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The change in financing patterns from fee for service to the INA-CBGs pattern is both an opportunity and a threat for hospitals. Opportunities arise if hospitals can run the JKN-KIS (National Health Insurance-Healthy Indonesia Card) program effectively so that claims are positive, otherwise JKN-KIS turns into a threat if the services provided by the hospital are not effective and efficient (Mardiah and Rivany, 2017). Therefore casemix and casemix index are important parameters. The aim of this research is to determine the hospital casemix and casemix index achievements as well as the relationship between hospital characteristics, patient characteristics and hospital capacity on hospital casemix and casemix index. This research uses claim data submitted by hospitals to BPJS Health, data related to hospital capacity is obtained from the hospital. Analysis was carried out univariate, bivariate and multivariate using multiple linear regression. The results of the research showed a significant relationship between the hospital class D variable and the hospital class B variable, the hospital BOR variable, the number of intensive beds, the number of cases with advanced equipment in inpatient care, the proportion of treatment class 3, the proportion of severity level 3 and the proportion of BP with inpatient casemix. There is a significant relationship between the variables of hospital class, type of hospital, hospital ownership, hospital BOR, number of intensive beds, proportion of class 3, proportion of severity level 3, proportion of BP and proportion of women with inpatient casemix index. There is a significant relationship between the variable hospital class D and hospital class B, hospital ownership, the variable proportion of women, the number of cases with advanced equipment in outpatient care, the proportion of elderly people and the proportion of BP to outpatient casemix. There is a significant relationship between the variables of hospital ownership, proportion of women, proportion of BP, number of cases with advanced equipment in the outpatient setting and number of operating rooms with the outpatient casemix index.
The National Health Insurance System or better known as JKN is able to bring benefits to all Indonesian people. Moreover, in this JKN era, more and more people are aware of their health. This is directly proportional to the increasing number of outpatient and inpatient visits at Pasar Minggu Hospital. The number of outpatient visits reached more than 20,000 visits per month since 2018 until 2020. If this high figure is not balanced with the comparable ability to collect JKN claims, it will hamper the hospital cash flow. Therefore, RSUD Pasar Minggu has implemented an IT system that supports the entire process up to the billing stage. Hopefully IT system at Pasar Minggu Hospital have a high level of effectiveness and efficiency so that it can support the hospital cash flow
Pemanfaatan ketiga indikator (casemix, CMI, dan HBR) secara berkala untuk mempertahankan mutu sembari menjaga efisiensi pelayanan RS di era JKN. Penelitian ini bertujuan untuk menganalisis dan strategi peningkatan capaian indikator casemix, casemix index dan hospital baserate RSU Bali Royal tahun 2019 - 2024.
Penelitian dilakukan di RSU Bali Royal selama bulan Mei - Juni 2025, menggunakan data primer wawancara mendalam dan focus group discussion dan sekunder yang didapatkan dari rekapitulasi elektronik klaim (e-klaim) Kemenkes, laporan keuangan, dan laporan rumah sakit. Penelitian ini menggunakan studi observasional pendekatan kualitatif untuk menganalisis capaian indikator Casemix, CMI dan HBR rawat inap dan rawat jalan.
Hasil penelitian menunjukkan bahwa terdapat unsur struktur (sumber daya manusia, material, mesin, anggaran, dan metode) dan unsur proses (manajemen pasien, manajemen koding, dan manajemen klaim) membuahkan unsur output (indikator casemix, casemix index, dan hospital baserate) Dinamika penambahan unsur struktur berdampak pada proses pelayanan pasien, efisiensi koding hingga 50%, dan keberhasilan klaim. Casemix rawat jalan tahun 2019 – 2024 diperoleh 11.393; 16.037; 32.763; 59.520; 111.193; dan 129.423. Casemix rawat inap kelas 1 tahun 2019 – 2024 diperoleh 907; 1.321; 2.657; 3.165; 3.829; dan 4.014. Casemix rawat inap kelas 2 tahun 2019-2024 diperoleh 818; 1.013; 1.800; 2.511; 3.052; dan 3.309. Casemix rawat inap keas 3 tahun 2019 – 2024 diperoleh 205; 539; 1.557; 2.023; 2.646; dan 3.038. Nilai CMI rawat jalan tahun 2019 – 2024 diperoleh 0,98; 1,11;1,16; 1,21; 1,35;dan 1,24. CMI rawat inap kelas 1 tahun 2019 – 2024 diperoleh 1,32; 1,60; 1,84; 1,57; 1,45; dan 1,37. CMI rawat inap kelas 2 tahun 2019 – 2024 diperoleh 1,17; 1,36; 1,58; 1,41; 1,33; dam 1,33. CMI rawat inap kelas 3 tahun 2019 – 2024 diperoleh 1,46; 1,82; 1,67; 1,54; 1,53; dan 1,45. HBR rawat jalan tahun 2019 – 2024 diperoleh 354.393; 333.231; 257.536; 243.675; 226.650; dan 238.494. HBR rawat inap kelas 1 tahun 2019 – 2024 diperoleh 5.257.416; 6.028.120; 5.477.120; 5.970.918; 6.542.667; dan 7.082.825. HBR rawat inap kelas 2 tahun 2019 – 2024 diperoleh 4.449.693; 5.628.665; 4.817.066; 4.993.043; 5.156.750; dan 5.563.012. HBR rawat inap kelas 3 tahun 2019 – 2024 diperoleh 3.616.138; 4.594.204; 3.746.071; 4.325.317; 4.584.260; dan 4.789.356. Nilai casemix dan casemix index mengalami peningkatan setiap tahunnya dengan capaian CMI di atas standar rumah sakit swasta kelas C regional 2. HBR rawat jalan pada tahun 2021-2024 dibawah HBR nasional, namun HBR rawat inap kelas 1, 2, dan 3 selalu berada di atas HBR nasional. Strategi yang dapat ditempuh untuk peningkatan casemix, casemix index, dan penurunan HBR adalah optimalisasi unsur struktur dengan perbaikan sumber daya manusia dan pengkajian metode, efisiensi mesin, material, dan anggaran, dan evaluasi pada unsur proses (manajemen pasien, koding, dan klaim).
ABSTRAK Nama : Albert Hasibuan Program Studi : Kajian Administrasi Rumah Sakit Judul :Analisis Kinerja Tim Casemix RSU UKI Berdasarkan Malcolm Baldrige Criteria for Performance Excellence Tahun 2018 Pembimbing : dr. Adang Bachtiar MPH DSc Tim Casemix rumah sakit akan menjadi penggerak membantu melakukan sosialisasi, monitoring dan evaluasi implementasi INA-CBGs di rumah sakit. Pada awal mulainya menjalankan program JKN/BPJS rumah sakit ini mengalami peningkatan jumlah kunjungan pasien yang cukup signifikan, namun semakin ke depan terdapat penurunan jumlah pasien dan semakin tingginya beban biaya rumah sakit berkenaan dengan banyaknya klaim biaya yang tertunda/ditolak pembayarannya. Penelitian ini untuk melakukan penilaian kinerja Tim Casemix RSU UKI Berdasarkan Malcolm Baldrige Criteria for Performance Excellence untuk mendapatkan gambaran rencana perbaikan kinerja manajemen rumah sakit. Metode yang digunakan adalah metode penelitian kombinasi menggunakan Analisis data kuantitatif dan kualitatif, dimana peneliti melakukan pengumpulan data dengan menggunakan kuesioner diikuti dengan wawancara mendalam informan kunci, telaah dokumen, observasi, dan diskusi kelompok terarah. Hasil penelitian didapatkan Tim Casemix RSU UKI Jakarta memiliki aspek kesempatan untuk peningkatan (Opportunity For Improvement /OFI) di semua kriteria selain sistem kerja, dimana pada kriteria-kriteria tersebut penilaian masih di bawah 50% dari nilai kesempurnaan MBCfPE. Total skor kriteria Malcolm Baldrige pada Analisis Kinerja Tim Casemix berdasarkan Malcolm Baldrige Criteria for Performance Excellence RSU UKI Jakarta tahun 2018 adalah 376,31, yang artinya tim casemix mencapai predikat kinerja “Early Improvement” dengan tingkatan mutu “Average”. Kata kunci: Malcolm Baldrige; Rumah Sakit; Tim Casemix
ABSTRACT Name : Albert Hasibuan Study Program : Magister Of Hospital Administration Title : Performance Analysis of UKI Hospital Casemix Team based on Malcolm Baldrige Criteria for Performance Excellence on 2018 Counsellor : dr. Adang Bachtiar MPH DSc Hospital Casemix team will become a driving force helping to conduct socialization, monitoring and evaluation of the implementation of INA-CBGs in hospitals. At the beginning of start run programs JKN/BPJS hospital is experiencing an increase in the number of patient visits are significant enough, but getting to the front there is a decrease in the number of patients and the increasing costs of hospitals with regard to the number of claims pending/rejected charges that the payout. The research is to conduct a performance analysis of UKI Hospital Casemix Team based on Malcolm Baldrige Criteria for Performance Excellence to get an overview of performance improvement plan of hospital management. The method used is a combination of research methods using quantitative and qualitative data analysis, where the researchers doing data collection using the questionnaire followed by in-depth key informant interviews, document review, observation, and discussion groups. The Research Team obtained Casemix RSU UKI Jakarta has the opportunity for improvement (Opportunity For Improvement/OFI) on all criteria in addition to the working system, where in the criteria of assessment is still under 50% of the value MBCfPE perfection. A total score of Malcolm Baldrige on performance analysis of UKI Hospital Casemix Team based on Malcolm Baldrige Criteria for Performance Excellence Jakarta in 2018 is 376.31, meaning that the casemix team reached the predicate "Early Improvement" performance with the "Average" level of quality. Keywords: Malcolm Baldrige; The Hospital; Casemix Team
ABSTRAK Nama : Wita Prominensa Program Studi : Kajian Administrasi Rumah Sakit Judul : Faktor-faktor yang Berhubungan dengan Proses Revisi Berkas Penyebab Terhambatnya Pencairan Klaim BPJS Pasien Rawat Inap di RS. XYZ Jakarta tahun 2015. Penelitian dengan pendekatan kualitatif dan kuantitatif ini secara umum bertujuan untuk menggali lebih dalam faktor yang berhubungan dengan proses revisi berkas klaim pasien BPJS rawat inap dimana secara tidak langsung menjadi penyebab terhambatnya proses pencairan klaim BPJS rawat inap tahun 2015. Penelitian dilakukan selama 4 (empat) bulan Sejak Februari hingga Mei 2016, dengan mengambil 235 sampel dari total populasi 568 berkas yang bermasalah penyebab klaim pending, yakni berkas yang dikembalikan dan harus direvisi selama 4 bulan terakhir tahun 2015 (September – Desember 2015). Pendekatan kualitatif dilakukan dengan metode wawancara mendalam untuk mencari hubungan faktor 5M (Man, Money, Methode, Material, Machine) terhadap revisi berkas yang mempengaruhi klaim pending. Wawancara dilakukan peneliti kepada seluruh pihak terkait pengelolaan klaim BPJS rawat inap sejumlah 14 informan dengan menggunakan pedoman wawancara. Sementara pendekatan kuantitatif dilakukan dengan metode checklist telaah berkas dan observasi untuk mencari hubungan faktor proses (alur penerimaan berkas, kelengkapan berkas, proses coding, proses entry, verifikasi) terhadap revisi berkas yang mempengaruhi klaim pending. Hasil penelitian kualitatif, diketahui bahwa kebijakan secara operasional belum dioptimalkan, tim casemix baru dibentuk sejak Februari 2016 (RS menerima BPJS sejak 2014), kinerja masih multijobdesk, sosialisasi dan edukasi belum merata, monitoring atau evaluasi belum diterapkan maksimal. Sementara analisa kuantitatif didapatkan bahwa faktor dominan penyebab revisi pada masing–masing kategori pasien BPJS berbeda, yakni; ada pasien PBI faktor dominan ada pada proses verifikasi yang lama justru menyebabkan revisi menjadi cepat; pada Non PBI sesuai kelas faktor dominan dipengaruhi oleh kelengkapan berkas, sama halnya dengan Non PBI upgrade. Secara umum, proses revisi berkas berhubungan dengan proses coding, kelengkapan berkas, proses entry serta proses verifikasi, dengan faktor dominan dipengaruhi oleh variabel kelengkapan berkas. Dari penelitian ini diperoleh kesimpulan bahwa sangat diperlukan kebijakan untuk menetapkan Standar Operational Procedure, mengoptimalkan dengan memfokuskan tim Casemix tanpa multi jobdesk, melakukan sosialisasi, motivasi dan edukasi dalam pelaksanaan casemix. Kata kunci: casemix INA CBGs, BPJS rawat inap, revisi berkas klaim
ABSTRACT Name : Wita Prominensa Program : Master of Hospital Administration Title : The Determinants Factors in Revising Process the Files that Impede the BPJS Payment for the In-Patients in XYZ Hospital Jakarta in 2015. In general, the current qualitative-quantitative study aims to investigate the problems related to the file revisions process of the in-patient’s BPJS claim that may impede the searching process of the BPJS claim itself in 2015. The study was conducted for four (4) months, from February to May 2016. The study took 235 random sampling of the 568 problematic files in total that cause the claim into pending, in which the files should be returned and revised for the last four (4) months in 2015 (September to December 2015). The qualitative approach was conducted by thorough interview to find out the relationship between 5M factors (Man, Money, Method, Material, and Machine) and the file revision that causes the claim into pending. The interview with the fourteen (14) informants on the BPJS claim management was conducted based on the interview ethical guidelines. In addition, the quantitative approach was conducted with file searching checklist method and observation. It was conducted to find out the relationship between the process factors (file receiving process, the file completion, coding process, entry process, and verification) and the file revision that causes the claim into pending. The result of qualitative study illustrates that the operational policy has not been optimized. Moreover, the casemix team has just been established since February 2016 (in fact, the hospital has accepted BPJS since 2014), the multijobdesk still remains, socialization and education on the policy have not been spread evenly, and the monitoring or evaluation has not been applied to the greatest degree. Furthermore, the quantitative study depicts that the prevailing factors of the file revision on each BPJS patient category are different. On the PBI patients, the inverted relationship dominant factor of the lengthy verification process speeds up the revision. On the non-PBIs, the dominant factors are on the file completion, same as Non PBI upgrades. Overall, the prevailing factors of the file revision of BPJS generally are coding process, file completion, entry process and verification. Additionally, the dominant related factors is file completion. The current study concludes that the policy to formulate the Standard Operating Procedure is required. In addition, it is necessary to optimize the casemix team without multijobdesk. Furthermore, the socialization, motivation, and education in the casemix are required. Keywords : Casemix INA CBGs, BPJS Inpatient, Revision Claim File.