Definition of Health Insurance :

Health Insurance  is an agreement made and agreed upon by two or more parties in which the insurer binds itself to the insured in order to receive insurance premiums

Health insurance is a type of insurance product that specifically guarantees health costs or care for members of the insurance if they fall ill or have an accident. There are two types of treatments offered by insurance companies, namely in-patient treatment and out-patient treatment.

Definition at define Dictionary.com

1.the act, system, or business of insuring property, life, one’s person, etc., against loss or harm arising inspecified  contingencies, as fire, accident, death, disablement, or the like, in consideration of a paymentproportionate to the risk involved.

2.coverage by contract in which one party agrees to indemnify or reimburse another for loss that occursunder the  terms of the contract.

3. the contract itself, set forth in a written or printed agreement or policy.

 

What  is Health Insurance

Health Insurance  is insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over a large number of persons. By estimating the overall risk of health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement.[1] The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity. (Wikipedia)

According to the Health Insurance Association of America, health insurance is defined as “coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment” (1)

Indonesia’s national health insurance scheme (Jaminan Kesehatan Nasional, or JKN) supports the government’s commitment to promoting health and wellbeing among its citizens.(2)

Health insurance are relationship with the risk of health care and  There are two types of treatments offered by insurance companies, namely in-patient treatment and out-patient treatment.

The Social Security Organizing Agency, here in after abbreviated as BPJS, is a legal entity formed to carry out social security programs (Law No. 24 of 2011). BPJS consists of BPJS Health and BPJS Employment. BPJS Health is a legal entity formed to organize health insurance programs. Health insurance is a guarantee in the form of health protection so that participants benefit from health care and protection in fulfilling the basic health needs given to everyone who has paid contributions or paid by the government.

In Indonesia we have a National Health Insurance managed by BPJS  from 2014 until now which is very helpful for patients even though there are still many shortcomings, especially managed by BPJS Health, so the problem is still deficit, and the government budget is still small for health and also the contributions of participants who are still in arrears are still an important issue in this JKN era. UU  No. 40 of 2004 tentang JKN and UU  No.24 concerning BPJS and  Perpres No.82 of  2018

Improving the quality of public services at the Social Security Agency (BPJS) Health in Indonesia  is essential in order to increase the satisfaction of the public in obtaining health services safe, quality, system and an affordable price. Ideals of the early implementation of BPJS is so that people can be served well in the clinic but still there are problems that must be addressed. The purpose of writing is 1) to identify and discuss service Social Security Agency (BPJS) Health in Indonesia, 2) gather information and develop concepts BPJS health services in Indonesia. This writing method is the study of literature with a descriptive and exploratory approach. It is concluded that 1) Social Security Agency, here in after abbreviated  BPJS is a statutory body established to administer social security program. BPJS consists of BPJS Health and BPJS Employment.  BPJS Health is a legal entity formed to administer the health insurance program. 2) there are problems that must be addressed in the form of systems, procedures, human resources (medical personel), as well as infrastructure and not to apply the principle of responsiveness to community needs in order to improve the quality of public services in health in Indonesia , 3) public service in health sector not meet the standards good public services, people’s access to the benefits of the service is very limited,the public has not been able to get services in all health  facilities (4)

In Indonesia, the philosophy and foundation of the state of Pancasila, especially the 5th principle, also recognizes the human rights of citizens to health. This right is also contained in Article 28 H of the 1945 Constitution and Article 34, and is regulated in Law No. 23/1992 which was later replaced with Law 36/2009 concerning Health. In Law 36/2009 it is affirmed that “everyone has equal rights in gaining access to resources in the health sector and obtaining safe, quality and affordable health services. Conversely, everyone also has an obligation to participate in social health programs. ” To overcome this, in 2004, Law No. 40 concerning the National Social Security System (SJSN) was issued. This Law 40/2004 mandates that social security is mandatory for all residents including the National Health Insurance (JKN) through a Social Security Administering Agency (BPJS). Act No. 24 of 2011 also stipulates that the National Social Security will be held by the BPJS, which consists of BPJS Health and BPJS Employment.

BPJS Health Services in Indonesia have not been able to meet the minimum service standards expected by the community. The following are still poor health BPJS services in Indonesia are: 1. BPJS implements a service flow with tiered referrals. Before going to a hospital or specialist, participants must first go to a designated level I health facility, namely a health center, family doctor or clinic, to get a referral letter. Except for emergencies, participants cannot go directly to the hospital or specialist doctor. As long as participants’ health problems can be handled by health facilities I, participants do not need to be referred to hospitals or specialists. The decision to refer to a hospital is the authority of health facilities I. Conditions that are very different from the process in health insurance. With insurance, participants do not need referrals and can go directly to the hospital or specialist according to their choice. 2. Puskesmas, which in fact is the starting point for all medical treatment processes at BPJS, has limited working hours. On weekends, Saturday and Sunday, the puskesmas is closed. Meanwhile, for many employees, especially in big cities, for reasons of busyness, a new health check can be done on weekends during holidays. Indeed, participants can go to other facilities, namely clinics or family doctors. But, they are still limited in number. In addition, because the puskesmas was closed at the end of the week, the burden of other health facilities became high, as a result of the participants having to queue long and midnight. 3. The BPJS stipulates that participants may only choose one facade I to get a referral. Participants cannot go to any faculties even though health facilities (health facilities) are already collaborating with BPJS. This condition, for example, makes it difficult for participants who are selected for health facilities far from work or from home. In addition, if you are out of town and will seek treatment, participants must first contact the nearest BPJS office, which will then show which Health Facilities can serve. BPJS participants can also only go to the hospital mentioned in the referral letter from Faskes I. For example, the puskesmas must go to the designated hospital. Participants cannot just go to another hospital even though the hospital is collaborating with BPJS. PT ASKES also implements referrals but referral requests can be made in all puskesmas. There is no provision for certain health centers. In the PT ASKES era, participants were able to choose a hospital as they wished during the hospital cooperation with PT.ASKES. 4. BPJS participants can only seek treatment at a hospital that has collaborated with BPJS. In hospitals that have not collaborated, participants cannot use BPJS health insurance. The problem is that not all private hospitals have collaborated with BPJS. Meanwhile, with health insurance, participants can seek treatment in all hospitals. In hospitals that have collaborated with health insurance, payment is made by showing a cashless card. In hospitals that have not been cooperated, payment with a reimbursement system. 5. BPJS room facilities only up to class 1  There are no VIP class facilities and above. Although the care and quality of the doctor is not differentiated between classes, the comfort of the rooms is certainly different between classes. In health insurance, the class of rooms offered is higher. Participants can enjoy VIP classes and above. 6. The challenges that BPJS participants often face in health services are: (1) long queues in hospitals, (2) difficulties in obtaining inpatient rooms because the rooms for BPJS participants are often full, (3) there are medicines that are not guaranteed by BPJS so participants (4) even though it should be free (as long as it fits the class) participants sometimes still have to pay the excess ceiling, which if not paid, the hospital is reluctant to serve. This is a complaint that often appears in the media

Indonesia achieves universal health coverage (UHC) status if all residents are guaranteed financially. So, when they fall ill, citizens get quality health services without worrying about the high medical costs that must be incurred. This is in line with the theme of World Health Day 2018 which is celebrated every April 7, namely “Universal Health Coverage”.

UHC has been defined by World Health 2005 as “access to promotive, preventive, curative and rehabilitative health interventions for all costs that are accountable, so as to achieve equity in access”

The target of BPJS is to be able to achieve Universal Health Coverage in 2019

 

Reference

  1. (How Private Insurance Works: A Primerby Gary Caxton, Institution for Health Care Research and Policy, Georgetown University, on behalf of the Henry J. Kaiser Family Foundation p.225)
  2. Expanding Markets while Improving Health in Indonesia: Private Health Sector Market in the JKN Era, Kate Britton (Palladium), Sayaka Koseki (Palladium), and Arin Dutta (Palladium) of the Health Policy Plus project. Suggested citation: Britton, K., Koseki, S., and Dutta, A. 2018.. Washington, DC: Palladium, Health Policy Plus;p.vi)
  3. http : // IJHPM.com Int J Health Policy Manag 2018, 7(7), p. 574–580
  4. “Health Insurance”.2018. Wikipedia.http :// en.wikipedia.org//index.php
  5. Health Insurance  Definition at define Dictionary.com. n.d accessed  4 November, 2018 http://www.dictionary.com//browse// health insurance

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