Chapter 23

1. Chapter 23 Includes Supplements 4 through 8

2. The Revenue Equation

3. Supplement Four • Pricing products and services • Billed charges • Cost reimbursement • DRG reimbursement • Capitation payment

4. Billed Charges • Used by individuals and small insurance companies that cannot negotiate discounts or prospective payment • The only way to lose money under billed charges is not to set your prices at a level that covers costs

5. Cost Reimbursement • Historical payment system for Medicare • Hospital was paid estimate of cost during fiscal year • Actual costs (per patient day) were audited at year end • Cost reimbursement provides few incentives for cost control

6. DRG Reimbursement • Now used by Medicare, Medicaid and some insurance companies • Each DRG has fixed payment • To make money a hospital must • Admit a patient • Keep costs under charges

7. Capitation Payment • First used by HMOs • Hospital is paid fixed payment per month per enrollee • To make money • Keep expensive services such as hospital admissions to a minimum • Capitation and DRG both require sophisticated costing information

8. Supplement Five Information Needs of Managers

9. Cost data is needed for . . . • Pricing • Cost Control • Strategic Planning • Measurement of Comparative Efficiency

10. Wes Learns That . . . • Since the early 1980s, rural hospitals have experienced revenue decreases due to • Shorter length of stays caused by DRG reimbursement • Caps on payment by insurance companies • Out-migration to larger metropolitan hospitals

11. He can increase volumes by • Offering new products and services • Capturing volume from competing hospitals

12. Supplement Six Cost Accounting Taxonomies

13. Should the costing system be? • Job-order-costing or process-costing? • Actual, normal, or standard costing system?

14. Job-order-costing systems • Used by firms that manufacture unique products • Costs are accumulated on a job ticket • Direct labor • Direct materials • Overhead • Examples include custom home builders, and auto repair shops

15. Process Costing Systems • Used by companies that manufacture homogeneous products • Costs are accumulated by department, then allocated to the products passing through the department that period • Examples of companies that use process-costing include manufacturers of petroleum and ball bearings.

16. Should the system be . . . • An actual cost accounting system? • Debit WIP for actual direct labor, actual direct materials, and actual overhead • A normal cost accounting system? • Debit WIP for actual direct labor, actual direct materials, but use overhead rate • A standard cost accounting system? • Debit WIP for standard direct labor, standard direct materials, and standard overhead

17. More accurate information on why the hospital is losing money Easier methodology for assigning costs to patients Better inventory and cash control Mechanism for involving employees in cost savings through bonuses Better methodology for implementation of responsibility accounting Possible advantages of standard costing system

18. Supplement Seven Designing Accounting Reports to Meet Information Needs

19. What is the difference between data and information? • Data are numbers processed by the accounting system • Information is data that is useful for decision making

20. The information needed is different to manage each of these contracts • Prospective payment contracts • DRG Reimbursement • Capitation Payment • Retrospective payment contracts • Billed Charges • Cost Reimbursement

21. Questions to ask in designing management reports • How does the hospital make or lose money on this particular type of contract? • What variables, therefore, should the manager monitor? • What information must be sent on these variables?

22. Questions to ask in designing management reports • How will we gather the data to prepare the reports? • What format should the information take? • How timely must the information be?

23. Identifying Information Needs Capitation payment demonstrated

24. How do we lose money under capitation payment? • Unnecessary hospital admissions • Longer than necessary length of stay • Treatment of patients with higher levels of care than necessary • Failure to keep patients well through preventive medicine • Failure to prevent hospital infections and complications

25. Variables to monitor • Admissions • Patient days • Costs • Preventive medicine programs • Infections control programs • Etc.

26. Variables to monitor • Admissions per 1000 population • Average length of stay per diagnosis • Intensity and volume of services provided • Preventive medicine services rendered • Infection rates, mortality and morbidity rates • Cost per capita per year for each employee

27. Sources of data • Medical records • Outpatient clinics • Physicians records • Admissions and Business Office • Accounting • Actuarial data

28. How Timely? • At least monthly

29. Global Functions of Proposed Costing System • Cost determination • Activity forecasting • Functional cost center budgeting • Performance reporting on a: • Product level • Functional level

30. Supplement Eight Designing the Pricing Module

31. Product Costing Detail Final Product Intermediate Product Intermediate Product Primary Product Primary Product Primary Product

32. Standard Labor Cost Standard Labor Cost Standard Hours Standard Hourly Wage X = Three Options 1. Industrial engineer study 2. Borrow standards 3. Use historical average as standard (use RVUs to determine) Take from Alma Cowdrey study

33. Using RVUs to Determine Standard Hours • What is an RVU? • A unit of measure of resource consumption (labor) • Who develops RVU schedules • Professional associations such as the American College of Pathologists

34. RVU Procedure • Separate total labor into fixed and variable labor costs with linear regression • Determine total RVUs by multiplying total procedures done by category by their respective RVU • Divide total labor cost by total RVUs to get cost per RVU • Multiply each test by its RVU cost