National Health Insurance Membership Association with Disease Claims under Non-Capitation Payment at Primary Healthcare Facilities

Vollständiger Abstract

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Introduction: Primary healthcare plays a central role in Indonesia’s National Health Insurance system in managing population health needs. Understanding morbidity patterns and their relationship with insurance membership categories is essential for service planning and financial sustainability. This study aimed to analyze disease claim patterns at non-capitation primary healthcare facilities and their association with insurance membership types between 2015 and 2023.Methods: A quantitative analytic study using secondary administrative claims data from primary healthcare facilities under the National Health Insurance scheme. The dataset consisted of 201,297 non-capitation service records collected between 2015 and 2023. Variables included diagnosis codes, insurance membership type, sex, and facility characteristics. Data using frequency distribution and chi-square tests to assess the association between insurance membership categories and disease claims.Results: The most frequently reported diagnoses across all membership categories are non-communicable diseases particularly type 2 diabetes mellitus and essential hypertension. Maternal and reproductive health conditions also rank among the top diagnoses especially among government-subsidized participants. A statistically significant association between insurance membership type and morbidity pattern (p < 0.001). The strength of the association is weak.Conclusion: Morbidity patterns in primary healthcare reflect a dual burden of chronic and maternal conditions and vary across insurance membership categories. These findings highlight the need for membership-based intervention strategies and strengthened chronic disease management to ensure sustainability within the National Health Insurance system.