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METODOLOGI KOSTING

INA CBGs

National Casemix Center


Outline

Metodologi kosting dlm INA CBG


Kebutuhan data kosting
Cara penghitungan tarif INA CBG
Praktek penghitungan
- Unit Cost
- Hospital based rate
METODOLOGI KOSTING INA CBG

Kombinasi stepdown/topdown dan bottom up costing

Dimulai dng stepdown costing


Hasil dari Stepdown Costing adalah unit cost perkunjungan dan unit
cost per hari rawat ( average cost per unit of service provided is
across providers, and for one provider, across patients and time.)

Menghitung Cost per CBG


Conduct Activity Based Costing on selected cases
based on Clinical Pathways (Optional)
Refine Cost per CBG when necessary
Develop Cost-weights, Casemix Index & Base Rate
Develop INA-CBG Tariff
Prinsip Stepdown Costing
The essence of the Step-down costing
methodology is to accurately determine the
cost of achieving program outputs or results,
by allocating all the costs of running a
hospital to departments providing the final
output of the hospital.
(Lewis et al 1990, Drummond et al 1997)

Step-down costing starts with total


expenditures & then divides these by a measure of total
output to give
averagecost per patient per visit, per
day or per admission.
(Creese and Parker 1994
Cost Accounting Methodologies
Compared
Bottom-up Approach Top-down Approach
Microcosting, Detailed Costing Macrocosting, Gross Costing, Average
A.K.A. Costing
To calculate the individual cost of a service To calculate the average cost for a volume
Objective or patient. of services or patients.

Best For Unit cost point estimates Relative unit costs


1. Measure the quantity of resources 1. Document the total cost of resources used
consumed by a service/patient by a hospital
2. Attach a unit cost to each resource 2. Assign costs to departments directly

Process 3. Sum the unit costs to calculate the total cost 3. Allocate costs to departments
per service/patient proportionally according to their
4. Construct the average cost for a particular consumption of resources
service or patient group 4. Divide department costs by its service
volume to estimate unit costs
Unit cost estimates are built from the Unit cost estimates are averaged from the
Cost Flow individual service or patient level upwards facility and department level downwards

Resource DRG Forum 5 | R4D.org


Bottom-up Approach

Resource DRG Forum 6 | R4D.org


Top-down Approach

Resource DRG Forum 7 | R4D.org


Unit Cost Interpretation

Top-down results are best for relative cost comparisons and bottom-up
results are best for absolute cost estimates.
Top-down Costing Results Bottom-up Costing Results
Unit Cost of Hospital Discharge Unit Cost of Complicated Delivery
$140 $140 $5

Cost per Complicated Delivery by Cost Component


$10
$4
$120 $120 $14 $10
Capital
$14
$100 $100 $4
Cost per Discharge

$8 $36 Other
$12 $29 Opera ng
$80 $80
Diagnos c
$140
$20
$60 $60
$110 Drug/Medical
Supply
$40 $80 $40 $75 Labor
$68
$56
$20 $20

$0 $0
Medicine Surgery Maternity Pa ent 1 Pa ent 2 Pa ent 3
Selected Hospital Departments Sample of Pa ents

The average cost of a Medicine discharge is $80, compared to On average, a complicated delivery costs $122, ranging
$140 for Surgery and $110 for Maternity. Assuming the from $100 to $140 across patients. Staff time and
average hospital discharge costs $100, the cost weights are drugs/medical supplies account for the majority of the cost,
0.80, 1.40, and 1.10 respectively. at 55% and 23%.

Resource DRG Forum


Mixed Methods

Top-down costing exercises sometimes use bottom-up approaches


to generate allocation statistics or to cost a limited number of
services to validate top-down cost estimates.

Bottom up designs within a top down costing exercise typically include bottom up
measurement of:
Priority services, treatment episodes, activities, or cost items
Services that are heterogeneous in their resource use (vary widely in their complexity and cost
e.g., ICU services, laboratory tests, surgical procedures
Services where precision and accuracy of cost measurement is considered important
Services where there is heavy personnel time or overheads that go into a technology
Services or technologies where there is extensive sharing of personnel, buildings, or equipment
Cost items that are anticipated to have the highest impact on total cost
Data that are missing or not routinely captured
Data for allocation statistics (e.g., personnel time worked)

Resource DRG Forum 9 | R4D.org


Data yg diperlukan
Data dasar kinerja RS RS 3- 5 thn terakhir
Data Pembiayaan RS 1 thn terakhir
Data koding 14 variabel ( dalam bentuk Txt file )

Data kosting di verifikasi kelengkapan dan


akurasinya , diisikan sesuai format template
costing
Jangan sampai terjadi losscounting atau double
counting
Steps in Costing Data Analysis

1. Review the costing data for Overhead CC


2. Review the costing data for Intermediate CC
3. Review the costing data for Final CC
4. Review the basic data : hospital performance n
financial data
5. Review the additional data
6. Calculate unit cost inpatient n outpatient
7. Calculate cost per episode of care ( CBG cost )
8. Conduct Statistical Costing data analysis
Hal penting dlm kosting INA
CBG

Pengumpulan data yg terstandar


Metodologi kosting
Standar alokasi dan proporsi biaya
Kelengkapan dan akurasi data
14 VARIABEL DATA KODING
1. Identitas pasien
2. Tanggal masuk RS
3. Tanggal keluar RS
4. Lama rawatan(LOS)
5. Tanggal Lahir
6. Umur (dalam tahun) ketika masuk RS
7 Umur (dalam hari) ketika masuk RS
8. Umur (dalam hari) ketika keluar RS
9. Jenis kelamin
10 Status Ketika Pulang
11. Berat Badan Baru Lahir (gram)
12. Diagnosis Utama
13. Diagnosis Sekunder (Komplikasi & Ko-morbiditi)
13
14. Prosedur/Pembedahan
Nama Rumah Sakit :
Kode Rumah Sakit : Data Dasar Rumah Sakit
Kelas Rumah Sakit :

DATA DASAR RUMAH SAKIT Tahun Tahun Tahun Tahun


2008 2009 2010 2011
BOR
ALOS
Turnover Interval (Hari)
Throughput/BTO (Pesakit/tempat tidur)

Jumlah Tempat Tidur Yang Tersedia


Jumlah Tempat Tidur Sebenarnya (Total)
Jumlah Tempat Tidur ICU/CCU/HDU
Jumlah Tempat Tidur Private Wing

Jumlah Hari Rawat Pasien


Jumlah Pasien Rawat Inap (Episode)
Jumlah Pasien Rawat Jalan (Episode)
Jumlah Perawat
Jumlah Semua Staf
Jumlah Biaya Operasional (Bukan Gaji)
Jumlah Biaya Operasional (Gaji)
Jumlah Biaya Non-Operasional (Investasi Alat)
Jumlah Biaya Non Operasional (Investasi Gedung
& Sarana Fisik Lainnya)
Total Biaya Rumah Sakit

Penerimaan Fungsional Rumah Sakit


a. Fungsional dari Jamkesmas
b. Fungsional dari Jamkesda
c. Fungsional dari Non Jamkesmas Jamkesda
Total Pendapatan
Nama Rumah Sakit : DATA PEMBIAYAAN
Kode Rumah Sakit :
Kelas Rumah Sakit :
Biaya Biaya
Investasi Investasi
Biaya Harga
Biaya Gedung yang Gedung Luas
Jml Jml Jml hari Jml Jumlah Biaya Jasa Jasa Peralatan yg
ALOS operasional Gaji staff Dibangun 25 yang lantai
Pusat Biaya Semua Peraw rawatan pasien Tempat Medis Lainnya dibeli dlm 5
(hari) (tidak (setahun) tahun Dibangun 40 bangunan
Staf at pasien pulang Tidur (Setahun) (Setahun tahun
termasuk gaji) terakhir tahun (m2)
) terakhir
(tidak terakhir
bertingkat) (bertingkat)
Tahun 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 (2007-2011) (1987-2011) (1972-2011) 2011
.
1 Administrasi
Administrasi
2 Perawatan
Instalasi
Pemeliharaan
3 Sarana RS
Biaya Langganan
4 Daya & Jasa
Telepon , Internet
5 and Fax
6 Cleaning Services
7 Security
Bahan Pakai
8 Habis
Sistem Informasi
9 Rumah Sakit
10 Perpustakaan
Pajak dan
11 Ansurasi
12 CSSD
13 Gizi
14 Rekam Medis
15 Binatu dan Linen
16 Diklat
17 Sewa
18 Lain-lain
Biaya Biaya
Investasi Investasi
Harga
Biaya Gedung yang Gedung Luas
JML Jml Jml hari Jml Jumlah Biaya Jasa Biaya Jasa Peralatan
ALOS operasional Gaji staff Dibangun 25 yang lantai
Pusat Biaya Semu Peraw rawatan pasien Tempa Medis Lainnya yg dibeli
(hari) (tidak (setahun) tahun Dibangun bangunan
a Staf at pasien pulang t Tidur (Setahun) (Setahun) dlm 5 tahun
termasuk gaji) terakhir 40 tahun (m2)
terakhir
(tidak terakhir
bertingkat) (bertingkat)
Tahun 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 (2007-2011) (1987-2011) (1972-2011) 2011
B. Pusat Biaya Penunjang Medik (intermediate)
1
9Farmasi
2
0Radiologi
2
1Laboratorium
2
2Rehabilitasi Medik
Rehabilitasi
2Psikososial / Rehab
3Karya
2Unit Perawatan
4Intensif (ICU)
2
5NICU & PICU
2
6ICCU & HCU
2Instalasi Bedah
7Sentral
2
8IGD
2Pemulasaran
9Jenazah
3
0Hemodialisa
3
1Bank Darah
3
2Bank Jaringan
3
3Lain-lain
PROSES PEMBENTUKAN TARIF DRG/CBG

DRG/CBG TARIF NASIONAL

Data pasien: 14 variabel data


Base rate
Data cost Casemix index
Overhead cost
Cost weight
Intermediate cost
Final cost CBG cost
Unit cost
17
Data Data
Costing Coding
Langkah Pembentukan
DATA DASAR
DATA TEMPLATE
Tarif TEMPLATE TXT
FILE

ANALISA EKSPLORING

REKAP VARIABEL CLEANING

INPUT CCM TRIMING

UNIT COST CBGS-N-LOS


(14 VAR)

CBGs COST

COST WEIGHT

CMI

HBR

PRELEMINARY TARIF

AF

TARIF
Struktur tarif stabil (should be as stable as possible)
Struktur tarif sederhana (should be as simple as
possible)
Struktur tarif berbasis pada pelayanan, bukan organisasi
(should be based on services not organisations)
Seluruh pemangku kepentingan harus dilibatkan dalam
proses penyusunan tarif
Tarif memiliki rujukan berbasis acuan biaya (should
continuous to be based on referrence cost)
Aim of Tariff Development
To ensure that providers are fairly reimbursed for
their work
To ensure that the price reflects the actual cost of
providing services which will promote system
sustainability
To ensure that the price structure support
appropriate medical and reward those providing
good outcomes

Sumber : UNU-IIGH
Providers may charge informal payment to
compensate for inadequate formal payment.
Providers may avoid treating sicker patients.
Inappropriate referrals may occur.
Providers provide suboptimal care.
Services may be over or under utilize.

Sumber UNU-IIGH
TARIF INA CBGs

Cost Adjustment
TARIF = HBR
HospitalBa X Weight X factor

Mostly a Technical and policy


political/economic consideration
Mostly a technical
consideration
calculation
(but can include policy
decisions) 22
Disain Keputusan strategis
Ajustmen
Cost Factor
Tarif = HBR X Weight X

Which services Will cost Will some


will be weights be hospitals be
included? developed or paid
What costs will taken off the more/less per
be included in shelf? case? E.g.
the base rate? Will cost rural or
weights be used teaching
Will the base hospitals
rate be the to give higher
same for all priority to some
hospitals? services?
23
Components of Tariff

Cost Casemix
CBG Cost
Weights Index

Adjustment Tariff
Base Rate
Factor
5 Steps Cost Acounting Proces
1. Menentukan pusat biaya
2. Mengelompokkan unit kerja ke dalam
administrative/overhead cost center
Supporting /Intermediate cost center
Clinical departments/ final cost center
3. Menempatkan direct cost ke cost center
4. Menetapkan dng spesifik alocation factor dan proporsi
5. Mengalokasikan indirect cost ke cost center,
Mengalokasikan overhead cost ( direct, indirect ) ke
intermediate cost dan final cost,
Mengalokasikan intermediate cost ke final cost
Statistic alocation factor/alocation bases
A. Overhead Cost Centre Allocation Statistics
1. Administration No. of staff
2. Maintenance Floor area
3. Utilities Floor area
4. Consumables No. of staff
5. Dietetic Patient days
6. Laundry & Linen Patient days

B. Intermediate Cost Centre


6. Pharmacy Patient days
7. Radiology Patient days
8. Laboratory Patient days
9. Physiotherapy Patient days
10. Operation Theatre (General) Patient days

C. Final Cost Centre


Inpatient Department
11. Medicine Department Patient days
12. Surgical Department Patient days

Outpatient Department
13. Medical Specialist Clinic Visit
14. Surgical Specialist Clinic Visit
Total
Proporsi IPD OPD
Inpatient fraction Outpatient fraction

Pharmacy 60% 40%

Radiology 60% 40%

Laboratorium 65% 35%

Physiotherapy 35% 65%

Theathre 100% 0%
Step-down Cost Allocation
The step-down method yields total cost per Clinical department after
allocating Administrative and Ancillary department costs.

Department Cost Administration Step-Down Allocation Ancillary Step-Down Allocation Total Clinical
Hospital
Department
Department Direct Indirect Total Admin Transport Maint Hygiene Kitchen Pharm Lab X-Ray Echo Blood Theater Cost

Hospital Totals $ 1,000,000 $ 800,000 $ 1,800,000 $ 132,141


Administration $ 112,006 $ 20,134 $ 132,141 236.00 $ 42,691
Transport $ 38,913 $ 1,819 $ 40,731 $ 1,960 16,000 $ 26,449
Maintenance $ 9,586 $ 14,343 $ 23,929 $ 2,520 $ - 74% $ 40,563
Hygiene $ 18,386 $ 8,633 $ 27,019 $ 12,878 $ - $ 666 $ 98,845 $ 12,787
Kitchen $ 6,798 $ 2,295 $ 9,093 $ 2,800 $ - $ 894 $ - $ 98,845 $ 111,093
Pharmacy $ 94,970 $ 8,204 $ 103,174 $ 4,759 $ - $ 3,159 $ - $ - 89% $ 125,357
Laboratory $ 71,743 $ 32,495 $ 104,238 $ 7,279 $ - $ 4,159 $ - $ - $ 9,681 3,429 $ 31,469
X-Ray $ 9,858 $ 14,887 $ 24,745 $ 3,360 $ - $ 2,199 $ - $ - $ 1,166 $ - 883 $ 11,381
Echography $ 5,179 $ 2,516 $ 7,695 $ 1,400 $ - $ 1,263 $ - $ - $ 1,023 $ - $ - 466 $ 22,760
Blood Bank $ 9,892 $ 8,120 $ 18,012 $ 2,520 $ - $ 929 $ - $ - $ 1,299 $ - $ - $ - 2,110 $ 148,733
Operating Theater $ 52,177 $ 71,078 $ 123,254 $ 9,519 $ - $ 1,997 $ - $ - $ 9,409 $ 4,554 $ - $ - $ - 1,050
Emergency $ 54,435 $ 102,271 $ 156,706 $ 7,279 $ 5,070 $ 1,431 $ 3,591 $ 1,280 $ 13,721 $ 23,747 $ 4,898 $ 2,387 $ 5,409 $ - $ 225,519
Surgery $ 77,360 $ 114,988 $ 192,349 $ 12,878 $ 8,805 $ 1,692 $ 10,053 $ 3,326 $ 17,982 $ 14,529 $ 4,267 $ 2,209 $ 2,403 $ 86,223 $ 356,715
ICU $ 54,611 $ 95,234 $ 149,844 $ 10,358 $ 2,401 $ 1,321 $ 2,995 $ 732 $ 19,057 $ 17,210 $ 4,858 $ 443 $ 1,295 $ - $ 210,517
Medicine $ 49,838 $ 60,753 $ 110,592 $ 12,038 $ 8,005 $ 1,845 $ 6,195 $ 1,659 $ 10,141 $ 18,538 $ 4,519 $ 4,461 $ 7,405 $ - $ 185,398
OB/GYN $ 92,117 $ 88,447 $ 180,564 $ 13,438 $ 9,872 $ 2,196 $ 6,684 $ 2,255 $ 10,617 $ 21,109 $ 4,322 $ 526 $ 2,330 $ 62,510 $ 316,424
Pediatrics $ 61,784 $ 88,120 $ 149,905 $ 12,598 $ 6,404 $ 1,697 $ 4,571 $ 1,375 $ 7,554 $ 14,087 $ 2,406 $ 162 $ 1,701 $ - $ 202,460
HIV/AIDS $ 94,856 $ 43,646 $ 138,501 $ 7,559 $ 800 $ 333 $ 2,846 $ 1,068 $ 5,189 $ 8,310 $ 4,029 $ 668 $ 834 $ - $ 170,137
TB $ 85,492 $ 22,016 $ 107,508 $ 6,999 $ 1,334 $ 666 $ 3,628 $ 1,091 $ 4,255 $ 3,271 $ 2,171 $ 524 $ 1,382 $ - $ 132,830
Hospital Totals $ 1,000,000 $ 800,000 $ 1,800,000 $ 132,141 $ 42,691 $ 26,449 $ 40,563 $ 12,787 $ 111,093 $ 125,357 $ 31,469 $ 11,381 $ 22,760 $ 148,733 $ 1,800,000

Resource DRG Forum 29 | R4D.org


UC dan CBG Cost
Unit cost : UC 4 Major : OG, Pediatric,Medical, Surgical
UC per visit ( rawat jalan )
UC per day of stay (rawat inap )
Dihitung dng software Clinical Cost Modelling ( CCM )
Blended all hospital sampel, diambil nilai average utk
mencari UC nasional
Uc x individual LOS per CBG = individual CBG Cost
Dikelompokkan per CBG dihitung averagenya
Sebagai dasar perhitungan CW
Tariff = HBR x CW x Adjustment Factor

Tarif nasional
Perkelompok RS
Review tiap 2 thn (Perpres no 12 thn 2013 ttg JKN
Average Cost for Specific DRG
CW =
Aggregate Average Cost

Relative resource use of one CBG in relation to average cost


of all CBGs
Also called Resource Intensity Weights or Relative Weights
Cost Weights are Unitless Numbers
Ideally to be developed from trimmed CBG Cost
Meliputi CW ranap dan rajal
Dihitung secara nasional
Menggambarkan rasio sumber daya yg digunakan antar CBG
CW ranap : local CW + Maryland CW
CW rajal : Maryland CW
Sumber UNU -IIGH
Cost weights--example

Average Cost spesific


CBG
Appendewpesific
with complicated
principal diagnosis
and with
complications and
co-morbidities
Rp 5.750.000 Cost
Weight
R =
Agregate Average 1,25
Cost/Case for all
Cases

RP 4.600.000
33
A Hospitals Case-Mix Index is a Value Which Relates one Hospitals
Production to Another Hospitals Production.

CMI = (Cost weight X # of cases)


Total # of cases for hospital A

Merupakan agregat dari CW per RS/perkelas RS


Dihitung per RS/per kelas RS
Menggambarkan produktifitas suatu RS thd RS lainya
Menggambarkan kompleksitas pelayanan di suatu RS thd RS
lainya
Variabel utk menghitung HBR

Sumber UNU-IIGH
Overall cost of treating a patient in the hospital by taking into account the
complexities of cases managed in the hospital

Total Cost
HBR = Total # of equivalent cases x CMI

Dihitung masing2 RS
Dikelompokkan berdasar kelas dan jenis RS
Perkelompok RS diambil Mean HBR
Menggambarkan total biaya RS ((inpatient,outpatient) dibagi
jmlh output (inpatient/outpatient)
Meliputi HBR ranap dan rajal

Sumber UNU -IIGH


MENGAPA DIPERLUKAN ADJUSTMENT?
Menutup biaya yg belum diperhitungkan dalam sistim casemix
Rumah sakit pendidikan
Biaya untuk penelitian dan pengembangan
Kelas Rumahsakit
RS swasta atau pemerintah

Memberikan Insentif bagi yang melakukan efisiensi


Insentif untuk pelayanan preventif
Insentif untuk pelayanan Day Care Surgery

Menutup biaya pelayanan yang mahal


Kasus yg memerlukan perawatan lama
Transplantasi

Perbedaan wilayah
Inflasi
Perbedaan biaya transportasi
Adjusment factor dipengaruhi oleh :

Location Geographic
Local wage rates
Direct and indirect health professions
education
Hospital role in healthcare delivery

Metode Adjustment
Formula
Pass throught of actual cost
Hospital spesific rates
Peer grouping
AF INA CBGs 2013
Kelas RS
RS Pendidikan non pendidikan
Jenis RS : Umum, Khusus
Regionalisasi
Ketersediaan anggaran agar terlaksana
kontinuitas pelayanan.
AF INA CBGs 2014
Kelas RS
Jenis RS : Umum, Khusus
Regionalisasi
Ketersediaan anggaran agar terlaksana
kontinuitas pelayanan.
CBGs ttt utk RS kelas C dan D
CBGs ttt utk kelas A-B
CBGS ttt vs tarif RS (cost to charge ratio )
Special CMG
REVIEW TARIF

CBG Cost : Every Two Years


Casemix Index : Every Two Years
Cost Weights: Every Two Years
Base Rates : Every Year
Adjustment Factors: Every Year
Perpres no 12 thn 2013 : tarif ditinjau sekurangnya
tiap 2 tahun
Who is involves in Tariff Updating?
National Level
National Casemix Team
Senior Management of Social Health Insurance Agency
Senior Management of MOH Hospital Level
Profesi
Asosiasi provider (RS dan klinik )
Akademisi

HOSPITAL LEVEL
Hospital Casemix Team
Clinical Specialists
Hospital Directors
Langkah pengumpulan data
Sosialisasi
Pengiriman template ke RS
Workshop
Pengisian template ke NCC
Verifikasi dan Validasi
Perbaikan pengisian template
Bimtek ke RS
Pengiriman ulang ke NCC
Rekap variabel cost oleh tim NCC
Kendala pengumpulan dan pengolahan
data
Respon RS kurang, merasa sbg beban tambahan
Data kurang lengkap, kurang akurat
RS hanya memiliki data agregat
Tidak tahu cara mengisi
Klasifikasi RS blm sesuai standar
Sistem laporan keuangan RS yg mengelompokkan
biaya berdasar kelas perawatan bkn berdasar jenis
layanan
Kelemahan : belum tersedia laporan keuangan
audited sbg dasar utk kroscek
Fasilitas IT kurang memadai
Solutions for Data Availability and Quality Challenges

Common Challenges Solutions


Data do not exist or are difficult to 1. Expert Opinion: Consult with hospital
Data locate staff to obtain estimates for missing
Availability Hospitals are reluctant to share data, discuss sensitive data off the
sensitive data record, and seek explanations on
difficult-to-interpret data
Data are not disaggregated to the
Data needed level 2. Data Triangulation: Leverage multiple
Aggregation Data are consolidated for multiple (potentially overlapping) data sources
to capture the full financial picture
facilities
3. Analysis Techniques: Make
Data are available in hard copy and are
assumptions, extrapolate data, or use
Data difficult to interpret
benchmarks or standards to fill data
Automation Heavy reliance on manual data entry gaps
risking inaccuracies
4. Data Validation: Confirm results and
Data sources are/or costing seek clarification with hospital staff
Data instruments are incomplete
Quality Data discrepancies exist between
different sources

Resource DRG Forum 44 | R4D.org


PRAKTEK PENGHITUNGAN UNIT COST DAN
HOSPITAL BASED RATE
Siapkan template data dasar dan data kosting
Isi sesuai juknis dan pedoman pengisian
Review hospital basic data
Review costing data
Review additional data
Costing data analysis
Input INA- CCM
Hitung Unit Cost
Hitung Hospital Based Rate
Preleminary tariff
Potensial losscounting
Self dispensing oleh unit diluar RS atau
individu : obat, alkes dll
Jasa utk dr tamu, pegawai dlm masa orientasi
Biaya utk petugas/ kegiatan outsourcing
Biaya pengurusan ijin dll
Potensial doublecounting
Hibah
Jasa utk tenaga dokter yg bekerja di beberapa
unit layanan
Obat program
Dll
MATERI COSTING \Cara Isi Data
Costing.xls
MATERI COSTING \Cara Isi Data
Dasar.xls

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