Abstract
Indonesia has implemented the National Health Insurance (JKN) program since 2014; however, various forms of fraud continue to be found. According to regulations, BPJS Kesehatan, as the national social security agency, is required to conduct Utilization Review (UR) as an effort to control costs and improve the quality of healthcare services. The effectiveness of UR remains questionable due to several implementation challenges. This study aims to explore the implementation of UR, identify its challenges, and examine the essential components required for its effective implementation. The study was conducted in August 2023 using a qualitative approach through in-depth interviews. Samples were selected purposively and consisted of five key informants. Data were analyzed using thematic analysis. The results showed that all respondents had good knowledge of the UR concept. BPJS Kesehatan applies a retrospective method. The UR results vary, including trends or patterns of patient visits, the ten most frequent Case Base Groups (CBG), the ten most common procedures, and the ten cases with the highest funding for outpatient and inpatient services. BPJS Kesehatan also formulates recommendations based on the UR results. However, strong commitment from healthcare providers is required to implement improvements. The challenges faced by BPJS Kesehatan include limited time for conducting UR, the large number of healthcare facilities to be assessed, as well as conflicts and misunderstandings with patients. Regarding essential components, three key aspects are needed: human resources, technology, and standardized UR procedures.
References
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Bahasa Abstract
Indonesia telah menerapkan Jaminan Kesehatan Nasional (JKN) sejak tahun 2014, namun masih banyak ditemukan kecurangan. Dalam regulasi, Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan sebagai lembaga jaminan sosial diwajibkan melakukan tinjauan pemanfaatan (Utilization Review/UR) sebagai upaya pengendalian biaya dan peningkatan kualitas pelayanan kesehatan. Efektivitas UR masih dipertanyakan karena implementasinya menghadapi berbagai kendala. Penelitian ini bertujuan mengeksplorasi implementasi, mengidentifikasi tantangan, serta menggali komponen esensial yang dibutuhkan. Penelitian ini dilakukan pada Agustus 2023 dengan menggunakan pendekatan kualitatif melalui wawancara mendalam. Sampel ditentukan secara purposif dan terdiri atas lima informan kunci. Data dianalisis menggunakan analisis tematik. Hasil studi menunjukkan bahwa seluruh responden memiliki pengetahuan yang baik mengenai konsep UR. BPJS Kesehatan menggunakan metode retrospektif. Hasil UR sangat beragam, meliputi tren atau pola kunjungan pasien, sepuluh kasus Case-Based Groups (CBG) terbanyak, sepuluh prosedur terbanyak, serta sepuluh kasus dengan pendanaan terbesar untuk layanan rawat jalan dan rawat inap. BPJS Kesehatan juga menyusun rekomendasi berdasarkan hasil UR. Namun, diperlukan komitmen yang kuat dari penyedia layanan untuk melakukan perbaikan. Tantangan yang dihadapi BPJS Kesehatan antara lain keterbatasan waktu dalam pelaksanaan UR, banyaknya fasilitas kesehatan yang harus dinilai, serta adanya konflik dan selisih paham dengan pasien. Terkait komponen esensial, terdapat tiga poin utama yang dibutuhkan, yaitu sumber daya manusia, teknologi, dan standar prosedur UR.
Recommended Citation
Ulandari, Luh Putu Sinthya and Indrayathi, Putu Ayu
(2025)
"Utilization Review pada Jaminan Kesehatan Nasional: Implementasi, Tantangan dan Komponen Essensial,"
Jurnal Ekonomi Kesehatan Indonesia: Vol. 10:
No.
2, Article 5.
DOI: 10.7454/eki.v10i2.1153
Available at:
https://scholarhub.ui.ac.id/eki/vol10/iss2/5
