INTRODUCTION:

Chronic kidney failure is a progressive and irreversible kidney function disorder. Impaired kidney function occurs when the body fails to maintain metabolism and fluid and electrolyte balance, causing retention of urea and other nitrogenous wastes in the blood.

This kidney damage causes problems with the ability and strength of the body which causes work activities to be disrupted, the body becomes tired and weak so that the patient's quality of life decreases.

The number of patients with chronic kidney failure in Indonesia continues to increase and is estimated to grow by around 10% every year. Data from the Indonesian Nephrology Association noted that in 2017 the number of active patients was 77,892 and new patients were 30,831, in 2018 there were 135,486 active patients and 66,433 new patients, in 2019 there were recorded increases to 185,901 active patients while new patients became 69,124.

Since 2014 the Health Insurance System has been implemented, where all Indonesian people who pay premiums will be covered by the government's health costs. In the INA-CBGs system, the cost components borne by the health insurance consist of costs for treatment, lodging, actions, medicines, use of medical devices, and services which are calculated integrated in the package. In Rohhenti's research, 2019¹the implementation of the INA-CBGs system in Indonesia has created a polemic of its own. This happens because of the high real costs used in maintenance but not covered by the INA-CBGs tariff paid by the government, this shows that there is a difference between the total real costs and the INA-CBGs tariff. This difference makes the hospital a loss and the loss becomes a cost burden for the hospital. Another study wrote that the implementation of INA-CBGs was appropriate; hospitals could make funds efficient in treating patients with kidney failure. However, on the other hand, Nurwanti's research (2018) writes that there is no significant difference between real costs and INA-CBGs rates so that hospitals have succeeded and achieved profits².

This study looks at the differences in total real costs with INA-CBGs rates carried out in different regions and the influencing factors. The results obtained will later be useful for efficiency measures in the treatment of chronic kidney failure in Indonesia.

RESEARCH METHODS:

This study used a cross-sectional analytic study design with a hospital perspective. Data collection using retrospective method. The data collection period was 14 months starting from October 2019 - December 2020. This research was conducted in two regions, namely regional I (Sardjito Central General Hospital Yogyakarta, Yogyakarta City Hospital, PKU Muhamadiyah Hospital Yogyakarta) and regional III (Central General Hospital). Makassar, Labuang Baji Regional Hospital, Faisal Islamic Hospital) each region represents class A, B and private government hospitals so that a total of 6 hospitals are used for the study. The amount of the sample is done by stratified random sampling method. A total of 97 patients met the inclusion criteria in each hospital, so the total sample in this study amounted to 582 samples. The subjects in this study were patients who met the inclusion and exclusion criteria.

Patients diagnosed with chronic kidney disease with a diagnostic procedure of making new, revising and moving dialysis equipment (mild, moderate and severe), kidney tumors, urinary tract and kidney failure (mild, moderate and severe), and moderate kidney inflammation, kidney infections and Urinary tract (mild, mild, moderate and severe), Moderate urinary stones, Middle urinary tract procedures, Kidney and other urinary tract diagnosis (mild, mild moderate and severe), Urethral and transurethral procedures (mild and moderate). The data taken are in the form of patient medical records (medical record number, gender, class of care, length of treatment, severity, JKN status, Charloson Comorbidity Index (CCI), and comorbidities) as well as patient therapy costs including: costs of severe action and surgery, hemodialysis costs, visit fees, service fees, radiology fees, laboratory fees, blood transfusion costs, drug costs, medical equipment costs, accommodation and supplies costs. The data that has been obtained is then processed, grouped based on their respective financing groups. The data obtained were presented and analyzed descriptively. To see the difference between real costs and INA-CBGs rates, statistical analysis was used with the Mann-Whitney test.

RESULT AND DISCUSSION:

The results showed that the majority of chronic kidney disease patients in this study suffered from men aged 30-60 years. Clinically, men have twice the risk of developing chronic kidney disease compared to women³. Class III treatment is the choice of most chronic kidney patients in both regional 1 and regional 3⁴ with length of stay (LOS) varying 5 days and 5 days⁵. The majority of chronic kidney disease patients in both regions were in severity II (moderate) with mild comorbidities (≤3). Chronic kidney disease patients in regional 1 and regional 3 have diversity related to comorbid groups. Characteristics of chronic kidney disease patients in regions 1 and 3 are shown in table 1.

Table 1. Characteristics of Chronic Kidney Disease Patients in Regions 1 and 3

Characteristics	Regional 1						Regional 3
	RSUP Sardjito		RSUD Kota Jogjakarta		RS PKU Muhammadiyah		RSUP Makasar		RSUD Labuang Baji		RS Islam Faisal
	n	%	n	%	n	%	n	%	n	%	n	%
Ages
≤ 30 tahun	4	4%	42	43%	6	6%	11	11%	9	9%	5	5%
30-60 tahun	60	62%	22	23%	54	56%	68	70%	60	62%	61	63%
≥60	33	34%	33	34%	37	38%	18	19%	28	29%	31	32%
Jenis Kelamin
Laki-laki	48	49%	55	57%	54	56%	54	56%	44	45%	48	49%
Perempuan	49	51%	42	43%	43	44%	43	44%	53	55%	49	51%
Kelas Perawatan
Kelas I	14	14%	21	22%	10	10%	8	8%	8	8%	29	30%
Kelas II	54	56%	17	18%	25	26%	20	21%	9	9%	43	44%
Kelas III	29	30%	59	61%	62	64%	69	71%	80	82%	25	26%
Length of Stay (LOS)
≤ 5 Hari	29	30%	27	28%	57	59%	29	30%	73	75%	35	36%
≥ 5 Hari	68	70%	70	72%	40	41%	68	70%	23	25%	62	64%
Severity
I	30	31%	63	65%	11	11%	7	7%	55	57%	23	24%
II	56	58%	18	19%	57	59%	53	55%	32	33%	22	23%
III	11	11%	16	16%	40	41%	37	38%	10	10%	52	54%
JKN Status
PBI	36	37%	97	100%	53	55%	23	24%	97	100%	40	41%
NON PBI	61	63%	0	0%	44	45%	74	76%	0	0%	57	59%
CCL Comorbid
Mild (≤3)	42	43%	61	63%	56	58%	68	70%	57	59%	25	26%
Moderate (4-5)	35	36%	26	27%	28	29%	21	22%	25	26%	23	24%
Severe (≥ 6)	20	21%	10	10%	13	13%	8	8%	15	15%	49	51%
Group of Comorbidities
No comorbid	4	4%	44	45%	47	48%	3	3%	37	38%	14	14%
1 comorbid	14	14%	39	40%	29	30%	9	9%	31	32%	20	21%
2 comorbid	29	30%	8	8%	11	11%	18	19%	19	20%	23	24%
≥ comorbid	50	52%	6	6%	10	10%	67	69%	10	10%	40	41%

Note: Regional I Class A ; Sardjito Central General Hospital, Class B; Yogyakarta City Hospital, Private; PKU Muhammadiyah Regional III Hospital Class A; Makassar Central General Hospital, class B ; Labuang Baji Regional General Hospital, Private; Faisal Islamic Hospital

Differences in Cost of Chronic Kidney Disease Therapy in Class A Hospitals:

The calculation of the cost of chronic kidney therapy in regional 1 was carried out at the Sardjito Central General Hospital while regional III was carried out at the Makassar Central General Hospital. In this study, there were various diagnoses with procedures including the diagnosis of kidney and other urinary tract categories (moderate, severe) urinary tract category (moderate), making new, revising and moving dialysis equipment categories (mild, moderate and severe), kidney tumors, urinary tract and renal failure categories (mild, moderate and severe), kidney and urinary tract infections categories (moderate, severe). The cost of treating chronic kidney disease in a class A hospital generally shows the difference between the real cost and the INA-CBGs rate.

The results of statistical tests show that there is a significant difference between real costs and INA-CBGs rates in both regional 1 and regional 3 (p<0.005). These differences were shown in several treatment groups and classes. New diagnostic procedures with mild dialysis (treatment classes 2 and 3) and moderate category (treatment class 2) showed significant results. The total real cost at Sardjito Hospital, which is a class A hospital in regional 1, reached Rp. 14,914,095.00 for treatment class 2 only get INA-CBGs claims of Rp.7,836,400 (p=0.043). Likewise for class 3 treatment with the same diagnosis, the total real cost reached Rp. 13,647,573 while the claim for INA-CBGs tariffs was only Rp. 6,368,464 (p=0.012). Not only in regional 1, similar results were also shown by class A hospitals in regional 3. The total real costs for moderate and severe dialysis showed a higher value than the total tariff for INA-CBGs. For example, the total real cost of a class A hospital in treatment class 2 reached Rp. 30,721,658 while the total tariff for INA-CBGs was Rp. 18,529,800 (p = 0.005). These results indicate that the difference between total real costs and INA-CBGs rates in hospitals is still common, so it is not uncommon to experience negative differences. From the data above, the hospital suffered a loss of Rp. 12,191,858 and the difference will be borne by the hospital. The results of this study are in line with Utami's (2021) research conducted at Dr. Moewardi Hospital Solo, where the real cost value is still higher than INA-CBGs. The amount of real costs compared to INA-CBGs rates was also seen at the Sardjito Central General Hospital, in Azalea's research (2016)⁵ it is written that the real cost of chronic kidney care class 1 reaches Rp. 18,760,724 while the INA-CBGs tariff is only Rp. 7,648,000 (p = 0.000). This resulted in a negative 29.47% cost difference which became the burden of the hospital. The factor causing the difference in the difference in negative claims was caused by the length of time treated for chronic kidney patients in the hospital (p = 0.000).

The high cost in class A hospitals is because class A hospitals are referrals from other health facilities so that patients who come to the hospital are already in severe condition with varied cases, causing longer treatment times and increasing the cost of care⁶. From the analysis of therapy costs, not all of the total real costs for class A hospitals were higher than the rates for INA-CBGs. Dialysis patients for moderate and severe categories in different treatment classes showed a lower total real costs compared to INA-CBGs rates. The same thing also happened in patients with a diagnosis of kidney/urinary tract tumor and mild and severe category of kidney failure and moderate and severe category of kidney/urinary tract infection. The results of this study are supported by Fitri's previous research (2011) concluding the average cost of chronic kidney therapy at Dr. Hospital. Moewardi is lower than INA-CBGs. rates⁷. The same thing is in line with Ahriansyah's research (2019)⁸ thus causing the average difference between INA-CBGs rates and real costs to reach Rp. 185,506.24 with an average profit of 21% (p=0.000). One of the reasons for this difference is the service factor and the provision of EPO to chronic kidney patients who do not follow the PERNEFRI guidelines, causing cost differences. The higher INA-CBG rates compared to the real hospital costs could also be due to inappropriate coding that affects the final diagnosis and procedures that have been carried out during treatment⁵. The total real cost in a class A hospital is quite high seen in patients with a diagnosis of kidney tumor and kidney failure. This condition occurs in both regions 1 and 3 . The highest cost reached Rp.75,936.563.00 at the Makassar Central General Hospital. The high cost is due to the fact that patients who need dialysis undergo various and repeated examinations of their respective kidney function, thus causing the high cost. The high cost is also due to the severity of each patient and the type of treatment class occupied. When reviewed, this value is higher when compared to the INA-CBGs tariff for the same type of diagnosis in a class A hospital. This of course causes losses for the hospital. The high cost is also seen in the diagnosis of kidney tumors and severe kidney failure. It can be seen in table 2 that the cost for diagnosing kidney tumors and severe renal failure is Rp. 40,207,181 for class 1 treatment, while for treatment class 3 patients the cost is Rp. 29,684,963.00. This figure is certainly much different from the amount of INA-CBGs claim rates that have been set. Patients with a diagnosis of kidney tumor and kidney failure show high costs due to risky treatment procedures and a series of surgeries which of course require large costs. Patients with moderate or severe diagnosis will certainly undergo nephrectomy (kidney removal surgery) and kidney transplantation. Such action will require additional costs and increase the total real cost of the hospital.

The difference in the cost of chronic kidney disease therapy in class A hospitals is shown in table 2.

Table 2. Analysis of the Difference in Cost of Chronic Kidney Disease Therapy in Class A Hospitals

Group INA-CBGs	Class	n	Real Cost	Tarif INA CBGs	p	Group INA-CBGs	Class	n	Real Cost	Tarif INA CBGs	p
Group INA-CBGs	Class	n	average	rata-rata	p	Group INA-CBGs	Class	n	Average	average	p
N-1-12-I	Class 1	5	Rp 9,750,563	Rp 9,142,400	0.686	N-1-12-I	Class 2	1	Rp 27,606,174	Rp 7,929,800	-
	Class 2	5	Rp 14,914,091	Rp 7,836,400	0.043*	N-1-12-I	Class 3	3	Rp 13,223,426	Rp 6,608,200	0.109
	Class 3	14	Rp 13,647,573	Rp 6,386,464	0.008*	N-1-12-II	Class 1	4	Rp 32,496,731	Rp 18,203,450	0.144
N-1-12-II	Class 1	5	Rp 17,405,427	Rp 21,435,900	0.500		Class 2	13	Rp 30,721,658	Rp 18,592,800	0.003*
	Class 2	8	Rp 11,296,843	Rp 18,373,700	0.012*		Class 3	29	Rp 28,969,663	Rp 15,494,000	0.000*
	Class 3	23	Rp 14,777,065	Rp 15,311,400	0.412	N-1-12-III	Class 1	2	Rp 75,936,563	Rp 39,523,800	0.655
N-1-12-III	Class 1	1	Rp 15,529,402	Rp 39,061,900	-		Class 2	7	Rp 45,843,627	Rp 33,880,900	0.176
	Class 2	3	Rp 21,806,726	Rp 33,481,600	0.285		Class 3	16	Rp 54,098,765	Rp 28,234,100	0.002*
	Class 3	6	Rp 29,654,835	R p 27,901,400	0.917	N-1-20-II	Class 3	1	Rp 19,509,688	Rp 17,948,100	-
N-4-10-I	Class 2	1	Rp 1,966,901	Rp 6,323,300	-	N-4-10-I	Class 1	1	Rp 6,396,962	Rp 6,398,700	-
N-4-10-I	Class 3	5	Rp 3,811,615	Rp 5,058,600	0.500		Class 2	1	Rp 2,196,284	Rp 5,484,000	-
N-4-10-II	Class 1	1	Rp 12,157,801	Rp 7,648,000	-		Class 3	1	Rp 4,555,298	Rp 4,570,500	-
	Class 2	6	Rp 8,208,226	Rp 6,555,500	0.600	N-4-10-II	Class 2	2	Rp 21,400,161	Rp 6,633,000	0.180
	Class 3	5	Rp 9,968,609	Rp 5,462,900	0.043*	N-4-10-II	Class 3	1	Rp 14,925,638	Rp 5,528,000	-
N-4-10-III	Class 1	2	Rp 6,718,417	Rp 15,197,900	0.180	N-4-10-III	Class 1	1	Rp 40,207,181	Rp 15,377,700	-
	Class 2	3	Rp 8,788,951	Rp 19,845,067	0.109	N-4-10-III	Class 3	4	Rp 29,684,963	Rp 10,984,000	0.144
	Class 3	4	Rp 16,807,668	Rp 10,855,700	0.273	N-4-12-II	Class 1	1	Rp 15,464,776	Rp 21,691,600	-
						N-4-12-III	Class 2	2	Rp 13,011,474	Rp 21,420,950	0.655
						N-4-12-III	Class 3	3	Rp 12,765,688	Rp 21,809,733	0.285
						N-4-16-II	Class 1	1	Rp 19,986,420	Rp 9,870,500	-
						N-4-16-II	Class 3	1	Rp 14,159,020	Rp 15,494,000	-
						N-4-16-III	Class 1	1	Rp 35,568,863	Rp 17,513,400	-
						N-4-16-III	Class 2	1	Rp 27,089,472	Rp 12,509,500	-

Note: Regional I; Rumah Sakit Umum Sardjito, Regional III ; Rumah Sakit Umum Pusat Makasar

Analysis of Differences in Cost of Chronic Kidney Disease Therapy in Class B Hospitals:

The calculation of the cost of chronic kidney disease therapy in class B hospitals is carried out in regional 1 and regional 3. Regional 1 is carried out at the Yogyakarta City General Hospital while regional 3 is carried out at the Labuang Baji Regional General Hospital. Chronic kidney patients who took part in this study had a diagnosis of kidney and urinary tract in other categories (mild, moderate and severe), new procedures in dialysis category (mild, moderate and severe), kidney tumor and urinary tract renal failure category (mild, moderate and severe). moderate and severe), moderate kidney inflammation, kidney infection and urinary tract infections (mild, moderate and severe). The data shows that patients at the Yogyakarta City General Hospital (region 1) have a more complex disease diagnosis than patients at Labuang Baji Hospital (region 3).

The results showed that the cost of chronic kidney disease therapy in Class B hospitals described the tariff adjustment between the total real costs and the INA-CBGs rates. Of all the diagnosis groups studied at the Yogyakarta Regional General Hospital, the total real costs were the same as the INA-CBGs rates. All diagnosis groups in each treatment class showed compliance with the standard cost of the INA-CBGs tariff. Researchers assess the hospital has been able to make efficient funds and work optimally, in adjusting the cost of chronic kidney care. Different things were shown in class B hospitals in regional 3. Patients with a diagnosis of a new dialysis procedure in the medium category showed a higher total real cost compared to the INA-CBGs rates. Dialysis patients in the moderate category showed the highest total real cost (Rp. 31,540,350) for the overall cost in class B hospitals with the INA-CBGs rate of Rp. 15,042,100. This of course causes a loss of Rp. 16,498,250, a situation that is much different from a class B hospital in regional 1 which shows better cost efficiency in the same diagnosis. Patients with a diagnosis of kidney tumor, mild, moderate and severe category of renal failure showed a lower total real cost compared to INA-CBGs rates. The total real cost for kidney tumors in the mild category of kidney failure is Rp. 3,057,731 while the higher INA-CBGs tariff is Rp. 8,135,405 (p = 0.000) as well as in the weight category, the total real cost for treatment class 3 is Rp. 6,353,455 while the tariff for INA-CBGs is Rp.12,848,888 (p=0.000). From the results of these calculations, it can be said that the class B hospital has made fund efficiency, resulting in a positive difference in the cost of chronic kidney care. The results of the statistical test showed that there was no significant difference between real costs and INA-CBGs rates in class B hospitals for regional 1. The significant difference was only seen in regional class B hospitals 3. This is in line with Dumaris' research (2016⁾⁹ and Ahmad Yani (2019)¹⁰. Of the 2384 cases at the Budi Asih Regional General Hospital, 72.95% showed that the hospital rate was less than or equal to the INA-CBGs rate and resulted in a positive difference. The class B hospital was able to make a fund efficiency of Rp. 187,208,273 from the positive difference⁹. Lower real costs are also shown at Aryawinangun Hospital and Waled Hospital, which are class B hospitals in Cirebon. The tariff for INA-CBGs is still 9.9% higher than the real cost. However, the differences shown are not sufficient when compared to the ideal cost value for chronic kidney patients¹⁰. Several hospitals benefited from the fact that the real costs were lower than those set by the INA-CBGs. However, with the benefits obtained by the hospital, they still have to take into account the fixed costs for treating chronic kidney disease¹. Dumaris (2016) writing down one way to make funds efficient is by controlling each item in the action package, using drugs according to the formulary. This step is considered to be able to control the use of funds efficiently. The difference in the cost of chronic kidney disease therapy in class B hospitals is shown in table 3.

Table 3. Analysis of Differences in Cost of Chronic Kidney Disease Therapy in Class B Hospitals

Group INA-CBGs	Class	n	Real Cost	Tarif INA CBGs	p	Group INA-CBGs	Class	N	Real Cost	INA CBGs Rate	P
Group INA-CBGs	Class	n	average	average	p	Group INA-CBGs	Class	N	average	Average	P
N-1-12-I	Class 3	1	Rp 6,357,152	Rp 6,357,152	-	N-1-12-II	Class 2	1	Rp 31,540,350	Rp 15,042,100	-
N-1-12-II	Class 2	2	Rp 11,634,294	Rp 11,634,294	0.655	N-4-10-I	Class 1	3	Rp 4,012,422	Rp 10,929,400	0.109
N-1-12-II	Class 3	1	Rp 9,418,811	Rp 9,418,811	-		Class 2	4	Rp 1,634,526	Rp 9,368,100	0.068
N-1-12-III	Class 1	1	Rp 19,238,003	Rp 19,238,003	-		Class 3	19	Rp 3,057,731	Rp 8,135,405	0.000*
N-4-10-I	Class 2	1	Rp 2,725,619	Rp 2,725,619	-	N-4-10-II	Class 1	21	Rp 4,689,471	Rp 14,828,500	0.000*
N-4-10-I	Class 3	8	Rp 3,442,916	Rp 3,442,916	0.327		Class 2	7	Rp 4,769,569	Rp 12,708,900	0.018
N-4-10-II	Class 1	9	Rp 4,626,656	Rp 4,626,656	0.173		Class 3	21	Rp 3,876,826	Rp 10,793,429	0.000*
	Class 2	10	Rp 6,244,051	Rp 6,244,051	0.575	N-4-10-III	Class 1	5	Rp 9,459,376	Rp 17,220,200	0.080
	Class 3	26	Rp 6,058,646	Rp 6,058,646	0.118	N-4-10-III	Class 3	16	Rp 6,353,455	Rp 12,848,888	0.000*
N-4-10-III	Class 1	4	Rp 8,076,223	Rp 8,076,223	0.465	N-4-12-II	Class 1	1	Rp 9,655,957	Rp 10,591,800	-
N-4-10-III	Class 3	9	Rp 5,361,200	Rp 5,361,200	0.139
N-4-11-II	Class 1	1	Rp 9,136,820	Rp 9,136,820	-
N-4-12-I	Class 1	4	Rp 2,788,056	Rp 2,788,056	0.068
N-4-12-I	Class 3	4	Rp 1,905,750	Rp 1,905,750	0.068
N-4-12-II	Class 2	1	Rp 2,209,898	Rp 2,209,898	-
N-4-12-II	Class 3	4	Rp 1,788,449	Rp 1,788,449	0.068
N-4-12-III	Class 1	1	Rp 6,841,224	Rp 6,841,224	-
N-4-12-III	Class 3	1	Rp 6,046,177	Rp 6,046,177	-
N-4-16-I	Class 1	2	Rp 4,647,583	Rp 4,647,583	0.655
N-4-16-II	Class 1	2	Rp 8,561,757	Rp 8,561,757	0.180
N-4-16-II	Class 3	1	Rp 7,127,942	Rp 7,127,942	-
N-4-16-III	Class 1	2	Rp 8,139,961	Rp 8,139,961	0.655
N-4-16-III	Class 3	2	Rp 3,075,008	Rp 3,075,008	0.180

Note: Regional I; Rumah Sakit Umum Kota Yogyakarta, Regional III; Rumah Sakit Umum Daerah Labuang Baji

Differences in Cost of Chronic Kidney Disease Therapy in Private Class Hospitals:

The cost analysis of chronic kidney disease therapy is not only carried out in government-owned hospitals, but also in private-owned hospitals. This is done to see if there is a difference between real costs and INA-CBGs rates in terms of hospital ownership. The study was conducted at PKU Muhamadiyah Hospital Yogyakarta representing hospitals in regional 1 and Faisal Makassar Islamic Hospital representing hospitals in regional 3. Chronic kidney patients in private hospitals had a diagnosis of moderate category of kidney and urinary tract, new procedure dialysis category (mild, moderate and severe), kidney tumors, kidney failure categories (mild, moderate and severe), moderate kidney inflammation, kidney and urinary tract infections (mild, moderate and severe), moderate urinary stones, urethral and transurethral procedures (mild, moderate). The data shows that patients in private class hospitals in Region 3 have more severity than those in Region 1.

The results showed that the total real cost of chronic kidney disease in private hospitals was higher than the rates for INA-CBGs, although in some diagnosis groups and treatment classes it was also found that the total real costs were lower than the rates for INA-CBGs. The high and low total real costs are seen in regional 1 and regional 3 private class hospitals. The statistical test results show that there is a significant difference between real costs and INA-CBGs rates in the group of patients with a diagnosis of kidney tumor with mild, moderate and severe categories of kidney failure in regional 1. Total real costs in patients with this diagnosis each showed a higher value than the INA-CBGs rates with a significance level of p<0.05. Patients with a diagnosis of mild dialysis showed a value of Rp. 4,343,750 with an INA-CBGs rate of Rp. 3001,700 (p = 0.002) for the medium category, the total real cost was higher than the mild category (p = 0.000) as well as for dialysis in the heavy category the total real value was reach Rp. 10,304,734 (p=0.028). The same thing happened in regional 3, the total real cost showed Rp. 9,840,025 with the INA-CBGs tariff of 14,665,454 (p=0.039). This result shows a positive difference. The hospital gets a profit of Rp.4,825,429 for this diagnosis. The benefits obtained from the efficiency of funds are a good step for improving the care of chronic kidney patients. The positive difference from previous research is also seen in Rahayuninggrum's research (2016)¹¹ shown lower real costs causing a positive difference of Rp. 780,000. The high real cost in private class hospitals is shown in patients with mild, moderate and severe dialysis diagnoses. In all of these categories the total real costs are much higher than the INA-CBGs rates. The results obtained are in line with Rosmila's research (2020)¹² where the real cost is higher than the INA-CBGs tariff. Real costs higher than INA-CBGs rates were also found in patients undergoing mild and moderate urethral and transurethral procedures. All patients in the treatment class showed a much higher total real cost compared to the INA-CBGs rates. The high cost is understandable because of the high severity of chronic kidney disease that requires patients to undergo surgical procedures on the urinary system to improve the body's excretory system. The results of this study are in line with several studies conducted in private hospitals with real costs much higher than the rates for INA-CBGs. Zahirah Hospital suffered a loss of up to Rp.49,039,137 about 4% of the total cost of therapy due to the difference in rates ¹³. Mardhati's research (2017) writes that the value of real costs in private hospitals is also quite high. Length of Stay (LOS), doctor's compliance in prescribing drugs is said to be a factor that makes the cost of medical care high¹⁴. While in Monica’s research (2021) ¹⁵the diagnostic factor also affects because the accuracy in diagnosis and medical treatment is related to the amount of real costs and INA-CBGs rates which will later be claimed in the INA-CBGs software. The real costs which are higher than the INA-CBGs rates in private hospitals must be properly managed and controlled. Therefore, the pricing of medical care costs must be based on and guided by clinical guidelines in order to carry out quality control and cost control effectively and efficiently. The real cost for chronic kidney disease in private hospitals is quite large, in this study it reached Rp. 29,431,528.00 in patients with a moderate category of urinary stone diagnosis who were treated in class 3 regional hospitals 3. While the largest INA-CBGs rate (Rp. 22,770,800) were in patients with severe dialysis who were admitted to class 2 treatment in the same hospital. The difference in the cost of chronic kidney disease therapy in private hospitals is shown in table 4.

Table 4. Analysis of Differences in Cost of Chronic Kidney Disease Therapy in Private Hospitals

Group INA-CBGs	Class	n	Real Cost	INA CBGs Rate	p	Group INA-CBGs	Class	N	Real Cost	INA CBGs Rate	p
Group INA-CBGs	Class	n	average	average	p	Group INA-CBGs	Class	N	average	average	p
N-1-12-I	Class 2	1	Rp 4,081,200	Rp 3,602,000	-	N-1-12-I	Class 1	3	Rp 21,065,630	Rp 5,288,500	0.109
N-1-12-I	Class 3	1	Rp 7,366,200	Rp 3,001,700	-		Class 2	2	Rp 17,458,353	Rp 4,533,000	0.180
N-1-12-II	Class 2	1	Rp 10,690,500	Rp 4,854,400	-		Class 3	3	Rp 13,834,620	Rp 3,777,500	0.109
N-1-12-II	Class 3	2	Rp 9,885,150	Rp 4,045,400	0.180	N-1-12-II	Class 1	11	Rp 19,749,717	Rp 16,246,500	0.248
N-1-12-III	Class 3	1	Rp 11,542,030	Rp 7,007,400	-		Class 2	3	Rp 14,867,490	Rp 15,042,100	1.000
N-4-10-I	Class 1	3	Rp 4,409,000	Rp 4,202,400	0.276		Class 3	10	Rp 15,306,689	Rp 12,535,100	0.169
	Class 2	8	Rp 2,944,838	Rp 3,602,000	0.093	N-1-12-III	Class 2	1	Rp 16,956,636	Rp 22,770,800	-
	Class 3	17	Rp 4,343,750	Rp 3,001,700	0.002	N-1-12-III	Class 3	3	Rp 25,074,574	Rp 22,770,800	0.593
N-4-10-II	Class 1	4	Rp 6,991,950	Rp 5,663,500	0.068	N-1-40-I	Class 3	1	Rp 24,633,199	Rp 7,715,500	-
	Class 2	13	Rp 5,320,362	Rp 4,854,400	0.422	N-1-40-II	Class 3	2	Rp 15,124,746	Rp 10,467,000	0.655
	Class 3	36	Rp 5,402,756	Rp 4,045,400	0.000*	N-4-10-I	Class 1	7	Rp 12,863,324	Rp 10,929,400	0.612
N-4-10-III	Class 1	2	Rp 14,182,000	Rp 9,808,400	0.655		Class 2	4	Rp 6,284,781	Rp 9,368,100	0.144
	Class 2	2	Rp 15,838,900	Rp 8,492,900	0.655		Class 3	3	Rp 6,611,772	Rp 7,806,700	0.285
	Class 3	6	Rp 10,304,734	Rp 7,007,400	0.028*	N-4-10-II	Class 1	13	Rp 9,840,025	Rp 14,665,454	0.039
							Class 2	9	Rp 9,683,728	Rp 12,708,900	0.110
							Class 3	6	Rp 7,054,951	Rp 10,591,800	0.116
						N-4-10-III	Class 1	3	Rp 8,483,726	Rp 15,580,600	0.109
						N-4-10-III	Class 3	2	Rp 3,235,318	Rp 12,301,400	0.180
						N-4-11-II	Class 3	2	Rp 4,630,400	Rp 4,301,800	0.180
						N-4-12-I	Class 3	2	Rp 2,958,077	Rp 2,334,300	0.655
						N-4-12-II	Class 3	2	Rp 7,877,095	Rp 7,897,050	0.655
						N-4-12-III	Class 3	1	Rp 18,397,157	Rp 4,435,400	-
						N-4-13-II	Class 3	1	Rp 29,431,528	Rp 3,457,900	-
						N-4-16-II	Class 2	1	Rp 2,280,165	Rp 4,836,300	-
						N-4-16-II	Class 3	2	Rp 2,923,120	Rp 4,030,700	0.180

Note: Regional I ; Rumah Sakit PKU Muhamadiyah, Regional III, Rumah Sakit Islam Faisal

Table 5. Differences in the Total Cost of Chronic Kidney Disease Therapy Based on Hospital Class

Regional	Hospitals	n	Real Cost			INA CBGs Rate			p
Regional	Hospitals	n	Total	Average	SD	Total	Average	SD	p
Regional 1	Rumah Sakit Umum Pusat Sardjito Jogjakarta	97	Rp 1,329, 851,773	Rp13, 709,812	Rp 10,650, 167	Rp 1,326,816,500	Rp 13,678,521	Rp 7,991,433	0.081
	Rumah Sakit Umum Kota Jogjakarta	97	Rp 536, 852,113	Rp 5, 534,558	Rp 4,240, 053	Rp 602,795,500	Rp 6,214,387	Rp 4,208,027	0.593
	Rumah sakit PKU muhammdiyah Jogjakarta	97	Rp 577, 581,587	Rp 5, 954,449	Rp 3,653, 822	Rp 429,051,000	Rp 4,423,206	Rp 1,423,903	0.000*
Regional 3	Rumah Sakit Umum Pusat Makasar	97	Rp 3,201, 043,693	Rp33, 000,450	Rp 23, 214,493	Rp 1,857,419,200	Rp 19,148,652	Rp 8,474,327	0.000*
	Rumah Sakit Umum Daerah Labuang Baji	97	Rp 470, 443,998	Rp 4, 849,938	Rp 4,340, 583	Rp 1,158,581,400	Rp 11,944,138	Rp 2,899,426	0.000*
	Rumah Sakit Islam Faizal	97	Rp 1,212, 826,072	Rp 12, 503,362	Rp 8,283, 455	Rp 1,132,367,500	Rp 11,673,892	Rp 4,824,102	0.947

Class: Regional I Class A ; Sardjito Central General Hospital, Class B; Yogyakarta City Hospital, Private; PKU Muhammadiyah Regional III Hospital Class A; Makassar Central General Hospital, class B; Labuang Baji Regional General Hospital, Private; Faisal Islamic Hospital.

The results of statistical tests showed that there was a difference in total real costs with INA-CBGs at PKU Muhamadiyah Hospital (p=0.000), Makassar Central Hospital (p=0.000) and Labuang Baji Regional General Hospital (p=0.000). Looking at the comparison of total real costs and INA-CBGs rates, real costs in private hospitals appear to be lower than class A hospitals which are government owned. Likewise for the amount of INA-CBGs claim rates. Meanwhile, the INA-CBG rates for class A hospitals have a higher value than class B hospitals. This result is in line with Budiarto's research¹⁸who calculated the cost of catastrophic disease in several hospitals with different classes. The real cost of class A hospitals is much higher than class B and private classes, this also applies to INA-CBGs rates. Private hospital rates are lower than government hospitals due to differences in rate adjustments. Due to the status as a private sector, the tariff adjustment is carried out as efficiently as possible in order to compete with government hospitals and other private hospitals. Government hospitals whose rates follow local regulations must have special calculations and management so that they are different from other hospital rates. Tania (2017)¹⁹ wrote different things in his research, it was written that there was no difference in the real costs incurred by the hospital, whether it was class B or C for chronic kidney disease and HD. The difference between the two is the investment cost. Government hospitals are funded by the government while private hospitals are not.

CONCLUSION:

From the results of the study, it can be concluded that there is a significant difference between the total real costs and the INA-CBGs rates, both for class A, B and private hospitals. In some treatment groups and classes, the total real cost is still higher than the INA-CBGs rates and vice versa. The average real cost of class A hospitals is higher than that of class B and private hospitals. The highest average real cost is in a regional A class hospital 3. The average real cost in a class A hospital is IDR 33,000,450 for each patient/year. This figure is higher than the INA-CBGs tariff of Rp. 19,148,652 patients/year and shows a statistically significant test result (p=0.000). The total difference obtained is Rp. 13,851,798. The average real hospital cost in regional 1, the highest value reached Rp. 13,678,521 patients/year, this value is in accordance with the INA-CBGs rates in the hospital class. The resulting negative difference becomes a loss and a burden for the hospital.

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Received on 18.03.2022 Modified on 05.07.2022

Research J. Pharm. and Tech 2023; 16(4):1781-1789.

DOI: 10.52711/0974-360X.2023.00293