National Health Insurance Databases in Indonesia, Vietnam and the Philippines

Bridging Real-World Data Gaps: Connecting Dots Across 10 Asian Countries

The economic trend and the health care landscape are rapidly evolving across Asia. Effective real-world data (RWD) for regulatory and clinical decision-making is a crucial milestone associated with this evolution. This necessitates a critical evaluation of RWD generation within distinct nations for the use of various RWD warehouses in the generation of real-world evidence (RWE). In this article, we outline the RWD generation trends for 2 contrasting nation archetypes: "Solo Scholars"-nations with relatively self-sufficient RWD research systems-and "Global Collaborators"-countries largely reliant on international infrastructures for RWD generation. The key trends and patterns in RWD generation, country-specific insights into the predominant databases used in each country to produce RWE, and insights into the broader landscape of RWD database use across these countries are discussed. Conclusively, the data point out the heterogeneous nature of RWD generation practices across 10 different Asian nations and advocate for strategic enhancements in data harmonization. The evidence highlights the imperative for improved database integration and the establishment of standardized protocols and infrastructure for leveraging electronic medical records (EMR) in streamlining RWD acquisition. The clinical data analysis and reporting system of Hong Kong is an excellent example of a successful EMR system that showcases the capacity of integrated robust EMR platforms to consolidate and produce diverse RWE. This, in turn, can potentially reduce the necessity for reliance on numerous condition-specific local and global registries or limited and largely unavailable medical insurance or claims databases in most Asian nations. Linking health technology assessment processes with open data initiatives such as the Observational Medical Outcomes Partnership Common Data Model and the Observational Health Data Sciences and Informatics could enable the leveraging of global data resources to inform local decision-making. Advancing such initiatives is crucial for reinforcing health care frameworks in resource-limited settings and advancing toward cohesive, evidence-driven health care policy and improved patient outcomes in the region.

The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia.

METHODS

This retrospective cohort study analyzed the NHI database from 2016-2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households.

RESULTS

The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (β = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres.

CONCLUSIONS

CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.

Effects of the COVID-19 pandemic on cardiovascular disease financing in Indonesia (JKN claims data analysis 2019–2020)

The disease burden related to non-communicable diseases is a major public health problem in Indonesia. About one-third of all deaths in Indonesia are caused by cardiovascular disease. This study describes the cost of cardiovascular disease from claims data for Advanced Referral Health Facilities at BPJS Kesehatan before and during the COVID-19 pandemic. We analyzed claims data on the National Health Insurance system managed by BPJS. The data comes from referral health facilities throughout Indonesia in 2019 and 2020. Cardiovascular service claims data by sex and age group were analyzed descriptively and with different tests between years. There was a decrease in the number of patients accessing cardiovascular services at referral health facilities for all genders, age groups, and types of main diagnoses, by around 27.8%, from 933,017 (2019) to 673,801 (2020). There was a significant decrease in total claims for all types of cardiovascular disease during the COVID-19 pandemic compared to before, especially the reduction in aneurysms and aortic dissection (40.2%) and hypertensive heart disease (39.6%). The decline also occurred in all sexes and age groups, with an average percentage decline of 31.2%. Our findings show that the reduction in the cost of cardiovascular disease claims goes hand in hand with the decrease in the number of cardiovascular patient visits. To guarantee treatment for cardiovascular disease patients during the COVID-19 pandemic, BPJS can maximize the telemedicine services that have been built. The organizer of the National Health Insurance program in Indonesia has developed a JKN mobile application that has the potential for telemedicine services guaranteed by JKN. On the other hand, BPJS needs to limit promotive and preventive budgets related to CVD so that it does not become a potential catastrophic financing.

The sensitivity of hospital coding to prices: evidence from Indonesia

This study examines a newly introduced DRG system in Indonesia. We use secondary data for 2015 and 2017 from Jaminan Kesehatan Nasional (JKN), a patient level dataset for Indonesia created in 2014 to record public and private hospitals' claims to the national health insurance system to investigate whether there is an association between changes in tariffs paid and the severity of inpatient activity recorded in hospitals. We find a consistent small, positive and statistically significant correlation between changes in tariffs and changes in concentration of activity, indicating discretionary but limited coding behaviour by hospitals. The results indicate that reducing price differentials may mitigate discretionary coding, but that the benefits of this are limited and need to be compared to the potential risk of having to rebase all prices upwards.

Missed opportunities in hypertension risk factors screening in Indonesia: a mixed-methods evaluation of integrated health post (POSBINDU) implementation

OBJECTIVES

To assess the implementation and contextual barriers of POSBINDU, a community-based activity focusing on screening of non-communicable diseases (NCDs), mainly hypertension and diabetes, in Indonesia.

DESIGN

This was a concurrent mixed-methods study, with a cross-sectional analysis of secondary data and focus group discussions (FGDs) on stakeholder of POSBINDU.

SETTING

The study was conducted in seven districts in three provinces in Indonesia, with approximately 50% of the primary healthcare (PHC) were selected as areas for data collection (n PHC=100).

PARTICIPANTS

From 475 POSBINDU sites, we collected secondary data from 54 224 participants. For the qualitative approach, 21 FGDs and 2 in-depth interviews were held among a total of 223 informants.

PRIMARY OUTCOMES AND MEASURES

Proportion of POSBINDU visitors getting the hypertension screening and risk factors' assessment, and barriers of POSBINDU implementation.

RESULTS

Out of the 114 581 POSBINDU visits by 54 224 participants, most (80%) were women and adults over 50 years old (50%) showing a suboptimal coverage of men and younger adults. Approximately 95.1% of visitors got their blood pressure measured during their first visit; 35.3% of whom had elevated blood pressure. Less than 25% of the visitors reported to be interviewed for NCDs risk factors during their first visit, less than 80% had anthropometric measurements and less than 15% had blood cholesterol examinations. We revealed lack of resources and limited time to perform the complexities of activities and reporting as main barrier for effective hypertension screening in Indonesia.

CONCLUSIONS

This study showed missed opportunities in hypertension risk factors screening in Indonesia. The barriers include a lack of access and implementation barriers (capability, resources and protocols).

Factors Affecting Payment Compliance of the Indonesia National Health Insurance Participants

Background

The study aims to explore factors that affect the compliance of Indonesia National Health Insurance (INHI) in paying the premiums.

Methods

The study design was qualitative with grounded theory research approach and constructivism paradigm. The study was conducted in 2018 and carried out for 3 months. We recruited 22 respondents from four different cities/districts. Triangulation was carried out through 26 informants from various stakeholders. Data were analyzed through coding, categorizing and pattern matching to obtain substantive theory.

Results

The resulting substantive theory consists of 6 constructs and 14 categories. Compliance with paying insurance premium depends on the intention to pay for contribution. Meanwhile, the intention to pay is related to internal and external factors of INHI participants. To improve payment contribution of independent participants, INHI program has to pay attention for factors originating internally from the participants themselves (understanding of INHI program, financial ability and self-attitude) and also externally such as operational system and the quality of health care.

Conclusion

Compliance of paying insurance premium is related to internal and external factors of participants. Thus, interventions to improve compliance to pay premium should take these factors into account, and not merely on increasing the knowledge of participants.

Costs of providing hospital-based psychotic disorder treatment in Indonesia

BACKGROUND

Mental illness prevalence is increasing globally and has caused a significant economic burden. However, information from developing countries regarding this issue is still limited.

AIMS

To estimate the cost of treating psychotic disorders in outpatient and inpatient wards in a provincial referral mental health hospital in West Java province, Indonesia.

METHODS

We collected data on the direct cost of treating psychotic disorders within 2014-2015. Billing data from 1565 patients were used to calculate inpatient cost, while micro-costing was used to estimate outpatient cost. One hundred and five patients visiting the hospital were interviewed to estimate indirect costs, for example, patients' and caretakers' travel, meal, and opportunity costs.

RESULTS

For inpatient care, the average direct and indirect cost/patient/episode are USD328.84 and USD213.22, respectively. For outpatient care, the direct and indirect costs are USD148,484.83/year (USD25.38/visit) and USD88,503.70/year (USD15.13/visit), respectively. The total societal cost of treating patients in the hospital is USD1,085,310.21/year (39% is an indirect cost, dominated by productivity loss).

CONCLUSION

The societal cost of treating psychotic disorders is large and potentially catastrophic to the patients. Early treatment for mental illness may avoid the high costs and lead to better productivity. Potential access barriers such as financial factors and stigma should be addressed.

Myocardial Infarction Complications After Surgery in Vietnam: Estimates of Incremental Cost, Readmission Risk, and Length of Hospital Stay

Myocardial infarction is a considerable burden on public health. However, there is a lack of information about its economic impact on both the individual and national levels. This study aims to estimate the incremental cost, readmission risk, and length of hospital stay due to myocardial infarction as a post-operative complication. We used data from a standardized national system managed by the Vietnam Social Insurance database. The original sample size was 1,241,893 surgical patients who had undergone one of seven types of surgery. A propensity score matching method was applied to create a matched sample for cost analysis. A generalized linear model was used to estimate direct treatment costs, the length of stay, and the effect of the complication on the readmission of surgical patients. Myocardial infarction occurs most frequently after vascular surgery. Patients with a myocardial infarction complication were more likely to experience readmission within 30 and 90 days, with an OR of 3.45 (95%CI: 2.92–4.08) and 4.39 (95%CI: 3.78–5.10), respectively. The increments of total costs at 30 and 90 days due to post-operative myocardial infarction were 4,490.9 USD (95%CI: 3882.3–5099.5) and 4,724.6 USD (95%CI: 4111.5–5337.8) per case, while the increases in length of stay were 4.9 (95%CI: 3.6–6.2) and 5.7 (95%CI: 4.2–7.2) per case, respectively. Perioperative myocardial infarction contributes significantly to medical costs for the individual and the national economy. Patients with perioperative myocardial infarction are more likely to be readmitted and face a longer treatment duration.

Direct Medical Cost of Type 2 Diabetes Mellitus and Its Associated Complications in Indonesia

OBJECTIVES

To estimate the direct medical cost of type 2 diabetes mellitus (T2DM) and its complications in the Indonesian population from a payer perspective using a prevalence-based approach.

METHODS

The direct medical costs in 2016 were estimated using the database of Indonesia's National Health Insurance, known as Jaminan Kesehatan Nasional, which included diagnosis-related group costs and unbundled costs for patients accessing advanced care. The study population included people aged 30 years or older having a diagnosis of T2DM. T2DM and its related complications were identified using the International Classification of Diseases, 10th Revision, code. Hypoglycemia and all complications listed in the Diabetes Severity Complications Index were included. Descriptive analysis was conducted. Costs were converted to 2016 US dollar equivalent.

RESULTS

Of the 18.9 million Jaminan Kesehatan Nasional members who accessed secondary and tertiary care, 812 204 (4%) were identified with T2DM, of which 57% had complications. The most common complication was cardiovascular diseases (24%). The total direct medical cost was US $576 million, with 56% spent on hospitalization, 38% on specialist visits, 4% on unbundled non-diabetes-related medication, and 2% on unbundled anti-hyperglycemic medications. Approximately 74% of the total costs was used for the management of people with complications. People with complications (US $930/person/year ± US $1480/person/year) incurred twice the cost of those without complications (US $421/person/year ± US $745/person/year).

CONCLUSION

The direct medical cost for management of people with T2DM in Indonesia was high. Early diagnosis and optimal management of T2DM to prevent complications may reduce the costly sequelae and have a possibility of cost savings.

Direct medical costs of type 2 diabetes mellitus in the Philippines: findings from two hospital databases and physician surveys

OBJECTIVE

To estimate the annual direct medical cost of type 2 diabetes mellitus (T2DM) in hospitals and outpatient care clinics from a healthcare payer perspective in the Philippines.

DESIGN AND PARTICIPANTS

(1) A review of electronic hospital records of people with T2DM in two tertiary hospitals-Ospital ng Makati (OsMak) and National Kidney and Transplant Institute (NKTI) and (2) a cross-sectional survey with 50 physicians providing outpatient care for people with T2DM.

SETTING

Primary, secondary and tertiary healthcare facilities in Metro Manila.

OUTCOME MEASURES

Cost of managing T2DM and its related complications in US dollars (USD) in 2016.

RESULTS

A total of 1023 and 1378 people were identified in OsMak and NKTI, with a complication rate of 66% and 74%, respectively. In both institutions, the average annual cost per person was higher if individuals were diagnosed with any complication (NKTI: US$3226 vs US$2242 and OsMak: US$621 vs US$127). Poor diabetes control was estimated to incur higher per person cost than good control in both public outpatient care (poor control, range: US$727 to US$2463 vs good control, range: US$614 to US$1520) and private outpatient care (poor control, range: US$848 to US$2507 vs good control, range: US$807 to US$1603).

CONCLUSION

The results highlight the high direct medical cost resulting from poor diabetes control and the opportunity for cost reduction by improving control and preventing its complications.

Improving antibiotic prescribing for community-acquired pneumonia in a provincial hospital in Northern Vietnam

Objectives

To test the effectiveness of a quality improvement programme to promote adherence to national quality standards (QS) for patients hospitalized with community-acquired pneumonia (CAP), exploring the factors that hindered improvements in clinical practice.

Methods

An improvement bundle aligned to the QS was deployed using plan-do-study-act methodology in a 600 bed hospital in northern Vietnam from July 2018 to April 2019. Proposed care improvements included CURB65 score guided hospitalization, timely diagnosis and inpatient antibiotic treatment review to limit the spectrum and duration of IV antibiotic use. Interviews with medical staff were conducted to better understand the barriers for QS implementation.

Results

The study found that improvements were made in CURB65 score documentation and radiology results available within 4 h (P < 0.05). There were no significant changes in the other elements of the QS studied. We documented institutional barriers relating to the health reimbursement mechanism and staff cultural barriers relating to acceptance and belief as significant impediments to implementation of the standards.

Conclusions

Interventions led to some process changes, but these were not utilized by clinicians to improve patient management. Institutional and behavioural barriers documented may inhibit wider national uptake of the QS. National system changes with longer term support and investment to address local behavioural barriers are likely to be crucial for future improvements in the management of CAP, and potentially other hospitalized conditions, in Vietnam.

Respiratory complications after surgery in Vietnam: National estimates of the economic burden

Background

Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking.

Methods

We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits.

Findings

Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications.

Interpretation

The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients.

Funding

The authors did not receive any funds for conducting this study

Health claims databases used for kidney research around the world

Health claims databases offer opportunities for studies on large populations of patients with kidney disease and health outcomes in a non-experimental setting. Among others, their unique features enable studies on healthcare costs or on longitudinal, epidemiological data with nationwide coverage. However, health claims databases also have several limitations. Because clinical data and information on renal function are often lacking, the identification of patients with kidney disease depends on the actual presence of diagnosis codes only. Investigating the validity of these data is therefore crucial to assess whether outcomes derived from health claims data are truly meaningful. Also, one should take into account the coverage and content of a health claims database, especially when making international comparisons. In this article, an overview is provided of international health claims databases and their main publications in the area of nephrology. The structure and contents of the Dutch health claims database will be described, as well as an initiative to use the outcomes for research and the development of the Dutch Kidney Atlas. Finally, we will discuss to what extent one might be able to identify patients with kidney disease using health claims databases, as well as their strengths and limitations.

Primary health care policy and vision for community pharmacy and pharmacists in Indonesia

The practice of community pharmacy in low and middle-income countries, including in Indonesia, is often described as in the state of infancy with several intractable barriers that have been substantially and continuously hampering the practice. Such description might be valid in highlighting how pharmacy is practiced and the conditions within and beyond community pharmacy organizations. Therefore, it is not surprising that the concept of integrating community pharmacy into the primary care system may not be considered in the contemporary discourse despite the fact that community pharmacy has been operating within communities for years. However, in the case of Indonesia, we argue that changes in the health care system within the past decade particularly with the introduction of the universal health coverage (UHC) in 2014, may have significantly amplified the role of pharmacists. There is good evidence which highlights the contribution of pharmacist as a substantial health care element in primary care practice. The initiative for employing pharmacist, identified in this article as primary care pharmacist, in the setting of community health center [puskesmas] and the introduction of affiliated or contracted community pharmacy under the UHC have enabled pharmacist to work together with other primary care providers. Moreover, government agenda under the “Smart Use of Medicines” program [Gema Cermat] recognizes pharmacists as the agent of change for improving the rational use of medicines in the community. Community pharmacy is developing, albeit slowly, and is able to grasp a novel position to deliver pharmacy-related primary care services to the general public through new services, for example drug monitoring and home care. Nevertheless, integrating community pharmacy into primary care is relatively a new notion in the Indonesian setting, and is a challenging process given the presence of barriers in the macro, meso- and micro-level of practice.

Health insurance literacy: discussion and reaction of Facebook users' towards the National Health Insurance in Indonesia

Universal Health Coverage always persevered as a pro poor policy in many countries, characterized by a major impact on higher out-of-pocket healthcare costs, with low-cost alternative prescription drugs and capitation payments made to physicians, in order to reduce inequity. These concerns have been discussed widely on social media, including Facebook, but social media are consistently neglected as a source of scientific information. The purpose of this study, therefore, is to analyze the thought process or feelings of individuals about the policies, also focusing on the possible reactions. Hence, a systematic review in the form of discussion forums on the Facebook page of the National Health Insurance Agency, Indonesia was conducted from 2015 to 2016, with regards to the implementation of National Health Insurance, within a year and half after the policy was launched. In addition, the contents of 148 discussions were deductively analyzed, and the findings showed the pragmatic disposition of most Facebook users towards health care utilization, the costs of Insurance, and the possible benefits of payment. Furthermore, the debate conducted in social media related with the policy and its practice issues ought to be countered through appropriate modification.

Economic burden of venous thromboembolism in surgical patients: A propensity score analysis from the national claims database in Vietnam

BACKGROUND

Venous thromboembolism (VTE) associated with surgery can cause serious comorbidities or death and imposes a substantial economic burden to society. The study examined VTE cases after surgery to determined how this condition imposed an economic burden on patients based on the national health insurance reimbursement database. Methods: This retrospective analysis adopted the public payer's perspective. The direct medical cost was estimated using data from the national claims database of Vietnam from Jan 1, 2017 to Sep 31, 2018. Adult patients who underwent surgeries were recruited for the study. Patients with a diagnostic code of up to 90 days after surgery were considered VTE cases with the outcome measure being the surgery-related costs within 90 days.

RESULTS

The 90-day cost of VTE patients was found to be US$2,939. The rate of readmission increased by 5.4 times, the rate of outpatient visits increased by 1.8 times and total costs over 90 days in patients with VTE undergoing surgery increased by 2.2 times. Estimation using propensity score matching method showed that an increase of US$1,019 in the 90-day cost of VTE patients.

CONCLUSION

The VTE-related costs can be used to assess the potential economic benefit and cost-savings from prevention efforts.

Direct non-medical and indirect costs of diabetes and its associated complications in Vietnam: an estimation using national health insurance claims from a cross-sectional survey

OBJECTIVE

The prevalence of diabetes in Vietnam has increased from 2.5% in 2007 to 5.5% in 2017, but the burden of direct non-medical and indirect costs is unknown. The objective of this study was to estimate the direct non-medical costs and indirect costs due to type 2 diabetes mellitus (T2DM) and its associated complications among Vietnam Health Insurance System (VHIS) enrollees in Vietnam.

DESIGN

The first phase was a cross-sectional survey of patients with T2DM. In the second phase, data from the previous phase were used to predict direct non-medical costs and presenteeism costs of VHIS enrollees diagnosed with T2DM based on demographic and clinical characteristics in 2017. The human-capital approach was used for the calculation of indirect costs.

SETTING AND PARTICIPANTS

This study recruited 315 patients from a national hospital, a provincial hospital and a district hospital aged 18 or above, diagnosed with T2DM, enrolled in VHIS, and having at least one visit to hospitals between 1 June and 30 July 2018. The VHIS dataset contained 1,395,204 patients with T2DM.

OUTCOME MEASURES

The direct non-medical costs and presenteeism were collected from the survey. Absenteeism costs were estimated from the VHIS database. Costs of premature mortality were calculated based on the estimates from secondary sources.

RESULTS

The total direct non-medical and indirect costs were US$239 million in 2017. Direct non-medical costs were US$78 million, whereas indirect costs were US$161 million. Costs of absenteeism, presenteeism and premature mortality corresponded to 17%, 73% and 10% of the indirect costs. Patients incurred annual mean direct non-medical costs of US$56. Annual mean absenteeism and presenteeism costs for patients in working age were US$61 and US$267, respectively.

CONCLUSIONS

The impact of T2DM on direct non-medical and indirect costs on diabetes is substantial. Direct non-medical and absenteeism costs were higher in patients with complications.