Perbandingan Biaya Riil Obat Terhadap Tarif INA-CBGs dan Klaim Obat Kronis Pasien Skizofrenia Rawat Jalan dengan Jaminan Kesehatan Nasional di Rumah Sakit Jiwa Sambang Lihum Provinsi Kalimantan Selatan

Abstract

The prevalence of schizophrenia in South Kalimantan Province was documented at 0.35%; however, treatment coverage through the National Health Insurance (JKN) only reached 62% of the total patient population. JKN financing for hospital payments utilizes the INA-CBG's claim method and chronic claims. Discrepancies frequently arise between the Hospital's actual cost and the combined claim rate. Consequently, this study aims to determine the magnitude of the difference between the hospital's actual cost and the INA-CBGs and chronic drug claim rates, as well as to identify the factors contributing to this difference, specifically for outpatient schizophrenia patients covered by national health insurance at Sambang Lihum Mental Hospital. This research employed a retrospective, non-experimental descriptive design, analyzing a sample of 3,797 outpatient medical record data from January to June 2024. The study findings indicate a negative difference of IDR 99,743,262 between the INA-CBGs tariff and the hospital's actual cost, and a negative difference of IDR 521,283,120 between the chronic drug claim rate and the hospital's actual chronic drug cost. Conversely, there was a positive difference of IDR 468,487,716.00 in the total cost of the combined claim rate compared to the hospital's actual chronic drug cost. The influencing factors identified include: the difference in unit price reference between the actual price and the chronic claim price in the Online Pharmacy application; the volume of prescribed drugs exceeding the prescription stipulated in the Online Pharmacy application; the disparity between the prescription contents listed in the National Formulary and those in the Online Pharmacy application; and the exclusion of some prescribed drugs from the chronic drug category, resulting in their financing reimbursement being solely sourced from the INA-CBGs tariff claim. The Wilcoxon test results demonstrated a statistically significant difference between the actual rate and the combined claim rate for outpatient schizophrenia patients with JKN at Sambang Lihum Mental Hospital.