BACK-REFERRAL PROGRAM IN THE ERA OF NATIONAL HEALTH INSURANCE AT BALUNG DISTRICT GENERAL HOSPITAL OF JEMBER IN 2017

Background: In 2014, National Health Insurance Program (BPJS Kesehatan) implemented Back-Referral Program (BRP) to facilitate access to health care for patients with chronic diseases in stable conditions. However, the program did not run well at District General Hospital of Balung which had the lowest back-referral program (6 participants) in 2015-2016. Aim: The study aims to examine the BRP at Balung District General Hospital of Jember in 2017. Methods: This study is designed as qualitative case study. The informants consisted of head of treasury verification, secretary of JKN service controlling, officers of local government’s free care scheme, coordinator of internal and neurological disease, specialists in internal and neurological diseases, officers of Social Security Agency for Health, officers of patient eligibility verification, and participants of Back-Referral Program. The study was conducted from October to December 2017. Results: Results show that the attendance of BPJS Kesehatan officers has no contribution to the services of BPJS Kesehatan in the hospital. Participants also find it difficult to follow the steps of BRP due to unavailability of drugs at primary healthcare centers. Moreover, neurologists have not written any referral recommendation since 2016, so there was no patient admittance. Conclusions: The BRP at Balung District General Hospital did not achieve its target (<5 cases/week). In the contrary, the average number of patients referred to the hospital was 86 patients per week. Balung District General Hospital should implement Standard Operating Procedure for letters signed by responsible physician for patients and evaluate the BRP.


INTRODUCTION
Health is one of the most important assets for a person to carry out activities. Hence, it is vital to support a productive life, socially and economically (Ministry of Health of the Republic of Indonesia No. 36 Year 2009 about health). A nonhealthy person will generally have to use health services and need to pay for treatment expenses. Particularly, people with chronic diseases are likely to pay more for extensive and long-term treatments (Setyawan, 2018: 121). Chronic diseases include non-communicable diseases with long duration and generally slow development. A comparison of Basic Health Research or Riskesdas in 2007 and 2013 shows an increase in the prevalence of chronic noncommunicable diseases (Badan Penelitian Dan Pengembangan Kesehatan, 2013). Chronic diseases treatment also increases the utilization of health care because people with chronic diseases needed routine care (Susyanty and Pujiyanto, 2013: 95).
A sovereign government must be able to guarantee the well-being of its people. Therefore, the government is obliged to provide affordable, if not free, health services. The Indonesian government is undergoing the same course through the National Health Insurance Program or Jaminan Kesehatan Nasional (JKN). As an insurance provider, JKN covers health treatment related costs incurred at primary healthcare centers (PHC). Insurance-covered health treatment incurred at secondary healthcare centers (SHC) can only be covered if the patient is under referral from the initial PHC. This is regulated by the Ministry of Health of the Republic of Indonesia regulation Number 71 Year 2013. The SHC which act as referral recipient must refer the patient back to the initial (PHC) once the patient is stabilized. This is later be known as the Back-Referral Program (BRP) or Program Rujuk Balik which is legalized by a referral letter made and signed by a physician.
Back-Referral Program (BRP) is a health service which provides treatment and distributes medicines specifically for patients with chronic diseases at PHC based on the recommendation of a specialist at SHC (BPJS Kesehatan, 2014: 3). The Security Agency for Health (BPJS Kesehatan) states that the realization number of back-referral by the end of 2015 was 34.05% (401,848 out of 1.18 million participants with chronic diseases according to the types of diseases classified in the backreferral program) (Rusady, 2016: 18) . This caused an increase in hospital claim submissions. By the end of 2017, BPJS Kesehatan had experienced a deficit of 4.4 trillion (Idris, 2018). This highlights the many challenges caused by chronic disease patients' hesitance to be registered in the backreferral program (Rusady, 2016: 18).
Based on the data of BPJS Kesehatan from 2014 to 2016, ambulatory groups-episodic cases had always been the most common cases at Outpatient Secondary Healthcare Facilities (OSHF) or Rawat Jalan Tingkat Lanjut. This caused a longer queue at Referral Healthcare Facilities (RHF) or Fasilitas Kesehatan Rujukan Tingkat Lanjut. The highest cost at OSHF was for re-diagnosed cases, which increased by 4.9 million cases compared to in 2015. This was caused by non-optimal BRP (Rusady, 2017).
Based on preliminary studies conducted in May and June 2017, there were 394 back-referred participants in Jember from 2015 to 2016. In 2016, Balung District General Hospital had the lowest number of referral recipients compared to other state hospitals. Referral participants are patients whose health care and follow-up medicines are referred back to the PHC. The number of patients with chronic diseases included in the back-referral program at Balung Hospital reached 503 visits in 2016. From these visits, only five patients got referred back to PHC. Whereas, the target of backreferral visit was ≥5 cases per week (Sutriso et al., 2017: 171). This BRP target is not determined by BPJS. It indicates that there are still many patients who are not registered or do not participate in backreferral program. The gap between the number of patient visits having chronic diseases and backreferred participants visits indicates that the program was not going well. Based on the data, it appears that since 2016, there has been no new patients registered in the BRP at Balung District General Hospital.
Previous study by Primasari (2015: 82) at Adjidarmo District Hospital of Lebak shows that the failure of back-referral program (BRP) was due to the unawareness of some doctors. A study in Kotawaringin Timur explains that BRP is failing because there is no collaboration among health care professionals and lack of commitment to cooperate between professional associations (Sutriso et al., 2017: 176). Furthermore, patients still have a specialist-oriented mind and thus request to be referred to a specialists/hospitals of their preferences (Wulandari et al., 2013: 51).
BRP is important to facilitate access to healthcare for patients needing long-term care. The ineffectiveness of BRP causes higher number of outpatients in the Outpatient Secondary Healthcare Facilities. This, in turn, causes increase in hospital claims to BPJS Kesehatan. Therefore, this study aims to examine Back-Referral Program at Balung District General Hospital of Jember Regency in 2017. This study can be used to identify obstacles in implementing BRP and is expected to facilitate improvement of this program at hospitals.

METHOD
This study used a qualitative approach with a case study design which aimed to examine a particular phenomenon (Creswell, 2010: 20). This study was conducted at Balung District General Hospital of Jember Regency from October to December 2017. This study used a purposive sampling method to determine its informants. The key informants are the head of treasury verification, secretary of JKN service controlling, officers of local government's free care scheme, coordinator of internal and neurological disease, specialists in internal and neurological diseases, officers of Social Security Agency for Health (BPJS Kesehatan), officers of patient eligibility verification, and participants of Back-Referral Program.
Primary data of this research are the results of in-depth interviews and referral observation sheets. The research instrument was composed by the researchers because there was no study related to BRP available. Meanwhile, the secondary data were gathered by conducting documentation study, such as the number of back-referred patients, number of JKN patients with chronic diseases, back-referred patients' evaluation in records from department of internal disease and department of neurology. Data were collected using triangulation, interviews, observations, and documentation study. Data gathered from interviews were presented as naration (thematic analysis). Data analysis in this study was presented through detailed explanations.

RESULTS AND DISCUSSION
The components of the implementation of BRP are based on the system theory, which consists of input, process, and output. Input components are the human resources (knowledge of health workers and staffs of BPJS Kesehatan, staffs attendance, years of service, and commitment), money (funds and promotional budget), material (back-referral control books, backreferrals, and BRP medicines), machine (computers and networkings), methods (BRP guidelines and standards), and markets (targets). In addition, process components consists of planning (goals and strategies), organizing (division of labor and coordination), implementation (writing of referral letters and prescription drugs and registration of participants in the hospital), and supervision (evaluation of referrals and report). Furthermore, the output component is the achievement of the BRP return visit. There were seven informants participating in this study.

Input
Several phenomena related to input were found during interviews with seven informants. The knowledge aspects of health workers were collected from specialists, clinic coordinators, and BPJS Kesehatan officers. Knowledge is the result of knowing, and this happens after people sense an object (Notoatmodjo, 2012: 138 Responses to questions during interviews are derived from remembering experiences and events that have been experienced either intentionally or unintentionally, and they happen after people have observed an object (Mubarok and Iqbal, 2007). Health workers and BPJS Kesehatan officers can explain correctly what was meant by back referral, benefits, and steps of implementation. Conformity between the guidelines set by BPJS Kesehatan and informants shows that officers know about the definition of BRP. Informants also understand that BRP benefits the patients in a way that they do not need to always come to hospitals if they are running out of medicine. In terms of BRP steps, informants point out that patients can be treated by the hospital after receiving referrals from PHC. In addition, medicinal services are then handled by PHC if patients' condition are stable. Hospitals have to handle BRP patients who are yet to stabilize, while stabilized patients have to be referred back to PHC, except on certain cases in which patients' status are still under evaluation. If hospitals always handle BRP patients with stable condition, the number of patients will surge. These patients should not be treated because they will depend on hospitals. Such patients will become a burden, which in turn will decrease service quality of the hospitals. Service quality and patient satisfaction have a positive relationship, which means that the better the quality of service is, the higher the patient satisfaction will be (Zaniarti, 2011: 150).
"Only once a month in the verification schedule. Four days at the most. He came here only for verification, not to provide service at the BPJS center" 47 year) The presence of BPJS Kesehatan officers influences the performance of the program. The influence of employees with regard to their duties and obligations is marked by their presence (Nitisemito, 2002: 427). Based on the results of interviews, it can be seen that the staffs of BPJS Kesehatan do not routinely come to office. The BPJS officers come to office only to verify hospital claims, for a maximum of 4 working days each month. Thus, their presence is not for providing service at the BPJS Kesehatan counter at Balung District General Hospital. This is due to the lack of BPJS Kesehatan officers so that one officer is assigned to three to four hospitals to verify the claims. There is no BPJS officer in charge of providiing services at the BPJS counter of the hospital.
Employee attendance is one of performance measurements.
Employees are considered incapable to optimally perform if their presence is below standard working days (Mathis and Jackson, 2006). The BPJS Kesehatan officers who are unable to standby on their counter lead to no increase in reconciliation of participants throughout 2017. Registration of new participants cannot be done because only BPJS Kesehatan officers have the authority to register and verify participants into the JKN referral system.
Working period can be interpreted as a piece of time where the workforce is assigned in one area of business location to a certain time limit (Suma'mur, 2009: 71). Another definition of work period is the length of time in which an employee or officer works for a company (Fitriantoro, 2009: 18). The informant has a long period of work (> 5 years) to get experience and skills in running their profession as doctors, health workers, and nonmedical personnels at the hospital according to their respective tasks and functions. Additional experience because of the longer working period is also related to the increase of psychological empowerment (Koesindratmono and Septarini, 2011: 51). Psychological empowerment gives someone strength and control to do work, such as implementing BRP. The program must be implemented within the duration of working period. Considering the link between working period and program implementation, the service period and the program implementation have a positive relationship (Astriana et al., 2014: 5). Working period will be influential on the quality of performance if the officers have more experience and skills. Working skills will be better if employees have adapted to their work (Akbar, 2012: 22). The commitment of health workers can be seen through their attitude towards the program. Based on the above quote, the internists still hold their commitment by giving directions to patients who participate in BRP. This is different from the neurologists who had no commitment in the program. Based on the interview, the neurology clinic coordinator stated that neurologists at the hospital rarely refer patients back. This is evidenced by the absence of visits from BRP patients who came from neurology clinic. All of the 84 patients being referred back were chronic disease patients in internal medicine clinic, dominated by hypertension, diabetes mellitus, chronic heart disease, and/or its complications. Organizational commitment has a positive and significant effect on employee performance (Respatiningsih, 2015: 62).
"yes, there are no special funds. We invite friends in the service, then inform you that the patients were referred back to this program. We give the steps and the format like that. We also come to serve." 47 year) Dissemination is a process of making the public know and understand a program and its procedures (Suharsono, 2012: 91). Dissemination fund is related to the way dissemination was carried out to the targets who got information from the beginning of JKN. According the interviews about money, there was no special budget assigned for program dissemination at Balung District General Hospital. Likewise, there was no special budget for BPJS Kesehatan. Internal dissemination within the hospital is carried out by inviting health workers and discussing BRP. The dissemination to chronic patients is carried out directly by the doctor. BPJS Kesehatan and hospitals are also evaluated through review utilization meetings. During this meeting, BRP is discussed, but not specifically and deeply, just by calling for JKN patients to be referred back to PHC for further treatment.
Materials in the study, namely back-referral letters, are always available in internal medicine and neurology clinics while back-referral control books are not available at the BPJS Kesehatan counter at Balung District General Hospital. BPJS Kesehatan counter has been moved to the second floor of the medical center building, and so do all its files. BPJS officers also forget where they put the referral control books after the move took place. These officers are then ask the participants to provide the book stock. The book stock is supposed to be readily available so that new registered participants can easily get it. BPJS Kesehatan officers should be more careful in keeping the back-referral control books and put the books at the counter so that they can still be distributed by other officers who are in charge of the registration.
"There are many complaints from the patients. They must come back here because there is no medicine at the PHC ... after arriving at the PHC, the medicine is not in stock. The medicine is not available. That happens a lot..." (EDL-IT, 33 year) Drugs unavailability is commonly experienced by BRP participants. They often find it difficult to obtain medicines at PHCs, so they come to the hospital although it is not their regular checkup schedules. Collaboration between pharmaceutical centers at various helath service providers must be maintained to improve procurement of BRP drugs and availability of distributors at the network pharmacy (Ianathasya and Nadjib, 2015: 16 All informants stated that the referral process is easy to be carried out, as described above. The internists also stated that it is easy to implement such referrals because the format of the referral is clear and very easy to be understood. The steps re also very clear. Feedbacks can also be easily given. Both returning and new participants thought that the referral system is easy to follow. The system provides information to patients, examines patients, offers, and writes back-referrals.
In the contrary, it turns out that referral participants experienced difficulties when obtaining drugs at PHC. Based on Regulation of Minister of Health No. 71 of 2013, pharmacy services for BRP are provided by the pharmacy counter at PHCs, pharmacies, and first-level clinical pharmacy in collaboration with BPJS Kesehatan. Unfortunately, PHCs do not provide the referral drugs. Meanwhile, those distributed by the network pharmacies in the area of Balung are insufficient to be stocked at the hospital. BPJS Kesehatan officers at the networking pharmacies are not evenly distributed; hence, BRP goals are not achieved.
The analysis on the standard component of BRP shows that the informants were not aware of certain standards or guidelines and target of the BRP organizers. The key informant stated that the target of the BRP is the internal information of BPJS Kesehatan. The computer is available at the BPJS Kesehatan counter. BPJS Kesehatan officers are not working at the counter since the computer is not equipped with proper functionalities for new registration of BRP.
The target market is all JKN patients with chronic diseases who have registered for a referral program. Based on their understanding BRP, the program makes it easier for them to get treatments, especially for patients who live far from the hospital. Participants are also adequately aware of the benefits and the referral procedures of BRP. Knowledge related to BRP is obtained during checkup in hospital clinics.
"Yes, it's not practical. It used to seem like I had to get the medicines at Puger pharmacy. I was there, but it turns out there's nothingin stock. BRP gives me difficulties." 55 year) The inconvenience experienced by one BRP participant to follow the procedures can be seen in the quotation above. They felt objected if they had to return to PHC to get their medicine. This is what makes them think that BRP flow is complicated. They mentioned that the reconciliation was not practical because PHC often ran out of medication. They had to repeatedly visit the PHC to check drugs availability. As a result, they were unwilling to join BRP again.

Process
One of the objectives of Balung District General Hospital is to treat patients with chronic diseases. All informants agreed that the mutual goal is to maintain and improve the health quality of BRP participants. Balung District General Hospital expects that BRP for patients with chronic diseases can minimize complications because these patients are more susceptible to other complications.
Balung District General Hospital do not have a specific strategy for BRP implementation because the program has been applied for a long time and organized by BPJS Kesehatan. The ineffective implementation of BRP has led to a high number of visits of patients with chronic diseases at the hospital. As a result, Balung District General Hospital has an increasing number of outpatient service claims. Results of the interviews also show that Balung District General Hospital is one of BRP service providers which carries out the program according to BRP procedures.
Labor division is a very important variable to improve employee performance (Herawati, 2016: 9). The labor division of BRP at the hospital is basically very clear for which the main tasks and functions are clearly specified. Specialists are in charge of writing back-referral letters for patients, which are then taken to the verification officer at the hospital. The most important thing lies in how these specialists decide whether to write a referral letter or not. The results of interviews with internists at the hospital suggest that the they may continue writing back referrals according to the work division. This is contrary to what happened at the neurology clinic. Document study shows that neurologists in the JKN era never write back-referral letters for their patients. This means that the neurologist have not done the supposed task for the BRP.
Based on the interviews on the components of coordination, there is no direct coordination between BPJS Kesehatan officers and medical personnel as well as health staffs in the clinics. The coordination between health staffs at the hospital is also very minimal because they do not really understand the program. Furthermore, coordination should also be carried out by other parties, including the control team. The control team functions as a liaison between the health staffs and BPJS Kesehatan officers, or between the patients and BPJS officers. The control team assists issues on BRP-related information and other issues linked to JKN.
The BRP implementation refers to writing a referral letter and prescription medication by a specialist. The coordinator of the Neurology Department of Balung District General Hospital stated that neurologists rarely refer patients. Based on the document study, BRP patients diagnosed with neurological diseases got referred to the Balung District General Hospital, but are not referred back. The failed referral shows that the neurologist is not compliant in writing a referral letter. The neurologist does not agree to give any statement. Another health worker, though, mentioned that the doctor is unwilling to write a referral letter due to the unavailability of medicine at PHC. This can result in no additional referred patients and no visits from patients with neurological diseases.
".. the stable patients have to go to PHC later on. There is no cure here, but we still write down the referral until there is a cure. The goal is to give PHC the opportunity to prepare the medicine ..." 50 year) Unlike the neurologists, internists are always willing to write back-referrals. It represents the efforts of these specialist doctors to support the program sustainability when the referrral program implementation face some obstacles.
During its initial registration stage, in the beginning of JKN era in 2014, BRP registration was relatively smooth. There were many more patients at the beginning of the year compared to 2017 in which almost no patients visited. The rate of new BRP registration have decreased every year. When a specialist referred a patient back, it turned out that the patient could not register directly at the BPJS Kesehatan counter because no officers were present. Thus, the patient was confused and could not immediately get a return referral control book. BPJS Kesehatan officers must indeed be available on the counter. The registration process should be coordinated with other officers at each clinic so that BRP can be implemented well.
The supervision component is the evaluation of referral hospital. The referral evaluation at Balung District General Hospital is where the BRP participants conduct health assessments after 3month-treatment at PHCs.
"... it looks like everyone returns to the their doctors-in-charge (DPJP). The patient even asked for them. I just asked for DPJP instead of BRP since the medicine always out of stock." 38 year) According to the informant's statement, BRP participants return to the hospital not as BRP patients who have carried out their three-month health evaluations. Instead, these supposed-BRPparticipants come as general patients who seek for monthly check-ups. Finally, patients who have previously participated in the BRP do not follow BRP procedures properly because of the unavailability of drugs at the PHCs. Patients who come to the hospital for routine visits use a letter from the doctors-in-charge (DPJP) signed by a specialist. According to a health worker, the DPJP letter is a referral letter to the hospital directly without going to PHC, and this letter is valid for 3 months. Thus, patients can go directly to Balung District General Hospital without going to PHC, but the referral letter from the previous PHC must still be kept by the patients. The back-referred participants use the DPJP letter because it makes it easier for them obtain the medicines.
DPJP letter provided by a specialist is actually made for the not-yet-stabilized patients and in need of recheck-ups. This letter should not be freely given. Participants with stable conditions must be referred back to PHC. Doctors still give out these letters because the patients often complain of the services at the PHC.
Healthcare personnel at all levels of health facilities must equally receive the right proportion of patient services according to their medical indications. BRP faces serious obstacles because of inaccurate budgeting and cost inefficiencies. Capitation inefficiency at PHC is caused by chronic patients always getting referred to the hospital, making the capitation left unused. Regular monthly check-up for every JKN participant with chronic disease at the hospital also plays a role in cost efficiency. This is due to larger claims to BPJS Kesehatan caused by the increasing number of patients.
"No, we don't report it because those who are responsible of the program (BPJS Kesehatan), they are the one who should evaluate. We don't report how many times we make referral, but we keep a record." 47 year) The health workers do not prepare any report of BRP participants for the heads or representatives of authorities at Balung District General Hospital. Results of interviews firmly show that there have never been any BRP participant report. It is because BRP is a program of BPJS Kesehatan mandated by Referral Healthcare Facilities so that the referral data is not managed by the hospital. Online registration and participant approval is done by BPJS Kesehatan officers in their integrated system. There is no monitoring system and feedback for obstacles and achievements faced by the hospital.

Output
The program output is well-running BRP. Due to the many issues encountered in BRP implementation at the hospital, JKN participants are not interested to participate in the BRP. The document study finds there is no BRP participant visit during the course of 2017. This fact that BRP coverage is still low and needed to be improved is also acknowledged by the informants.

CONCLUSION
BPJS Kesehatan officers do not contribute much in the BRP services because their lack of commitment to implement BRP. This lack of commitment is also observed in the neurologists. There is no special funds used for BRP dissemination, either from Balung District General Hospital or BPJS Kesehatan. There is an unavailability of drugs at the PHCs. Consequently, BRP implementation is considered difficult by the participants, so they do not want to join BRP anymore. Balung District General Hospital does not have a specific strategy in implementing the program. Apart from that, neurologist at the hospital never write a back referral. Moreover, the registration is difficult because there is no BPJS Kesehatan officer avaiilable. Specialist doctors no It is suggested that Balung District General Hospital to continue implementing back-referral to internal medicine and neurological diseases, as well as carry out internal coordination for the BRP. Balung District General Hospital should apply SOPs on DPJP letters to right patients. Furthermore, BPJS Kesehatan officers should follow up BRP participants' complaints about drug unavailability and convey these problems to the heads of BPJS Kesehatan in Jember. Moreover, the hospital needs to plan for additional network pharmacy cooperation in the east and south Jember regions.