Introduction

Becomes the oldest hospital in Bali, RSUD Wangaya has gone through many challenges in realizing its vision of “Being an Innovative Hospital and Excellence in Service and Work Culture-Based Education”. In the Age of Health Guarantee National Security Agency (JKN), these challenges are increasingly visible. JKN, which has been implemented by the Health Social Security Administering Body (BPJS) since January 1, 2014, urges all hospitals in Indonesia to cooperate with BPJS Kesehatan. This is to ensure that all Indonesian people are covered by health insurance (total coverage) in order to meet the needs of decent public health. Hamza (2013).There is plenty of evidence that having health insurance increases financial security. Insurance coverage is considered to reduce the risk of large unexpected medical costs (Sommers, Gawande & Baicker 2018).

But on the way, the implementation of the BPJS Kesehatan program encountered many obstacles, one of which was the funding deficit which increased every year. Based on data from BPJS Kesehatan in 2014, BPJS experienced a deficit of 1.94 trillion. At the end of 2015 BPJS experienced a deficit of 5.85 trillion and according to the Director of BPJS Kesehatan Development Planning, Mundiharno, the potential deficit in 2016 was around 9.2 trillion. The President Director of the Health Insurance Agency (BPJS) of Health, Fachmi Idris in the 2015 BPJS Kesehatan public presentation, Wednesday, April 13, 2016 explained that the deficit occurred because actuarially the amount of participant contributions was lower than the health costs incurred (Simanjuntak & Darmawan, 2016).

In fact in 2014, the government has budgeted Rp.26 trillion to fund the preparation and operation of the Health Social Security Administration (BPJS) (Noviani, 2013). The allocation of funds that are not small in fact keeps BPJS in deficit in the first year of operation due to the imbalance between the amount of contributions collected and the health insurance paid (Uly, 2019). This deficit will continue until 2019. The BPJS Kesehatan deficit in 2019, which was originally predicted to be Rp. 28 trillion, has increased to Rp. 32 trillion (Julita, 2019). Whereas in 2019 BPJS Kesehatan should have achieved its target, which is to cover all Indonesian people in the health insurance program (total coverage).

Deficit budget of BPJS Kesehatan raises complex problems in hospitals. This deficit resulted in late payments for hospital health services, which led to a decrease in hospital revenues and hampered hospital operations. The Indonesian Doctors Association explained the impact of the financial deficit at BPJS Kesehatan. The Chairperson of the Executive Board of the Indonesian Doctors Association, Daeng M. Faqih, explained that the financial deficit experienced by the Health Social Security Administering Body (BPJS) had an impact on all parties involved, from hospitals to patients. Daeng in his statement said that the condition of the financial deficit in the National Health Insurance Program had the most impact on the service of health facilities to patients. Hospitals are in arrears in financing for medicines and supporting medical equipment such as medicines with consumables, which if not available, will hinder the work of doctors in treating patients. If a hospital cannot treat patients due to limited medicines and equipment, it will result in referring patients to other hospitals. In that condition, the patient will experience delays in handling which have an impact on his health condition. Thing this certain not in line with the original goal of BPJS Kesehatan, namely: meet appropriate public health needs. In addition to harming the community as patients, the BPJS Kesehatan deficit also has an impact on hospitals as BPJS Kesehatan partners. Hospitals have obstacles in managing BPJS receivable funds which are often late in disbursement (Moeljadi & Tiyas, 2018). In fact, the financial problems at BPJS Kesehatan also affect the remuneration of hospitals, where the services of health workers, namely doctors and nurses, are late being paid (Akbar, 2019). It is feared that this will reduce the performance of health workers and health services themselves.Cooperate with BPJS Kesehatan since January 1, 2014, Wangaya Hospital has the same problems as most hospitals in Indonesia. With apply a tiered referral system by BPJS Kesehatan, Wangaya Hospital which is an Advanced Referral Health Facility (FKRTL) 2, only serve referral patients who need specialist and sub-specialist health services. This causes the number of patient visits to Wangaya Hospital to decrease, especially outpatient visits. In inpatient care, the number of patients treated tends to increase, but most of them are BPJS Kesehatan patients, so there are often delays in paying claims for inpatients, not to mention BPJS Kesehatan rates are lower than the rates set by the hospital.

Decrease The number of patient visits has triggered a decrease in the income of Wangaya Hospital and is exacerbated by the delay in payment of health care claims due to deficit experienced by BPJS Kesehatan. At the beginning of the collaboration, the decline in income was not immediately felt, even hospital revenues tended to increase, even though in 2016 BPJS Kesehatan had started delaying claim payments. The decline in revenue began to occur in 2018, which was 9% of revenue in 2017 and in 2019 there was a decrease in income by 10% of revenue in 2018.

Lateness the payment of hospital claims by BPJS Kesehatan and the decline in hospital revenues have disrupted the operations of Wangaya Hospital. Plus with the status of a government-owned Regional General Hospital, Wangaya Hospital certainly cannot be "free" as a private hospital in carrying out its operational wheels. Besides being squeezed by various bureaucratic rules, Wangaya Hospital must also focus on improving services for the welfare of the community. This does not necessarily make Wangaya Hospital into a profit-oriented organization even though it has the status of the Regional Public Service Agency (BLUD), which incidentally has flexibility in financial management. Minister of Home Affairs Regulation No. 79 of 2018 concerning Regional Public Service Agencies). As a result of the complexity of these problems, health service and support activities are disrupted, such as hospitals being constrained in purchasing medicines, purchase of consumables, payment of salaries of non-civil servants to the disruption of the remuneration system. Development infrastructure supporting health services and infrastructure cannot be carried out optimally. The fulfillment of human resources to improve health services is also hampered because as a BLUD, Wangaya Hospital has to finance non-civil servants from hospital income. With this condition, how is Wangaya Hospital able to maintain its accountability? How is Wangaya Hospital able to answer the challenges of stakeholders in fulfilling their responsibilities?

This research focuses on the accountability of BPJS Kesehatan funds management at the Wangaya Regional General Hospital (RSUD) Denpasar City in the JKN era, where hospitals face a dilemma, between the lack of income due to the BPJS Kesehatan deficit and the demands of hospitals to meet stakeholder needs and prevent information asymmetry between hospital management and stakeholders. Researchers consider research this is important because accountability has become an important aspect of the global health sector (Bakalikwira et al., 2017). Dimensions of accountability which include dimensions transparency, the dimensions of regulation and the dimensions of the Wangaya Hospital's ability to respond to public needs will be the basis for revealing the accountability of BPJS Kesehatan fund management at Wangaya Hospital.

Literature Review

Accountability

Mechanism Accountability is one of the important things in maintaining and improving the performance of public sector organizations (Shillemans, 2016). Accountability is understood as the obligation of the holder of the trust to provide accountability, present, report and disclose all activities and activities that are their responsibility to the party giving the trust who has the right of authority to ask for accountability. The essence of the concept of accountability is that when the agent makes a decision, there must be a report to the principal (Acker & Bouckaert, 2017). Accountability is an instrument used to control and see the extent to which the achievement of the results of an organization's performance in responding to all demands for the application of good governance principles (effectiveness, efficiency, and transparency).

Theory Stakeholders

Theory Stakeholders views that the company is not an entity that only operates for its own interests, but must provide benefits to its stakeholders (shareholders, creditors, consumers, suppliers, government, society, analysts, and other parties). The survival of the company depends on the support of stakeholders and such support must be sought so that the company's activity is to seek such support. The more powerful the stakeholders, the greater the company's effort to adapt (Widianto et al., 2018). urge stakeholders of the importance of implementing accountability by implementing the principles good governance which includes transparency and a sense of justice in every organization is a phenomenon that must be observed by every organization, especially the public sector so that the organization can be trusted.

Agency Theory

In build stakeholder trust, public sector organizations must build their accountability on the basis of the expectations of stakeholder’s principal, not for the sake of the agent's interest alone. Agency Theory (Agency Theory) Jensen & Meckling (1976) assumes that the principal does not have enough information about the performance and condition of the company. Agents have more information about their own capacity, work environment, and overall company prospects in the future compared to principals (Hidayat, 2016). This is what causes an imbalance of information held between the principal and the agent, resulting in information asymmetry. The emergence of agency problems occurs because there are parties who have different personal interests but work together in different divisions of authority. This agency problem can be detrimental to the principal because the principal does not get adequate information and does not have sufficient access to manage the company. Problem this agency and information asymmetry can be minimized by implementing accountability in the organization.

Method

Research This study uses an interpretive paradigm with a case study approach. Case study research was chosen because: Case studies in the methodological treasures are known as comprehensive, intense, detailed and in-depth studies and are more directed as an effort to examine contemporary or contemporary problems or phenomena. Case studies have developed as an effective methodology for investigating and understanding complex real-world problems. Case study designs have been used in a number of disciplines to answer various research questions (Harrison et al., 2017).

This research was conducted at the Wangaya Regional General Hospital (RSUD) Denpasar City. The Wangaya Regional General Hospital (RSUD) is a regional general hospital owned by the City Government Denpasar and is a Class B Teaching Hospital which was established in 1921. RSUD Wangaya has the status of Regional Public Service Agency (BLUD) since 2008. Wangaya Hospital is located at Jalan Kartini No. 133 Denpasar, occupies a land area of 23,271 m², with a building area of 12,063,372 m2.The reasons researchers chose Wangaya Hospital Denpasar City, among others:

1) Wangaya Hospital is one of the hospitals that experienced a decrease in revenue due to the tiered referral system and the BPJS Kesehatan deficit, which disrupted hospital operations. With the implementation of a tiered referral system by BPJS Kesehatan, Wangaya Hospital which is the Advanced Referral Health Facility (FKRTL) 2, only serve referral patients from

2) FKRTL 1 who require specialist and sub-specialist health services. It was recorded that the decrease in revenue occurred by 9% in 2018 from the previous year and by 10% in 2019.

3) The highest number of patient visits at Wangaya Hospital are patients who are BPJS Kesehatan participants, which is 70-80% in 2017 to 2019, since the Bali Mandara Health Insurance (JKBM) is no longer enforced.

4) As a hospital owned by the Denpasar City government, Wangaya Hospital has had the status of a Regional Public Service Agency (BLUD) since 2008. Based on the Minister of Home Affairs Regulation no. 79 of 2018 concerning Regional Public Service Agencies, which means Regional Public Service Agency, hereinafter abbreviated as BLUD, is a system implemented by the technical implementing unit of the regional service/agency in providing services to the community that has flexibility in the pattern of financial management as an exception to the provisions of regional management in general. Flexibility is the flexibility in the pattern of financial management by applying sound business practices to improve services to the community without seeking profit in order to promote general welfare and educate the nation's life.

5) With the status of a government-owned Regional General Hospital, Wangaya Hospital certainly cannot be "free" as a private hospital in carrying out its operational wheels. Besides being squeezed by various bureaucratic rules, Wangaya Hospital must also focus on improving services for the welfare of the community. This does not necessarily make Wangaya Hospital into a profit-oriented organization even though it has the status of the Regional Public Service Agency (BLUD), which incidentally has flexibility in financial management. Minister of Home Affairs Regulation No. 79 of 2018 concerning Regional Public Service Agencies).

The data in this study are primary data obtained through interviews and secondary data in the form of regulations and hospital accountability reports related to the management of BPJS Kesehatan funds, hospital income reports from 2014 to 2019 and reports on the number of patient visits, theses, as well as the mass media. The interview technique used in this research is in-depth interview or interview in-depth interview with informants who have insight and are directly involved with the management of income sourced from BPJS Kesehatan. To prevent bias in the interview results, researchers used interview guides, cameras and voice recorders as media to record the interview process with informants. The data processing of the interview results was carried out in several stages, including coding the interview transcript data for each subject, followed by compaction of facts, namely reconstructing the subject sentence into a sentence that is well organized and can make it easier for researchers to understand the meaning of the subject's narrative. After data compaction is done, it is continued with interpretation, namely conclusions to categorize these facts into psychological themes. After the compaction of facts is done thoroughly on all the data owned by the researcher and interpretation is carried out, the next step is the collection of similar facts. The purpose of collecting similar facts is to determine the quality of psychological facts that have been obtained from interview or other verbatim data. Collecting similar facts helps researchers to systematize categorization and ultimately find key themes as material for narrating data. (Mahpur, 2017).

Results and Discussion

After interviewing the informants and the data was complete, the results of the interviews were written in an interview manuscript then coded. Interview manuscripts were given code W, informant 1 was given code I1, informant 2 was given code I2, and so on. The implementation of the application of WI1(01) code refers to the data unit that is collected through interviews with Informant 1, where the data is taken from the interview manuscript notes in section 1. The accountability side of Wangaya Hospital that we would like to find through this research is the dimensions of transparency, compliance with regulations, and the dimensions of the Wangaya Hospital’s ability to respond to the public needs. Therefore, the data from the interviews were categorized (categorizing) based on these three dimensions. The next step is comparing the data obtained from the interviews with reports, minutes and regulations related to the management of income sourced from BPJS Health, and in the last stage, researchers conduct manual analysis to identify the final results of the study.

From the results of the study, it was found that the impact of the BPJS Kesehatan deficit and BPJS Kesehatan delays in paying claims submitted by Wangaya Hospital caused a shock to the hospital's cash flow, as stated by Informant I3 at WI3 (02) and Informant I1on WI1 (01). To overcome the cash flow problem, the management of Wangaya Hospital took several policy steps, including conducting comparative studies to other hospitals to find out what efforts other hospitals were doing so that they could overcome the deficit and even achieve a surplus of income, evaluate rates by comparing rates per actions with INA CBG's rates, preparing unit costs, namely the costs required per medical action given to patients and making efficiency in all lines. This is in accordance with the statement of Informant I1 on WI1 (01) and reinforced by the statement of Informant I3 on WI3(02). Informant I3 on WI3 (02) and WI3 (03) confirmed that efficiency does not reduce the quality of services provided to patients. In fact, hospitals that were previously “wasteful”, with efficiency, services become more effective. Services to the community can still be carried out even though the hospital's financial management is in a chaotic condition, as stated by Informant I1 in WI1 (06).

In response needs for the public, Wangaya Hospital overcomes the disruption of the hospital's cash flow by making loans to banks. Funds from the bank are used for hospital operations and returns are made when the hospital claim has been paid by BPJS Kesehatan, as stated by Informant I1 on WI1 (04) and Informant I3 on WI3 (02). Regarding the complaint regarding the availability of drugs, Informant 4 on WI4 (03) said that the hospital had tried to prevent a shortage of drugs. If one of the drugs is not available, the hospital will communicate with partners so that the drugs that are not available will be replaced with other drugs with similar content. Communication is an important key in solving this drug problem as continued by Informant I4 on WI4 (10) and supported by Informant I3 on WI3 (08). Still according to Informant I4 on WI4 (02), the Wangaya Hospital also wrote to partners regarding delays in drug payments.

In addition to meeting the availability of drugs, accountability in the dimension of responding to public needs in the era of BPJS Kesehatan deficit is realized by Wangaya Hospital in providing maximum health services. Informant 6 at WI6 (06) and WI6 (12) said that during health care at Wangaya Hospital there were no obstacles and differences in services provided between general patients and BPJS patients. Those who use BPJS Kesehatan are still well served. The infrastructure in the service is also felt to be quite adequate in terms of health and administrative services. Meanwhile, for the transfer of patients from type C hospitals to Wangaya hospitals, there were never any problems. Informant 7 on WI7 (10) said that the process of transferring patients to Wangaya Hospital can always be carried out properly.

In responding to the needs of internal stakeholders, Wangaya Hospital has also made maximum efforts, namely by providing rewards in the form of the application of fee for service to doctors for their support in an effort to implement an effective and efficient service revolution, as stated by Informant I1 on WI1 (01). Informant I2 on WI2 (11) and Informant I3 on WI3 (07) also said that payment for services was also carried out maximally so that there was no crisis of trust from internal stakeholders to management.

In realizing accountability for compliance with regulations, Wangaya Hospital always relies on applicable laws and regulations and every policy has a legal basis, as conveyed by Informant I1 in WI1(11) that for fee for service determination there is a Director's Decree which regulates as well as for loans. the bailout fund carried out by Wangaya Hospital has been approved by the Mayor of Denpasar through the Supervisory Board, as stated by Informant I3 on WI3 (11).

Realizing transparency accountability, all problems that arise due to the disruption of the Wangaya Hospital's cash flow can be overcome by the disclosure of information between the Wangaya Hospital management and stakeholders. Informant I3 at WI3 (03) said that from the beginning the management of Wangaya Hospital had involved stakeholders in every decision-making process.Management is open with all stakeholders and involves stakeholders in implementing policies, especially doctors as service providers. In line with what was conveyed by Informant I3, Informant I1 on WI1(07) and Informant I2 on WI2(24) explained that the process of delivering information is usually carried out in meetings involving all units and the Supervisory Board of Wangaya Hospital. In addition to conveying information verbally through meetings, Informant I1 at WI1 (10) revealed that the form of accountability of Wangaya Hospital to the owner (Denpasar Mayor) is also carried out by sending hospital performance reports every 6 months. Regarding borrowing from banks to facilitate hospital operations,

As a form of financial transparency, Informant I2 on WI2 (14) stated that payments to partners or payments for services have been made by RSUD Wangaya using non-cash payments through mobile banking. In relation to all information regarding the payment of services paid to the doctor, sent via email to the doctor concerned. Informant I2 added on WI2 (22) and Informant I3 on WI3 (04) that the collateral for loans to Bank BPD is BPJS receivables,

Conclusion

The deficit condition that hit BPJS Kesehatan had an impact on almost all BPJS Kesehatan partner hospitals. Wangaya Hospital Denpasar City is one of the BPJS Kesehatan partner hospitals where 80% of the patients are BPJS Kesehatan users. In the 2018-2019 period, Wangaya Hospital experienced a decrease in revenue due to BPJS Kesehatan regulations that did not allow cost contributions so that there was a negative difference between hospital rates and INA CBG's rates. In addition, the frequent delays in payment of hospital claims by BPJS Kesehatan have an impact on the disruption of the Wangaya Hospital's cash flow and threaten the continuity of hospital operations.

Even though it is in a state of deficit, Wangaya Hospital still strives to provide optimal services to the community and maintain the continuity of hospital operations. All the success of Wangaya Hospital in overcoming problems in the BPJS Kesehatan Deficit Era cannot be separated from the efforts of Wangaya Hospital in realizing accountability in the dimensions of transparency, regulation dimensions and dimensions of responding to public needs.

Accountability in the dimension of transparency is shown by the Wangaya Hospital management by always involving its stakeholders, both internal and external, in making every policy. Management realizes that internal stakeholders, especially doctors, have a vital role in the continuity of Wangaya Hospital services. No less important, the owner in this case the Mayor of Denpasar and his representative, namely the Supervisory Board, are the main supporters and determinants in every policy taken by the management. Communication is the key in finding solutions to any problems encountered. The management always tries to communicate with stakeholders through meetings, hearings and direct correspondence. In terms of financial transparency, payment of bills for drugs and doctor's services is made by transfer and details of the amount of services paid are sent via email to each doctor. In addition, to maintain the security of claim funds paid by BPJS, as long as the loan is carried out, the incoming funds are transferred to the escrow account of Wangaya Hospital.

In compliance with regulations, all policies taken are based on applicable laws and regulations. This can be seen from the regulations that form the basis for the Wangaya Hospital in making policies and evidence of regulations such as IKS with Bank BPD Bali and the Director's Decree regarding Details of JKN Patient Claims.

In the dimension of responding to public needs, the accountability of Wangaya Hospital is indicated by: perform efficiency, compile unit costs and use the proceeds from claims for payment of bailout funds from banks. Efficiency is done by providing services with generic drugs and a very thorough history of the patient so it does not require additional examination. The unit cost preparation itself aims to calculate every detail of the costs needed to carry out an action (health services). While borrowing at the bank is a solution for Wangaya Hospital in solving the problem of disrupted cash flow. By doing efficiency, income and costs are directly proportional so that Wangaya Hospital is able to reach the break event point. Although efficiency is carried out on all fronts, this does not reduce the quality of service at Wangaya Hospital. It is proven that patients who use services at Wangaya Hospital and hospitals that refer patients to Wangaya Hospital do not feel the impact of the disturbed cash flow condition because the services provided by Wangaya Hospital are considered satisfactory. In addition, the distribution of medical services and payment of salaries for contract employees can still be carried out. This shows that Wangaya Hospital has been able to realize its accountability in responding to the needs of the public or its stakeholders.

Based on From the description above, it can be concluded that Wangaya Hospital has implemented accountability, both from transparency dimension, dimensions of compliance with regulations and dimensions of the ability of Wangaya Hospital in responding to public needs. Accountability is a form of individual/group accountability for the authority that has been delegated by a higher party to him, so that the authority is carried out in accordance with the interests of the organization and accountability can also be used as a means of controlling things that deviate from the main goals of the organization. By realizing accountability, Wangaya Hospital has been able to protect stakeholders and prevent information asymmetry.

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