Cost Analysis of Chronic Kidney Disease Patients in Indonesia

Introduction

Chronic kidney disease is one of the most expensive diseases in Indonesia. The high cost is due to the increasing number of chronic kidney patients from year to year. The community must understand that these high costs can burden the state, in this case, the BPJS as the agency in charge of administering health insurance for people in Indonesia. This disease is developing bad impact and generally cannot recover. Treatment for chronic kidney disease guaranteed by BPJS Health costs trillions of rupiah. In this case, treatment is related to dialysis (hemodialysis) in patients with kidney failure. BPJS Health data in 2017 recorded 3,657,691 dialysis procedures with a total cost of IDR 3.1 trillion. This funding is high in the category of non-communicable disease treatment. Data from the Ministry of Health in 2015 showed that at least until 2015 there were an addition of 2000 new cases per year for chronic kidney patients who were in the final stage and more than 10% of chronic kidney patients underwent hemodialysis. Hemodialysis for chronic kidney patients is routinely done because it is one of the symptomatic therapies. The survival rate of chronic kidney patients increases by undergoing hemodialysis routinely.¹ Undergoing hemodialysis is said to give an average time preference of 5.1 years.² However, behind that, the high cost of hemodialysis is still a problem for patients. Several cost analysis studies write that the cost of treating chronic kidney disease in hospitals is high due to the high cost of hemodialysis. More than 1.5 trillion was spent by BPJS in 2014, where chronic kidney disease with hemodialysis cost components ranks 2nd as the largest cost.³ In addition to the cost of hemodialysis, the high cost of treating chronic kidney disease also comes from other components such as the cost of medicines, services and hospitalization costs.⁴ The cost of the treatment will increase if the patient has a history of disease and comorbidities.⁵ The high cost of chronic kidney care has an impact on hospitals. The negative difference between total real costs and INA-CBGs rates in hospitals often occurs so that losses are unavoidable. The difference in rates in each hospital class and region also affects this. In this article, the author will discuss the analysis of the cost of chronic kidney care in hospitals, and see the cost components.

Research Methodology

This study covers an analysis of the cost of chronic kidney disease in hospitals with different regional class types. This research has received approval from the health research ethical commission at the Jogjakarta city regional general hospital with no.38/KEP/RSUD/VIII/2019. The study used a hospital perspective with a cross-sectional design. Researchers used secondary data. The data was obtained from the collection of patient medical records and data on the cost of treating chronic kidney patients who were hospitalized at several selected hospitals in the period October 2019-December 2020. The total sample involved in this study was 582 samples. The study sample was hospitalized patients in 6 hospitals from different classes and regions who met the inclusion and exclusion criteria. The study was conducted in class A, B and private hospitals. Regional 1 was represented by Sardjito Central General Hospital Yogyakarta (class A), Yogyakarta Regional General Hospital (class B) and PKU Muhammadiyah Yogyakarta Hospital (private class). Meanwhile, regional 3 is represented by the Makassar Central General Hospital (class A), Labuang Baji Hospital (class B), Faisal General Hospital (class Private). Sampling was carried out by purposive sampling from patient medical record data and medical cost data for chronic kidney patients receiving treatment. Characteristic data include patient age, gender, class of care, length of stay (LOS), history of comorbid and comorbid diseases, severity. Cost data in the form of costs for severe actions/operations, visits, services, radiology, laboratories, transfusions, drugs, medical devices, hospitalization, supplies and hemodialysis. Descriptive data analysis is used to describe the profile of chronic kidney patients, components of hospital care costs, total costs and average hospital treatment in regions 1 and 3. The Mann–Whitney test was used to see whether there was a difference in the total cost of chronic kidney care in each different region.

Results and Discussions

A total of 582 samples were involved in this study. The majority of chronic kidney patients in the 6 hospitals were men aged 30–60 years. The treatment class chosen varies from treatment class II to III. Chronic kidney patients have a severity that varies from severity I to III. Chronic kidney disease patients have mild to severe comorbidities with a mean length of stay (LOS) >5 days. Characteristics of chronic kidney disease patients in regional hospitals 1 and 3 are shown in Table 1.

Table 1 Characteristics of Chronic Kidney Patients in Regional Hospitals 1 and 3

Cost Analysis of Chronic Kidney Disease in Class A Hospitals in Regions 1 and 3

Cost analysis was carried out at regional 1 and 3 class A hospitals. The selected hospital will describe the cost components and the difference in total costs between the two hospitals. Patients at the Sardjito Central General Hospital and Makassar Central General Hospital were the samples for hospitals in regional 1 and 3. The results showed that the total cost of treating chronic kidney disease in a class A hospital was quite high. Based on the results of the analysis of the results of the total cost components accumulated in class A hospitals, the total cost of treating chronic kidney disease reaches Rp. 1,259,723,990 with an average of Rp. 14,150,552. The total cost is lower when compared to chronic kidney care in class A hospitals in regional III. The total cost reached Rp. 3,198,367,914 with an average of Rp. 36,889,400. These results provide a significant value of 0.000 which indicates there is a difference in the total cost of treating chronic kidney disease in class A hospitals in regions 1 and III. The results showed that the total cost of chronic kidney care in class A hospitals was quite high. The total cost in each region shows a varying value. Class A hospitals in regional 1 showed that the cost of hemodialysis, severe surgery/operation and laboratory costs were the 3 highest cost components. The total cost of hemodialysis in a class A hospital reached Rp. 246,589,540, with an average of Rp. 2,542,160 ± Rp. 2,067,865 per patient/year. This value is the highest cost component in a class A hospital in regional 1. The same thing happened in a class A hospital in regional 3. The cost of hemodialysis is the highest cost component with a total cost of Rp. 840,132,546 average cost Rp. 8,661,160±Rp. 6,653,226 per patient/year. The results of statistical tests showed that there was a difference in the cost of hemodialysis for class A hospitals in regional 1 and regional 3 (p = 0.000). The total difference in average costs incurred between hospitals in regional 1 and 3 reached Rp. 6,119,000. The high cost of hemodialysis in hospitals is because class A hospitals are referral hospitals for other regions,⁶ where chronic kidney patients undergoing treatment have been in a high level of severity so that they require hemodialysis with a more frequent frequency and sometimes require surgery/severe action to improve the patient’s health. The results of this study are in line with research⁷ where the cost of hemodialysis in a class A hospital provides a fairly high total cost, it is influenced by the frequency of patients doing hemodialysis. The results of the Azalea 2016 study suggest that chronic kidney patients with a frequency of >3 times per inpatient perform hemodialysis, the total costs incurred are higher than patients with hemodialysis frequency <3 times per inpatient (p = 0.000). Overall, the cost components that show high costs in class A hospitals are the costs of hemodialysis, laboratory, services and severe/surgery procedures and have a significant difference between class A hospitals in both regions 1 and 3. The difference in the cost of chronic kidney disease therapy in Class A hospitals in regions 1 and 3 is shown in Table 2.

Table 2 Differences in Cost of Treatment for Chronic Kidney Disease Class A Hospitals in Regions 1 and 3

Cost Analysis of Chronic Kidney Disease in Class B Hospitals in Regions 1 and 3

The cost analysis of chronic kidney disease in a class B hospital was carried out at the Yogyakarta Regional General Hospital for regional 1 and the Labuang Baji Hospital in Makassar for regional 3. From the results obtained, the cost analysis in class B hospitals was quite varied. In contrast to the results in a class A hospital, in this study hemodialysis was not the highest cost component in a class B hospital. In several studies, the cost analysis of chronic kidney disease conducted in a class B hospital showed that the cost of hemodialysis was still the cost component that caused the highest cost. As in research of Tandah⁸ and Roggeri,⁹ it was stated that class B hospitals often experience losses and negative differences due to the high cost of hemodialysis in these hospitals. For hospitals in regional 1, the highest cost components are supplies, services and heavy treatment/operations. As for regional 3, the highest cost components are services, medicines and hospitalization costs. From the results of statistical tests, it can be seen that there is a difference between the total cost of services in regional 1 and regional 3 class B hospitals (p = 0.008). The resulting difference for the total cost of class B hospital services in regions 1 and 3 reached Rp. 24,276,025, a fairly high figure for the difference in rates in the two regions. It can be seen in Table 3 that the average cost of services at a class B hospital in regional 3 is higher than the average cost at a regional 1 hospital. The results of this study indicate that the regional location of the hospital affects the cost of a disease. The second highest cost component in a class B hospital is the cost of supplies, followed by the cost of hospitalization and medicines. The results of this study are in line with several similar studies.¹⁰ In his research, it was stated that pharmaceutical supplies in class B hospitals were components that cost quite a lot. Medical and severe measures performed by chronic kidney patients on hemodialysis cause the cost of supplies to increase. High hospitalization costs¹¹ and medicine¹² and¹³ In class B, the increase is influenced by the clinical condition of chronic kidney patients who are at a high level of severity so that it affects the length of hospitalization, as well as for the use of drugs. The clinical condition of patients with complex comorbidities and comorbidities makes the cost of medicines increase. The three cost components showed significant statistical test results (p < 0.05). Overall, the results of the study show that the total cost of treating chronic kidney disease in a class B hospital reaches Rp. 548,497,638 with an average of Rp. 7,660,898. The total cost is lower when compared to chronic kidney care in class A hospitals. The total cost of chronic kidney care in regional III class B hospitals is IDR 541,461,530 with an average of IDR 11,491,446. These results provide a significant value of 0.000. This shows that there is a significant difference in the total cost of class B hospitals in region 1 and region 3. This shows that there is a significant difference in the total cost of class B hospitals in regional 1 and regional 3. The difference in the cost of chronic kidney disease therapy in class B hospitals in regions 1 and 3 is shown in Table 3.

Table 3 Differences in Cost of Treatment for Chronic Kidney Disease Class B Hospitals in Regions 1 and 3

Cost Analysis of Chronic Kidney Disease in Private Class Hospitals in Regions 1 and 3

The cost of treating chronic kidney patients in private class hospitals in both regions shows varying costs. The total cost of treating chronic kidney disease in private hospitals is quite high. The results showed that the total cost of treatment in private class hospitals in region 3 was much higher than the private class hospitals in region 1. This was due to the difference in rates in the two regions. From the results, the total cost component accumulated in regional III private hospitals reached Rp. 2,158,646,616 with an average of Rp.23,516,473 The total cost is quite high when compared to chronic kidney care in class A and B hospitals. These results provide a significant value of 0.000 which indicates there is a difference in the total cost of chronic kidney care in private hospitals in the region 1 and 3. Hemodialysis, laboratory costs and inpatient costs are the highest cost components in regional private class hospitals 1. Laboratory costs are high due to variations between one patient and another, especially for patients with comorbidities and various comorbidities.¹⁴ For regional 3, services, hospitalization and serious treatment are the highest cost components. The highest total cost in the two regions is the cost of services at regional 3 hospitals with a total value of Rp.792,155,000. This value is much different from the total cost for services at regional 1 hospital which is only Rp.19,540,220 (p = 0.000). This shows that there is a considerable difference between the cost of services at regional 1 and 3 private hospitals. The service rates at regional 3 private hospitals may be due to the different tariff bases in the two regions. This significant difference also occurs in other cost components such as the cost of visits, medicines, medical devices and hospitalization. Several previous studies have written that often the total cost in private class hospitals is higher than government-owned hospitals. Private class hospitals are said to have a different tariff range from government-owned hospitals. Tabrani’s 2016 research suggests that there is no difference between government-owned and private hospitals in setting rates. There is no difference in operating costs incurred by class A, B or private hospitals for chronic kidney disease. The difference is often the investment costs where private hospitals do not get the same funding as government-owned hospitals. Privately owned hospitals fund themselves in terms of hospital operations.¹⁵ The high cost of treatment in private class hospitals and the differences in each region should be an evaluation material for the government and the hospital to set rates according to the actual unit cost calculation.¹⁶ The hospital was asked to be even better in managing funds and making adjustments in accordance with a clinical pathway that was based. The difference in the cost of therapy for chronic kidney disease in the private class in regions 1 and 3 is shown in Table 4.

Table 4 Differences in the Cost of Chronic Kidney Disease Therapy for Private Class Hospitals in Regions 1 and 3

Conclusion

Based on the results of the study, it can be concluded that the total cost of chronic kidney disease in class A hospitals is higher than class B and private hospitals. The highest component of treatment costs was in a class A hospital. Hemodialysis, severe surgery and services were the components with the highest cost compared to other cost components. The highest total cost of hemodialysis reached Rp.840,132,546, severe treatment Rp. 423,156,000 and services Rp. 792,155,000. The results of statistical tests for the three components showed significant results. It can be concluded that there are differences in the total cost of chronic kidney care for the three components in regions 1 and 3 (p < 0.05).