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Farida Trihartini; Pembimbing: Suprijanto Rijadi; Penguji: Mieke Savitri, KalsumKomaryani, Agus Dwi Susanto
Abstrak: Abstrak

Tesis ini bertujuan untuk melakukan analisis implementasi administrasi klaim Jamkesmas di rumah sakit vertikal tahun 2012. Latar belakang permasalahan dalam penelitian ini adalah banyaknya permasalahan di rumah sakit daerah akibat keterlambatan klaim seperti cash flow rumah sakit, pembayaran insentif yang terlambat, dan pembelian obat terhambat. Di rumah sakit vertikal, efek dari keterlambatan pengajuan klaim Jamkesmas belum diketahui, karena belum pernah ada laporan tertulis mengenai implementasi administrasi klaim Jamkesmas sementara data dari Rekapnas menunjukkan adanya keterlambatan klaim di rumah sakit vertikal. Penelitian ini menggunakan pendekatan kualitatif dengan melakukan wawancara mendalam dari informan terpilih.

Hasil penelitian menunjukkan dari berdasarkan kepada teori implementasi kebijakan Edward III faktor komunikasi, sumber daya, disposisi dan birokrasi, serta kendala yang menyebabkan keterlambatan klaim.

Kesimpulannya,implementasi administrasi klaim Jamkesmas di rumah sakit vertikal telah berjalan baik meskipun ada kendala,yaituhambatan faktor komunikasi, sumber daya, dan komitmen. Kedua, belum ada pengawasan langsung terhadap jalannya proses administrasi klaim Jamkesmas di RS vertikal baik oleh Kemenkes ataupun rumah sakit. Saran peneliti bagi Kemenkes adalah membentuk tim casemix di setiap rumah sakit, dan menyusun format pengawasan sistem klaim.

This thesis aims to undertake an analysis of the implementation of the administrative claims Jamkesmas at hospital owned by Ministry of Health (MoH) in 2012. Background problem in this research is the large number of problems in the hospital area due to the delay in the claim such as cash flow, the incentive payment is late, and the purchase of drugs inhibited. At the hospital, the vertical effects of the delay in filing claim Jamkesmas unknown, because there has never been a written report regarding the implementation of the administrative claims data from temporary Jamkesmas national data claims showed a delay in hospital owned by MoH claims. This study used a qualitative approach by doing in-depth interviews of the selected informant.

The results showed of policy implementation based on the theory of Edward III communication factors, resources, disposition and bureaucracy, as well as the obstacles that cause delays in claims.

In conclusion, the implementation of administration claims Jamkesmas vertical hospital was going well despite the constraints, obstacles to communication factors, resources, and commitment. Second, there has been no direct supervision over the course of the administrative proceedings at hospital owned by MoH Jamkesmas claims either by Ministry of Health or the hospital itself. Advice for Ministry of Healthare forming teams of casemix at every hospital, and composing format of supervision claims.

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T-3878
Depok : FKM-UI, 2013
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Lies Nugrohowati; Pembimbing: Adik Wibowo; Penguji: Kaunang, Mardiati Nadjib, Amal C. Sjaaf, Kalsum Komaryani
B-1575
Depok : FKM UI, 2013
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Nelly Mustika Sari; Pembimbing: Adang Bachtiar; Penguji: Puput Oktamianti, Dumilah Ayuningtyas, Chita Septiawati, Kalsum Komaryani
T-4236
Depok : FKM-UI, 2014
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Syed Matiullah Wahidi; Advisor: Purnawan Junadi; Examiner: Heru Susetyo, Anhari Achadi, Ede Surya Darmawan, KalsumKomaryani
T-3508
Depok : FKM-UI, 2012
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Ida Bagus Yudistira Nugraha Yustama; Pembimbing: Atik Nurwahyuni; Penguji: Masyitoh, Prastuti Soewondo, Kalsum Komaryani, Ni Putu Ayu Prima Dewi
Abstrak:

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).

 

The periodic utilization of three key indicators—casemix, Casemix Index (CMI), and Hospital Base Rate (HBR)—is crucial for maintaining service quality while ensuring operational efficiency in hospitals, particularly within Indonesia's National Health Insurance (JKN) system. This study aimed to analyze factors influencing, and develop strategies for enhancing the performance of, casemix indicators, the Casemix Index, and the Hospital Base Rate at Bali Royal General Hospital over the period 2019–2024. The research was conducted at Bali Royal General Hospital from May to June 2025. Primary data were collected through in-depth interviews and focus group discussions, while secondary data were obtained from the Ministry of Health's electronic claim (e-claim) database, hospital financial reports, and institutional records. This study employed an observational design with a qualitative approach to analyze the performance of casemix indicators, CMI, and HBR for both inpatient and outpatient services. The findings revealed that structural elements (i.e., human resources, materials, machinery, budget, and methods) and process elements (i.e., patient management, coding management, and claims management) collectively determine output elements, identified as casemix indicators, the Casemix Index, and the Hospital Base Rate. Strategic enhancements to these structural elements were found to positively impact patient service processes, improve coding efficiency by up to 50%, and increase claim success rates. Results for the 2019–2024 period were as follows: Outpatient casemix counts were 11,393; 16,037; 32,763; 59,520; 111,193; and 129,423 for the years 2019 to 2024, respectively. Inpatient casemix counts for the years 2019 to 2024 were, respectively: Class 1: 907; 1,321; 2,657; 3,165; 3,829; and 4,014. Class 2: 818; 1,013; 1,800; 2,511; 3,052; and 3,309. Class 3: 205; 539; 1,557; 2,023; 2,646; and 3,038. Casemix Index (CMI) values for the years 2019 to 2024 were, respectively: Outpatient CMI: 0.98, 1.11, 1.16, 1.21, 1.35, and 1.24. Inpatient CMI: Class 1: 1.32, 1.60, 1.84, 1.57, 1.45, and 1.37. Class 2: 1.17, 1.36, 1.58, 1.41, 1.33, and 1.33. Class 3: 1.46, 1.82, 1.67, 1.54, 1.53, and 1.45. Hospital Base Rate (HBR) values for the years 2019 to 2024 were, respectively (currency unit not specified in the original text): Outpatient HBR: 354,393; 333,231; 257,536; 243,675; 226,650; and 238,494. Inpatient HBR: Class 1: 5,257,416; 6,028,120; 5,477,120; 5,970,918; 6,542,667; and 7,082,825. Class 2: 4,449,693; 5,628,665; 4,817,066; 4,993,043; 5,156,750; and 5,563,012. Class 3: 3,616,138; 4,594,204; 3,746,071; 4,325,317; 4,584,260; and 4,789,356. Overall, casemix counts and the Casemix Index exhibited an upward trend annually, with CMI performance exceeding the established standard for Class C private hospitals in Regional Area 2. While the outpatient HBR from 2021 to 2024 fell below the national HBR, the inpatient HBR for Classes 1, 2, and 3 consistently surpassed the national benchmark. Recommended strategies to enhance casemix performance, improve the Casemix Index, and reduce the Hospital Base Rate center on optimizing structural elements. This includes improving human resource competencies, refining methodologies, and increasing the efficiency of machinery, materials, and budget allocation. Furthermore, a rigorous evaluation of process elements—such as patient management, clinical coding accuracy, and claims management procedures—is deemed essential.

 

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T-7325
Depok : FKM UI, 2025
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Andreas Wijaya; Pembimbing: Wachyu Sulistiadi; Penguji: Ede Surya Darmawan, Mardiati Nadjib, Melvin Lukito, Kalsum Komaryani
Abstrak:
Latar Belakang: Siloam Hospitals Kupang, sebagai rumah sakit swasta dengan layanan unggulan urologi, mampu melakukan berbagai tindakan pemecahan batu ginjal yaitu, Extracorporeal Shock Wave Lithotripsy (ESWL), Percutaneous Nephrolithotomy (PCNL), dan Retrograde Intrarenal Surgery (RIRS). Namun, tingginya jumlah pasien yang menjalani tindakan ESWL berulang lebih dari 1 kali setiap bulan, menimbulkan pertanyaan penting bagi manajemen rumah sakit terkait efektivitas biaya dari setiap prosedur yang tersedia. Tujuan: Penelitian ini bertujuan untuk menganalisis efektifitas biaya dari beberapa tindakan pemecahan batu ginjal di Siloam Hospitals Kupang. Metode: Penelitian dilakukan terhadap data 3 tindakan pemecahan batu ginjal selama periode September 2024 – November 2024 dengan mengambil seluruh sampel yang memenuhi kriteria inklusi dan ekslusi pada periode tersebut. Selanjutnya sampel dianalisis dengan analisis biaya yang membandingkan Average Cost Effectiveness Ratio (ACER) dan Incremental Cost Effectivenes Ratio (ICER) antara setiap tindakan terhadap pasien batu ginjal. Data primer didapatkan melalui kuesioner dan data sekunder dari laporan biaya rumah sakit serta rekam medis pasien. Pengukuran efektifitas dilakukan dengan menggabungkan antara indikator bebas batu, skala nyeri, durasi rawat inap, serta tingkat komplikasi. Hasil: Tindakan RIRS memiliki tingkat efektivitas yang paling baik dengan skor total 53,3%, nilai ACER sebesar Rp36.978.877. Diikuti oleh PCNL dengan efektivitas 20% degan ACER Rp80.940.986, dan ESWL dengan efektivitas 12,5% dengan ACER Rp16.268.591. Bila ESWL digantikan dengan RIRS akan memberikan nilai ICER Rp43.429.793, sedangkan bila digantikan dengan PCNL maka akan memberikan nilai ICER Rp189.360.602.  Kesimpulan: Tindakan RIRS adalah tindakan yang paling efektif diikuti oleh PCNL, dan ESWL memiliki efektifitas yang paling rendah. Jika ESWL diganti dengan RIRS maka biaya yang dibutuhkan akan lebih rendah dibandingkan bila diganti dengan PCNL. Jika dibandingkan dengan tarif klaim dari BPJS Kesehatan, maka hanya ESWL yang masih sesuai dengan nilai tarif yang disediakan oleh BPJS Kesehatan. Meskipun demikian RIRS masih bisa dilakukan untuk pasien dengan jaminan BPJS Kesehatan dengan catatan perlu dilakukan efisiensi dari sisi biaya alat flexible urethroscope, biaya dokter, dan biaya sewa gedung.
Background: Siloam Hospitals Kupang, as a private hospital with a distinguished urology service, can perform various kidney stone treatment procedures, including Extracorporeal Shock Wave Lithotripsy (ESWL), Percutaneous Nephrolithotomy (PCNL), and Retrograde Intrarenal Surgery (RIRS). However, the high number of patients undergoing repeated ESWL procedures more than once per month has raised a critical question for hospital management regarding the cost-effectiveness of each available treatment option. Objectives: This study aims to analyze the cost-effectiveness of various kidney stone removal procedures at Siloam Hospitals Kupang. Methods: This study was conducted using data from three kidney stone treatment procedures during the period of September 2024 to November 2024 by including all samples that met the inclusion and exclusion criteria within that timeframe. The samples were then analyzed using a cost analysis approach, comparing the Average Cost-Effectiveness Ratio (ACER) and Incremental Cost-Effectiveness Ratio (ICER) among the procedures for kidney stone patients. Primary data were collected through questionnaires, while secondary data were obtained from hospital billing reports and patients’ medical records. Effectiveness was measured by combining multiple indicators, including stone-free status, pain scale, length of hospital stay, and complication rate. Results: RIRS demonstrated the highest level of effectiveness with a total score of 53,3% and an ACER of Rp36.978.877. This was followed by PCNL, with an effectiveness of 20,0% and an ACER of Rp80.940.986, and ESWL, which had the lowest effectiveness at 12,5% but the lowest ACER at Rp16.268.591. Replacing ESWL with RIRS resulted in an ICER of Rp43.429.793, whereas replacing it with PCNL led to a significantly higher ICER of Rp189.360.602. Conclusion: RIRS was found to be the most effective procedure, followed by PCNL, while ESWL had the lowest level of effectiveness. When ESWL is substituted with RIRS, the additional cost required is lower compared to substituting it with PCNL. In comparison to the reimbursement tariffs provided by BPJS Kesehatan, only ESWL remains within the acceptable claim limit. Nevertheless, RIRS may still be performed for patients under BPJS Kesehatan coverage, provided that cost efficiencies are implemented, particularly in the use of flexible urethroscope devices, physician fees, and facility rental charges.
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B-2528
Depok : FKM-UI, 2025
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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Adinda Syarifah Noor; Pembimbing: Ede Surya Darmawan; Penguji: Atik Nurwahyuni, Jaslis Ilyas, Mula Dharma Virtaariyus, Kalsum Komaryani
Abstrak:
Penundaan pembayaran klaim (pending claim) Jaminan Kesehatan Nasional (JKN) oleh BPJS Kesehatan mengakibatkan gangguan arus kas rumah sakit dan peningkatan beban kerja petugas. Rumah Sakit Umum Menteng Mitra Afia (RSU MMA) merupakan rumah sakit swasta kelas C dengan proporsi pasien rawat inap JKN lebih dari 98%, sehingga tingginya angka klaim pending berisiko menimbulkan beban finansial dan administratif yang serius. Hingga saat ini, belum dilakukan analisis mendalam mengenai kegagalan dalam proses pengelolaan klaim yang berpotensi menyebabkan pending. Penelitian ini bertujuan untuk menganalisis potensi penyebab klaim pending rawat inap JKN dalam setiap tahapan proses pengajuan klaim dan mengembangkan sistem perbaikan dalam rangka mencegah, menangani, dan memprediksi klaim pending rawat inap. Penelitian ini menggunakan metode kualitatif dengan pendekatan operational research yang dilakukan pada bulan Mei-Oktober 2025. Pengumpulan data dilakukan melalui telaah dokumen klaim pending Januari 2024-Agustus 2025, wawancara mendalam dengan 11 informan, observasi partisipatif, dan Focus Group Discussion (FGD). Analisis risiko dilakukan menggunakan metode FMEA untuk menentukan prioritas masalah berdasarkan nilai Risk Priority Number (RPN). Hasil penelitian menunjukkan bahwa klaim pending rawat inap mengalami lonjakan signifikan pada Agustus-Oktober 2024 dengan puncaknya sebanyak 77,4% di bulan September. Pada tahun 2025, klaim pending menurun tetapi tetap fluktuatif di angka 6,5%-21%. Penyebab klaim pending didominasi oleh konfirmasi indikasi rawat inap, konfirmasi diagnosis, dan ketidaklengkapan berkas penunjang. Berdasarkan perhitungan RPN, tiga failure mode dengan prioritas tertinggi adalah: (1) ketidaksesuaian indikasi rawat inap pada proses asesmen di poliklinik; (2) diagnosis tidak sesuai kriteria dan tata laksana spesifik belum sesuai pada pelayanan rawat inap; dan (3) koding diagnosis belum sesuai atau membutuhkan konfirmasi pada verifikasi internal Casemix (RPN 24). Identifikasi akar masalah menunjukkan kurangnya pemahaman dan kesadaran Dokter Penanggung Jawab Pelayanan (DPJP) terhadap regulasi BPJS yang dinamis, tidak adanya penyampaian data penyebab klaim pending secara rutin kepada DPJP, belum adanya mekanisme reward and punishment terkait kelengkapan pengisian resume medis, serta beban kerja verifikator yang tinggi. Faktor eksternal seperti pengetatan danperubahan regulasi BPJS Kesehatan juga berkontribusi terhadap terjadinya klaim pending. Sistem penanggulangan klaim pending yang dikembangkan berupa prototipe pencegahan dengan “clean claim,” penanganan menggunakan register klaim pending, serta prediksi klaim pending mberupa prediktor risiko pending.
Delayed payment of claims (pending claims) under the National Health Insurance (JKN) program by BPJS Kesehatan disrupts the hospital’s cash flow and increases the workload of claim management staff. Menteng Mitra Afia General Hospital (RSU MMA), a Class C private hospital with more than 98% of its inpatient population covered by JKN, is highly vulnerable to financial and administrative burdens caused by high pending claim rates. To date, no in-depth analysis has been conducted to identify failures within the claim management process that potentially lead to pending claims. This study aims to analyze the potential causes of inpatient JKN claim pending at each stage of the claim submission process and develop an improvement system to prevent, manage, and predict pending inpatient claims. This research employed a qualitative method with an operational research approach conducted from May to October 2025. Data were collected through a review of pending claim documents from January 2024 to August 2025, in-depth interviews with 11 informants, participatory observation, and Focus Group Discussions (FGD). Risk analysis was carried out using the FMEA method to determine priority issues based on the Risk Priority Number (RPN). The results showed a significant increase in inpatient pending claims during August–October 2024, peaking at 77.4% in September. In 2025, pending claims decreased but remained fluctuating at 6.5%–21%. The dominant causes of pending claims included confirmation of inpatient indication, confirmation of diagnosis, and incomplete supporting documents. Based on RPN calculations, the three highest-priority failure modes were: (1) inappropriate inpatient indication assessment at the outpatient clinic; (2) diagnosis not meeting clinical criteria and specific management standards during inpatient care; and (3) inaccurate or unconfirmed diagnosis coding during internal casemix verification (RPN 24). Root cause analysis identified limited understanding and awareness of attending physicians (DPJP) regarding dynamic BPJS regulations, lack of routine feedback on pending claim causes, absence of a reward-and-punishment mechanism for completeness of medical resumes, and high workload among internal verificator. External factors, such as stricter verification and regulatory changes from BPJS Health, also contributed to the occurrence of pending claims. The developed system for managing pending claims consists of a preventive prototype based on a “clean claim” approach, a handling mechanism using a pending claim register, and a pending claim prediction component in the form of a risk predictor for pending claims.
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B-2578
Depok : FKM-UI, 2026
S2 - Tesis   Pusat Informasi Kesehatan Masyarakat
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:: Pengguna : Pusat Informasi Kesehatan Masyarakat
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