What I (un)Learn During Internship - Part 2 (Abusing Social Insurance)

Since January 1st, 2014 Indonesia has finally implemented its new national social health insurance system (SJSN) with goal of realizing health for all. The new funding system aims to deliver accessible and affordable health care for every Indonesian, living everywhere in the country. 

Social insurance has long been admired to cover all Indonesian, regardless their economic and social status. However, before the realization of SJSN, only the poorest and least fortunate households were covered by social insurance, under Jamkesmas, Jamkesda and Gakin, while the middle class people who were not eligible for these insurances were forced to pay healthcare by out of pocket funding. According to their economic status, most of Indonesians can be classified as middle income people, thus out of pocket spending shared the biggest health financing source in this country.

Middle income people do not own enough money to keep purchasing for health care, thus if they continue this habit of health spending they will finally be 'exhausted' and overwhelmed by it. To cut this suffocating condition, Indonesian government then decided to reform its health financing system by implementing new national social insurance with universal health coverage as the main goal.

For 8 months long since it first runned, most of Indonesians are still unregistered for the insurance. In fact, there are less than 20% of citizenz covered until now, still we are far from our dream to provide health for all. Nonetheless, misconduct from healthcare provider has been able to be spotted in many places, including the hospital where I am posted during my internship. One of its massive wrongdoings lays in how it overclaim diagnosis. 

As a secondary health care provider, scheme of the new social insurance in it is to receive costumized financing from health insurance provider (BPJS) according to disease diagnosis as listed in INA CBGs. If you have certain disease such as severe head trauma, the allocated fund for your case is Rp 8.000.000. It means that the cost of treating you from laboratorium test until surgery cannot exceed this amount whereas such case usually may spend about Rp 12.000.000 in your hospital. If you (by using healthcare) exceed this amount, like Rp 4.000.000, 00 higher in this case, your hospital will suffer financial loss. Imagine if it happens over and over again, the hospital will not be able to endure it and will collapse as a result. 

By this means, the hospital should manage each case cost efficiently in order to survive. Unnecessary tests and treatment should not be administered to patients, generic drugs should be chosen over patents. However, old habits hard to die. Some hospitals (including the place I'm posted in) keep operating ineffeciently, yet they know the consequences. As a result, they cheat their way out by putting more diagnoses so that the social insurance will cover higher amount for them. How brilliatnly despicable.

This problem should be seen as systemic problem, rather than one hospital management misconduct. Doctors are not innocent. They take part in this corosive act, by growing preferences in prescribing patent over generic drugs. If their reasons to do so is because the generic isn't available yet, it doesn't make sense since most of their drug choices have long been invented after their patent runs out. Even if they argue that patent drugs are better than generic, this isn't correct either. They are identically the same, made with the similar substances. I don't see how they can be more superior than the generic. Their superiority claim might only lays in their pamphlets and brochures brought and spread to the doctor's office by the med reps.

Patients aren't guilty free either. They often encourage doctors to prescribe expensive drug with belief it has better effect, whereas it is purely precipitated by placebo effect. There's a study by Branthwaite and Cooper which find that packaging effect has beneficial effect in enhancing pain relief. Even more interesting, another study exhibited that pain relief drug was more potent when subjects were told it cost more ($2.5) than when they were told it cost 10 cents.
However, even if doctors finally agree to compromise and decide to use generic over patents, the hospital has marked up drug prices some extra rupiahs for all social insurance patients.

This is how complex the problems are. Everybody takes part in abusing social insurance.

The last disturbing fact that I can provide you is that once BPJS delivered funds for the claim, each people work here enjoy extra money since received funds exceeds their real expenses.Imagine if this is how social insurance is conducted in most places, Indonesiay will declare bankruptcy in no time.

Here some things that I will be doing if I were anyone important:

• carry out audit each month for every social insurance providers
• place at least 2 BPJS officers in every providers to make sure fair play
• forbid doctors to prescribe patent drugs where generic drugs available
• deliver massive education for public awareness of similar drugs effect between generic and patent
• include healthcare providers, doctors, and patients in SJSN and BPJS feedback and evaluatio

Last but not least, if all of mentioned above have been done eventually but show no significant improvement, hire a shaman and ask him to put a curse on everyone who conduct cheating. Problem solved.