Jurnal Jaminan Kesehatan Nasional

Hospitalization Costs and Duration for Preterm and Low Birth Weight Infants under National Health Insurance

2025-07-17T17:40:28+07:00

Preterm birth and low birth weight are major contributors to neonatal morbidity, mortality, and healthcare costs in Indonesia. This study investigates how maternal risk factors and hospital characteristics jointly influence length of stay and inpatient costs for preterm and low birth weight infants covered by the national health insurance program (JKN) in 2022–2023. Using a retrospective cohort of administrative claims data and multilevel generalized linear models, we find that younger maternal age, neonatal complications, and concurrent diagnoses of prematurity and low birth weight significantly increase both length of stay and costs. Infants from non-government-subsidized members group (PBI – Penerima Bantuan Iuran) and those admitted to referral or public hospitals experience longer stays, while regional tariff differences and hospital ownership shape cost variations. By linking maternal risk, facility capacity, and financial burden under Indonesia’s case-based payment system (INA-CBGs – Indonesia Case-Based Groups), this study highlights pathways to improve neonatal care efficiency. Strengthening antenatal services and referral systems may help reduce avoidable admissions and optimize resource use.

Utilization of Preventive Care Visits in Primary Healthcare: Evidence from Indonesia’s National Health Insurance

2025-10-02T09:43:33+07:00

Visiting primary health care providers for preventive care services is vital for early disease detection and overall population health improvement. In Indonesia, various barriers such as financial, systemic, and social, contribute to the underutilization of preventive health visits. This analytic cross-sectional study analyzed secondary data from a 1% representative sample of Indonesia’s National Health Insurance (JKN) participants in 2023, including 608,572 individuals who had accessed at least one healthy visit at a primary care facility between 2017 and 2023. Descriptive statistics and a Generalized Linear Model assessed associations between healthy visit utilization and sex, generation, residence, and JKN membership segment. Utilization was higher among participants living in urban areas, government-subsidized members, non-workers, and older generations (particularly Baby Boomers), whereas the lowest rates were observed among informal workers, post-millennials, males, and participants residing in rural regencies. All associations were statistically significant (p < 0.01). These findings highlight significant disparities in healthy visit utilization across demographic and insurance groups in Indonesia’s National Health Insurance program. Targeted interventions to increase preventive care uptake among underrepresented populations are critical to achieving equitable health outcomes.

Factors Causing Fraud in Hospitals Under National Health Insurance and Prevention Strategies: A Scoping Review

2025-09-19T14:33:00+07:00

Fraud in the implementation of the National Health Insurance program poses a significant challenge to hospital governance in Indonesia, resulting in financial losses and eroding public trust in healthcare services. We conducted a scoping review to identify the root causes of fraud and summarize prevention strategies applied in hospitals participating in the scheme. The review analyzed literature published between 2022 and 2024, selected through database searches and manual screening, with a focus on fraud-related issues and prevention efforts within healthcare facilities. Findings reveal that multiple factors, including discrepancies between case-based payment tariffs and the actual cost of services, weak internal control systems, limited understanding among staff regarding the accountability of public funds, inadequate reporting mechanisms, and poor organizational ethics, drive fraud. Identified prevention strategies include the establishment of anti-fraud teams, implementation of internal audits, utilization of hospital information systems, staff training initiatives, and intersectoral collaboration. In conclusion, fraud prevention in national health insurance requires a comprehensive approach encompassing institutional policies, human resource capacity building, and the reinforcement of transparent and accountable governance across hospital management systems.

Technology Acceptance Model Toward Pandawa Service at the Social Security Administrative Body for Health Depok

2025-08-04T14:08:36+07:00

Digital transformation has become a prominent topic in the era of globalization. Despite the growing digital transformation trend, many health service users in Indonesia still prefer face-to-face interactions, indicating a gap in digital literacy and service adoption. In response to this issue, the Social Security Administrative Body for Health launched a digital administrative service called Pandawa (Administrative Service via WhatsApp). This study aims to explore the perceptions of National Health Insurance participants who visited Social Security Administrative Body for Health Depok in 2025, focusing on the perceived ease of use and usefulness of the Pandawa service. The research employs a quantitative approach using the Technology Acceptance Model (TAM) through a cross-sectional study design. The secondary data used in this study consists of participant visits to the agency in 2024. Primary data will also be needed through distributed questionnaires. The sample consists of 109 National Health Insurance participants who are users of the Pandawa service and visited the agency during the study, conducted in February 2025. The analysis techniques of the research used the Chi-Square Test and the Binary Logistic Regression Test. The multivariate analysis shows that age, education, perceived ease of use, perceived usefulness, and attitude are significantly related to the intention to use the Pandawa service, with attitude being the dominant factor. Meanwhile, sex does not show a significant relationship to the intention to use the Pandawa service. Overall, user acceptance of the Pandawa service is relatively good, although further improvements in service quality are necessary to optimize its implementation.

Linkage Between Hospital Accessibility and Health Insurance Ownership in East Kalimantan Province

2025-07-23T15:13:28+07:00

Healthcare accessibility remains a persistent challenge in Indonesia, particularly in resource-limited regions where geographical barriers, transportation constraints, and financial limitations create significant disparities in health service utilization. Hospital accessibility encompasses multiple dimensions that collectively influence healthcare utilization patterns. The physical presence of healthcare facilities, commonly referred to as hospital existence, serves as the fundamental prerequisite for healthcare access. This study seeks to analyze how dimensions of hospital accessibility correlate with health insurance ownership in East Kalimantan. 2023 Indonesian Health Survey. This research was quantitative approach with cross sectional design. The population in this research refers to the population of 2023 Indonesian Health Survey, with total . Chi square analysis was used to determine the relationship between the independent variable and dependent variable. The result shows that the independent variables that are significantly related to the health insurance ownership with p-value < 0.005, namely marital status, age group, education level and occupation. Meanwhile, sex (p-value= 0.185), residence (p-value= 0.093) and hospital accessibility (p-value= 0.134) showed no significant associations with health insurance ownership with p-value > 0.005. The lack of association between hospital accessibility and insurance ownership indicates that physical proximity to healthcare facilities is not a primary determinant of insurance enrolment decisions.

Determinants of National Health Insurance Coverage for Family Planning Services Among Women in Indonesia

2025-07-22T15:04:44+07:00

Access to family planning services remains unequal in Indonesia despite the establishment of the National Health Insurance (NHI) program (Jaminan Kesehatan Nasional, JKN) to promote universal coverage. Disparities persist, particularly in contraceptive services, among women of reproductive age. This study examined the determinants of NHI coverage for contraceptive methods among Indonesian women of reproductive age. A cross-sectional analysis was conducted using data from 6,256 married or partnered women aged 15–49 years from the 2017 Indonesia Demographic and Health Survey (IDHS). Survey-weighted descriptive, bivariate, and multivariable logistic regression analyses were performed using Stata to identify the factors associated with NHI-covered contraceptive use. The results showed that Women with insurance schemes specifically covering family planning were significantly more likely to report contraceptive coverage through NHI (AOR: 47.5; 95% CI: 37.2–60.7). Secondary education (AOR: 2.08; 95% CI: 1.01–4.07) was positively associated with coverage, while rural residence (AOR: 0.71; 95% CI: 0.56–0.91), middle wealth status (AOR: 0.64; 95% CI: 0.46–0.88), and current employment (AOR: 0.79; 95% CI: 0.65–0.97) were negatively associated. These findings highlight persistent socioeconomic and geographic inequities in access to insured family planning services. Addressing these disparities requires targeted policy efforts, including automatic enrollment strategies for women in the informal sector, mobile registration units in rural areas, and public education campaigns to improve insurance literacy. Strengthening equitable access to family planning under the national insurance scheme is essential to achieving Indonesia’s reproductive health and universal coverage goals.

A Qualitative Study of Referral Back Programme Implementation in Palembang Health Centres for Chronic Disease

2025-08-31T09:40:07+07:00

Despite the strategic intent of Indonesia’s National Health Insurance (NHI) to strengthen chronic disease management through the Referral Back Programme (PRB), its implementation at primary health centres (Puskesmas) continues to face operational and systemic barriers. This study aimed to analyse the implementation of the PRB for chronic non-communicable diseases in Palembang City. The research team employed a qualitative case study approach to explore key challenges in programme execution. The research team collected data from six purposively selected Puskesmas between July and September 2022, using in-depth interviews, focus group discussions, observations, and document reviews. They selected twenty-one informants—including BPJS Kesehatan officials, physicians, programme coordinators, and patients—using maximum-variation sampling to ensure diverse stakeholder representation. The team conducted a thematic analysis, identifying three key themes. First, organisational capacity constraints, such as staff shortages, dual workloads, inadequate training, and limited funding. Second, there are infrastructural and systemic barriers, including the lack of dedicated service corners, underdeveloped digital systems, medicine stockouts, and restricted distribution of referral tools. Third, communication and coordination gaps exist, including weak inter-agency reporting, inadequate feedback mechanisms, and limited outreach to JKN participants. These themes align with the input–process–output framework: input barriers reflected fragmented resources; process barriers involved absent guidelines and reactive supervision; output challenges included low patient adherence and insufficient reporting. These interlinked factors undermine the gatekeeping function of Puskesmas and disrupt the continuity of care for chronic conditions. Strengthening institutional capacity, aligning resources, and integrating digital infrastructure are crucial for enhancing the effectiveness and sustainability of the PRB, thereby supporting Indonesia's progress toward universal health coverage.

Visit Patterns of Human Immunodeficiency Virus Patients at Referral Health Facilities

2025-08-31T09:00:52+07:00

Human Immunodeficiency Virus (HIV) infection remains a health problem in Indonesia, with cases increasing annually. HIV care services in Indonesia involve Primary Health Facilities (PHF) and Referral Health Facilities (RHF). This study aims to identify patterns of HIV patient visits to RHF. This cross-sectional study used secondary data from the National Health Insurance (NHI) for 2015–2023. HIV patients were identified based on ICD-10 diagnosis codes (B20–B24), with referral status as the independent variable. Analysis was performed using chi-square tests, and visit patterns were visualized using Sankey diagrams. Of the more than one million patients, 2,532 were identified as having HIV, resulting in more than 38,000 visits. Most patients were referred from community health centers to general hospitals, primarily for outpatient care. Age was significantly associated with referral status, while other demographic factors showed no association. Overall, the referral system is functioning effectively, but strengthening service capacity in PHF remains crucial to reduce the referral burden on hospitals.

Managing Potential Fraud in Palembang Hospitals’ Health Insurance Implementation: A Qualitative Study in Indonesia

2025-07-23T12:35:54+07:00

Fraud poses a major threat to the integrity of Indonesia’s National Health Insurance–Healthy Indonesia Card (JKN-KIS) program, affecting health financing, hospital quality, and institutional reputation. Despite continuous efforts to combat fraud, allegations persist, particularly in hospitals in Palembang. This study aimed to identify potential fraud in hospitals in Palembang and analyze management countermeasures. Using a descriptive qualitative design with a phenomenological approach, the study was conducted from March to July 2022 and involved three hospitals in Palembang, the City Health Office, and the local branch of the Social Security Administrative Body for Health (BPJS Kesehatan). Data were collected through in-depth interviews with 16 informants representing hospitals, BPJS Kesehatan, and anti-fraud teams, supported by observations and document reviews. Thematic analysis revealed several fraud risks, including diagnosis manipulation, unnecessary treatment, and overcharging. Weak internal and external monitoring mechanisms fostered opportunities for fraud, often driven by financial pressure, revenue targets, and personal motives, and influenced by tenure and position within the organization. Fraud countermeasures remain suboptimal, although BPJS Kesehatan’s management shows potential that requires further improvement. Applying the Hexagon Vousina theory, this study emphasizes the need for a more comprehensive and integrated approach to fraud risk management. Strengthening oversight, professional ethics, inter-agency coordination, and policy enforcement is crucial to maintain the sustainability and effectiveness of the JKN-KIS program.

Comparative Analysis of Type 2 Diabetes Mellitus Association Patterns in Primary and Referral Care

2025-07-23T14:36:00+07:00

Understanding differential comorbidity patterns for Type 2 Diabetes Mellitus (T2DM) across healthcare levels is crucial for targeted prevention strategies in tiered systems. In this cross-sectional study, we analyzed 2023 BPJS Kesehatan claims data to examine ICD-10-coded comorbidities associated with T2DM between basic primary care facilities (FKTP) and advanced referral care facilities (FKRTL), using weighted and unweighted odds ratios. Distinct patterns emerged reflecting both appropriate care distribution and coding artifacts. FKRTL showed the highest associations with specialized diagnostic: abnormal glucose tolerance (R73, OR: 41.089), unspecified diabetes (E12, OR: 53.023), and insulin-dependent diabetes (E10, OR: 33.807). FKTP demonstrated unexpected associations with conditions beyond its diagnostic capability, notably pulmonary embolism (I26; OR: 112.912), absent in FKRTL’s top 20, suggesting follow-up coding rather than primary diagnosis. Common diabetic complications appeared in both settings: retinopathy (FKTP: OR 44.145 vs FKRTL: OR 25.980) and polyneuropathy (FKTP: OR 25.807 vs FKRTL: OR 26.482), though FKTP lacks specialized diagnostic equipment. Findings reveal appropriate healthcare distribution where FKRTL handles specialized care, while complex diagnostic codes in FKTP likely reflect monitoring of conditions initially diagnosed at referral facilities. This highlights critical interpretation challenges in administrative claims data across tiered healthcare systems managing Indonesia’s millions of T2DM cases.

Length of Stay Among Schizophrenia Patients in Referral Health Facilities 2023: Kaplan-Meier and Cox Analysis

2025-07-20T15:01:11+07:00

Schizophrenia contributes significantly to global disease burden, with hospitalization management being crucial for treatment outcomes. This study aimed to determine factors influencing length of stay and recovery outcomes among schizophrenia patients in Indonesian referral health facilities. Secondary data analysis was conducted using BPJS Kesehatan sample data from 2023. Of 54,820 mental health records, 2,562 schizophrenia patients treated at referral facilities were analyzed. Cox proportional hazards regression was used to identify factors associated with discharge status, while Kaplan-Meier analysis examined length of stay distribution. Mean length of stay was 19.9 days. Significant factors associated with better recovery outcomes included: treatment at general hospitals (HR=2.31, p<0.001), public hospitals (HR=0.57, p<0.001), undifferentiated (HR=1.45, p<0.001) and catatonic schizophrenia subtypes (HR=1.70, p=0.029), single medical procedure (HR=0.73, p<0.001), and local treatment facilities (HR=1.42, p=0.028). Healthcare service factors and clinical characteristics significantly outweigh demographic factors in determining recovery outcomes. These findings emphasize the importance of healthcare service quality and accessibility in schizophrenia treatment, supporting integrated care models and universal healthcare access policies.

Enhancing Clinical Coding Expertise in Indonesia’s National Health Insurance Program

2025-09-15T13:33:42+07:00

Coding medical records using classification systems can cause inconsistencies, sometimes leading to claim disputes. In January 2021, 440,749 disputed cases were reported, with a total disputed cost amounting to Rp873,111,325,287 for referral healthcare facility claims under the National Health Insurance (JKN). In May 2021, BPJS Kesehatan established the Clinical Coding Expert/Tim Ahli Pengodean Klinis (TAPK) for enhancing clinical coding expertise. The objective of this study was to examine the impact of establishing TAPK. We hypothesize that TAPK affects the decrease in disputed cases in 12 regions of Indonesia. We used data from the JKN Program prior to the establishment of TAPK in January 2021 as controls. We followed up on 86,272 cases for two years after its implementation (as of April 2023). Paired data from 12 regions were compared using descriptive statistics, inferential statistics (paired sample t-test), and boxplot visualization. We also described the knowledge management of clinical coding through Knowledge Spiral of Nonaka and Takeuchi. The finding showed a decrease in the number of claim dispute cases in April 2023 compared to January 2021 (by 80.43%). The average claim cases decreased from 36,729.08 (Before TAPK) to 7,189.33 (After TAPK; t = 2.620, p = 0.0238). TAPK has contributed to standardized coding practices in hospitals across regions. This study reinforces the importance of action to improve competence and organizational learning in TAPK through Knowledge Spiral Model and recommends that TAPK be more widely known to all JKN’s healthcare facilities. Future research should optimize AI-driven clinical coding while ensuring human oversight.

The Analysis of Factors Influencing Organizational Culture Success at Social Security Administrative Body for Health

2025-04-26T13:54:30+07:00

Organizational culture serves as the foundation for institutional behavior and performance. Employees’ perceptions of cultural success play a critical role in ensuring the effective implementation of core values. This study aims to analyze the factors associated with perceptions of organizational culture success at BPJS Kesehatan, using the INITIATIVE framework (Integrity, Collaboration, Excellent Service, and Innovation). A quantitative approach with a descriptive-analytical survey design was employed. Data was collected from 236 respondents using validated questionnaires and analyzed through Pearson correlation and multiple linear regression. The findings indicate that leadership role modeling, contextual value internalization, and system consistency are significantly associated with perceptions of cultural success. Other variables, such as change agents, communication, and structural support, show a positive but statistically insignificant association. These results provide practical recommendations to strengthen leadership, internalize values, and align systems to sustain an effective organizational culture in public service institutions

Examining Patient Safety Culture in Hospitals: A Systematic Review

2025-02-28T17:13:46+07:00

Patient Safety Culture (PSC) is critical in healthcare organizations, influencing patient outcomes and care quality. This study is a systematic review that provides a comprehensive understanding of PSC in hospitals by synthesizing the current literature using the PRISMA framework and focusing on identifying key components, determinants, and factors influencing healthcare professionals’ attitudes and perceptions toward PSC. A systematic search of the SCOPUS database identified 19,129 documents on PSC, of which 21 were included after rigorous screening and application of eligibility criteria. Key findings highlight the importance of effective leadership, communication, teamwork, and organizational learning in fostering a positive PSC. Supportive leadership and non-punitive environments encourage error reporting, whereas continuous professional development and stress-reduction programs enhance safety culture. Factors such as work-related stress, professional commitment, and organizational culture significantly impact PSC. Understanding these factors is essential for designing strategies to deal with healthcare professionals’ specific needs and challenges. This systematic review also reveals gaps in research on the causal relationships and mechanisms that shape PSC, suggesting that further studies are needed to develop more effective interventions. Practical implications emphasize the importance of leadership training, regular safety training sessions, stress reduction programs, and evidence-based practices. This review provides actionable insights for healthcare administrators, policymakers, and practitioners aiming to improve patient safety, offering a comprehensive understanding of PSC components and strategies for enhancement. This study contributes to efforts to create safer healthcare environments and improve patient outcomes by bridging the gap between theory and practice, underscoring the necessity of integrated, continuous approaches to PSC.

Sentiment Analysis of National Health Insurance Participants’ Reviews on Google Reviews

2025-04-29T03:34:30+07:00

Public service institutions face constant expectations to provide excellent service to participants and minimize complaints. With advances in technology, participants can now provide direct feedback on public services via online platforms, such as Google Reviews. This study aims to analyze participants’ sentiment toward the services of the BPJS Kesehatan Kupang Branch using a quantitative approach. The data collection process employed Python web scraping to retrieve 530 reviews through March 2025. The collected text underwent comprehensive preprocessing, including cleaning, tokenization, stopword removal, and stemming, to ensure data . We assigned sentiment labels based on star ratings: 4- and 5-star reviews were classified as positive, 1- and 2-star reviews as negative, and 3-star reviews were excluded as neutral. A final dataset of 529 reviews was then processed using the Naïve Bayes classifier. The results show that the Naïve Bayes algorithm successfully classified sentiments with an accuracy rate of 98.11%. Additionally, the analysis revealed that positive sentiment accounted for 98.3%, driven by keywords related to service speed and staff friendliness. These findings indicate that sentiment analysis of online reviews is an effective and objective tool for evaluating participants’ perceptions of public service quality.