Ethan Frome - Magister Ilmu Kesehatan Masyarakat

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DESCRIPTION OF IMPLEMENTATION REFERRAL OF JAMKESMAS
PATIENTS IN THE PUSKESMAS OF SOUTH LAMPUNG
THESIS SUMMARY
POSTGRADUATE IN HOSPITAL MANAGEMENT
Written by:
SUTJI SEPTINA ICHTYARNI MENDROFA
09/295267/PKU/11191
FACULTY of MEDICINE
GADJAH MADA UNIVERSITY
YOGYAKARTA
2011

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GAMBARAN PELAKSANAAN RUJUKAN PASIEN JAMKESMAS DI
PUSKESMAS LAMPUNG SELATAN
DESCRIPTION OF IMPLEMENTATION REFERRAL OF JAMKESMAS
PATIENTS IN THE PUSKESMAS OF SOUTH LAMPUNG
Sutji. S. I. Mendrofa 1 , Felix Kasim 2 , Kusmedi Priharto 3
ABSTRACT
Background: Referral system is one of health service provisions which delivering
delegation of mutual responsibility towards one case of illness or health problems
vertically or horizontally. Referring to PT. ASKES information, good national
referral standard is 7%-10%. What below 7%-10% ratio is considered poor.
Based on the data from 14.290 Jamseskes member of 2009 doing visit, the
average visit per month is 4.115 people, and from those visits only 340 people
were referred. 71% patients were referred on their own inquiry without prior
diagnosis from the puskesmas doctors. If this is happened to 24 Puskesmas in
Lampung Selatan district or perhaps to all over Indonesia, would it be affecting to
the health costs? This research is to evaluate the referral service in Lampung
Selatan by interviewing 12 doctors working in Puskesmas, and patients of
Jamkesmas member inquiring referral by their own.
Objective: To achieve data referring understanding of Puskesmas doctors toward
their function as gate keepers, and reasons to give referral letter without prior
diagnosis. Also it’s expected to find reasons for referral inquiry to main hospital by
patients,
Method: This research is qualitative research using single spike case study
design. The data were collected by deep interview, observation and document
analysis.
Result: The referrals were made by general practitioners by employing limited
clinical skill of theirs, The cases needing specific action, the limited access of
medicines and equipments in PPK I, and by the patient own inquiry. The biggest
problem is referral made of patient own inquiry, since the staff felt reluctant to
refuse. Other problems are limited access to the tools and equipments at PPK I,
and lack of communication between general practitioner in PPK I and specialist
doctor in PPK II.
Conclusion: The quality of referral services at Puskesmas in Lampung Selatan
district are poor, since still there are inappropriate referrals, and the general
Practitioner are not function well as gate keepers
Key Words: General Practitioner, Referral, Gate Keeper, Referral System
1 Bakauheni Puskesmas of Lampung Selatan
2 Public Health Science Programs, Faculty of Medicine, Kristen Maranatha University
3 Tarakan Hospital of Jakarta

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INTRODUCTION
Health or illness is a continuum that starting from good health to severe
pain. Health of a person is in the spans. Similarly it had some level of pain or
gradations. In General can be divided in three levels, namely the ache (mild), sick
of being (moderate), and severe pain (severe) 8 . With the three gradations of this
disease, it requires a different form of health care as well. For mild disease does
not require sophisticated services, but instead to have severe disease that is not
enough just to service is simple, but requires a more specific service. Therefore it
is necessary to distinguish the three forms of service that is:
1. The first level health care (Primary Health Care)
2. The second level health care (Secondary Health Care)
3. The third level health care (Primary Health Care)
In a health care system, all three strata or type of service does not stand
alone, but are in a system, and interconnected. If the primary health care can not
perform medical acts primary level, then he handed over that responsibility to the
level of service on it, and so on. Handover of responsibility from one health care
into other health services is called a “referral”.
Can be formulated in full “referral system” is a the provision of services
system that implements a reciprocal transfer of responsibility for one case of illness
or health problem vertically from the units that are better able to handle, or
horizontally between units of equivalent capacity 8 .

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Following this, the scheme of health care referral system in Indonesia.
Hospital Type A
Province
Hospital Type B
District
Village
Primary healthcare /Balkesmas
Primary healthcare assistants
Physicians in
private practice
Midwives practice
polyclinic
Posyandu
Posyandu
Posyandu
Posyandu
Figure 1. Schematic of Health Services Referral System inIndonesia

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Subdistrict Bakauheni an expansion of the subdistrict's Penengahan in
South Lampung District. Bakauheni Subdistrict Puskesmas has a master of fruit,
two Pustu, and two village health post, to serve the community in the region.
Bakauheni Puskesmas working area covers 5 villages (Bakauheni, Kelawi, Hatta,
Semanak, and Totoharjo). The population in the working area Bakauheni
Puskesmas in 2009 was 20,729 souls, which consist of 9607 souls of men, and
11,112 women's lives. Of the many residents, most of the Gakin. The monetary
crisis that occurred around 1997 have increased the number of poor people and
increase healthcare costs doubled, so that pressing the access of the population,
especially the poor to health services. To overcome this, various attempts have
been made by governments to ensure access for the poor to health services,
including the Community Health Insurance program (Jamkesmas).
The following membership data Jamkesmas Puskesmas of patients
capitation Bakauheni:
Table 1. Jamkesmas of patients membership data
Years Population
The number of Jamkesmas
2005 17912
2006 18288
2007 18747
2008 18983
2009 20729
6374
15207
15207
14290
14290
Sources: South Lampung Regent decree in 2005-2009
From Table 1 shows that more than 50% of the population to be participants
Jamkesmas.
Bakauheni Puskesmas provides health care services include promotive,
preventive, and curative (basic healthcare). For health problems that require

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treatment with more facilities, the Puskesmas Bakauheni refer to the Regional
General Hospital of of South Lampung.
Here is a data utilization.
Table 2. Data Utilization Jamkesmas
No Utilization 2005 2006 2007 2008
1
The number of who
decapitation
6.347 15.207 15.207 14.290
2
Visits on average
any month
116 257 320 386
3
Average referrals
any month
12 21 33 23
3
Ratio of referrals
any month
1034% 8,17% 10,31% 5,95%
Sources: Data SP2TP Bakauheni Puskesmas
2009
14.290
442
51
11,53
From Table 2 looks Jamkesmas patient referral ratio that varies each year.
According to PT. Askes (2002), the national standard of good referral is 7% - 10%.
The ratio of below 7% and above 10% including the bad criteria. According to the
MOH (2009), the scope of patient referrals from Primary Health Care to the
Hospital, by 8%. Reference numbers in the Puskesmas Bakauheni varies each
year. After declining in 2008, the figure increased again in 2009 (11.53%) and it
turns out after the note on the data SP2TP, 71% are referred at the request of of
patients (APS).

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The following reference data based on physician and of patients demand.
Table 3. Patient referral data on request
Years
Number of
Medical
patient
case referrals
%
reasons
demand
Jamkesmas
%
2005 144 32 23 112 77
2006 252 69 27,3 183 72,7
2007 396 107 18 217 55
2008 276 98 35,5 178 64,5
2009 612 184 29 428 71
Sources: Data SP2TP Bakauheni Puskesmas
From table 3 appeared to be not a general physician role as a gate keeper
so that the door to control access and referral service channel has not run well.
In puskesmas B there is no clear path for patients who need medical care
which should be referred or not. Starting from the initial entry and register diloket of
patients, for patients who only require a letter of referral, served by counter staff, by
providing a referral that does not contain medical diagnoses, and has been first
signed by a physician/ puskesmas head. In fact, often of patients had first come to
the service unit to the second level facilities (district hospitals), and then returned to
the Puskesmas to ask for a referral, as the requirement of obtaining a facility
Jamkesmas.
The Health Insurance aims to improve access to health services in the hope
that participants can use the services needed. However, the Health Insurance
should also serve to control the service, because the consumption of health
services of certain anomalies could occur: (a) supply induced demand and (b)
moral hazard.
Supply induced demand are actions that do not need will still be performed
by the provider. The form can vary, for example, a sophisticated examination but
did not improve the accuracy of diagnosis, but rather "up coding" of improving the
classification of the diagnosis with the aim of getting a higher claim costs, etc.

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Moral hazard is conducted by the participants because they felt no longer the cost
of treatment time, tend to use excessive service 2 .
Supply induced demand and moral hazard could threaten financial stability
insurance/ Health Insurance and guarantee further sustainability as a whole.
Therefore any need to do a Health Insurance Utilization Review (UR).
According to Anwar (1994), because participants were not issued for cash
every time medical treatment, then there is a tendency for excessive use of health
services. Conversely for service providers (KDP II) obtaining a fee for each service
they provide, then to raise revenue, the service was performed in which excessive.
Many of health care system such as in England, Holland, and some health
care organizations in the United States use gate keeper to manage the flow of
referrals from both the public service, as well as from specialist services. Interest in
managing the increased demand for services in the U.S. during the middle of
1990s due to health care providers trying to cut costs 4 .
The high demand for Jamkesmas patients referred to a specialist can lead
to various perceptions, so please note, what factors are affecting the accuracy of
patient referral Jamkesmas in of South Lampung.
The purpose of this research was to describe the reasons for referral by
general practitioners, general physicians in evaluating the role of a reference
control, and evaluate the quality of referrals in Puskesmas of South Lampung.
RESEARCH METHODS
This research is a qualitative research, using case study design with a
single case design approach stuck. Data was collected through in depth interviews,
observation and document analysis.
In depth interviews conducted by general physicians who serve patients in
the puskesmas. Interviews were conducted to dig deeper into the reasons for
general practitioners to refer patients, the obstacles encountered in efforts to
control the reference numbers, and other matters related to the referral process.

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Observations carried out to observe the referral process that runs in the
puskesmas and in hospitals.
Analysis of the documents in the form of a referral letter from PPK I
(Puskesmas) and referral response letter from the PPK II (hospitals) to assess the
completeness and clarity of the contents of referral letters.
RESULTS AND DISCUSSION
1. Some of the reasons general physician in puskesmas to refer is:
a. Patient's request
b. Incentives physician puskesmas
c. Cases that require specialist handling and action
d. Drug Limitations and equipment
e. Specialist is not complete in hospitals
From interviews, patient request for referral to a specialist is a consideration
of respondents in making referrals. Patient's request will be considered if there are
indications that are considered appropriate to refer, or if the patient is still forcing
the respondent to give a referral although it has strived to get the patient will seek
treatment in PPK I.
The cases that require specialist treatment is surgical cases (surgery),
emergency obstetrics, cases with complications, and need investigation such as
laboratory and radiological examinations.
The perceived less support facilities are limited tools and medicines.
Because the Hospital District of South Lampung there are only 4 specialties
(obsgin, internal, surgical, children), then for the cases of eye diseases, skin, THT
etc., puskesmas physician refer patients to the provincial hospitals, or to a private
hospital.
2. Barriers in an effort to reduce referrals at PPK I
From the interviews, the barriers perceived by the respondents in the control
reference number is a referral procedure that is not according to the rules, lack of

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communication between general physician in PPK I with a specialist at PPK II, and
the lack of clinical skills in managing the patient's general physician.
Referral process is often reversed, the patients have gone to the hospital,
then came to the puskesmas to ask for a referral. Jamkesmas cardholders feel
entitled to enjoy the health care without following the rules, otherwise physician
PPK I could not resist if forced to make a referral by the patient.
The lack of communication between general physician in PPK I with a
specialist at PPK II, seen from the letter of referral of patients made by general
practitioners in PPK I contains less information about the patient because it is not
complete, and there is no answer to a referral letter from a specialist in PPK II to a
general physician in PPK I.
The lack of general physician clinical skills in diagnosis is doubt, hesitation
in determining therapy, and do not believe in dealing with certain cases.
3. Letters of Reference
a. Referral letter from PPK I (Puskesmas) to the PPK II (Hospital Kalianda)
From the results of data collection at the Hospital in April 2011, there were
366 outpatient referrals from 9 health centers, who once observed, there is the
following composition:
Number of References Upon
Request
206
160
APD
APP
Figure 4. Composition Number of References from PPK I, on request

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From the diagram, the largest number of referrals is on request as many as
206 patient referrals (56%) and on demand physician referral 160 (44%).
On request, the largest is on demand patient referral (APP). Observations in
nine health centers, reference Letter APP was made only for the administrative
requirements only. Most patients do not come to PPK I do need to be examined
whether or not referred by a health center. And most of the letter of referral is made
by nurses and midwives.
As for the reasons I provide PPK on demand patient referral letter is:
1. Refuse difficult
2. Not willing to take risks, wrong diagnosis.
3. Fear of hampering the process of treatment of patients
For the referral APD, the average of all the referral letter is to include the
purpose of referral, diagnosis or patient complaints, physical examination results
that support the diagnosis, as well as the reasons for referring physician. Reason
refers to was written with the phrase "Please managing next". For the therapy or
actions that have been given previously, most are not written.
Below is a table of comprehensiveness referral letter from the PPK I
Table 5 Completeness of Referral Letter from PPK I
No Point Number %
1 Referral destination 183 50
2 patient data 366 100
3 Anamnesa 74 20,2
4 physical examination 41 11,2
5 WD/ 76 20,7
6 therapy 39 10,6
7 Referring to the reasons 36 9,8
Referral Letter is default, not in the Puskesmas South Lampung. Each
Puskesmas create a form letter references each, and most of the referral form is

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not eligible referral letter is good, because it is not accompanied by: physician
referral purposes, a physical examination, diagnosis, and therapy or actions taken
in PPK I, as well as what is expected to be done by a specialist at PPK II.
Table 6 Physician Referral Specialist Aim For APD
No Physician destination Number %
1 Internist 119 32,51
2 Surgery 98 26,77
3 Child 82 22,40
4 SpOG 67 18,30
From Table 6 shows that a referral is made on request at most physician
PPK I directed her to a specialist in internal medicine (32.51%), followed by the
surgeon (26.77%), then a pediatrician to the third sequence (22, 40%), and the
latter is a specialist obstetric physician (18.30%).
From the observation by using the checklist, it turns out of 366 referral, all
(100%) are not rewarded with referral response letter from the Hospital.
Table 7 Results Analysis checklist for referral in of South Lampung Puskesmas
No Point Number Percentage
1. Referral Response Letter
- There
- None
0
366
0
100

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b. Referral letter from PPK II To PPK I
Obtained from observations of researchers, in Kalianda Hospitals there is no
form referral response letter addressed to PPK I or Puskesmas physician who
refer.
From interviews found that the letter is assumed to resume home patient
referral response letter to the PPK I or Puskesmas referring the patient.
Referral letter from PPK I, which is not complete, is not considered a
problem because every patient who came for treatment to Hospital Kalianda, reregistration
at the counter asked, what the complaint, or what will control to the
doctor?
4. Referral System
From interviews and observations in PPK I, referral procedures during this
run are as follows: Jamkesmas patients who need to be referred to the PPK II,
when examined by doctors at PPK I, made a referral letter, referral letter called
APD (On Demand Physician).
For patients who did not come to the puskesmas, but asked for a letter of
referral, referral letter also will be created called on demand patient referral letter
(APP). Letter of reference APP is usually made by a midwife / nurse in charge, and
without a completed diagnosis, because patients who are referred are not checked
by a doctor first.
At the Puskesmas, controlling the referral has not been going well. Has
never held an audit of PPK I and the PPK II in terms of referral.
Meetings were held with general practitioners in PPK I just stressed to
reduce the number of referral only. But efforts to redress the factors that affect the
implementation of referral, such as uniform referral form is never done
Incentive systems are different for PPK I may also be influential in
increasing referral rates. Incentives for capitation-based PPK I require the number
of visits and lower health care costs in order to obtain a great incentive. While

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incentives for PPK II-based fee for the service it requires the number of visits and
services are much greater incentive to acquire.
Referral of good quality is obtained from referral accuracy, as seen from the
contents of referral letters, referral systems or procedures, the guidelines for
referral and reasons for general physician in making referral. Said to be good
referral if appropriate patients referred to specialist services or the right, at the right
time also.
Reference is said is not good when directed to a specialist service or wrong,
does not contain enough information, or not in accordance with the agreed clinical
guidelines. For the accuracy of this referral, general practitioners as a gate keeper
role in regulating the flow reference.
From these results, it was found that, physician a referral letter made public
as a gate keeper in South Lampung Puskesmas is still not good. Referral reason is
not listed in a clear and specific, simply described by the phrase "please the next
management". According Kongstvedt (1989), the sentence is not a sentence that is
informative, and does not explain the intent of the physician who make referrals.
Sentence allows a specialist to take over the management of the patient and not
return to the general practitioner. Referral reasons which made the respondent, in
the checklist should also be written in letters of reference that they made, with
appropriate clinical information that supports.
This also applies for re-a referral letter, to include the results of evaluations
conducted in PPK I and request advice on whether the patient can be managed at
PPK I if it is possible.
Control of referral in managed care systems play an important role, it has
not run its full potential, in PPK I and PPK II. Deputy medical director, has not
conducted an audit on a regular basis upon authorization granted in the form of a
referral letter I PPK. Similarly, referral response letter from the PPK II. However,
control efforts have been made through a referral form to manufacture a standard a
referral letter in the PPK-I and referral response letter in PPK II.

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The lack of guidance in the implementation of the referral, either for PPK I
and PPK II, also affects the efforts to reduce referral rates. The absence of criteria
and a clear division of authority between the PPK I and PPK II make the referral
process runs at will as expressed by respondents in interviews.
CONCLUSION
From the above results, it can be concluded That the quality referrals in
South Lampung primary health care has not been good, referral system has not
been on the run as it should, and general practitioners in the health center is not
maximized in carrying out its functions as a Gate Keeper.

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