Achieving Universal Health Coverage (UHC) has become a critical health policy goal in many countries, including Indonesia. The analysis found that STHC utilization cases were dominated by PBPU members (285,302 cases or 31.5% of all cases). PBI members accounted for 155,965 cases, or 17.2% of STHC cases. The result also shows that PBI members preferred to seek treatment at PHC, indicated by the high number of cases by PBI members (26.9%) compared to PBPU members (16.8%). On the average length of stay, PBI members need 1.4 days for treatment, or 0.52 days (12 hours) longer than PBPU members. Meanwhile, the regression results showed that cases by PBI members acquired 0.398 days longer compared to PBPU members (statistically significant).
Regarding healthcare expenditures, cases by PBI members cost IDR 113,110 or USD$ 7.85 higher than cases by PBPU members. However, the highest cost was found in the case by PBPU members with a difference of IDR 117,272,200.00 or USD$ 8139.97 up to the 75th percentile. Cases by PBI members still cost higher, with a difference of IDR 981,600 or USD$ 68.13. In the estimation model, the hospital cost in cases by PBI members was IDR 171,681 or USD$ 11.92 higher than in cases by PBPU members (statistically significant).
Our study has revealed that, on the whole, those PBI patients, who were subsidized, were seeking medical treatments in very severe conditions than PBPU patients. Meanwhile, many PBPU cases did not show a higher severity level than PBI cases. Of the 285,298 PBPU cases, 81.6% were outpatient cases, with 18.4% being hospitalized. While for PBI cases, out of a total of 155,956 cases, only 69.6% were outpatient, and the remaining 30.4% were inpatient cases. Based on the regression results of the severity level regression, the coefficient shows that PBI cases tend to be more severe than PBPU, which is significant at the 1% level with a value of 0.130 points.
The study results show that PBI members had an average hospital index utilization value higher than PBPU members, which indicated that PBI members seeking STHC services or treatment had poorer health conditions than PBPU members. The result is consistent with the regression results showing that PBI members had a higher utilization index of 0.00257 compared to PBPU members. The results of the interaction variables in the interaction model also show that PBI members with older age have a higher utilization index compared to PBPU members.
While we found evidence of the inequity in JKN utilization among different types of patients due to data unavailability, we cannot conclude the rationale behind the patient's behavior in seeking outpatient treatment. However, this study's finding is consistent with a previous study in Israel and Vietnam associating socioeconomic status with the utilization of healthcare services (Filc et al., 2014; Palmer, 2014). In addition, a strong linkage between inequity in healthcare utilization and education level is found in Danish diabetes patients (Sortsø et al., 2017). Despite similar findings, given the variations of the country's context, this study strengthens the current discourses on healthcare utilization inequity, especially for countries like Indonesia. To extend it to a global context, we recommend that universal health coverage not only improve the curative services but also be more rigorous in reaching different socioeconomic groups regarding promotive and preventive measures.
The research indicates the potentially higher burden of healthcare among PBPU members. From 2014 to 2016, the PBPU group contributed the highest healthcare expenditures (Rp 17.2 billion) yet the least contribution to insurance premiums fees (Rp 5.7 billion). The insurance premiums' income rate was 32.5%, and the claim ratio was 645.3%. Therefore, the PBPU group receives higher JKN benefits than what they paid for (Dartanto, 2017). During the same period, PBPU members were attributed to almost 80% of healthcare expenditures in secondary and tertiary healthcare (STHC) facilities, which mainly were hospitals, while only 17% of healthcare expenditures in primary health care (PHC) through capitation (Prabhakaran S. et al., 2019). In contrast, the subsidized members (PBI) of JKN have difficulties reaching healthcare services and facilities. In the early implementation of JKN, the utilization rate of PBI members was only 4.1%, with a claim ratio of 47.2% (Prabhakaran S. et al., 2019). Those issues indicate the overutilization of secondary and tertiary health care services by PBPU members and the underutilization of STHC services by PBI members. Consequently, underutilization by PBI members could lead to higher healthcare expenditures since many PBI members seeking treatment at STHCs are usually already in severe conditions and hence require longer or more complex treatments. Moreover, the overutilization of STHC by PBPU members could lead to higher healthcare expenditures due to adverse selection.
Limitations
This study has multiple strengths. First, this study used the largest available administrative claims data sources in Indonesia to assess the type of illness, treatments, and long-term outcomes in all patients of JKN. Second, the claims data source of JKN can capture the income disparity among the JKN's members, which are classified by their JKN membership status.
This study has limitations. First, JKN claim data does not reflect the real income of all patients as this study assessment is based on a proxy variable—the type of JKN user membership a client possesses and whether the Indonesian government has subsidized them or not. Second, JKN claims data is cross-sectional and not prospective. Therefore, cause and effect cannot be determined. Subsequently, we only know the severity of a patient's illness from what is provided to the JKN, which may not reflect the reality of a patient’s situation. Furthermore, JKN users who seek treatment from private sector doctors or hospitals are not recorded in the data.