Affecting Factors BPJS Users on the Tiered Referral System in the Pokenjior Community Health Center, Padang Sidempuan City

Health is a human right and one of the elements of welfare that must be realized by the ideals of the Indonesian people as referred to in Pancasila and the 1945 Constitution of the Republic of Indonesia. By the basic philosophy of the state, Pancasila, especially the fifth principle, recognizes the human rights of citizens to health. . This is also contained in article 28 H and article 34 of the 1945 Constitution. In-Law Number 36 of 2009 concerning Health it is emphasized that everyone has the same rights in gaining access to resources in the health sector and obtaining safe health services good quality and affordable. Health is a very important element of the quality of life in national development. The national health system has established that the goal of health development is to increase awareness, willingness, and ability to live healthy for everyone so that a high degree of public health can be realized high human resources, as an investment for socially and economically productive development. (Hasibuan et al, 2020) Health services are one form of basic services that are very much needed by the community, so it is very necessary to Abstract


I. Introduction
Health is a human right and one of the elements of welfare that must be realized by the ideals of the Indonesian people as referred to in Pancasila and the 1945 Constitution of the Republic of Indonesia. By the basic philosophy of the state, Pancasila, especially the fifth principle, recognizes the human rights of citizens to health. . This is also contained in article 28 H and article 34 of the 1945 Constitution. In-Law Number 36 of 2009 concerning Health it is emphasized that everyone has the same rights in gaining access to resources in the health sector and obtaining safe health services good quality and affordable.
Health is a very important element of the quality of life in national development. The national health system has established that the goal of health development is to increase awareness, willingness, and ability to live healthy for everyone so that a high degree of public health can be realized -high human resources, as an investment for socially and economically productive development. (Hasibuan et al, 2020) Health services are one form of basic services that are very much needed by the community, so it is very necessary to  Research and Critics Institute-Journal (BIRCI-Journal) Volume 4, No 2, May 2021, Page: 1822-1831e-ISSN: 2615-3076 (Online), p-ISSN: 2615-1715 www. bircu-journal.com/index.php/birci email: birci.journal@gmail.com always be addressed, to realize fast, accurate, and inexpensive services. (Siregar et al, 2021) Awareness of the importance of social protection security continues to grow by the mandate of the amendment to the 1945 Constitution Article 34 paragraph 2, namely that the State develops a Social Security System for all Indonesian people. The inclusion of the National Social Security System (SJSN) is strong evidence that the government and related stakeholders have a strong commitment to realizing social welfare for all people. Through the National Social Security System (SJSN) as a form of social protection, it aims to ensure that all people can fulfill their basic needs for a decent life. The government implemented the 1945 Constitution by issuing Law Number 40 of 2004 concerning the National Social Security System (SJSN) to provide comprehensive social security for everyone to meet the basic needs of a decent life towards the realization of a prosperous, just, and prosperous Indonesian society.
By the mandate of Law Number 40 of 2004 concerning the National Social Security System (SJSN) and Law Number 24 of 2011 concerning Social Security Administering Bodies (BPJS), it is stipulated that BPJS Kesehatan operations begin on January 1, 2014. BPJS Kesehatan as the Implementing Body is a public legal entity established to administer health insurance programs for all Indonesians. The National Health Insurance (JKN) is part of the National Social Security System (SJSN) which is administered by the Health Social Security Administration (BPJS) through a mandatory social health insurance mechanism. Every JKN participant has the right to obtain comprehensive, tiered, effective, and efficient health services by applying the principles of quality control and cost control based on medical indications.
The referral system is organized to provide quality, effective and efficient health services so that the goal of health services is achieved without the use of expensive costs. The referral system established is in line with the referral system implemented by BPJS Kesehatan. The community can make referrals to the FKTL with the approval of the FKTP so that the role of the FKTP can optimally run according to its function, namely as a provider of basic health services. However, many problems occurred in the FTP, namely the high ratio of referrals from FKTP to FKTL. The referral system means that it aims to run effectively and efficiently, which means reduced waiting for time in the referral process and fewer unnecessary referrals because they can be handled at the FTP. The implementation of a tiered referral system requires BPJS patients to prioritize treatment at a health center, which is a primary service facility. If a patient cannot be treated in a primary care facility, then the patient will be referred to a secondary service facility (Umami, et al., 2017).
The high number of referrals was due to patients with non-medical indications who could still be handled at the FKTP but asked to be referred to the FKRTL, indicating that the patient's trust in doctors in the FKTP was low. The high number of referrals is an indication that the referral system has not been implemented properly so it is important to research the implementation of the referral system by comparing it with the referral system guidelines from the Regulation of the Minister of Health of the Republic of Indonesia Number 1 of 2012 and the Guidelines for the National Referral System.
Based on the initial survey conducted at the Pokenjior Health Center of 2 (two) health workers and 5 (five) BPJS users, it is known that the BPJS service process at the Public Health Center is carried out by BPJS users registering at available counters and then continuing the examination process. After that, a diagnosis is carried out by a doctor to see whether or not a referral is needed. If it is necessary to be referred to a further service, a referral letter will be given, the patient can also immediately ask for a referral letter if the referral visit (control) is repeated with the requirements of a referral letter to an advanced FKTP, namely the Hospital. Based on interviews with several BPJS users seeking treatment at the Pokenjior Health Center, it is known that the reason for BPJS users to ask for referrals is because of the existing equipment.

II. Research Methods
This type of research is an analytical survey research with an explanatory research type, namely through hypothesis testing which aims to determine the factors that influence the tiered referral system at Pokenjior Health Center in Padangsidimpuan City, namely knowledge, attitudes of officers, availability of infrastructure and human resources as well as reference information. This research was conducted at the Pokenjior Health Center, Padangsidimpuan City. The reason for choosing the research location was due to the high number of BPJS patient referrals at the Pokenjior Health Center, Padangsidimpuan City. There is a sample in this study is BPJS health card user patients who undergo health services at the Pokenjior Health Center who meet the inclusion criteria. Samples can be selected because they are at the right time and place. Based on the results of the above calculations, the number of samples taken was 98 people. The hypotheses tested in this study are: (1) There is an effect of the knowledge of BPJS users on the tiered system at Pokenjior Health Center, Padangsidimpuan City. (2) There is an influence of the officers' attitudes on the tiered referral system at the Pokenjior Health Center, Padangsidimpuan City. (3) There is an effect of the availability of infrastructure and human resources on the tiered referral system at Puskesmas Pokenjior, Padangsidimpuan City. (4) There is an effect of referral information on the tiered referral system at Puskesmas Pokenjior, Padangsidimpuan City. (5) Dominant factors affecting the tiered referral system in the working area of the Pokenjior Health Center, Padangsidimpuan City

III. Results and Discussion
This research was conducted at the Pokenjior Health Center, Padangsidimpuan City, North Sumatra Province. Puskesmas Pokenjior is one of the public health center located in the City of Padangsidimpuan in the Padangsidimpuan District of Angkola Julu, to be precise in the southern part. Padangsidimpuan Selatan is located at 00o -02o North Latitude, 98o -49o East Longitude with an altitude of ± 415 meters above sea level and officially merged into the government area of the City of Padangsidimpuan in December 2004. The Pokenjior Community Health Center work area consists of 4 (four) villages, namely Simatohir, Rimba Soping, Mompang, and Joring Natobang with a population of 4,281 people. Skesmas Pokenjior is located at Pokenjior Village, Padangsidimpuan District Angkola Julu. Public health center Pokenjior is an inpatient health center. General practitioners 2 2 Dentist 1 3 Public health 3 4 Midwife 7 5 General Nurse 12 6 Dentist 1 7 Pharmacy 1 8 Nutrition 1  9 Non-health personnel 2 amount 30 Based on table 1 above, it can be seen that the personnel of the Puskesmas Pokenjior Kota Padangsidimpuan in 2018 were 30 people with 2 general doctors, 1 dentist, 3 Public Health personnel, 7 midwives, 12 General Nurses, 1 Dental Nurse. person, Pharmacy 1 person, Nutrition 1 person, and 2 non-health personnel.
Univariate analysis was carried out to obtain a description of the frequency distribution of respondent characteristics (age, gender, education, occupation, personality, length of time as a participant in BPJS for health and health referrals) and research variables included independent variables, namely knowledge (X1), the attitude of officers (X2), availability. infrastructure and human resources (X3), and reference information (X3), and the dependent variable, namely the BPJS tiered referral system (Y).
The frequency distribution of the characteristics of respondents/research samples according to age, based on the results of the study is briefly presented in Table 2  Based on the data in Table 2 above, it can be explained that the characteristics of research respondents according to age, as many as 17 people (17.3%) were less than 30 years old, as many as 47 people (48.0%) were between 30-45 years old and as many as 34 people (34.7%) were more than 45 years old. The results above indicate that the majority of people using BPJS Kesehatan as respondents (samples) in this study are between 30-45 years old as much as 48.0%.
The frequency distribution of the characteristics of respondents / research samples by gender, based on the results of the study, is presented in Table 3  Based on the data in Table 3 above, it can be explained that the characteristics of the research respondents according to gender, as many as 37 people (37.8%) were male and as many as 61 people (62.2%) were female. The results above indicate that the majority of people using BPJS Kesehatan as respondents (samples) in this study are female, as much as 62.2%.
The frequency distribution of the characteristics of respondents / research samples according to education, based on the results of the study is presented in Table 4  Based on the data in Table 4 above, it can be explained that the characteristics of the research respondents according to their education, as many as 5 people (5.1%) did not pass SD / MI, 14 people (14.3%) passed SD / MI, 25 people (25, 5%) passed SLTP / MTs, 36 people (36.7%) graduated from high school / MA, and as many as 18 people (18.4%) were tertiary graduates. The results above show that the people who use BPJS Kesehatan as respondents (samples) in this study, the majority of their education is high school / MA graduates, which is 36.7%.
The frequency distribution of the characteristics of respondents / research samples by occupation, based on the results of the study, is presented in Table 5 below: Based on the data in Table 5 above, it can be explained that the characteristics of research respondents according to their occupation, as many as 25 people (25.5%) do not work or are housewives, 4 people (4.1%) work as private employees, 21 people (21 , 4%) were self-employed, 16 people (16.3%) were civil servants, and as many as 32 people (32.7%) worked as farmers. The results above indicate that the majority of people who use BPJS Kesehatan as respondents (samples) in this study work as farmers, namely as much as 32.7%.
The distribution of the BPJS membership frequency based on the research results is presented in Table 6  Based on the data in Table 6 above, it can be explained that the characteristics of research respondents according to BPJS membership, as many as 39 people (39.8%) received contribution assistance and as many as 59 people (60.2%) did not receive contribution assistance. The results above indicate that the people who use BPJS Kesehatan as respondents (samples) in this study, the majority of participants are noncontributory recipients, which is as much as 60.2%.
The frequency distribution of the characteristics of respondents / research samples according to the length of time they were participants in the BPJS, is briefly presented in Table 7  Based on the data in Table 7 above, it can be explained that the characteristics of the research respondents according to the length of time they were participants in the BPJS, as many as 7 people (7.1%) became BPJS participants 6 months to 1 year, as many as 54 people (55.1%) 1 to 3 years, and as many as 37 people (37.8%) became BPJS participants for more than 3 years. The results above indicate that the majority of BPJS health users who were used as respondents (samples) in this study were BPJS participants between 1 to 3 years, namely as much as 55.1%.
The frequency distribution of the characteristics of respondents / research samples according to the number of health referrals in the last 6 months, based on the research results are briefly presented in Table 8  Based on the data in Table 8 above, it can be explained that the characteristics of the research respondents according to the number of health referrals in the last 6 months, as many as 24 people (24.5%) had made health referrals 1-2 times in the last 6 months, 58 people (59 , 2%) 3-4 times, 14 people (14.3%) 5-6 times and 2 people (2.0%) made health referrals more than 6 times in the last 6 months. The result above shows that the people using BPJS for health who were used as respondents (samples) in this study, the majority have made health referrals in the last 6 months between 3-4 times, namely as much as 59.2%.
Knowledge data (X1) in this study were obtained through a questionnaire given to research respondents with the aim of knowing to what extent patients or BPJS users know the definition of BPJS, BPJS criteria, and the referral system for BJS patients. The number of items in the questionnaire was 12 questions. The results of the questionnaire obtained were then processed and given a score. Furthermore, the respondent's knowledge data were grouped into two criteria, namely good and unfavorable. The frequency distribution of knowledge data (X1) of patients or respondents, based on the results of the study, is briefly presented in Table 9  Based on the data in Table 9 above, it can be explained that the respondent's knowledge regarding the definition, criteria and referral system for BPJS patients, as many as 41 people (41.8%) were in the poor category and 57 people (58.2%) were classified as good. The results above indicate that the majority of BPJS health users who were used as respondents (samples) in this study had relatively good knowledge regarding the definition, criteria and referral system for BPJS patients, namely 58.2%.
Attitude data of officers (X2) in this study were also obtained through a questionnaire given to research respondents with the intention of knowing how the respondent's views or perceptions of the attitudes of officers (nurses and doctors) regarding the tiered referral system while BPJS users are in health facilities. The number of questionnaire questions about the attitude of the officers was 10 questions. The questionnaire results obtained were also processed and given a score. Furthermore, the officers 'attitude data based on the respondents' views or perceptions were grouped into two criteria, namely positive and negative.
The results of the correlation test obtained the Pearson Correlation value of 0.297 with a probability value (Sig) of 0.003 <0.05. Because the probability value is 0.003 <0.05, statistically the fourth hypothesis is accepted, so it can be concluded that there is an effect of referral information on the tiered referral system in the working area of Puskesmas Pokenjior, Padangsidimpuan City.
Multivariate analysis was carried out to determine the effect of BPJS user knowledge (X1), attitude of officers (X2), availability of infrastructure and human resources (X3), and referral information (X4) simultaneously (together) on the tiered referral system (Y) in the region. Puskesmas Pokenjior Padangsidimpuan City. Because the data from each variable, especially the tiered target system variable (dependent variable), is categorized as dichotomous or binary, the multivariate analysis in this study was tested using multiple logistic regression tests with the help of the SPSS 16.0 program. The variables included in the backward method of multiple logistic regression prediction models are those that have a sig or p value <0.25 in their bivariate analysis.
The results of the first multivariate modeling showed that the variable BPJS user knowledge (Sig. = 0.047 <0.05), the attitude of the officers (Sig. = 0.105> 0.05), the availability of infrastructure and human resources (Sig. = 0.007 <0.05) , and reference information variables (Sig. = 0.022 <0.05). Because the significant value for the officer attitude variable is 0.105> 0.05 (not significant), this modeling still has to be continued in the second multivariate modeling, where the officer attitude variable with the highest significant value is excluded from the modeling. Based on Table 18 above, it can be explained that the joint correlation between the knowledge variable of BPJS users (X1), the availability of infrastructure and human resources (X3) and reference information (X4) with the tiered referral system variable (Y) using the Chi-Square technique is obtained a value of 26.496 with a probability value (Sig.) Of 0.000 <0.05, which means that simultaneously (together) the knowledge of BPJS users (X1), the availability of infrastructure and human resources (X3) and referral information (X4) has a significant effect on the tiered referral system. (Y). Based on Table 11 above, it shows that the Nagelkerke R Square value or the logistic regression determinant coefficient is 0.327 which means the contribution of the BPJS user knowledge variable (X1), the availability of infrastructure and human resources (X3) and referral information (X4) to the tiered referral system (Y ) is 32.7% or in other words, the knowledge factor of BPJS users (X1), the availability of infrastructure and human resources (X3) and the referral information factor (X4) together have an effect of 32.7% on the tiered referral system ( Y).  Table 12 above shows the results of multivariate modeling 2, where the knowledge variable of the use of BPJS has a Wald value of 6.908 with a Sig. equal to 0.009 <0.05; the availability of infrastructure and human resources variable has a Wald value of 8.004 with a Sig. by 0.005 <0.05; and the reference information variable has a Wald value of 6.374 with a Sig. amounting to 0.012. These results indicate that the variables of BPJS user knowledge, the availability of infrastructure and human resources as well as reference information variables are the most dominant factors affecting the tiered referral system in the working area of Puskesmas Pokenjior, Padangsidimpuan City. Furthermore, the results above also show that the factor of the availability of infrastructure and human resources has the highest Wald value.

IV. Conclusion
Based on the findings of the research and analysis carried out, the following conclusions are obtained: (1) There is a significant influence on the knowledge of BPJS users on the tiered referral system in the working area of Puskesmas Pokenjior, Padangsidimpuan City. (2) There is an influence of officers' attitudes on the tiered referral system in the working area of the Pokenjior Health Center, Padangsidimpuan City. (3) There is an effect of the availability of infrastructure and human resources on the tiered referral system in the working area of the Pokenjior Health Center, Padangsidimpuan City. (4) There is an effect of referral information on the tiered referral system in the working area of the Pokenjior Health Center, Padangsidimpuan City. (5) Knowledge of BPJS users, availability of infrastructure and human resources, and referral information simultaneously (together) is a factor that has a significant and dominant influence on the tiered referral system in the working area of Puskesmas Pokenjior, Padangsidimpuan City. The availability of infrastructure and human resources factor is the biggest or most dominant factor affecting the tiered referral system in the working area of the Pokenjior Health Center, Padangsidimpuan City.