Muhammad Alfarizi, dkk (2024) – Referral Healthcare Services…| 160

Jurnal Jaminan Kesehatan Nasional,

Volume 4 Number 2, (December, 2024). Page 160 - 175
DOI : 10.53756/jjkn.v4i2.278
ISSN : 2798-6705 (online)
ISSN : 2798-7183 (print)

Referral Healthcare Services and Efficiency of Indonesian

Health Insurance on Patient Satisfaction and Life Quality
Muhammad Alfarizi1*, Lissa Rosdiana Noer2, Rafialdo Arifian3
1-2
Department of Business Management, Faculty of Creative Design and Digital Business, Institut Teknologi
Sepuluh Nopember, Surabaya, Indonesia
3
Department of Medical Doctor, Faculty Of Medicine, Public Health and Nursing, Universitas Gadjah Mada,
Yogyakarta, Indonesia
e-mail: [email protected]

Abstract: The UN's Sustainable Development Goals (SDGs) target Universal Health Coverage (UHC) to
ensure equitable access to health without financial burden. The National Health Insurance Program-Healthy
Indonesia Card (JKN-KIS) by BPJS Kesehatan seeks to meet the health needs of the Indonesian people,
especially vulnerable groups, including in East Java, which faces many cases of catastrophic diseases. This
study aims to analyse the impact of the quality of referral health services and the efficiency of insurance
administration on the satisfaction and quality of life of catastrophic patients in East Java. This study uses a
positivist quantitative approach with a questionnaire-based Cross-Sectional design to collect data from
outpatient catastrophic patients in East Java. Two hundred sixty-three responses were analysed using the
PLS-SEM technique through SmartPLS 4.0 software to test hypotheses regarding the quality of referral
services, insurance administration, patient satisfaction, and quality of life. The results showed that the ease
of JKN-KIS administration significantly affected participant satisfaction, corroborating previous findings
regarding the importance of easy access and simple administrative procedures in increasing the positive
perception of services. In addition, the quality of referral health facility services also increases satisfaction,
especially in meeting the care needs of catastrophic patients. Satisfaction with JKN-KIS also significantly
impacts patients' quality of life, improving their physical health, emotional stability, and social satisfaction.
These findings encourage optimising JKN-KIS services through digitisation and improving the quality of
special services for catastrophic patients to maintain participant satisfaction and trust .
Keywords: Administration, Health Services, National Health Insurance, Patient Satisfaction, Quality of Life

INTRODUCTION
The Sustainable Development Goals (SDGs), launched by the United Nations, aim to achieve
sustainable development by 2030, including ensuring healthy lives and well-being for all (SDG 3).
Universal Health Coverage (UHC), a key target of SDG 3, seeks to provide access to quality
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healthcare without financial burden (Hossain et al., 2024). UHC requires health system reforms,
infrastructure improvements, and equitable services, particularly for vulnerable groups (Wallengren
et al., 2024). In Indonesia, the 1945 Constitution mandates access to health services for all citizens
(Ardiansah & Silm, 2020). To meet this, the government launched the National Health Insurance-
Healthy Indonesia Card (JKN-KIS) in 2014 (Salim, 2020). The program has two categories: PBI
(government-subsidized) for the underprivileged and Non-PBI (self-funded) for other groups (Prasja
et al., 2023). Improving equity includes developing the Standard Inpatient Class (KRIS) system and
ensuring equal treatment for all participants (Mz et al., 2023).
The existence of JKN-KIS is crucial in handling catastrophic diseases in Indonesia.
Catastrophic diseases, which include severe medical conditions such as cancer, heart disease, and
chronic kidney disease, often result in very high medical costs. (Situmeang & Hidayat, 2018)JKN-
KIS is designed to provide financial protection for participants so that they are not trapped in the
heavy cost burden of the disease. Through a tiered referral system, JKN-KIS participants can access
health services from health centres to high-end hospitals according to their medical needs. The
program guarantees that all health services related to catastrophic diseases will be covered, except
for certain conditions not covered by the regulations. (Solida et al., 2023)Financing for catastrophic
diseases absorbs most of BPJS Kesehatan's budget, which shows the magnitude of the disease's
economic impact. (Hildayanti et al., 2021).
East Java Province is one of the regions that face serious challenges related to catastrophic
diseases, which are health conditions that require high medical costs and have a significant impact
on people's quality of life. Diseases such as cancer, stroke, and heart failure are the leading causes
of death in Indonesia, including in East Java. Cardiovascular disease is one of the dominant
catastrophic diseases in Indonesia, including in East Java, with a total of 144,279 cases in 2018-
2019 (Sandi et al., 2019). Heart disease accounted for the first and second catastrophic costs,
accounting for 18.5% of health financing for catastrophic in 2023-2024. Cancer and Kidney Failure
are also the leading causes of catastrophic costs in East Java (Kustiyanti, 2023). BPJS data shows
that the provinces of East Java, West Java, DKI Jakarta, and North Sumatra have the highest
financing for cancer services (Meidayanti & Nurwahyuni, 2023). The high prevalence of
catastrophic cases in East Java Province requires excellent health services due to the complexity of
diagnosis and treatment. High-quality care ensures that patients receive appropriate and effective
treatment, which is crucial to increasing the chances of recovery (Williams & Radnor, 2022). In
addition, straightforward financing administration is also crucial to reduce the financial burden of
patients (Jackson et al., 2016). The efficient and transparent claims process in health insurance helps
patients access medical services without barriers. With optimal services and a transparent financing
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system, patients can focus on recovery without worrying about high costs or delays in receiving the
necessary care.
In neoclassical consumer theory, the individual's primary goal is to maximise utility, often
understood as the level of satisfaction obtained from consumption. (Costa et al., 2021). Some
researchers associate quality of life (QoL) with utility theory, where QoL is considered something
individuals want to achieve (Buselli et al., 2020). However, efforts to achieve QoL often face various
obstacles, such as health problems. This is especially true when individuals have to face unexpected
financial stress due to a catastrophic chronic illness. The disease carries physical, emotional, and
financial impacts that patients and their families often feel even after treatment ends. (del Pozo-
Rubio et al., 2019).
Several studies have explored the relationship between health insurance and user satisfaction
in different countries. For example, Geng et al. (2021) found that comprehensive health insurance
improves patient satisfaction with chronic diseases in China. (Geng et al., 2021). Kaplan et al. (2017)
identified that insufficient insurance coverage can reduce patient satisfaction in the United States.
(Kaplan et al., 2017). Meanwhile, Pahlevan Sharif (2017) showed that factors such as locus of
control also affect patients' perception of the quality of health services in Iran. (Pahlevan Sharif et
al., 2021). Other European research emphasises the importance of quality of service in improving
patient satisfaction, especially for those with catastrophic diseases. (Jürges & Stella, 2019). The
study shows that the effectiveness of health care and insurance administration plays a vital role in
the patient experience.
Although many studies have examined the relationship between health insurance and user
satisfaction, there is a gap in understanding, especially regarding JKN-KIS in the Indonesian context.
Studies on the impact of referral health services and the efficiency of insurance administration on
catastrophic patient satisfaction are still limited. Previous research has shown that patient
satisfaction can decrease if the insurance policy does not cover the expected services. (Kaplan et al.,
2017). However, no research has directly examined how the quality of referral services and the
efficiency of insurance administration affect the satisfaction and quality of life of cancer patients in
East Java. This study aims to analyse the impact of the quality of referral health services and the
efficiency of insurance administration on the satisfaction of catastrophic patients and their quality
of life under the JKN-KIS program in East Java.

METHOD
This study chooses a positivist quantitative approach with a cross-sectional questionnaire-based
research design. This approach was chosen to obtain relevant and representative data regarding the
experience and satisfaction of catastrophic patients under the JKN-KIS program. By using
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questionnaires, the study was able to collect systematic and structured information from respondents
over some time, allowing for a more efficient analysis of the variables associated with the study
selected an analysis unit of patients who were undergoing routine outpatient treatment at an
advanced referral health facility (Hospital) in East Java Province. This selection aims to obtain
relevant data regarding patient experience and satisfaction with insured health services and the
administrative process of JKN-KIS insurance. This study develops a research model based on the
hypothesis proposal shown in Figure 1.

Figure 1. Proposed Research Model

Hypothesis 1: Ease of National Health Insurance Administration has a significant positive effect on
National Health Insurance Satisfaction
Hypothesis 2: Quality of Referral Health Facility Service has a significant positive effect on National
Health Insurance Satisfaction
Hypothesis 3: National Health Insurance Satisfaction has a significant positive effect on Patient's
Quality of Life (QoL)

The questionnaire instrument was developed by referring to relevant previous research for each
variable. The Ease of National Health Insurance Administration variable was measured using ten
items adapted from the study. (Daramola et al., 2017; Merlis, 2014), which includes ease of access,
administrative procedures, and transparency. The instrument, based on the study, consists of 10
items for the Quality of Referral Health Facility Service variable. (Abu-Salim et al., 2017; Sarker et
al., 2018), covering aspects of facilities, medical personnel competence, and service quality.
Meanwhile, the National Health Insurance Satisfaction variable, which includes as many as five
items, and the Patient's Quality of Life (QoL) variable, which includes as many as six items, refer
to the research. (Hofstetter et al., 2023; Pahlevan Sharif et al., 2021), includes general satisfaction
and the patient's quality of life. All constructs were operationalised into structured statements,
measured using a 5-point Likert scale ranging from "Strongly Disagree" to "Strongly Agree." This
approach ensures a consistent and reliable measurement of respondents' perceptions across all
dimensions, allowing for precise data analysis and comparison.
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This study uses a purposive sampling technique to target the population of patients enrolled in
the JKN-KIS program across Indonesia. Respondents must meet the criteria of being a catastrophic
outpatient with a diagnosis of Cancer, Heart, Chronic Kidney, Mild Stroke, Chronic Obstructive
Pulmonary Disease, Diabetes Mellitus and Autoimmune (Lupus, Rheumatoid, etc.), not in an
emergency condition or hospitalisation to not interfere with the treatment process, domiciled in the
East Java Region and the treatment process using JKN-KIS insurance within a minimum treatment
period of 6 months. The minimum sample was determined using the G*Power approach with the
criteria of effect size of 0.15 (moderate), alpha error rate of 0.05, power of 0.8, and two dependent
variables. Based on the analysis results from G*Power, this study requires at least 68 respondents to
produce representative data.

Figure 2. G*Power Minimum Sample Analysis Graph

The data collection process is hybrid, with data collected through Google Forms and
disseminated through social media to reach a broader range of respondents. The researcher also
visited affordable respondents directly to ensure participation and minimise barriers to accessing
technology due to health conditions by answering researchers' questions. This technique helps
collect data efficiently, with respondents filling out questionnaires independently at flexible times.
Research ethics are carried out by ensuring informed consent, where respondents are given
complete information about their objectives, procedures, and rights to participate in or withdraw
from research at any time without consequences. The confidentiality of personal data is guaranteed
by storing information anonymously and only using it for academic purposes. The study ensured
that respondents' participation would not interfere with their treatment and considered convenience
and safety in the data collection. From the outset, the researcher provided an overview of the study,
along with the researcher’s profile and affiliated institution, to ensure that respondents were well-
informed about the legitimacy of the research. Initially, 263 respondents participated in this study,
with a screening process based on the completeness of information and answers, resulting in 250
respondents who were worthy of analysis. Table 1 illustrates the characteristics of respondents based
on demographics and further patient health.
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Table 1. Characteristics of Respondents

Total Percentage
Gender
Man 66 26%
Women 184 74%
Origin of Agglomeration Areas
Gerbangkertosusila Area (Gresik, Bangkalan, Mojokerto, 64 26%
Sidoarjo, Surabaya City, Mojokerto City)
Malang Raya Area (Malang, Malang City, Batu City) 51 20%
Mataraman Area (Madiun, Magetan, Ngawi, Ponorogo, Pacitan, 50 20%
Trenggalek, Tulungagung, Nganjuk, Kediri, Madiun City, Kediri
City
Tapal Kuda Area (Banyuwangi, Situbondo, Bondowoso, Jember, 23 9%
Lumajang, Probolinggo, Probolinggo City)
Madura Area (Bangkalan, Sampang, Pamekasan, Sumenep) 38 15%
Pantura Area (Tuban, Lamongan, Bojonegoro) 24 10%
Age
25-34 Years 12 5%
35-44 Years 36 14%
45-54 Years 107 43%
55-64 Years 95 38%
Last Education
Junior High School 30 12%
High School 87 35%
Diploma/Bachelor 93 37%
Master/Doctorate 40 16%
Outpatient Care Catastrophic Diagnosis
Heart Disease 13 5%
Mild Stroke Disease 15 6%
Stage 1-2 Cancer 11 4%
Diabetes Mellitus 75 30%
Kidney Failure 9 4%
Chronic Obstructive Pulmonary Disease (COPD) 60 24%
Autoimmune diseases 67 27%
Hospital Admission Pathway
Primary Health Facility Referral 202 81%
Emergency Lines 48 19%
JKN-KIS Financing Scheme
JKN-KIS Contribution Assistance Recipients (PBI) 147 59%
JKN-KIS Non-PBI-Wage Recipient Workers 75 30%
JKN-KIS Non-PBI-Non-Wage Recipient 28 11%

This study uses the Partial Least Squares Structural Equation Modeling (PLS-SEM) analysis
technique with the help of SmartPLS 4.0 software. PLS-SEM was chosen because it is suitable for
modelling complex relationships between latent variables and their indicators; SmartPLS 4.0 is used
to simplify the analysis process with interactive visualisation features and ease of interpretation of
results (Becker et al., 2023).
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RESULT
Validity and Reliability Testing
The validity and reliability testing in PLS-SEM at the Measurement Outer Model stage aims to
ensure that indicators or items in the model can measure constructs accurately and consistently.
Validity and reliability are evaluated through several vital criteria. First, the Average Variance
Extracted (AVE) value should be >0.5, which indicates that the construct successfully explains more
than 50% of the indicator's variance. (J. F. Hair et al., 2017). Second, the Cronbach Alpha value
must be >0.7 to indicate the internal consistency of the indicators in the construct (J. F. Hair et al.,
2021). Finally, Composite Reliability should also be >0.7 to measure the combined reliability of all
indicators in measuring construction (J. F. Hair et al., 2021) The validity and reliability test results
in Table 2 show that the AVE value for each variable is also above 0.5, so the associated construct
explains more than 50% of the indicator's variance. Cronbach's Alpha (CA) and Composite
Reliability (CR) on all constructs are more significant than 0.7, indicating good internal consistency
and high composite reliability.
Table 2. Validity-Reliability Test Results
Variable AVE CA CR
Ease of National Health Insurance 0.526 0.852 0.877
Administration
Quality of Referral Health Facility Services 0.595 0.891 0.906
National Health Insurance Satisfaction 0.700 0.889 0.920
Patient’s Quality of Life 0.763 0.936 0.950

Results of Hypothesis and Coefficient of Determination Testing

In PLS-SEM, hypothesis testing and determination coefficient (R-squared) are crucial in
assessing the relationship between latent variables. Hypothesis testing is carried out through a
bootstrapping procedure, which is used to estimate the significance of paths between variables in
the model. Bootstrapping involves randomly sampling the original data and calculating path
coefficients repeatedly, resulting in t-statistics and p-values to determine the significance of the
influence between constructs (Streukens & Leroi-Werelds, 2016). The hypothesis is considered
significant if the t-statistics > 1.96 at a significance level of 5%. On the other hand, the determination
coefficient test (R-squared or R2) measures the amount of variation described by the independent
variable to the dependent variable (J. et al. et al., 2019). The R-Square value ranges from 0 to 1,
where the higher the value, the greater the variation of the dependent variable that the model can
explain. PLS-SEM suggests R-Square values of 0.75 (strong), 0.50 (moderate), and 0.25 (weak) as
a reference, thus aiding in the evaluation of overall model fit (J. Hair et al., 2017). Figure 3 and
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Table 3 illustrate the bootstrapping output and the results of the hypothesis-determination coefficient
test.

Figure 2. Output Bootstrapping

The results of hypothesis testing in Table 3 showed that the entire hypothesis in the model
was accepted, with a p-value below 0.05, which means significant. A path coefficient 0.405 between
the Ease of National Health Insurance Administration and National Health Insurance Satisfaction
indicates a significant favourable influence. In addition, the Quality of Referral Health Facility
Service significantly positively influences National Health Insurance Satisfaction, with a path
coefficient of 0.173. The third hypothesis shows the most potent effect, 0.730, of National Health
Insurance Satisfaction on Patient's Quality of Life, supported by the highest t-test (22.435). These
results confirm the positive and significant relationship between the variables in the model.
The results of the determination coefficient test in Table 3 show that the model has strong
predictive power. The variables Ease of National Health Insurance Administration and Quality of
Referral Health Facility Service explain 68% (R-squared = 0.680) of the variability of National
Health Insurance Satisfaction, indicating the significant influence of these two factors on participant
satisfaction. In addition, National Health Insurance Satisfaction explained 73.2% (R-squared =
0.732) of the variability of Patient's Quality of Life, indicating that JKN-KIS service satisfaction
substantially impacts the patient's quality of life. This high R-squared value indicates that the model
explains the relationships between variables well.
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Table 3. Results of Hypothesis and Coefficient of Determination Testing

Hypothesis Path t-test p-value Decision R-
Coefficient Square
Ease of National Health Insurance 0.405 4.575 0.000 Accepted 0.680
Administration → National Health
Insurance Satisfaction
Quality of Referral Health Facility 0.173 2.328 0.000 Accepted
Service → National Health
Insurance Satisfaction
National Health Insurance 0.730 22.435 0.000 Accepted 0.732
Satisfaction →Patient’s Quality of
Life

DISCUSSION
The Effect of Ease of National Health Insurance Administration on National Health Insurance
Participant Satisfaction
The results of the first hypothesis test show that the ease of national health insurance
administration significantly affects national health insurance satisfaction. These results align with
previous research, which found that the ease of administration of national health insurance services
is closely related to user satisfaction. (Getaneh et al., 2023; Ridiarsih et al., 2024). These findings
indicate that the ease of administrative processes, such as registration, claims, and access to health
services, is one of the main factors affecting JKN-KIS user satisfaction. When administrative
procedures are easy for participants to understand and execute, a more positive experience is created,
increasing satisfaction. Participants felt that JKN-KIS services met their expectations of providing
affordable health protection without sacrificing service quality, especially for community groups
that previously had difficulty accessing health care. One of the main reasons ease of administration
affects satisfaction is the user's perception of the administrative burden. The complicated
administrative burden can create additional stress for participants, especially in emergencies where
they need medical help as quickly as possible. When administration becomes simpler, participants
can focus on their health needs without facing unnecessary additional obstacles. This directly
contributes to improving the quality of participants' experience when using health services covered
by JKN-KIS.
In a broader analysis, the acceptance of this hypothesis can be perceived as JKN Mobile's
interest in the national health insurance administration process. Applying more advanced
technologies, such as digitisation of administrative processes, mobile application development, or
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automation of claims processes, can be considered strategic steps to optimise existing systems. This
digitisation makes it easier for participants to access information and services and manage and
monitor them by health service providers and JKN-KIS managers. The positive impact of this easier
administration is not only felt in individual satisfaction but also has the potential to increase public
participation and trust in the JKN-KIS program. Thus, the effectiveness of the national health
insurance program in providing fair and equitable health services can continue to be maintained and
developed.
For catastrophic patients, the ease of administration of JKN-KIS is crucial, especially
considering the urgent and ongoing medical needs. For patients with chronic diseases or conditions
that require intensive care, such as cancer or heart disease, easy administration helps them focus on
treatment without having to get caught up in complicated procedures. Efficient administrative
processes, from referrals to claims, significantly affect the satisfaction and quality of life of
catastrophic patients who rely on JKN-KIS to gain access to costly and long-term care. For example,
the JKN Mobile application can be a practical solution for catastrophic patients in East Java,
allowing them to quickly obtain service information, file claims, and access referral status. This
simplification and digitalisation help reduce the administrative burden, which has been the main
obstacle. Hence, it can potentially increase the positive perception of the quality of services and
health support received through JKN-KIS.

Quality of Referral Health Facility Services and Their Impact on National Health Insurance
Participant Satisfaction
The results of the second hypothesis test show that the quality of referral health facility service
significantly affects national health insurance satisfaction. These findings are consistent with
previous research that shows responsive, quality, and easily accessible referral services encourage
higher levels of satisfaction because participants feel their health needs are optimally met. (Adewole
et al., 2022; Tefera et al., 2021). These findings show that JKN-KIS user satisfaction depends on the
administrative and access aspects and the quality of services received at health facilities, especially
in referral facilities such as hospitals. Adequate service quality is essential for JKN-KIS participants
who need follow-up care, where the reliability and competence of referral facilities greatly determine
the treatment results they get. In this case, the quality of service in referral facilities can include
several essential elements, such as the suitability of diagnosis, speed of service, adequacy of
facilities, availability of drugs and medical equipment, and competence of health workers.
One of the reasons for the importance of quality of service in referral facilities is the high need
for JKN-KIS participants for advanced care and medical specialities that can only be provided in
referral facilities. In the case of more complex diseases, the quality of service at the referral facility
 Muhammad Alfarizi, dkk (2024) – Referral Healthcare Services…| 170

is decisive for treatment success. Quality referral health facilities can provide services that meet
standards, thereby increasing the effectiveness of the JKN-KIS program in meeting public health
needs. In addition, the quality of services at referral facilities is closely related to participants'
perceptions of the government's commitment and BPJS Kesehatan's commitment to providing
adequate access to health services for all levels of society. If the quality of service at the referral
facility is well maintained, participants will feel recognised and appreciated as part of the national
health insurance system. This can ultimately increase public trust in JKN-KIS and maintain
participant loyalty to the program.
The quality of referral health facility services is a crucial factor that affects the satisfaction and
quality of life of catastrophic patients. Those with severe conditions, such as cancer or heart disease,
require intensive and ongoing care at referral hospitals, so a high standard of service is urgently
needed. Fast and responsive referral services, such as the availability of medical equipment,
competent medical personnel, and easy access to follow-up treatment, can help catastrophic patients
feel safer and cared for. The existence of quality referral facilities for JKN-KIS participants has a
direct impact on the treatment experience of catastrophic patients, as they often require complex and
expensive medical procedures. Continuous improvement in this referral service can increase
patients' confidence in JKN-KIS while ensuring they receive equal and optimal protection in the
national health insurance system.

The Relationship between National Health Insurance Satisfaction and Patient Quality of Life
The results of the final hypothesis test found a significant positive effect of national health
insurance satisfaction on the patient's quality of life. Previous studies have revealed that easier access
and lower costs, supported by adequate services, increase patient satisfaction with insurance,
improving the physical, emotional, and social aspects of their quality of life (Pahlevan Sharif et al.,
2021). Theoretically, satisfaction with JKN-KIS services can indicate the quality of health services.
According to the theory of subjective well-being, a positive perception of the services provided can
improve the overall quality of life, especially for individuals who rely on health services to meet
their medical needs. If patients are satisfied with the services they receive, they may experience
reduced stress levels, an increased sense of security towards health conditions, and increased trust
in the health system. This is consistent with the theory that the perception of public services impacts
psychological well-being, further improving the quality of life. This significant positive effect can
also be explained through a domino effect: Patients satisfied with JKN-KIS services may be more
motivated to use health services earlier and more routinely. They are more likely to have regular
check-ups or follow preventive health programs offered, which have the potential to prevent more
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severe health conditions. Finally, this can lead to improved quality of life characterised by better
physical health, fewer illnesses, and increased emotional stability.
From the perspective of catastrophic patients, satisfaction with JKN-KIS services has more
profound implications. They rely heavily on fast, effective, and quality healthcare to maintain or
improve their quality of life. Efficient referral services and timely insurance administration are the
main factors that affect their satisfaction. If these aspects go well, catastrophic patients tend to feel
safer and more financially secure, which reduces anxiety related to high medical costs. The positive
impact of adequate JKN-KIS services can also be seen from their increased motivation to undergo
continuous care and conduct regular check-ups, which can help maintain the stability of health
conditions. This study emphasises that catastrophic patients' satisfaction with JKN-KIS services can
significantly improve their psychological well-being and quality of life, especially in severe and
challenging health conditions.

CONCLUSION
This study concludes that the ease of administration and the quality of services of referral health
facilities significantly affect the satisfaction of JKN-KIS participants, positively impacting their
quality of life. Ease of administration, such as simplifying claim procedures and accessing
information through digital applications, allows participants to access services without barriers,
increasing satisfaction and positive perception of health insurance services. In addition, the quality
of services at referral health facilities, especially in terms of speed, accuracy of diagnosis, and
competence of medical personnel, greatly determines patient satisfaction, especially for those with
chronic health conditions that require ongoing care. This satisfaction improves the patient's quality
of life physically and emotionally and increases their trust in the JKN-KIS system. The results of
this study can encourage the government and BPJS Kesehatan to continue to optimise the quality
and accessibility of JKN-KIS services to maintain the sustainability and effectiveness of the national
health insurance program.
Practical recommendations are intended for BPJS Kesehatan to prioritise strategies to improve
the ease of administration and quality of referral health facility services for catastrophic patients.
BPJS Kesehatan can implement a more structured case management program for catastrophic
patients, such as cancer or heart disease. In this program, special officers or case managers will assist
patients in managing long-term treatment plans, helping them access the care they need, handling
administrative constraints, and coordinating between health facilities. This assistance will
significantly help catastrophic patients in overcoming administrative burdens. BPJS Kesehatan can
expand access by forming a network of exceptional hospitals to handle catastrophic diseases.
Hospitals in this network can have more complete facilities, a fast referral process, and specially
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trained medical personnel to handle catastrophic diseases. This can prevent long queues and speed
up access for catastrophic patients to the specialised services they need.
The availability of ambulance services needs to be integrated with the BPJS Kesehatan system
and emergency service centres for catastrophic patients to ensure faster access in critical conditions.
In addition, medical teams in the field can be given exceptional guidance to handle emergency
conditions for catastrophic patients. Next, the development of a digital health monitoring feature
that allows catastrophic patients to report their condition periodically through the JKN Mobile
application. This data can help BPJS and hospitals monitor patient health developments more
proactively, provide timely treatment, and identify emergency conditions faster.
This research has several limitations that need to be considered. First, the primary focus on ease
of administration and quality of referral services may overlook other factors, such as participants'
psychological and socio-economic support, affecting the satisfaction and quality of life of
catastrophic patients. Second, the research sample is limited to JKN-KIS participants in certain
regions, so the results may be less representative of the participants' experiences in areas with more
limited access to health facilities. For future research, more in-depth studies of psychosocial factors
and their impact on catastrophic patient satisfaction may provide new insights for service
improvement. Additionally, future research could employ a retrospective cohort design to explore
causal relationships between healthcare services and patient satisfaction thoroughly. The study can
also expand the scope of the sample area to capture the variation of participants' experiences in
various regions, especially in rural and remote areas.

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