TUTORIAL 2

- Ananda Ayu Pramono - Yumna Yudantoro

- Amalia Qurrotu’Aini - Vania Cindy Ega R
- Rifqi Mutia Zahwa - Khubba Indahu Zulfa
- Galih Hanur Cahyo - Eni Puji Rahayu
- Fineza Rovi
- Muthia Nisa Fadira
- Rusydia Safitri
- Faiq Bachtiar Utama
- Estetika Prapinanti
-
 SKENARIO PBL 2

The lack condition of quality oral health care in Indonesia, currently made
government implement the program of primary care dentist. The
government contracted a general dentist to serve 10.000 people, running
family dentist program and also appoint the third party. Noted in the MoU,
type of service, unit cost, utilization, premium, capitation, and Ina - CBG’s
system financing. The family dentist system and manage care must be
executed by the concept of He alth Paradigm, so it is expected that the
capitation for the payer dan all of the oral health care with 10.000 people
will be assured.. The third party will always monitor the service quality and
required report on periodic. The family dentist system with its Health
Paradigm will develop mutual cooperation for all parties and assure the
quality and the health financing.
 QUESTION
1. Mention definition and elemen managed care?
2. Mention the characteristic managed care!
3. Mention the advantages and disadvantages managed care!
4. Mention the difference between managed care and conventional
insurance health system!
5. Mention the actors in managed care!
6. Mention the Insurance in other country!
 MANAGE CARE
• Definition :
a health insurance system that integrates the health service system
and the financing system
• Elemen :
a. provider selection
b. provider payment system
c. gradual service system
d. utilization review
e. promotive and preventive efforts
 CHARACTERISTIC MANAGED CARE
a. There is a contract with the doctor or hospital choosen to provide
services that include promotion and prevention to participants
b. provider payment system with prospective payment system
including capitation
c. Administration of quality and utilization where the doctor or
hospital has passive approval in the contract
e. Promotive and preventive efforts
f. Payment of premium per person per month has been
predetermined
 ADVANTAGE DISADVANTAGE
Integrated health services Hospital finansial risk is higher

Lighter participants cost Participants founded it difficult to

get services from specialis
doctors directly

Improving service quality Difficult to managed financing

because management from the
center
THE DIFFERENCE BETWEEN MANAGED
CARE AND CONVENTIONAL INSURANCE
SYSTEMS
ACTORS IN MANAGED CARE
 CAPITATION CALCULATION
METHOD
a. Unit cost is derived from the sum fixed cost + semivariable cost +
variable cost
b. Utilization (%) = the number of participant visitsx 100%
the number of registered participants
c. Capitation = Unit cost x Utilization
 • Example :

No Service Unit Cost Utilization Kapitasi

(Rp) (%) (Unit cost x
Utilization)
1 Cursing 70000 0.5 350
2 Scaling 50000 1 500
3 Tooth extraction 60000 0.8 480

Total Rp 1.330
 INSURANCE IN OTHER
COUNTRY
A. England
• The national social security system in the UK is called the National Health
Service (NHS). Health insurance is funded and managed by the
government nationally (not decentralized), but the nature of its
management is partly financed from mandatory contributions by workers
(including in the informal sector) and employers. Whereas the distribution
of funds through the state budget which is largely sourced from general
tax (tax-funded). For participant coverage, the NHS covers the entire
population (universal coverage). Besides, there are no classes in hospitals
because health care centres are in primary health care.
B. Canada
• The health insurance system in Canada is also called Medicare. Medicare
uses basic principles that guarantee universal, portable, equal guarantee
packages for all residents and are implemented autonomously in each
province.
TERIMA KASIH :)