The Corruption Eradication Commission put forward six recommendations to the government related to the management of Health Social Security Funds. The six recommendations are stated in KPK’s letter to the President of Indonesia Joko Widodo dated 30 March 2020.

These recommendations were given as prevention efforts since the deficit in BPJS Kesehatan has increased the risk of corruption practice in the operational level. Furthermore, the amount of deficit is projected to increase every year.

In the letter to the President, KPK strengthens the arguments with the decree from the Supreme Court dated Thursday, 27 February 2020 regarding the Amendment to Presidential Regulation No.82 of 2018 concerning Health Insurance.

In accordance with its authorities to conduct monitoring of state government, KPK gives the recommendations, which cover the income and expenditure aspects fundamentally, to overcome the deficit

These recommendations are given to fully support the achievement of universal health coverage in line with Indonesia’s commitment in 2005 as a part of WHO. Universal Health Coverage is a program that ensures the citizens to gain access to health services without having to face any financial hardship. This is supported by the high quality health services facilities.

Firstly, KPK recommends that the government, in this case the Ministry of Health to complete the National Medical Practice Guidelines (PNPK) for all the types of diseases required. Until today, there are only 33 of the 74 PNPK targets.  In addition, there are 60 more recommended PNPK targets until 2024.

It is important for PNPK to reduce the unnecessary treatment in BPJS Kesehatan claims. KPK has found unnecessary treatment as one of the causes of deficit in BPJS Kesehatan. As a reference, in the United States, the unnecessary treatment claims worth 5-10 percent of the total claims.

In Indonesia in 2018, the claims for cataract treatment reached Rp2 trillion. If the unnecessary treatment claims made up 5-10 percent, there was an unnecessary expenditure of over Rp200 billion. Moreover, this is a predicted amount for only one type of disease, while in 2018 there were also cases of unnecessary treatment for the cases of Caesarean Section and physiotherapy.

Secondly, KPK recommends the government to immediately conduct a control regarding hospital classes. This is based on the findings in 2018 when there was a mismatch in classes of 4 out of 6 hospitals which led to claim overpayment of Rp33 billion per year.

This fact was discovered after the visits to 10 hospitals by KPK, the Minister of Health, and BPJS Kesehatan, followed up by the review conducted by the Ministry of Health related to the classes of all hospitals in Indonesia as well as the claims to BPJS. The Ministry of Health later found that 898 hospitals did not match their classes.

Upon the joint findings and the evaluation of the Ministry of Health, KPK recommends that the government conducts a follow up action by lowering the classes of hospitals, and in order to do this, the Ministry of Health must work in coordination with the Ministry of Home Affairs and Regional Health Agencies.

This reorganization of hospital classes is projected to result in the reduction in the overpayment to hospitals by about Rp6 trillion per year.

The third recommendation given by KPK is that the Ministry of Health implements a co-payment or joint-payment system for independent members. This co-payment scheme is already regulated in the Ministry of Health Regulation No.51 of 2018, and this scheme acts as an effort to ask the capable participants to cover 10 percent of the health cost.

The reason for this is that so far the claims from independent members have been far greater than the income from the premiums. For example, in 2018 the total claims of independent members reached Rp22 trillion. The co-payment scheme will help save the income of BPJS Kesehatan by Rp2.2. trillion.

The fourth recommendation from KPK is that the government applies the benefit limitations for catastrophic diseases, caused by lifestyle, such as smoking, diet, and lack of physical exercises. Until the end of 2018 a third or 30 percent, as much as Rp28 trillion, of the total claims received by BPSJ Kesehatan was from catastrophic diseases.

The fifth recommendation given by KPK is the application of the Coordination of Benefit (CoB) with private insurance companies, which means that the all the members also using private insurance other than BPJS Kesehatan can combine both benefits when sick.

In this case, the Ministry of Health must lead and accelerate the joint-benefit scheme so that the health cost can be shared between the government and the private sectors.

In the sixth recommendation, KPK suggests the integration between the obligation to pay BPJS Kesehatan premiums and other public services. For instance, fulfilling the obligation to pay BPJS Kesehatan premiums can be put as one of the requirements when citizens want to extend the permits of Driving Licenses or Vehicle Registration Numbers.

The Letter of Recommendation to Overcome Health BPJS Deficits