Clinical Pathway & Cost of Treatment

(Conceptual Thinking & Application)

Ronnie Rivany
Health & Hospital Economics
Pusat Kajian Ekonomi & Kebijakan Kesehatan FKMUI

JASTIFIKASI
Standarisasi tarif RS ?
Belum ada Clinical Pathway sebagai penjaga
mutu & sebagai basis layanan MUTU dan
basis perencanaan/perhitungan biaya
Sistem, Kebijakan dan Prosedur yang tidak
jelas dan tidak konsisten serta belum
terintegrasi
Buku Tarif Departemen Kesehatan 2007 (?)

Major Diagnostic Categories (AR-DRG v 5,2, 2006)

1

Diseases and disorders of the nervous system

Disease and disorders of the eye

Disease and disorders of the ear, nose, and throat

Disease and disorders of the respiratory system

Disease and disorders of the circulatory system

Disease and disorders of the digestive system

Disease and disorders of the hepatobiliiary system and pancreas

Disease and disorders of the musculoskeletal system and connective tissue

Disease and disorders of the skin, subcutaneous tissue, and breast

10

Endocrine, nutritional, and metabolic diseases and disorders

11

Disease and disorders of the kidney and the urinary tract

12

Disease and disorders of the male reproductive

13

Disease and disorders of the female reproductive system

14

Pregnancy, childbirth, and the purperium

15

Newborn and other neonates with conditions originating in the perinatal period

16

Disease and disorders of blood and blood forming organs and immunological disorders

17

Myeloproliferative disease and disorder, and poorly differentiated neoplasm

18

Infectious and parasitic disease (systemic or unspecified sites)

19

Mental diseases and disorders

20

Alcohol/drug use and alcohol/drug- induced organic mental disorders

21

Injuries, poisoning, and toxic effects of drugs

22

Burns

23

Factors influencing health status and other contact with health services

DRG Numbering
The format = A DD S
A = Pre MDC DRGs ; B = nervous system
DRG; O = Reproductive System; Z = DRGs
relating to other health factors; 9 = the error
DRGs
DD = DRGs partition;
Range 01 39 Surgical Partition
Range 40 59 Other Partition
Range 60 99 Medical Partition

S = split indicator
A = highest resources DRG
B = second highest resources

General Logic,
Diagnosis Related Groups

All acute admited patien

Principal diagnosis

Major diagnostic category # 1

MDC # 2

Yes
Surgical Partition of MDC # 1

MDC # 3

MDc # 4

No
Medical Partition of MDC # 1

What procedure

Procedure
Custer A

Procedure
Cluster B

Procedure
Cluster C

Procedure
Cluster D

What age groups

Over
Procedure cluster A over age X

Under X
Procedure cluster A under age X

Significant secondary condition ?

Yes
Procedure cluster A
Over Age X, with CC

No
Procedure cluster A
Over Age X, without CC

INDONESIAN DRGs

INDONESIAN DRGs
Pola pikir
ICD tetap
MDC untuk sementara tetap
Clinical Pathway bisa dibuat
DRG di konfirmasi + bisa dibuat
Casemix di konfirmasi + bisa dibuat
Costing dilakukan dengan pendekatan
Activity Based Costing + Simple
Distribution

POLA PIKIR INDONESIAN DRGs (1)

INA - DRG
1.Konfirmasi DRG

2.Hitung Cost/DRG

Clinical Pathway & Casemix

Activity Based Costing

POLA PIKIR INDONESIAN DRGs (2)

ICD
MDC

1
DRG

DRG
COST

DRG
CASEMIX

TARIF

COST
TARIF

Clinical Pathway

Anticipated Recovery Pathway (ARPs)

Multidisciplinary Pathways of Care (MPCs)
Care Protocols
Integrated Care Pathways
Pathways of Care
Care Packages
Collaborative Care Pathways
Care Maps
Care Profiles

Konsep perencanaan pelayanan

terpadu yang merangkum setiap
langkah yg diberikan kepada pasien
berdasarkan standar yanmed,
standar asuhan keperawatan&
standar pelayanan tenaga kesehatan
lainnya , yg berbasis bukti dng hasil
yg dpt diukur dan dalam jangka
waktu tertentu selama di rumah sakit

Major Diagnostic Categories (Pedoman Tarif ?? DEPKES,2007)

1

Diseases and disorders of the nervous system

Disease and disorders of the eye

Disease and disorders of the ear, nose, and throat

Disease and disorders of the respiratory system

Disease and disorders of the circulatory system

Disease and disorders of the digestive system

Disease and disorders of the hepatobiliiary system and pancreas

Disease and disorders of the musculoskeletal system and connective tissue

Disease and disorders of the skin, subcutaneous tissue, and breast

10

Endocrine, nutritional, and metabolic diseases and disorders

11

Disease and disorders of the kidney and the urinary tract

12

Disease and disorders of the male reproductive

13

Disease and disorders of the female reproductive system

14

Pregnancy, childbirth, and the purperium

15

Newborn and other neonates with conditions originating in the perinatal period

16

Disease and disorders of blood and blood forming organs and immunological disorders

17

Myeloproliferative disease and disorder, and poorly differentiated neoplasm

18

Infectious and parasitic disease (systemic or unspecified sites)

19

Mental diseases and disorders

20

Alcohol/drug use and alcohol/drug- induced organic mental disorders

21

Injuries, poisoning, and toxic effects of drugs

22

Factors influencing health status and other contact with health services

23

Medical Outpatient Visit

HUBUNGAN C.P & DRG/CASEMIX

ICD

MDC
Clinical Pathway

DRG

DRG
COST
TARIF

DRG
CASEMIX
COST
TARIF

Clinical Pathway in Hospital

Pengembangan Konsep
Clinical Pathway
International Classification of Disease (ICD)

Major Diagnostic Categories (MDC)

Clinical
Pathway

Surgical / Other / Medical

Diagnosis Related Groups (DRGs)
Casemix

Format dasar Clinical Pathway

Aktivitas pelayanan

Pra R.I
(Poliklinik/
UGD)

Hari I
Tgl

Hari 2
Tgl

Komplikasi
/
Comorbidity

Pendaftaran
Penetapan Diagnose
Pra-Perawatan

Perawatan
Tindak Lanjut

Rawat Inap (R.I)

CLINICAL PATHWAY DALAM

TAHAPAN PRA PERAWATAN & PERAWATAN

Aktivitas pelayanan

1
Pra-Perawatan
Assessment klinis
pemeriksaan/visite dokter
konsultasi
Pemeriksaan penunjang
laboratorium
Radiologi
Dst sesuai SPM, SAK & SPO
Perawatan
Tindakan medis
Pemberian obat

Dst-nya, sesuai SPM,SAK & SPO

Pra R.I
(Poliklinik/
UGD)

Rawat Inap (R.I)

Hari I
Tgl

Hari 2
Tgl

Komplikasi
/
Comorbidity

DUMMY TABLE (1)

Clinical Pathway
Utilisasi
No SOP

Hari.1
Diag.Utama + Serta

Admission

Diagnostic

Pra Therapy

Therapy

Follow Up

Discharge

+ Sulit

+
Serta
+ Sulit

DUMMY TABLE (2)

Clinical Pathway
Utilisasi
No

Aktivitas

Admission

Diagnostic

Pra Therapy

Therapy

Follow Up

Discharge

SDM

OBAT

OVERHEAD

DUMMY TABLE (3)

Clinical Pathway
Utilisasi
No

Aktivitas

Admission

Diagnostic

Pra Therapy

Therapy

Follow Up

Discharge

Min
Utilisasi

Max
Utilisasi

Mean /
Median
Utilisasi

CLINICAL PATHWAY

SYMPTOM

1
Admission

Activities

ABC

DIAGNOSIS

THERAPY

Diagnosis

Activities
ABC

4
Pre Therapy

Activities
ABC

FOLLOW UP

5
Therapy

Activities
ABC

Follow up

Activities
ABC

PEMBUATAN CLINICAL PATHWAY (1)

Diawali dengan membuat template untuk

mendapatkan clinical pathway. Langkahlangkah dalam membuat clinical pathway
adalah sebagai berikut :
Membuat koding untuk memudahkan entry
data.
Entry data karakteristik, identitas, tanggal
masuk dan keluar rumah sakit, lama hari
rawat, jenis pembayaran, diagnosa utama,
penyakit penyerta, penyakit penyulit, cara
masuk, status keluar dan kelas rawatan dari
masing-masing pasien. Entry data dilakukan
berdasarkan kelompok AR-DRG.

PEMBUATAN CLINICAL PATHWAY (2)

Entry semua aktivitas yang diterima pasien dari masuk

sampai pulang dan pada waktu rawat jalan. Semua
aktivitas dekelompokkan berdasarkan tahap clinical
pathway.
Konfirmasi tahap clinical pathway dan variabel
kegiatan dengan SPM IDI, SPM Profesi dan para
dokter dan paramedis di Rumah Sakit .
Draft clinical pathway diisi berdasarkan frekuensi
masing-masing kasus.
Berdasarkan nilai mean atau median didapatkan nilai
rata-rata masing-masing variabel dalam clinical
pathway perhari rawatan berdasarkan kelompok ARDRG.

Cleaning dan pengecekan ulang terhadap nilai

utilisasi berdasarkan tahap dalam clinical pathway
masing-masing kelompok AR-DRG sehingga
didapatkan nilai utilisasi kelompok AR-DRG
berdasarkan clinical pathway.

PEMBUATAN CLINICAL PATHWAY (3)

Draft & Finalisasi Clinical Pathway

Setelah draft Clinical Pathway yang

berbasis evidence tadi telah dibuat, maka
tahapan akhir dari penyusunan Clinical
Pathway ini adalah Focus Group
Discussion dengan Panel Expert ( para
spesialis ) dan Ikatan Profesi , untuk
bersama-sama menyepakati jenis dan

jumlah tindakan/FORMULARIUM
yang akan dipergunakan dalam Clinical
Pathway

DUMMY TABLE (1)

Clinical Pathway
Cost of Treatment
Activities

Day.1

Day.2

Day.3

Day
..

Admission

Diagnosis

Pre Therapy

Therapy
Follow Up
Discharge

DUMMY TABLE (2)

Clinical Pathway
Cost of Treatment
No Activities

Day.1
Principal
Diagnosis

Nursing

Consultation

Doctor visits

Medical Procedures

Nursing

Medical /DRUGS
Treatment

Supporting exams

Nutrition

Physiotherapy

10

Etc

Penyulit

Penyerta

PP

DUMMY TABLE (3)

Clinical Pathway
Cost of Treatment

No Activities
1

Admission

Diagnosis

Pre Therapy

Therapy

Follow Up

Discharge

TOTAL

DC

IC

TC UC

U x UC

C/DRG

Cost of Treatment
(Cost DRG/Casemix)
No Cost of Treatment /
Activity Based
Costing
1 Admission

Direct Cost

IndirectCost

Investasi Operasional Pemeliharaan

INDEX

Diagnostic

Pra Therapy

Therapy

Follow up

6.

Discharge

APLIKASI COST/DRG/Casemix dalam PK BLU(1)

Cost of Treatment Rawat Inap dan Rawat Jalan
No AR-DRG KLS. III KLS. II
KLS.I
1 B70A
2 B70B
3 B70C

5181485
4075179
1905273

5281384
4153671
1976629

5339924
4199667
2018443

4 B70D

1848767

1863038

1871401

UTAMA

VIP

5778045 5805053 803121

4543904 4565126 995167
2331386 2350678 987047
1933989 1937848

Perbandingan Biaya Rawat Inap KLS.III

No AR-DRG KLS. III Tanpa Gaji Tanpa Obat
1
2
3
4

B70A
B70B
B70C
B70D

5181485
4075179
1905273
1848767

4250350
3476706
1489521
1624600

RAJAL

2972007
2250808
1438879
1030735

Tanpa Gaji
Dan Obat
2040872
1652334
1023127
806568

CLINICAL PATHWAY

COST of TREATMENT

TARIFF DETERMINANT per DRGS

TARIFF

Margin
COST/DRGs
UNIT COST
ROOM & BOARD

Total cost

UNIT COST
DRUGS

UNIT COST
LAB

UNIT COST
MED SUPPLIES

UNIT COST
OK

ACTIVITY BASED COSTING + SIMPLE DISTRIBUTION

LAPORAN
Clinical Pathway & Cost of Treatment
Diagnosis Related Group (DRGs)
Sectio Caesaria, Diare Anak & Katarak (2008)
Apendictomy & Pneumonia Anak (2009 - 2010)

DINAS KESEHATAN
Pemerintah Propinsi Daerah Khusus Ibukota Jakarta

REKAM MEDIK DI RUMAH SAKIT

LAPORAN
Clinical Pathway & Cost of Treatment
Diagnosis Related Group (DRGs)
10 Dept International Wing
2009 - 2010

RUMAH SAKIT
Dr Cipto Mangunkusumo, Jakarta

LAPORAN
Clinical Pathway & Cost of Treatment
Diagnosis Related Group (DRGs)
Rumatan Methadon, 2010
RUMAH SAKIT KETERGANTUNGAN OBAT
Cibubur - Jakarta

DIREKTORAT JENDERAL BINA PELAYANAN MEDIK

DEPARTEMEN KESEHATAN
2005

 RS wajib memp.CP, Diagnosis mengacu

pada ICD-10,Prosedur mengacu pd ICD9CM
Flowchart penyusunan CP
ICD
SPM Profesi

Model Dummy
Surgical

SPM RS

SOP Aktivitas

Clinical Pathway
Terukur(admissi
on to discharge)
contoh :
-Diare anak
-Sectio Caesaria

Medical

DRG

Case Mix

TUJUAN :
utk meningkatkan mutu Yan pasien
memaksimalkan penggunaan sumber daya
scr efisien dng mengurangi dokumentasi yg
tdk diperlukan.
membantu identifikasi & klarifikasi proses
Yan klinis
mendukung efektivitas klinik, audit medis &
risk management

 Dalam menyusun clinical pathway (C.P) di RS peru

memadukan & menyesuaikan dng bbagai sistem yg
tlh dibangun serta tlh bjalan sehingga stiap bagian
yg ada di RS lebih mudah menyesuaikan & saling
mendukung pd saat C.P. selesai dibuat &
disosialisasikan.
Komite Medik sngt bperan dlm mbantu penyusunan
& plaksanaan C.P. di RS.

Pedoman C.P. di RS diharapkan dpt mbantu RS dlm

menyusun C.P. dlm rangka mendukung plaksanaan
pengembangan DRGs Casemix di RS.

TERIMA KASIH
atas perhatian & kesempatan
kerjasamanya

www.ina-drg-rr.net