The Effect of Outpatient Health Services on Health Social Security Administrator Participant Satisfaction

The purpose of this study was to determine the effect of outpatient health services on the satisfaction of BPJS health participants. This type of research is an analytic survey with a cross sectional approach using primary data with questionnaires and secondary data from Puskesmas reports. The population in this study were all outpatients who participated in BPJS Kesehatan who visited Puskesmas Aek Habil Sibolga City with a total sample of 95 people who were determined using the accidental sampling method. The analysis used univariate, bivariate and multivariate analysis. Chi square test results showed that responsiveness (p = 0.001 <0.05), reliability (p = 0.000 <0.05), assurance (p = 0.002 <0.05), caring (p = 0.000 <0.05) and physical evidence (p = 0.060> 0.05). The logistic regression test shows that the variable that most influences patient satisfaction is care with an Exp (B) value of 4.781. The conclusion of this study is that responsiveness, reliability, assurance, care have a relationship with patient satisfaction, while physical evidence has no relationship with patient satisfaction. Efforts are needed to improve the quality of outpatient services by increasing a sense of attention to patients and being able to provide good responses in response to patient complaints so that a harmonious relationship between health workers and patients is established in order to achieve services that are able to satisfy patients.


Introduction
One of the government's efforts in realizing the highest health degree and the goal of health development towards a healthy Indonesia is that the government sets the National Health Insurance (JKN). Health Social Security Administering Bodies, hereinafter referred to as BPJS Kesehatan, are legal entities established to administer the Health Insurance program (Farianita, 2015).
The community health center (Puskesmas) is one of the public health service facilities that provides comprehensive and integrated services to the community in its working area in the form of main activities (Arianto, 2017). Puskesmas as one of the public health organizations in carrying out its duties is required to be able to provide satisfaction with the patient (Yuswantoro, 2018).
Community service can be said to be good if the community can easily get services and procedures that are not long, low cost, fast time and almost no complaints are given to them (Butar-Butar & Simamora, 2016). There are five main dimensions of satisfaction in health services including responsiveness, reliability, assurance, empathy and physical evidence (Librianty, 2017).
The community health center (Puskesmas) of Aek Habil is one of the health service providers located in Sibolga City, North Sumatra. This Puskesmas is located in an urban area so that it has a fairly large working area. Many patients visit every day, especially outpatients. However, in recent months the number of visiting patients has decreased. This is one of the reasons that Puskesmas Aek Habil is a suitable place to measure the health services provided from various aspects.
The results of the patient satisfaction survey report in 2019 found that patients gave complaints related to delays in service at the pharmacy, waiting too long at the registration counter because the officers took a long time to look for files, ignorant officers and lacking doctors so that the service was less effective and the parties puskesmas conducts monitoring again related to these service problems.
A preliminary study conducted by researchers at the Aek Habil Public Health Center in Sibolga City by interviewing 12 outpatient BPJS participants who were currently undergoing treatment showed that 8 respondents expressed dissatisfaction with outpatient services because 3 respondents stated complaints of ineffective service speed and 5 respondents expressed complaints about the unfriendliness of health workers when providing services. So that not a few patients ask for referrals to be able to get services at the hospital, even though their illnesses can still get help from the public health center.

Methods
This research was conducted at Puskesmas Aek HabilKota Sibolga in 2020. The time used in carrying out this research started from February to August 20120. The population in this study included all outpatients who participated in BPJS Kesehatan who visited Puskesmas Aek Habil Kota Sibolg which on average -The average monthly visit is 2,081 people. Sampling using the Slovin formula as many as 95 respondents with the sampling technique by accidental sampling. This type of research is an analytical survey research (survey or research that tries to explore how and why health phenomena occur) using a cross-sectional design, which aims to measure or observe at the same time (one time) between risk factors, namely to analyze the effect of health services. Outpatient care towards the satisfaction of BPJS health participants at the Aek Habil Community Health Center, Sibolga City in 2020.  Based on the table above, it can be seen that the respondents with primary education as many as 9 people (9.5%), 13 people from junior high school (13.7%), 40 people from high school (42.1%) and 33 people from college (34 , 7%). Based on table 4.3 it can be seen that the respondents as civil servants were 18 people (18.9%), respondents who worked as private employees were 14 people (14.7%), selfemployed as many as 16 people (16.8%), workers as many as 22 people (23.2%), and did not work as many as 25 people (26.3%). Based on the table above, it can be seen that of the 95 respondents who have the age category of adolescents as many as 22 people (23.2%), adults as many as 44 people (46.3%) and the elderly as many as 29 people (30.5%). Based on the table above, it can be seen that of the 95 respondents who thought the service responsiveness at Aek Habil Puskesmas was not good, 44 people (46.3%) and those who thought that the service responsiveness at Aek Habil Puskesmas was good as many as 51 people (53.7%). Based on the table above, it can be seen that of the 95 respondents who thought that service reliability at Aek Habil Health Center was not good, 44 people (46.3%), and those who thought that service reliability at Aek Habil Puskesmas was good was 51 people (53.7%). Based on the table above, it can be seen that of the 95 respondents who thought that service guarantees at Aek Habil Health Center were not good as many as 49 people (49.5%) and who thought that service guarantees at Aek Habil Puskesmas were good as many as 50 people (50.5%). Based on the table above, it can be seen that of the 95 respondents who thought that service care at Aek Habil Health Center was not good, there were 47 people (49.5%), and 48 people who thought that service at Aek Habil Health Center was good were 48 people (50.7% ). Based on the table above, it can be seen that of the 95 respondents who thought that the physical evidence of service at Aek Habil Health Center was not good as many as 47 people (49.5%), and who thought that the physical evidence of service at Aek Habil Health Center was good as many as 48 people (50.5%). Based on the table above, it can be seen that of the 95 respondents who thought they were unsatisfactory with the health services provided by the Aek Habil Health Center as many as 63 people (66.3%) and those who thought that they were satisfied with the health services provided by the Aek Habil Health Center were 32 people (33.7 %). Based on table 11, it is known that of the 95 respondents, the majority of respondents thought that the service responsiveness at Aek Habil Public Health Center Sibolga was good as many as 51 people (53.7%) felt less satisfied as many as 26 people (33.8%) and were satisfied as many as 25 (17 , 2%). Meanwhile, a minority of respondents thought that the service responsiveness at Aek Habil Public Health Center, Sibolga City was not good, as many as 44 people (46.3%) felt less satisfied as many as 37 people (29.2%) and felt satisfied as many as 7 people (14.8%).

Results and Discussion
The results of the Chi-Square test obtained a probability value (p-value) = 0.001 <0.05, this indicates that there is a relationship between responsiveness and patient satisfaction at Aek Habil Public Health Center, Sibolga City in 2020. Based on table 12, it is known that from 95 respondents the majority of respondents thought that the service reliability at Aek Habil Health Center Sibolga was good as many as 51 people (53.7%) felt less satisfied as many as 25 people (33.8%) and were satisfied as many as 26 (17, 2%). While a minority of respondents thought that the service reliability at Aek Habil Public Health Center Sibolga was not good as many as 44 people (46.3%) felt less satisfied as many as 38 people (29.2%) and were satisfied as many as 6 (14.8%).
The results of the Chi-Square test obtained a probability value (p-value) = 0.000 <0.05, this indicates that there is a relationship between reliability and patient satisfaction at Aek Habil Public Health Center, Sibolga City in 2020. Based on table 13, it is known that of the 95 respondents the majority of respondents thought that the service guarantee at Aek Habil Public Health Center in Sibolga City was not good as many as 52 people (54.8%) felt less satisfied as many as 42 people (34.5%) and were satisfied as many as 10 (17 , 5%). While a minority of respondents thought that service guarantees at Aek Habil Public Health Center in Sibolga City were good as many as 43 people (45.2%) felt less satisfied as many as 21 people (28.5%) and were satisfied as many as 22 (14.5%).
The results of the Chi-Square test obtained a probability value (p-value) = 0.002 <0.05, this indicates that there is a guarantee relationship with patient satisfaction at Aek Habil Public Health Center, Sibolga City in 2020.

Table 14. Cross-tabulation of the Relationship between Concern and Patient Satisfaction at
Aek Habil Public Health Center, Sibolga City The results of the Chi-Square test obtained a probability value (p-value) = 0.000 <0.05, this indicates that there is a relationship between care and patient satisfaction at Aek Habil Public Health Center, Sibolga City in 2020. Based on table 15, it is known that of the 95 respondents the majority of respondents thought that the physical evidence at Aek Habil Public Health Center Sibolga was good as many as 48 people (50.5%) felt dissatisfied as many as 27 people (31.8%) and felt satisfied as many as 21 (16 , 2%). Meanwhile, a minority of respondents thought that the physical evidence at Puskesmas Aek Habil Sibolga City was not good as many as 47 people (49.5%) felt less satisfied as many as 36 people (31.2%) and felt satisfied as many as 11 (16.8%).
Chi-Square test results obtained probability value (p-value) = 0.060> 0.05, this indicates that there is no correlation between physical evidence and satisfaction of Pasiendi Puskesmas Aek Habil, Sibolga City in 2020. The results of the first stage regression analysis show that there are 2 variables that have a p-value <0.05, namely responsiveness (0.025) and concern (0.042). Meanwhile, the reliability, assurance and physical evidence variables have a p-value> 0.05. So that for the next stage of the logistic regression test the variables reliability, guarantees and physical evidence are issued and for variables that have a p-value <0.05, it is continued to the next stage The results of the second stage regression analysis showed responsiveness with a pvalue of 0.013 <0.05 and a caring p-value of 0.003 <0.05. From the above analysis, the most dominant variable with patient satisfaction is care with a p-value of 0.003 <0.05 and an Exp (B) value of 4.781, which means that the care given by health workers to patients is 4.781 times greater in influencing patient satisfaction.
The results of this study are in line with research conducted by Abidin (2017) entitled "The Effect of BPJS Health Service Quality on Patient Satisfaction at Cempae Public Health Center, Parepare City" which shows that the better the responsiveness of health workers, the more satisfied patients will be with the health services provided ( Abidin, 2016).
Responsiveness is related to the ability of health workers to help users and their readiness to serve patients according to standard procedures and who can meet user expectations. The expectations of health service users for the speed of services tend to increase from time to time in line with advances in technology used by service providers and health information owned by users. Health services that are responsive to user needs (Calundu, 2018).
The concept of patient satisfaction can also be used as a reference for each puskesmas to serve as evaluation material. Puskesmas as a health service institution that has capital and human resources, requires good management. The main key to the success of the Puskesmas lies in two main things, namely the effective and efficient use of resources, especially human resources, and the satisfaction of the health center service users (patients and families) (Az-Zahroh, 2017).
The results of this study are in line with research conducted by Fajri (2016) with the title "Analysis of the Influence of Health Service Quality on Patient Satisfaction at the Karanganyar District General Hospital" which shows that the T test results show that the variable of concern has a significant effect on patient satisfaction. The results of the F test show that the empathy variable simultaneously has a significant effect on patient satisfaction (Pratiwi, 2016).
Empathy is related to the staff's special care and attention to each service user, understanding their needs and making it easy to call back at any time if service users want their help, good communication between doctors and patients, personal approach (Calundu, 2018).
This study shows that the comfort dimension concerning good communication is established between health workers and patients, giving special attention to each patient, health workers meeting patient needs, patients getting information and assistance from health workers easily, and patients getting attention and response both for any complaints from health workers have a relationship with patient satisfaction.
Emphaty is a concern by providing a sincere and individualized attitude given to patients by the hospital, such as the ease of contacting the health center, the ability of employees to communicate with patients and the efforts of the puskesmas to understand the patient's wants and needs. Where a health center is expected to have an understanding and knowledge of patients, understand specific patient needs, and have a comfortable operating time for patients (Tores, 2015).
From the above understanding, it can be concluded that concern is special or individual attention to all patient needs and complaints, and good communication between employees and patients. With special attention and good communication from employees on patients, it will also affect patient satisfaction, because patients will feel cared for by the hospital, that is what they need and their complaints are well responded to by the hospital (Pratiwi, 2016).

Conclusion
The results showed that responsiveness and care had an influence on patient satisfaction. Meanwhile, reliability, assurance and physical evidence have no effect on patient satisfaction. The variable that most influences patient satisfaction is the care shown by health workers to the patient with 4.781 times greater influence on patient satisfaction. It is recommended that health workers have a sense of concern for patients and be able to provide good responses in response to patient complaints. So that there is a harmonious relationship between health workers and patients in order to achieve services that are able to satisfy patients.