Cost Disparities Between Hospital Expenditures and Reimbursement Schemes in Indonesia: A Study on Chemotherapy for
Muh Deni Kurniawan1, Erfan Abdissalam1, M Wahyu Ariawan1
1Faculty of Pharmacy, Universitas Mulawarman, Samarinda, Indonesia.
Objective:
Significant gaps exist between hospital-incurred medical costs and national health insurance reimbursement rates, challenging the sustainability and equity of breast cancer care in Indonesia. Fixed tariffs often fail to capture the complexities and financial burdens associated with chemotherapy. This study compares hospital-incurred medical costs with both INA-CBG and non-INA-CBG reimbursement rates for breast cancer chemotherapy, identifies the key cost components, and evaluates the appropriateness of current tariffs under the National Health Insurance (JKN) scheme.
Methods:
A retrospective cross-sectional study was conducted at a tertiary hospital in Surabaya, Indonesia, using data from breast cancer patients who underwent chemotherapy in 2021. Clinical and cost data were obtained from hospital billing records, electronic medical records, and BPJS Kesehatan claims. The Wilcoxon signed-rank test was used to compare hospital-incurred medical costs with reimbursement rates. Subgroup analyses by INA-CBG code and chemotherapy regimen were performed to assess variability in coverage.
Results:
A total of 80 patients were included, predominantly female (97.5%) and diagnosed with stage IV disease (64.1%). Most were categorized under INA-CBG code C-3-13-0 (93.75%). Overall, the median hospital-incurred medical costs significantly exceeded reimbursement rates: IDR 3,657,290 vs. IDR 1,161,000 for C-3-13-0 (p < 0.001) and IDR 3,964,189 vs. IDR 2,151,900 for C-4-13-I (p = 0.031). Key cost drivers were chemotherapy administration (57.93%), nursing care (14.04%), and handling of cytotoxic drugs (7.88%). Specific regimens, such as vinorelbine, showed significantly higher costs that were not adequately reimbursed.
Conclusion:
JKN tariffs for breast cancer chemotherapy substantially underestimate actual treatment costs. To improve financial sustainability and access, periodic tariff adjustments, adoption of activity-based costing, and consideration of hybrid payment models should be implemented to ensure equitable financing of oncology care in Indonesia.
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