Understanding referral pattern in the primary care: potential efficiency and improving policy to support universal health coverage
Penulis/Author
dr. Guardian Yoki Sanjaya, M.Health.Info (1); dr. M. Lutfan Lazuardi, M.Kes., Ph.D. (2); dr. Mubasysyir Hasan Basri, MA. (3); Prof. dr. Hari Kusnanto Josef SU., Dr.PH. (4)
Tanggal/Date
27 2019
Kata Kunci/Keyword
Abstrak/Abstract
Introduction
Primary care facilities have a strategic role in improving the efficiency of health services through controlled referrals (gatekeepers) while ensuring better referral services. In the midst of the deficit problem of the national health insurance budget, strategies are needed to provide access to health services efficiently, while maintaining the quality of referral services.
Purpose of study
This study aims to estimate efficiency of referral services in the context of national social health insurance.
Method
Descriptive analysis of secondary claim data of the Social Security Agency for Health in 2015 and 2016 was conducted to look at patterns of referral and identify potential efficiency of referral services in DI Yogyakarta. Spatial and network analysis was conducted to understand referral pattern. Whereas efficiency was assessed from 22,016 claims data with non-specialist primary diagnoses or cases with severity levels 0 and 1 that referred to level 2 or 3 referral hospitals.
Results
Average hospital visits per patient for non-specialist and severity level 0 and 1 cases were 4.5 in 2015 and rose to 4.6 times in 2016. Network analysis showed that 45.85% of the cases were referred to Level 2 and 3 referral hospitals, where 15.16% of the cases were non-specialist diagnoses. Family physicians more often refer the non-specialist cases compared to other types of primary care.
This study showed an estimated cost reduction of 4.62% if non-specialty cases were not referred to the hospital. However, there was no difference the value of claims between first and second or third level referral hospitals in the handling of referral cases with severity levels 0 and 1.
Conclusion and recommendation
There is potential for efficiency if health services with non-specialist diagnoses can be handled in primary care. Hospital competency-based referral is possible by taking into account availability of hospital resources and the quality of patient care. The regulation of tiered referral needs to be updated to accommodate non-tiered referral services.
