PENERAPAN MANAGED CARE DALAM PROGRAM JAMINAN KESEHATAN SEPINTU SEDULANG KABUPATEN BANGKA PROVINSI KEPULAUAN BANGKA BELITUNG

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