Tobacco Associated Disease Claims and ICD-10 F17 Tobacco Dependence Coding Among Psychiatric Patients in Indonesia National Health Insurance Dataset: A Retrospective Claims-Based Observational Study, 2015 - 2023

Design: Retrospective claims based observational study using routinely collected administrative claims reported according to STROBE and the RECORD extension. 
Setting: Indonesian national health insurance scheme Jaminan Kesehatan Nasional including referral hospital and primary care claims from 2015 to 2023.
Participants: A national mental health claims sample of 54820 members with at least one ICD 10 mental or behavioral F code diagnosis weighted to 1032022 members and 2074277 referral hospital visits. 
Primary and secondary outcome measures: The primary outcome was verified claim costs in USD for hospital visits with a primary diagnosis of chronic obstructive pulmonary disease J44 or tracheal bronchial or lung cancer C33 to C34 or ischemic heart disease I20 to I25 or stroke I60 to I69. Secondary outcomes were counts of ICD 10 F17 tobacco dependence coding and the disease to F17 coding ratio. Results The four tobacco associated disease groups accounted for 13946 visits among 5223 patients and USD 4.20 million in verified costs representing 6.0 percent of hospital spending in the sample. Weighted costs were USD 74.7 million of which cardiovascular and cerebrovascular disease accounted for 95 percent. F17 appeared in only 51 referral hospital encounters and 26 primary care encounters. Only 2 of 5223 patients with these tobacco associated diseases or 0.04 percent were ever coded with F17. Conclusions The Indonesian national insurer paid substantially for tobacco associated morbidity while tobacco dependence was almost never coded. Smoking related diseases were reimbursed but tobacco dependence treatment was not captured as a financed care target. Embedding brief cessation care reimbursable pharmacotherapy and routine F17 coding into primary care could help shift tobacco related expenditure from downstream complications toward addiction care.