dr. I Gede Subawa, MKes
President Director of PT Askes Indonesia
Phrarmaceutical Sector Meeting on 8 November 2012 Nikko Bali Resort Spa, Nusa Dua, Bali
SUPPLY SIDE OF HEALTH INSURANCE SYSTEM IN INDONESIA
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Overview Of Indonesia
• Total population : 237,641,326 (2010 National Census) • Gross national income per capita (PPP international $):
3,600 • Life expectancy at birth m/f (years): 66/71 • Probability of dying under five (per 1 000 live births) : 34
(2007) • Probability of dying between 15 and 60 years m/f (per 1 000
population) : 234/143 • Total expenditure on health per capita (Intl $, 2009) : 99 • Total expenditure on health as % of GDP (2009) : 2.4
Source; WHO (2012)
ECONOMIC GROWTH OF INDONESIA
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
2007 2008 2009 2010 2011 2012 2013 2014
Indonesia Emerging/Developing Economies ASEAN
Indonesia real GDP grow faster than ASEAN and emerging/developing economies … % GDP growth (real) 2007 - 2014
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PER CAPITA INCOME GROWTH
0%
20%
40%
60%
80%
2008 2010 2012 2014
% Gr
owth
ASEAN
Emerging/Developing
Economies
…& per capita income is also expected to grow faster % Per Capita income growth 2007 - 2014
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INDONESIAN POPULATION GROWTH
116,9 123,8116,6 123,7233,5 247,6
050100150200250300
2010 2015
Po
pu
la
tio
n (M
) Female Population (m)
Male Population (M)
Source: BPS (Central Statistics Bureau)
INDONESIAN POPULATION GROWTH Growth at 6% to 2015
Increasing life expectancy will create demand for chronic therapies
The elderly population increase in the next 5 years
0 to 1010 to 1920 to 2930 to 3940 to 4950 to 5960 to 69
70+2010 2015
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DISTRIBUTION OF POPULATION
42,0% 48,3% 54,2% 59,5%
58,0% 51,7% 45,8% 40,5%
0%
20%
40%
60%
80%
100%
2000 2005 2010 2015
Po
pu
latio
n S
plit b
y
Urb
an
/Ru
ra
l (%
)
Rural
Urban
Indonesia population increasingly moving to urban area
2000 2010 2005 2015
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7
HEALTHCARE SPENDING
Source: 1Worldbank report, WHO Global Atlas, Datamonitor
0,0%
0,5%
1,0%
1,5%
2,0%
2,5%
3,0%
3,5%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
% GDP spent on healthcare growing 2.4% of GDP (USD 44 per capita)
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Source: 1Worldbank report, WHO Global Atlas, Datamonitor
…% spend is low compared to peer countries % GDP Spent on Healthcare, comparative
0
2
4
6
8
Vie
tnam
Wor
ld A
vg
Mal
aysi
a
Phi
lippi
nes
Thai
land
Sin
gapo
re
Indo
nesi
a
Mya
nmar
HEALTHCARE SPENDING
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Indonesia Healthcare Transformation Universal Healthcare Coverage in 2014
• Indonesia Minister of Health has already set a target to start covering all people’s health costs as early as 2014.
• Law No. 40/2004 on National Social Security System (SJSN)
• Law No. 36/2011 on Social Security Implementation – BPJS I (Health Insurance Carrier)
• ASKES +JAMKESMAS merge
• 5 Committees are now working to set the Insurance System
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Healthcare Transformation System Sistem Jaminan Sosial Nasional – Universal Health Coverage 2014
PT JAMSOSTEK
PT ASKES
PT TASPEN
PT ASABRI
Dewan Jaminan Sosial Nasional (National Social Security Council)
BPJS 1 BPJS 2
PT
JAM
SOST
EK
PT
ASK
ES
PT
TASP
EN
PT
ASA
BR
I
MOH JAMKESMAS
MO
H J
AM
KES
MA
S
Less fortunate/Poor
Employee – Health, Accident & Pension fund
Civil servants & Military Retirement
Pension for civil servants
Active Military Health Non-Health
Current
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2014
HISTORY PT ASKES (PERSERO)
1968: BPDPK
1984: PERUM HUSADA BHAKTI
1992: PT ASKES (PERSERO)
2014: Health Insurance Carrier ( BPJS)
Reimbursement
Managed care
Managed care
1968: Minister of Health: as an embryo of Universal Coverage
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ROAD MAP TO UHC
Preparation
Preparation
FORMAL SECTOR (ASKES, JAMKESMAS, JAMSOSTEK,
MILITARY/POLICE, BUMN/BUMD, SWASTA
FORMAL SECTOR BUMN/BUMD, SELF WORKER,
POOR, DISTRICT
INFORMAL SECTOR SELF WORKER, PBI
UC
2013
2014
2015
2019 ?
2012
2016
BPJS-1 (Health UHC Organization)
BPJS-2 (Pension Organization)
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Integration between quality and cost control
• Gatekeeper concept Primary care • Quality Assurances Credentialing & Recredentialing • Comprehensive health care benefits • Emphasizes on promotion and prevention • Referral system • Drugs Formularium DPHO • Prospective payment system • Utilization review • Medical Advisory Board
MANAGED CARE
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Supply Side - UHC Health Insurance Specialist
Supply Side
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Legal Aspect
UU 40/2004
• 23 (1)
(1) Benefit Delivery by BPJS Provider.
• 24 (1) (2) (3)
(1) Payment Negotiation BPJS vs Provider Association
(2) BPJS obligated to pay the provider at the latest 15 day
(3) BPJS develop a healthcare system, quality control, provider payment mechanism (efficiency and effectiveness)
• UU 24/2011: 11 (d) (e)
(d) Provider payment Regulator;
(e) Provider contract BPJS;
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Health Insurance Specialist
17
PROVIDER MANAGEMENT
BPJS (proposed)
1.Provider Mapping
• Primary, Secondary, Tertiary
• Provider with catastrophic care
• Pharm, Optical, Laboratory
2. Cre/Recredentialing
• All Provider
3. Payment Nego & Provider Contract
• BPJS nego to Provider Assosciation
• BPJS contract to provider
4. Updating Provider List
• Referensi Provider On Line (public)
5. Performance of Provider Evaluation
• Utilization Review, customer satisfaction
• Medical Audit, Cost Effectiveness, Comprehensiveness
PT Askes (Persero)
1.Provider Mapping
• Primary provider
• Provider with catastrophic care
2. Cre/Recredentialing
• All Provider
3. Payment Nego & Provider Contract
• Nego & Contract to Provider
4. Updating Provider List
• Referensi Provider On Line (internal)
5. Performance of Provider Evaluation
• Utilization Review, customer satisfaction
ASKES VS BPJS
Health Insurance Specialist
ROAD MAP HEALTH FACILITIES MANAGEMENT
Qt I
• Policy
Synchronizat
ion
• Finalization
of guideline
Qt II
• Socialization
of health
facilities
Qt III
• Health
Facilities
Selection
Qt IV
• Negotiation
• Contract
Semester I
• Perfomance
Evalualuation
of Health
Facilities
• Implementati
on of
Regional
Partnerships
Year 2013 Year 2014 Alt.1:
Qt I
• Policy
Synchronizat
ion
• Finalization
of guideline
Qt II
• Socialization
of health
facilities
Semester II
• Negotiation
• Contract with Health
Facilities:
Askes, Jamsostek,
TNI/POLRI, Jamkesmas, )
Semester I
• Perfomance
Evalualuation
of Health
Facilities
• Implementati
on of
Regional
Partnerships
Alt.2: Year 2013 Year 2014
Health Insurance Specialist
Take Precedence Accredited
If not accredited: • Administrative Criteria
• Having a license from ministry of Health and local Government. • Having a business license as a health Facilities. • AMDAL
• Facilities Criteria • Having facilities in accordance with the applicable regulation • Having medical and administrative personnel according to
regulations and the needs of the participants. • Strategic location.
• Quality Criteria • Having a quality accredited certification or other quality
certification.
Health Insurance Specialist Health Facilities Criteria
ASKES HEALTH CARE PROVIDERS 2011 Regional I
Regional II
Regional III
Regional IV
Regional V
Regional VI
Regional VII
Regional VIII
Regional IX
Regional X
Regional XI
Regional XII
• 8.774 Community Health Centers
• 3.753 Family Physicians/24 hours Clinic
• 270 Laboratories, 231 Indonesian Red Cross
• 952 Hospitals (506 Government hospitals; 109 TNI/POLRI hospitals; 263 private hospitals; 74 special hospitals)
• 162 providers for hemodialysis
• 1.184 pharmacies dan 756 optical
Regional XI
DPHO (List of Drugs Items and Prices) As a drugs in Universal Health Coverage
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• Indonesia has an enormous number of drugs that are available on the market :
15,498 items (Ind. FDA 2012)
208 farmacies
• a problem of Askes to select an appropriate and qualified drugs for its members
• ASKES must ensure that the drugs are selected according to evidence based criteria (EBM)
• the problem of distribution is an issue to be overcome, and which creates drug price disparity among the islands
• A widely range of drug’s price
WHY SELECTION?
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WITH THOSE CIRCUMSTANCES ASKES
DESIGN A DRUGS POLICY FOR ITS MEMBERS
EFFECTIVE, SAFE AND EFFICIENT List of Drug Items and Prices
(DPHO, Since 1987)
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Annual update of the DPHO.
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- Expert Team consist of : Pharmacologyst, Specialist, Health Ministry, and The National Agency of Food and Drug Control
- Hospital Recomendation consists of National Essential Medicines List, Generic and Branded Generic that had not been included in the recent DPHO
DPHO COMPOSEMENT PROCESS
DPHO & QUALITY OF SERVICES
• DPHO Board of Experts review the drug list by considering EBM and analyzing cost effectiveness.
• DPHO Board of Experts conducts a series of intensive discussions every week for 6 months every year.
• DPHO is composed based on the result of Board of experts recommendation to ensure all medical needs are accommodated for outpatient care (primary and specialist), and inpatient care.
• DPHO Board of Experts also recommends and specifies particular indications for certain drugs (restrictions), in order to ensure:
Prescribing is in accordance with treatment guidelines. Improving patient compliance with chronic disease medicines. Decreasing overuse of antibiotics. Decreasing overuse of injections. Increasing use of generic medicines.
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PRICING THE DRUGS
• The price negotiation is conducting after the quality of drugs is assured by certifying they fully meet of the following: Product Information, including meta analysis. Indonesia Food and Drugs Agency Register. Certificate of Analysis (COA). Good Manufacturing Practice (GMP) or Indonesian
Certification of Good Manufacturing Practice. • Price negotiation with pharmaceutical industries only at national
level. • By offering a large, fixed, captive market to the pharmaceutical
industry, ASKES could obtain a significantly efficient price of up to 60% off the regular market price.
• The same price is implemented around the country
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INDEPENDENCY OF DRUG FORMULARY
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1. Selection process efektive dan efficient
• efficacy & safety aspect by Experts Team
• Price and distribution by ASKES Team
2. Label use defined DPHO Experts Team
indications, restriction and maximum prescribe
3. Price based on negotiation between ASKES- Manufacturers including special arrangement
4. Askes Drug Formulary (DPHO) is designed for one year :
• The same policy and price around the country
• Evaluate and re-formulate every year
Members: – Health care services availability – Health care services quality
Health Care Providers: – More Choices and affailability – Assurance of Drugs Quality and Availability – Quality of Services Evidence-based practice
Manufacturers : – Captive Market, – Less Marketing Cost – Economies of Scales
Government : – Efficiency of Health Care Spending
DPHO BENEFIT FOR STAKEHOLDER
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OPTIMIZING DPHO IMPLEMENTATION
• Prescriber in government and private providers (primary, secondary, tertiary) should follow the drugs in DPHO for treating any ASKES patients.
• Communicating with ASKES members about the advantages of DPHO.
• Provide a scientific seminar or medicine workshop for prescribers at least four times each year at every ASKES branch office.
• Special analyses from the Medical Advisory Board (MAB) at every ASKES branch. The Medical Advisory Board recommends the medical judges and provides a second opinion in term of evidence based medicine drugs prescription.
• Review and evaluation of drug utilization, also prescribing drugs outside of DPHO.
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•Number of Drugs in DPHO, Years 2007 – 2012
•Number of Therapy Class in DPHO vs DOEN, Years 2007 – 2012
DPHO CONTENT
EVALUATION OF DPHO
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Members trustworthiness of using DPHO medicine increase every year
Outpatient Utilization
EVALUATION OF DPHO
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Members trustworthiness of using DPHO medicine increase every year
Inpatient Utilization
EVALUATION OF DPHO
DPHO CONTENT
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Antineoplastic and Paliatif Treatment - Cytotoxic
Indication:
For
gastrointestinal
cancer
Indication:
For metastases
breast cancer
with Positive 3
(+++) HER2 of
Positive FISH
Indication:
For Limfoma
Non Hodgkins
(LNH) Malignum
with Positive
CD20
Sample description of the Indication Guide for prescribing
Challenges • Wide variety of kind and price available in the
market potential to overuse, misuse
Inefficient
• Over prescription and irrational prescription
• Provider Compliances moral hazards
• Commitment from Distributor/Manufacturer
• Effectiveness of the drug’s prescription control
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