Snowball Effect of Chronic BPJS Health Deficit

Penulis: Martha Ruth Thertina

19/9/2018, 23.19 WIB

BPJS Health’s deficit is increasing. Although the government has injected bailout funds and made a series of new rules, it has not yet permanently improved its finances.

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A chronic financial deficit has been entangling the Healthcare and Social Security Agency (BPJS Kesehatan/Health) for four years. Although the government continues to disburse bailouts and provide assistance through various new rules, there has been no permanent solution to overcome financial mismatches in the agency. The issue also holds the potential for snowball effects disrupting the government.

The government will disburse Rp 4.9 trillion bailout funds for BPJS Health this weekend at the earliest, from the reserve fund of the National Health Insurance (JKN) program. The procedure for the provision, disbursement and accountability of the fund is regulated in Minister of Finance Regulation No. 113/PMK.02/2018, which was issued on 10 September.

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Based on information obtained by D-Inside, BPJS Health proposed this option to the Ministry of Finance a few months ago, due to the high number of complaints from hospital management and pharmaceutical industry players regarding the slow payment of claims disrupting the flow of corporate funds.

The Indonesian Pharmaceutical Association (GPFI) submitted a complaint through a letter to the finance ministry. Based on GFPI data, the slow payment of claims for medical services has affected pharmaceutical and health equipment industry players. The total debt of medicine and health equipment hit Rp 3.5 trillion at the end of July.

The bailout decision was finally taken to avoid disruption to health insurance services for BPJS participants. According to BPJS Watch Advocacy Coordinator Timboel Siregar, BPJS Health must pay a 1 percent fine per month if it is late in paying bills to its partners. This means if the claim payment is late at Rp 1 trillion, the monthly fine can reach Rp 100 billion.

The BPJS health deficit resembles a snowball that will only get bigger. In a joint meeting of the House of Representatives (DPR) Commission IX, BPJS Health, the ministries of finance and health, and related business associations on Monday (17/9), BPJS Head Fachmi Idris said the deficit had not yet reached its peak.

Based on BPJS Health’s prognosis, the cash flow deficit could hit Rp 16.58 trillion this year, consisting of last year’s deficit accumulation of Rp 4.4 trillion, plus this year’s projected deficit of Rp 12.1 trillion. Despite adding the policy mix, the Development Finance Comptroller (BPKP) projects a lower deficit of Rp 10.58 trillion.

With this projection, the BPJS health deficit risk is getting higher. It was Rp 3.3 trillion in 2014, Rp 5.7 trillion in 2015, Rp 9.7 trillion in 2016, and Rp 9.75 trillion last year. “The deficit has not reached its peak because the utilisation of this program has not reached its maturity level,” Fachmi said.

He added that the root of the deficit problem is low levies (underpriced) from BPJS Health participants, which are not commensurate with the average claim cost per person per month. The proposed solution is a gradual increase in the levies.

In 2016, the average premium was Rp 33,776 per month, while the average cost hit Rp 35,802 per month. Last year, the average premium was Rp 34,119 per month, while the average cost reached Rp 39,774 per month. Each month in 2016 there was a difference of Rp 2,026 and it rose twofold to Rp 5,625 a year later.

Under government regulations No. 87/2013 and No. 84/2015, adjustment of levies is allowed if the health social security fund assets are negative. However, President Joko Widodo has confirmed there will be no increase in levies this year.

Another option is injecting funds from the government and adjusting benefits, and the latter option is very unpopular.


DJSN Actuarial Count

Presidential Regulation No. 16/2016

1. Levy Assistance Recipients (PBI)

Rp 36.000

Rp 23.000

2. Peserta Bukan Penerima Upah (PBPU)



-          PBPU Class I

Rp 80.000

Rp 80.000

-          PBPU Class II

Rp 63.000

Rp 51.000

-          PBPU Class III

Rp 53.000

Rp 25.500

3. Participants Not Recipients of Wages (PPU)

6% wage deduction with the upper wage limit for PPU, which is 6 times Non-Taxable Income (PTKP)

5% wage deduction with the upper wage limit for PPU, which is Rp 8 million

Source: BPJS Health Press Release, Presidential Regulation No. 16/2016

Many Problems

BPJS Watch Advocacy Coordinator Timboel Siregar said levies that do not rise are not the only cause of the deficit. Other problems are high referrals to hospitals and a lack of supervision from BPJS Health management. As a consequence, there are many arrears in terms of payments from participants and fraud by hospital personnel.

Timboel said the percentage of patients who come to the Public Health Centres (Puskesmas) or private clinics (First Level Health Facilities/FKTP) and are then referred to hospitals (Advanced Referral Health Facilities/FKRTL) was 12.5 percent in 2017 and rose to 15 percent this year. According to him, the referral level can be reduced if the FKTP cures 144 diagnostic codes (diseases) in accordance with regulations. “Don’t easily provide referrals.”

Timboel also criticised BPJS Health supervision over the high number of participants who have arrears in terms of premium payments, and fraud allegations by hospital personnel.

The alleged fraud is that the patients are asked to return home before recovering and must come back to the hospital a few days later. As a consequence, one patient can have many claims for INA-CBGs (Indonesia - Case Base Groups), which is a system for hospitals to file claims to BPJS Health. The claims are filed based on the diagnosis of disease and procedures.

According to Timboel, supervision should be carried out by officers of BPJS Centre in hospitals. “The performance of the board of directors for supervision must be demanded.”

Government and DPR Solutions

The government is optimistic it can reduce the deficit and support BPJS’ finances by injecting funds and implementing a series of regulations. In a meeting with the House of Representatives (DPR) Commission IX, Deputy Minister of Finance Mardiasmo said some rules had been issued and others would be published soon.

It issued Minister of Finance Regulation No. 183/2017 concerning Procedures for Settlement of Arrears of Regional Government Health Insurance Levies through Deduction of General Allocation Funds and/or Profit Sharing Funds. With this, the central government is ready to discipline local governments that still have arrears in terms of payments to BPJS Health.

Under Minister of Finance Regulation No. 222/2017 on the Use of Profit Sharing Funds -Tobacco Excise (DBH-CHT), the DBH-CHT of Rp 1.48 trillion will support BPJS Health’s supply side.

There are also Presidential Regulation for National Health Insurance (JKN) to improve the efficiency and effectiveness of health services and Minister of Finance Regulation No. 2019/2017 to make BPJS Health’s operating funds more efficient.

Under Minister of Finance Regulation No. 10/2018 concerning Provision, Disbursement and Accountability Procedures for Health Insurance Levy Funds of Levy Assistance Recipients (PBI), the disbursement of funds for PBI is expected to run faster.

Minister of Finance Sri Mulyani Indrawati is preparing a regulation to encourage synergy between BPJS Health and other social security providers, such as PT Jasa Raharja, PT Taspen, and PT Asabri, in handling health issues, so the burden will not accumulate in BPJS Health.

The government also plans to review President Regulation No. 32/2014 concerning Management and Utilization of JKN Capitation Funds at regional government-owned FKTP. The aim is to improve the management and utilisation of the capitation funds.

House Commission IX is also allowing the government to provide greater funding support to cover the deficit, with the hope that public health services will not be disrupted. “I think the amount is from Rp 10 trillion to Rp 11 trillion if we do not want to see effort to save the deficit as a big thing because it affected hundreds of millions of people,” said Commission IX Chairman Dede Yusuf.

Commission IX member Ribka Tjibtaning agreed. “Village funds can be Rp 60 trillion. It is possible for future health.” In particular, Ribka hopes there will be no adjustment in benefits because this only brings difficulties to the public in accessing health services.