1) The document discusses strategies for improving cost effectiveness in cardiac catheterization labs in Indonesia under the country's universal health coverage program. It analyzes costs based on procedures, devices, hospitalization, and remuneration. 2) Several strategies are proposed, including standardizing devices and implants for UHC patients, clinical pathways to standardize length of stays, and using national formularies. Teamwork, physician champions, and data-driven management are emphasized. 3) Metrics like door-to-balloon times for STEMI patients are discussed as important for monitoring performance and outcomes. Overall the document focuses on balancing clinical needs with budget constraints of Indonesia's universal health coverage.

1. COST EFFECTIVENESS
PROCEDURES IN CATHLAB
Isman Firdaus, MD
FIHA, FAPSIC, FAsCC, FESC, FSCAI
Pusat Jantung Nasional
Harapan kita Hospital, Jakarta

2. Case Number Cost (USD) Disease
UNIVERSAL HEALTH COVERAGE IN
INDONESIA
January-June 2014 (6 months)
Catastrophic
Inpatient
735,827 case
232,010 134,821,667
172,303 55,600,810
138,779 55,600,810
70,584 23,232,524
56,033 23,192,193
53,948 12,951,916
12,170 5,277,811
2
Cardiac
Stroke
Kidney
Diabetes
Cancer
Thalassemia
Hemophilia
Main NCD
6 billion USD/year

3. Cardiac Catheterization Lab in Indonesia (2016)
Batam
22
10
7
10
22 3
1
2
11
3
2
1
3
3
3
51
1
3
2
1
3
4
Number of Cardiac Catheterization Lab
Total: 168 Cath Lab in 144 hospital

4. REFERRAL
SYSTEM
Primary
Health
Care
Primary Hospital
Regional
Referral
1 District/City Hospital
Province
Referral
Hospital
Regional Referral Hospital
District/City Hospital
Primary
Health
Center
Clinic
Physicians
Private
Practice
Midwives
Private
PracticeTertiary referral
(not available in all area)
Secondary referral
Primary referral
Primary
Health
Care
Primary
Health
Care
Regional
Referral
2
Regional
Referral
3
Regional
Referral
4
Regional
Referral
5
Taher, A. Regionalization Concept of Referral System and the Need of Specialist
Doctors. Dirjen BUK Ministry of Health Republic of Indonesia 2014

5. National Health Coverage Reimbursement
Reimbursement depend on case severity and hospital level of services
PCI
Tertiary Care
(Type A)
Type B
Hospital
Minimum
Reimbursement
3,414 USD 2,555 USD
Maximum
Reimbursement
7,343 USD 3,476 USD
Permenkes 59/2014 on the Healthcare Standard Tariff, Universal Health Coverage/National Health Insurance (JKN)
Indonesia Case Based Groups (INA-CBGs), Social Security Management Agency (BPJS)
PCI: Percutaneous Coronary Intervention
PCI Reimbursement

6. National Cardiovascular Center Harapan Kita, Hospital

7. Six Cathlab in NCC Harapan Kita Hospital:
3 Cathlab : Coronary and Emergency
1 Cathlab : Vascular and Coronary
1 Cathlab : Arrhythmia
1 Cathlab : Congenital

8. 7,750
8,060
8,854
9,162
8,998
7,000
7,500
8,000
8,500
9,000
9,500
Non surgical Procedure
2011 2012 2013 2014 2015
Number of Cathlab Procedures
in NCC Harapan Kita Hospital

9. Top 10 Procedure in 2015 in NCC HK
No ICD-9 Description N
1 36.06.1 Insertion of coronary PTCA 1 sten 1.123
2 88.56 Coronary arteriography using two cath 1.091
3 36.06.2 Insertion of coronary PTCA 2 sten 717
4 36.12 Aortocoronary bypass of two coronary arteries 352
5 35.23 Replace/repair mv w/tissue 295
6 37.34 Ablasi chateter lesi 248
7 88.54 Combined R&L heart angiocardiography 209
8 35.53 Repair of ventricular septal defect with prosthesis 187
9 37.23 Combined R&L cardiac catheterization 175
10 36.06.3 Insertion of coronary PTCA 3 sten 166

10. Procedures in Cathlab is
full and highly dependent
on devices or implant
 Cost effectiveness to
follow the budget

11. In the past :
The Budget will Follow the
treatment or technique
Today in UHC:
Every treatment or technique should
follow the budget

12. Device or Implant
Rp….
Drugs and
Hospitalization
Rp……
Salary or
Remuneration
Rp….
3 Component
• Device/implant
selection
• Medication
• Remuneration

13. No Strategy
Hospital Colaps
Device or Implant
Rp….
Drugs and
Hospitalization
Rp…..
Fee or Salary, Rp…

14. Cost
Effectiveness
in Cathlab
Device or Implant
Rp….
Drugs and
Hospitalization
Rp…..
Fee or Salary, Rp…
Device or Implant
Rp….
Drugs and
Hospitalization
Rp…..
Fee or Salary, Rp…

15. STRATEGY
Program Policy
Physician - Remunerasi VS fee for service
- Physician Champion
- Teamwork
Implant and Device for UHC
Standarization / e-Katalog
LoS Standarization in pts Hospitalization CP
Hospital Guidelines and
Clinical Pathways
Every physician should follow CP
Drugs/Formularium for UHC Using National Formularium for UHC pts
Resume of hospitalization Complete and systematic resume list
Identifikasi program
Unggulan /Income
generating/ High Cost Exp
Identifikasi program unggulan yang di inginkan
Managerial Always use data for improvement program

16. Ex/ Sign in every pts for operator Alarm
Kelas 3 Kelas 2 Kelas 1
Ringan
1 BMS, 1 balon, 1 wire 1 BMS, 1 balon, 1 wire 2 DES, 1 balon, 1 wire
Sedang
2 DES, 1 balon, 1 wire 2 DES, 2 wire, 1 balon 2-3 DES, 2 wire, 2 balon
Berat
1 BMS/1DES 1 BMS/1DES 1 BMS/1 DES

17. Ischemic Time
System Delay
Patient Delay
Hospital
Performance
STEMI Standard of Care: Targeting
Improvements in STEMI Care Continuum
Process Steps to Achieve Optimal Door to Balloon Times
Symptom awareness
and action
Fast EMR
response
• Patient awareness
of MI risk factors and
symptoms
• Rapid <5 min
ambulance
response
Accessibility to
24hr PCI centers
Hospital Triage
and Procedure
• 24 hr access
• Documented
transfer
• Early activation
• 15 min to return
to LV Function
EMR ECG
interpretation
EMR
Thrombolytics
infusion
• Remote ECG
• Interpretation
and diagnosis
by EMT or MD
consult
• Infusion started
in ambulance to
hospital
Patient Awareness/
EMS Response
Diagnostics
Hospital Triaging
Rapid Reperfusion
STEMI: ST – Elevation Myocardial Infarction
BUDGET

19. Definisi
Door to balloon time / door-to-device time is the time from the patient entered the
emergency room doors with Acute Coronary Syndrome until Coronary angioplasty is
done for the first time, or thrombus suction first attempt. Door to Balloon Time
targeted by the hospital is <90 minutes.
Numerator The number of ACS patients with Door to Balloon Time < 90 minutes
Denominator The number of ACS patients
86.11%
82.76% 81.25%
85.71%
80%
60.00%
70.00%
80.00%
90.00%
100.00%
Januari Februari Maret April
Door to Balloon Time < 90 Menit
Capaian Target

23. Buying A New Car

24. Tips and Strategy in UHC
• Schedule engineering in cathlab
• Case load and targetting for every interventionist
• Implant and device standarization for UHC pts
• All cardiologist should support cathlab director
who endorse by hospital management to succeed
the business process in cathlab.
• Cardiologists’ willingness to move on from
individual to team work.

25. • Team approach: Remember the famous quote,
“There is no ‘I’ in team?” To harness the best
of each individual, team members need to
understand each other’s strengths, roles,
responsibilities, and the scope of the task
• Re-used is not prohibited
Tips and Strategy in UHC