| Summary: | Background: Health insurance at District of Bangka has started since 2005. It
reflects commitment of local government in implementing National Social
Insurance System Act (Sistem Jaminan Sosial Nasional/SSJN), but so far there is
no evaluation on its implementation.
Objective: To explore and identify the practice of managed care in the
implementation of health insurance at District of Bangka.
Method: The study was descriptive qualitative with case study design. Subject of
the study consisted of the regent, head of health office, managers of health
insurance and health service providers. Research instruments were interview
guide, report and technical guideline of health insurance at District of Bangka.
Result: The concept of managed care adopted in the implementation of health
insurance at District of Bangka was building partnership contract with health
service providers through selection mechanism/credentials by undertaking proper
test and assessing documents of practice license. Payment system used
retrospective method with fee for service. Utilization was assessed using
prospective, concurrent, and retrospective mechanism. The comprehensive
service offered by the provider was mostly oriented on curative aspect and the
implementation of risk profit sharing had not been done accordingly.
Conclusion: The concept of managed care had not been fully implemented in
health insurance of District of Bangka. Method that had been implemented was
establishing partnership contract with health service providers through the
mechanism of selection/credentials and assessment on utilization. Some aspects
that had not been implemented were prospective payment pattern through
capitation, comprehensive service oriented on promotive and preventive aspect
and the implementation of risk profit sharing for the provider and participants.
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