Security Fund (DJS). This is in accordance with regulation No. 128/2018 on Procedures for Deduction of Cigarette Tax as a Contribution to Support Health Insurance Programs. In the third quarter, the DJS Kesehatan received Rp 1.34 trillion from 28 provinces. There will be another addition of Rp 83.61 billion from six provinces.
Sixth, efficiency of health service payments through synergy with other organizing agencies. The Finance Minister has signed the regulation and is being processed by the Ministry of Law and Human Rights. From this policy, there is a potential savings of Rp 120 billion.
Apart from the six policy mixes from the Ministry of Finance, there will be a revision of Government Regulation (PP) No. 87/2013 on Management of Healthcare and Social Security Assets. With the revised rule, there is the potential for additional bailout funds from BPJS assets up to a maximum of Rp 1.3 trillion.
With these steps, the government has not been able to ascertain the extent of the deficit reduction in BPJS Kesehatan until the end of the year. Finance Minister Sri Mulyani recently sent a letter to the Development and Finance Comptroller (BPKP) to conduct a second phase review of BPJS Kesehatan’s finances. “The study is still ongoing, and we will get the results from BPKP on the 5th,” Mardiasmo said.