An Analysis on Non-specialist Outpatient Referrals at Beji and Depok Jaya Health Centers in 2018

. The Health Social Security Agency (BPJS kesehatan) is one of the government’s efforts to provide quality healthcare for the people. To guarantee its quality and maintain efficiency, a tiered referral system is used. However, there were many problems in its implementation. One of the ways to investigate is to evaluate the non-specialist outpatient referrals (RRNS). Therefore, in March-July 2018, this research was performed in order to analyze whether the system was implemented at Beji and Depok Jaya Health Center. The method used was the qualitative research method, with primary data from in-depth interviews and secondary data from documents. It was discovered that both Centers had optimal RRNS ratios (0%). This was because the doctors at both Centers has provided referrals as indicated and there was feedback on the RRNS total. The civil servant (PNS) doctors at both centers were experienced and skillful, but the number of doctors was insufficient compared to their workload. The non-PNS doctors also were not sufficiently trained. Other problems include insufficient equipment and medication provision.


INTRODUCTION
Indonesia's national health system is established to provide quality healthcare for its people. This system comprises of several subsystems, which includes healthcare services; research and development; funding; human resources; pharmaceutical supplies, medical supplies, and food; management, information, and regulation; and public empowerment. 1 To provide optimal healthcare, a tiered referral system was applied, 2,3 where the primary care facility (faskes I) acts as the gatekeeper that screens and manages referrals to the next tier. 2 The second tier (faskes II) only accepts referrals from the faskes I, and the third tier only accepts referrals from the first or second tier. This system was applicable since 2014 for the participants of the BPJS kesehatan. 3 However, many problems were found in the system, particularly at the primary facility, such as patients wanting to be referred at their own request (APS), insufficient numbers and skills of the healthcare staff, or insufficient drugs. The healthcare referrals system regulates the job and task division of healthcare services. Patients are referred to the nearest healthcare facility that is capable of satisfying the patient's needs. This is to guarantee that the patient will receive quality healthcare at a reasonable cost. 3 However, an efficient referral system is only possible if the healthcare providers are well coordinated. 4 In Indonesia's healthcare system, personal healthcare services can be provided in three levels. The first level provides basic healthcare services and dental services at the health center, inpatient health centers, private practices, primary clinics, general practitioner clinics, and primary hospitals. The second provides specialist care and services. While at the third level, the patients are provided subspecialist care. 5 In the BPJS kesehatan system, the healthcare facility paid based on capitation, where the amount paid are determined by the contact number, non-specialist outpatient referral ratio, ratio of older patient visiting the center, and the number of home visits. For this research we will discuss the non-specialist outpatient referral ratio.
The non-specialist outpatient referral ratio (RRNS) is one of the indicators of quality healthcare services at the primary care facility. The number of non-specialist outpatient referrals are the number of participants referred to a higher healthcare facility with diagnoses that are included in the list of diseases that must be treated at the primary healthcare facility according to the regulations or based on an agreement between the BPJS kesehatan, health facility, health office, and professional organization. Also taking into consideration the capabilities of the facility and the disease progressivity (special indications and/or emergencies) and is written in the contract. The formula used for the RRNS ratio is: Which cases that must be treated at the primary facility is determined in a meeting between the BPJS kesehatan, the faskes I, the health office, the Cost and Quality Control Team, and local professional organizations. The Time-Age-Complication-Comorbidity (TACC) also is included in determining whether the case can be referred or not. According to the 2012 Indonesian Doctor Competence Standards, there are currently 144 diseases that a general practitioner must be able to treat at a primary care facility. However, in the contract between the Depok City Health Office and the BPJS in 2017, only 128 diseases were included with a RRNS ratio of <5% each month.

This research was performed at Beji and Depok
Jaya Health Centers, Depok City between March-July 2018 and used the qualitative method. The data used was primary and secondary data. The primary data was obtained through in-depth interviews and the secondary data was obtained through documentary research. In-depth interviews was performed with 4 doctors at the Beji Center and 2 doctors at the Depok Jaya Center that passed the inclusion and exclusion criteria. Documentary research was based on the RRNS data at both centers. And the instruments used in this research were in-depth interview guidelines and documentary research.

Non-specialist outpatient cases referrals ratio
The following table are data on the total numbers of referrals, non-specialist referrals, and RRNS at Beji Center in January-April 2018. From the table above we discovered that the number of referrals each month varied, with the highest in March totaling 928 referrals. However, there were no non-specialist referrals in any of those 4 months, which meant that the RRNS in January-April 2018 was constantly 0%. Therefore, the RRNS at this health center was optimal according to the standard set by the BPJS kesehatan.
Interestingly, according to the informants the RRNS at the last month was 3-5%, because there was intimidation and threats from the patient to the doctors to be referred. The patient was then referred, but an APS note was written on it. However, since the P-Care application only counts it as a referral when the facility the patient was referred to accepts the patient, and the patient was rejected at the referral hospital, the RRNS was still 0. 5 In the following table we present the total numbers of referrals, non-specialist referrals, and RRNS at Depok Jaya health center between February-April 2018. In the table above, we discovered that the number of referrals at Depok Jaya Health Center varies each month and the highest was in March with 775 referrals. However, the total non-specialist referrals in those three months was constantly 0, which meant that the RRNS was also 0%. Therefore, this health center had an optimal RRNS. This was also aided by the P-Care application.
Each month, the Depok City Health Office, BPJS, and IDI conducts a meeting that discussed the service commitment based capitation (KBKP). The results of this meeting would be conveyed in the 3monthly meetings with the head of the centers. The health office also reminds the centers on the regulations of the KBKP and the penalties from the BPJS, which is a cut in the capitation and also reminds the doctors to provide information to the patients so that they understand what are their goals.

Skills
According to the Indonesian Doctor Competence Standards, there are 4 levels of disease management for doctors, 1, 2, 3A, 3B, 4A and 4B. Doctors at the Health Centers must be able to treat all the diseases at the 4A level. 3 from the in-depth interviews we discovered that the doctors at both centers are able to diagnose 128 non-specialist diseases, therefore have the 4A competence standards. However, there were problems in the supply of medication and equipment, consequently some non-specialist cases had to be referred.
For level 3, the general practitioners must be able to diagnose, provide preliminary treatments, and then refer the patient. 6 Therefore, the doctors at Beji Center have 3A and 3B competence levels. However, the doctors at the Depok Jaya Center do not provide preliminary treatment and immediately would refer the patient, therefore they have level 2 competence in handling specialist cases.

Workload
The first shift at both centers begins at 07.30 AM and ends at 14.00 PM. The registration for patients begins at 07.30 AM and ends at 11.00 AM, therefore the patients would be handled between 08.00 AM -12.00 PM or later, depending on the number of patients. Any spare time would be used for breaks or perform other tasks, such as data input and other programs that they are responsible for. The informants at Beji Health Center have difficulty in finding enough time to complete all their tasks before going home, because of the large number of patients there was not much time was left after services. It also lengthened the patient's waiting time and the doctor rushes when providing care. Overworked staff would also be stressed and this would affect the quality of care. 7,8 However, the doctors at the other center did not complain this. Although they had the same work hours as Beji Health Center, they had no problem in handling the other tasks.
Beji Health Center has 4 honorary doctors that work on the second and third shift. The second shift begins at 14.00 PM and ends at 20.30 PM, although sometimes they might have to work overtime because of a patient that needs observation. While the night shift is between 20.30 PM and 07.30 AM. These doctors do not have any other task more than providing healthcare to the patient.
Based on the 2017 work load analysis, that the head of the Health Center performed and reported to the Health Office, Beji Health Center should have 8 doctors and Depok Jaya Health Center should have 5 doctors. However, there were only 4 doctors at Beji and 3 doctors at Depok Jaya center. Since Beji Health Center is a BLUD, it is authorized to hire its own doctors, and they did add 4 more doctors in 2018. However, since Depok Jaya Health Center is not a BLUD, it cannot do that and they are currently short of 2 doctors.

Knowledge
The informants at both centers are well educated on the indications for referrals, the referral system, its procedure, its benefits, and the functions of a gatekeeper, the role of doctors in gatekeeping, the consequences of a high referral rate, RRNS, and KBKP payment system.

Motivation
At both centers, patients are motivated to request for referrals. This is because the patient is used to going to a specialist, they feel that they weren't cured quickly, they don't trust the drugs at the health center, they feel that they cannot be treated at the health center, lack of comprehension, or feel that they are severely sick. According to Andersen, the usage of a health facility depends on their health beliefs, where trusted facilities is believed to aid in healing, and the individual evaluation factors which is evaluation of their own health, fear of disease, and the pain suffered.

Training
The PNS doctors at both centers have participated in several annual trainings. These trainings are provided 2-3 times a year by the Depok City Health Office, not by the BPJS. However, the not all the honorary doctors at the center has received similar trainings, 1 honorary doctor has not received any training, and another only participated in one training. PNS doctors are prioritized because honorary doctors are contractual and might not stay for a long time.

Equipment
Medical equipment plays a big role in providing optimal, effective, and efficient healthcare services. 9 However, the tools at the health centers are incomplete. Instruments such as minor surgery kits, blood sugar examination kits, and otoscopes are not available. And some of the equipment that are there, such as stethoscopes and electrocardiograms, may require calibration. This was either caused by the lack of funding or the health office does not consider it necessary. In Beji Health Center, to maintain the quality of care, the patient is then referred to a higher facility.
Another informant stated that the tools at Depok Jaya Center was incomplete, they do not have xrays or Ears, Nose and Throat examination tools. However, the head of the health center stated that they do have adequate tools. Patients that could not be treated with the existing equipment will then by referred to a higher facility.
According to the health office, the technical implementation unit (UPT) can present a proposal to the health office to provide the missing equipment. Although they must comply with the bureaucratic process.

Medications
Sometimes there were drug shortages at both centers (Stock-out). This was because there were delays in the shipment of medicine after the Ecatalogue order was completed. Some of the efforts performed to solve this was by providing referrals, distributing the available medicine, replacing it with other medicine, or providing prescriptions to the patient to buy the medication at an apothecary or by borrowing from another center. In addition, according to the health office, the pharmacy UPT can acquire any medication that is considered necessary SUMMARY According to the results, we can summarize that the RRNS at both health centers were optimal, which is evident from the 0% presented in the 2018 table. This was because the doctors were capable and there is a monitoring and evaluation process from the BPJS and the health office, which would be conveyed to the doctors at the monthly workshop. However, the doctors have a high work load, which prolonged the patient waiting time and reduced the time the doctors was able to provide care. The PNS doctors are well trained, but the honorary doctors are not. And the BPJS did not provide any kind of training. Other problems includes lack of equipment that increased the number of patients that must be referred, and delays in the shipment of medicine, which may cause stock outs.