Cesarean section tariff analysis based on Indonesian case base groups in Cipto Mangunkusumo Hospital

Introduction: Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan as the National Health Insurance Corporation/ Administration in Indonesia has two payment mechanisms through capitation for the primary health care and Indonesian Case Base Groups (INA-CBGs) for the secondary health service. Based on data from Indonesian Demographic Health Survey (IDHS) in 2012, the number of cesarean deliveries per year (95% CI) was 611,561 (570.165–655.962) and Cesarean delivery rate per 100 live births (95% CI) was 12.9 (12.0–13.8). Meanwhile, the study conducted in Dr. Cipto Mangunkusumo hospital (RSUPNCM) in 2012 revealed that 40% women delivered through Caesarean Section (CS). Therefore, we would like to analyse the CS tariff in Cipto Mangunkusumo Hospital (RSUPNCM) as the centre of referral compared to INA-CBG’s tariff. Methods: This cross-sectional study design was conducted in RSUPNCM from February to May 2016 by involving all CS claim records from 2014 to 2016. We performed the descriptive analysis consisting of diminishing risk of loss, CS tariff, and optimization of the tariff. Results: The average length of stay (ALOS) on CS cases in 2014 and 2015 was about 5 to 7 days. The difference between RSUPNCM revenue expectation and INA-CBG’s tariff was from 62.97% to 74.22%. By using unit cost, we could diminish the risk of loss between 58.9% for high risk CS in the third class and 75.7% for moderate risk CS in the first class. In assumption, the best efficiency potency was 50% reduction of RSUPNCM total claims combined with 40% increase of INA-CBG’s claim. Conclusion: Unit cost for Caesarean section on mild and moderate risk CS could be decrease to reduce the deficit potency. Medical service fee should be recalculated to reach the best efficiency.