Evaluation Managed Care Policy, Fraud Prevention and Commitment-Based Capitation in the Era of National Health Insurance in Bengkulu Province Used Realist Evaluation


Susilo Wulan(1*)

(1) STIKES Tri Mandiri Sakti Bengkulu
(*) Corresponding Author


Regulations related to health service quality policies in the era of National Health Insurance are needed to evaluate the effectiveness of programs based on sufficient evidence to become local as well as national policies. This research is important to do to support Universal Health Coverage (UHC) as issued by WHO. This study aims to evaluate the implementation of health service quality policy regulations and identify mechanisms of change and contextual factors that affect the implementation of regulations. Evaluation is carried out using a realist evaluation approach and analyzed in the form of a context, mechanism, and outcome configuration. The research was conducted in Bengkulu Province in 2018-2019 with the research subjects consisting of the director of the hospital, TKMKB, the fraud prevention team, the Health Office and the head of the Puskesmas. The sample selection used purposive sampling and data collection was carried out through in-depth interviews. Quality control and cost control (KMKB) programs, fraud prevention and Commitment-Based Capitation (KBK) are running in Bengkulu province. KMKB operates because of the SK which is always updated by BPJS Kesehatan every year, support from BPJS Kesehatan in the form of operational facilitation, coordination and incentives. The anti-fraud team in Bengkulu province in general has been formed at the district / city health office and hospital level, but not yet at the provincial level, this is because there is another team that has similar duties to the anti-fraud team at the provincial health office while at the health office district / city they are aware of the importance of the anti-fraud team. The KBK program shows that in general the target indicator for non-specialist referrals in Bengkulu province is achieved, namely 5%, but there are also city districts that have not been achieved, this is achieved because the Puskesmas has doctors in Bengkulu province, the competence of doctors is sufficient, adequate facilities and infrastructure, staff to receive capitation fund incentives, there is a JKN Monev team that is always active in conducting socialization, monitoring and evaluation at all Puskesmas, especially those that do not reach the target non-specialized referral indicator This study provides an overview of aspects of the context, mechanisms and outputs of health service quality policy regulations in the JKN era.



Managed Care; Fraud Prevention; Commitment Based Capitation; Realist Evaluation.


Agrawal S, Tarzy B, Hunt L, Taitsman J, dan Budetti P. (2013). Expanding Physician Education in Health Care Fraud and Program Integrity. Acad Med. 2013;88:1081–1087.

AHIMA Foundation. (2010). A Study Of Health Care Fraud And Abuse: Implications For Professionals Managing Health Information.

Bhatnagar, A., & George, A. S. (2016). Motivating health workers up to a limit: Partial effects of performance-based financing on working environments in Nigeria. Health Policy and Planning, 31(7), 868–877. https://doi.org/10.1093/heapol/czw002

BPJS Kesehatan. (2016). Peraturan BPJS Kesehatan Nomor 8 Tahun Tentang Penerapan Kendali Mutu Dan Kendali Biaya Pada Penyelenggaraan Program Jaminan Kesehatan Nasional.

BPJS Kesehatan. (2017). Tinjauan Pelaksanaan Kapitasi Berbasis Pemenuhan Komitmen. Jakarta.

BPJS Kesehatan. (2020). Laporan Pelaksanaan Program Jaminan Kesehatan Nasional Di Daerah Istimewa Yogyakarta Tahun 2019. Badan Penyelenggara Jaminan Sosial Kesehatan. DI Yogyakarta.

Cheng, J. S., Tsai, W. C., Lin, C. L., Chen, L., Lang, H. C., Hsieh, H. M., … Hsu, C. C. (2015). Trend and factors associated with healthcare use and costs in type 2 diabetes mellitus: A decade experience of a universal health insurance program. Medical Care, 53(2), 116–124. https://doi.org/10.1097/MLR.0000000000000288

Christianson, J. B., Knutson, D. J., & Mazze, R. S. (2006). Physician pay-for-performance: Implementation and research issues. Journal of General Internal Medicine, 21(SUPPL. 2), 2–6. https://doi.org/10.1111/j.1525-1497.2006.00356.x

Dean PC, Vazquez-Gonzalez J, dan Fricker L. (2013). Causes and Challenges of Healthcare Fraud in the US. International Journal of Business and Social Science, Vol. 4(14), 1-4.

Djasri, Hanevi. (2010). Modul Audit Medis. Yogyakarta: Pusat Kebijakan dan Manajemen Kesehatan (PKMK) FK-KMK UGM.

Djasri, H., Rahma, P. A., & Hasri, E. T. (2018). Korupsi Dalam Pelayanan Kesehatan Di Era Jaminan Kesehatan Nasional: Kajian Besarnya Potensi Dan Sistem Pengendalian Fraud. Retrieved from https://acch.kpk.go.id/en/component/content/article?id=672:korupsi-dalam-pelayanan-kesehatan-di-era-jaminan-kesehatan-nasional-kajian-besarnya-potensi-dan-sistem-pengendalian-fraud

Grant TM. (2017). Leadership Strategies for Combating Medicare Fraud. Diunduh di http://scholarworks.waldenu.edu/dissertations pada 4 Januari 2018.

Inseok Ko, MS and Hyejung Chang. (2017). Interactive Visualization of Healthcare Data Using Tableu. Healthc Inform Res. Published online October 31. https://doi.org/10.4258/hir.2017.23.4.349.

James, J., Damberg, C., Ryan, A., Agres, T., Schwartz, A., & Dentzer, S. (2012). Pay-for-Performance. Health Affairs, 19, 1–5. https://doi.org/10.1377/hpb2012.19

Janssen, W., de Dieu Ngirabega, J., Matungwa, M., & Van Bastelaere, S. (2015). Improving quality through performance-based financing in district hospitals in Rwanda between 2006 and 2010: A 5-year experience. Tropical Doctor, 45(1), 27–35. https://doi.org/10.1177/0049475514554481

Kalk, A., Paul, F. A., & Grabosch, E. (2010). “Paying for performance” in Rwanda: Does it pay off? Tropical Medicine and International Health, 15(2), 182–190.


Kementerian Kesehatan. (2011). Peraturan Menteri Kesehatan Republik Indonesia Nomor 2052/Menkes/Per/X/2011 Tentang Izin Praktik Dan Pelaksanaan Praktik Kedokteran.

Kementerian Kesehatan (2015). Peraturan Menteri Kesehatan Republik Indonesia Nomor 36 Tahun 2015 Tentang ”Pencegahan Kecurangan (Fraud) Dalam Pelaksanaan Program Jaminan Kesehatan Pada Sistem Jaminan Sosial Nasional

Kementerian Kesehatan, Badan Penyelenggara Jaminan Kesehatan (2017), Peraturan Bersama Sekretaris Jenderal Kementerian Kesehatan Republik Indonesia dan Direktur Utama Badan Penyelenggara Jaminan Sosial Kesehatan Nomor Hk.01.08/III/980/2017 Tahun 2017, Nomor 2 Tahun 2017, Tentang Petunjuk Teknis Pelaksanaan Pembayaran Kapitasi Berbasis Pemenuhan Komitmen Pelayanan Pada Fasilitas Kesehatan Tingkat Pertama

Komisi Akreditasi Rumah Sakit (KARS). (2020). Daftar Rumah Sakit Terakreditasi di Provinsi Bengkulu. http://akreditasi.kars.or.id/application/report/report_accredited.php

Laursen KK. (2013). Leadership Strategies and Initiatives for Combating Medicaid Fraud and Abuse. Diunduh di http://scholarworks. waldenu.edu/dilley pada 4 Januari 2018.

Liang, C., Mei, J., Liang, Y., Hu, R., Li, L., & Kuang, L. (2019). The effects of gatekeeping on the quality of primary care in Guangdong Province , China : a cross-sectional study using primary care assessment tool-adult edition, 1–12.

Li, J., Huang, K. Y., Jin, J., & Shi, J. (2008). A survey on statistical methods for health care fraud detection. Health Care Management Science, 11(3), 275–287. https://doi.org/10.1007/s10729-007-9045-4

Maharanti, S., & Oktamianti, P. (2018). an Analysis of the Healthcare Center System As a Gatekeeper in 2018. Journal of Indonesian Health Policy and Administration, 3(2), 46–50. https://doi.org/10.7454/ihpa.v3i2.2362

Mukti, G. A. (2007). Good Governance dalam Pembiayaan Pelayanan Kesehatan. Yogyakarta: Manajemen Kebijakan Pembiayaan dan Manajemen Asuransi Kesehatan UGM.

National Healthcare Anti-Fraud Association (NHCAA). (2007). The NHCAA Fraud Fighter's Handbook. A Guide to Healthcare Fraud Investigations & SIU Operations. NHCAA: New York.

Paul, E., Sossouhounto, N., & Sèdjro Eclou, D. (2014). Local stakeholders’ perceptions about the introduction of performance-based financing in benin: A case study in two health districts. International Journal of Health Policy and Management, 3(4), 207–214. https://doi.org/10.15171/ijhpm.2014.93

Pawson R, Tilley N. Realistic Evaluation. London: Sage; 1997

Pusat Kebijakan Manajemen Kesehatan, USAID, & Health Finance and Governance Project. (2017). Penguatan Pelayanan Primer Melalui Sistem Insentif Berbasis Kinerja. Indonesia: http://indonesia-implementationresearch-uhc.net. Retrieved from http://indonesia-implementationresearch-uhc.net/images/REV6_PB_IR_PKMK.pdf

Pusat Kebijakan dan Manajemen Kesehatan (PKMK). (2020). Data Sampel BPJS Kesehatan 1 % Tahun 2016. Diakses melalui DaSK: https://kebijakankesehatanindonesia.net/datakesehatan/file/utilisasi-peserta-JKN.html

Pusat Kebijakan dan Manajemen Kesehatan (PKMK). (2020). Data Sampel BPJS Kesehatan 1 % Tahun 2016. Diakses melalui DaSK: https://kebijakankesehatanindonesia.net/datakesehatan/file/utilisasi-peserta-JKN.html

Rudasingwa, M., & Uwizeye, M. R. (2017). Physicians’ and nurses’ attitudes towards performance-based financial incentives in Burundi: A qualitative study in the province of Gitega. Global Health Action, 10(1), 1–15. https://doi.org/10.1080/16549716.2017.1270813

Sripa, P., Hayhoe, B., Majeed, A., Greenfield, G., & Garg, P. (2019). Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure. British Journal of General Practice, 69(682), E294–E303. https://doi.org/10.3399/bjgp19X702209

Sub.Bag.Perencanaan, Evaluasi dan PelaporanDinas Kesehatan Provinsi Bengkulu. (2019) Profil Kesehatan Provinsi Bengkulu 2018. Diakses pada https://www.kemkes.go.id/resources/download/profil/PROFIL_KES_PROVINSI_2018/07_Bengkulu_2018.pdf.

TKMKB Nasional. (2015). Buku Petunjuk Teknis Kendali Mutu dan Kendali Biaya Program JKN. Jakarta: BPJS Kesehatan.

Trisnantoro, L. (2014). Paparan dalam diskusi Skenario Pelaksanaan JKN 2014 – 2019.

Quality and Patient Safety. (2017). Practical Guide To Clinical Audit. Irlandia: Quality and Patient Safety

World Health Organization. (2013). The World Health Report 2013: Research For Universal Health Coverage. ISBN 978 92 4 069083 7 (PDF)

World Health Organization. (2015). Tracking Universal Health Coverage: First global monitoring report. World Health Organization. ISBN 9241564970, 9789241564977

World Health Organization. (2018) New Perspectives on Global Health Spending for Universal Health Coverage.

Wibowo, N. M., Utari, W., Muhith, A., & Widiastuti, Y. (2019). Detection of Healthcare Fraud in The National Health Insurance Program Based on Cost Control, 103 (Teams 19), 284–288. https://doi.org/10.2991/teams-19.2019.46

DOI: https://doi.org/10.22146/jkki.63482

Article Metrics

Abstract views : 934


  • There are currently no refbacks.

Copyright (c) 2021 Jurnal Kebijakan Kesehatan Indonesia : JKKI

Creative Commons License
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

The Jurnal Kebijakan Kesehatan Indonesia : JKKI [ISSN 2089 2624 (print); ISSN 2620 4703 (online)] is published by Center for Health Policy and Management (CHPM). This website is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. Built on the Public Knowledge Project's OJS
Analytics View My Stats