O'Connell Meghan, Hafidz Firdaus, Saragih Sarah, Cashin Cheryl, Nugroho Aditia, Hatt Laurel, Farianti Yuli, Afflazier Ackhmad, Pambudi Imran
Results for Development, Washington, DC, United States.
Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
Front Public Health. 2025 Jul 9;13:1396596. doi: 10.3389/fpubh.2025.1396596. eCollection 2025.
The impact of provider payment mechanisms under Indonesia's National Health Insurance (NHI) scheme on healthcare providers' behavior-particularly in tuberculosis (TB) service delivery- remains underexplored. This study examines the consequences of provider payment incentives on TB service provider behavior.
A mixed-methods study was conducted using quantitative analysis of NHI claims data from 2015 to 2016 and qualitative data from focus group discussions with healthcare providers-22 primary care facilities and 14 hospitals across five provinces-. Quantitative analysis examined TB service utilization patterns, assessed referral appropriateness based on case complexity, and claim of TB services. Qualitative data were thematically analyzed to explore factors influencing provider decision-making in the context of payment mechanisms and service delivery under the NHI scheme.
Findings indicate that primary care facilities refer a high proportion of TB cases to secondary-level care, even for uncomplicated cases (81% of 782 visits). Secondary care recorded significantly more TB visits than primary care (5,249 vs. 1,094 visits), resulting in an estimated USD 14.1 million in potentially avoidable costs for the NHI program. If these cases had been managed at the primary level, potential cost savings could have been substantial. Qualitative analysis revealed that provider referral decisions were influenced by capitation-based payment structures, limited diagnostic tools, absence of dedicated TB rooms, lack of provider capacity, patient preferences, financial incentives favoring more profitable diseases, and providers' social ties. The high rate of up-referrals may negatively impact service quality and TB treatment outcomes.
Current provider payment mechanisms under NHI contribute to inefficiencies in TB service delivery by incentivizing unnecessary referrals to secondary care. Optimizing payment methods and strengthening implementation by addressing weak provider capacity at the primary care level could enhance incentives for primary-level management of TB cases, improving cost-effectiveness and service quality.
印度尼西亚国家健康保险（NHI）计划下的医疗服务提供者支付机制对医疗服务提供者行为的影响，尤其是在结核病（TB）服务提供方面，仍未得到充分研究。本研究考察了支付激励措施对结核病服务提供者行为的影响。
采用混合方法进行研究，对2015年至2016年的NHI索赔数据进行定量分析，并对来自五个省份的22个基层医疗机构和14家医院的医疗服务提供者进行焦点小组讨论获取定性数据。定量分析考察了结核病服务利用模式，根据病例复杂性评估转诊的适宜性，以及结核病服务的索赔情况。对定性数据进行主题分析，以探讨在NHI计划的支付机制和服务提供背景下影响提供者决策的因素。
研究结果表明，基层医疗机构将很大比例的结核病病例转诊至二级医疗机构，即使是简单病例（782次就诊中有81%）。二级医疗机构记录的结核病就诊次数显著多于基层医疗机构（5249次对1094次就诊），这给NHI计划带来了约1410万美元的潜在可避免成本。如果这些病例在基层得到管理，潜在的成本节约可能会很大。定性分析显示，提供者的转诊决策受到按人头付费的支付结构、诊断工具有限、缺乏专门的结核病病房、提供者能力不足、患者偏好、有利于更有利可图疾病的财务激励措施以及提供者的社会关系等因素的影响。向上转诊率高可能会对服务质量和结核病治疗结果产生负面影响。
NHI目前的提供者支付机制通过激励不必要地转诊至二级医疗机构，导致结核病服务提供效率低下。通过解决基层医疗机构提供者能力薄弱的问题来优化支付方式并加强实施，可增强对结核病病例进行基层管理的激励措施，提高成本效益和服务质量。
