Impact of Implementing Casemix for Hospital Reimbursement in a Social Health Insurance at a Teaching Hospital in Indonesia

Abstract

An appropriate provider payment method is one of the key factors for the sustainability of social health insurance. Both casemix and fee-for-service (FFS) have been used as hospital reimbursement methods in the social health insurance programme that covers most hospitals in Indonesia. The aim of this research was to study the impact of implementing the casemix method for reimbursing services in a teaching hospital in Indonesia. This cross-sectional study compared two groups of patients whose costs were reimbursed under the casemix and FFS methods and was conducted in a 1,001-bed teaching and national referral hospital in Jakarta. Data on the primary diagnoses for the five most common conditions for inpatient and outpatient services were extracted from medical records using universal sampling from January to December 2011. In addition, financial data were obtained from the hospital‘s annual report. A survey using self-administered questionnaires was also conducted among hospital billing administrators. The results of the study showed that median hospital charge for outpatients and inpatients and length of stay (LOS) for inpatients were significantly lower under the casemix method than under the FFS method (p<0.001). The unnecessary admission rate was 1.87 times higher for patients under the FFS method than for patients under the casemix method (72.0%; 38.6%, p<0.001). The multiple logistic regression model showed that compared with patients whose costs were reimbursed using the FFS method, patients whose costs were reimbursed using the casemix method were more likely to have a lower hospital charge (OR=1.387, p=0.0001) and shorter LOS (OR=1.255, p=0.009); were more likely to be female (OR=1.219, p=0.0001), younger (OR=1.127, p=0.0001), medical cases (OR=4.630, p=0.0001), and outpatient cases (OR=4.000, p=0.0001); and were less likely to have an unnecessary admission (OR=2.326, p=0.0001). The cost of the billing process was 23.2% lower under the casemix method than under the FFS method (p=0.033). The percentage of claims that were fully reimbursed was 8.5% higher for inpatients and 1.1% higher for outpatients under the casemix method than under the FFS method (p<0.001). Billing administrators had significantly more positive perceptions of managing cases under the casemix method than under the FFS method for the dimensions of reliability (p<0.001), responsiveness (p<0.001), and assurance (p<0.001). In conclusion, compared to the FFS method, the casemix method offered a much better option for provider payment for social health insurance. In contrast, the FFS method proved to be more complex and costly to manage than the casemix method. Hence, implementation of the casemix method as a provider payment method might help to ensure the sustainability of the social health insurance programme.