When developing a cost system in any entity, company or institution, we have to be clear about several elements, such as the type of company (industrial, service, transport, etc.), the information system used, the type of products offered, etc.
In this sense, the collective medical assistance institutions have particular characteristics that differentiate it from any other type of organization: it is a service company and operates in a health environment; in turn, the products that she provides also have their particularities: they are intangible, it is difficult to find a unit of measurement, they are handcrafted so they cannot be automated, and above all, they are not very or not at all homogeneous.
The objective of this work is to show which is the most suitable cost system to develop in these institutions so that it is a tool that provides data that makes decision-making a process with positive results.
Therefore, we understand that the only viable answer to the above is to obtain a COST PER PATIENT / PATHOLOGY. The patient's expense depends exclusively on the treatment of her disease (pathology), that is the reality and therefore what the cost system has to show.
1) The IAMC in Uruguay
The following lines are written with the aim of locating the reader in the subject, that is, defining the concept of IAMC, taking knowledge of their place in our health system, supervision and regulation by the Ministry of Public Health, the internal conformation of these institutions, etc. In summary, illustrate the external environment that surrounds them and the internal environment in which they operate daily; These are essential elements to administer a Collective Medical Assistance Institution.
It is necessary to limit that, as is evident, the scope that will be given to the subject in this work is very limited, given the objective that is intended. That is, issues related to the history and current situation of the health sector will not be addressed; There are already works on these topics and by well-known authors with years of experience in health.
1.1) The External Environment: The health system and the IAMC.
To quickly illustrate the external environment that surrounds these institutions, their location in the health system and the regulatory legal framework will be mentioned.
Location. A health system is "a set of parts that interact in an orderly and coordinated manner with each other, in order to maintain and improve the population's level of health."
Its components are basically the health authority and the institutions that provide the services. There are also others, such as services provided, human resources, financial resources, etc., but at the institutional level the most important components are the two mentioned.
Specifically in our country the first of those, that is, the health authority is constituted by the Ministry of Public Health who basically fulfills the functions of Planning, Supervision, Coordination and control of the health sector. The second, that is, the institutions that provide the services, are divided into two sub-sectors: Public and Private.
Within the public sub-sector we also have a large number of entities, which are the following:
The MSP itself: which also provides services to the community, that is, it fulfills both functions: Regulator and Effector. It provides services through ASSE (Administration of State Health Services).
Clinic hospital: which depends on the University.
Armed Forces Health Service: reports to the Ministry of Defense.
Police Health Service: reports to the Ministry of the Interior.
Others: departmental governments, Social Security Bank, State Insurance Bank, medical services in autonomous entities and decentralized services.
In turn, within the private sub-sector we have the following types of entities:
Collective Medical Assistance Institutions: they are the ones that concern us in this work.
Private Private Medical Assistance Institutions: Sanatoriums, Clinics, etc.
Partial Insurance: Private, they do not cover all the services provided by the IAMC but some.
National Fund of Resources and Institutes of Highly Specialized Medicine: The FNR is a parastatal entity created by law whose objective is to cover
high-risk interventions, generally the most expensive; it does not carry out the operations but contracts them with the IMAE´s.
TABLE 1: Components of the health system.
Regulatory Legal Framework. The above is regarding location; The current legal legislation for the IAMC is based on Law 15,181.
Like most of the laws in our country, Law 15,181 is also regulated. Two of the most important decrees are: 271/81 and 93/983. The first of them established the obligation on the part of the IAMC to provide accounting and other statistical information according to the models established. The 93/983, based a little on the previous one, regulates the law regarding technical and accounting aspects. The most important article is the 1 that says the following:
“… Article 1 ° The Institutions of Collective Medical Assistance must present before the competent dependencies of the Ministry of Public Health, from the effective date of this Decree, the data required by the National Information System (SINADI), as well as others statistical information that is requested… ”.
Therefore, the IAMC are obliged to send information to the MSP so that it somehow evaluates them or at least continues on its way. As the previously transcribed article says, it does this through SINADI.
SINADI is a document with which the MSP intends to implement uniformity in the accounting registration of the IAMC. That document can be divided into three: Uniform Accounting Registration in which it is established: The Chart of Accounts, the Manual of Accounts, Presentation of Financial Statements, Inventory System and Cost Center Model; National Information SystemProperly speaking, in which the instructions are presented to complete the extra-accounting information that must be submitted to the Ministry, for example, Census of affiliated population, registration and withdrawal of affiliates, External Consultation, emergency, non-emergency, Hospitalization, surgical interventions and deliveries, there is also financial and management information that allows calculating indicators to analyze the situation of the IAMC; IAMC Management Audit, where the management audit procedures to be carried out by the MSP in the institutions are established.
This information must be submitted on a monthly basis. It has the character of a Sworn Declaration and the MSP grants a certificate against the delivery of said information; This certificate is essential to carry out any procedure that the IAMC wishes to carry out before all the State offices.
TABLE 2: Institutional components of the health system and their relationship.
This was a tight and very superficial view of the external environment surrounding the IAMC. What should be clear is that IAMCs are constituted in the private health sector and operate under the supervision of the MSP, to which they must periodically report on their management.
1.2.) The Internal Environment.
Once located in the environment that surrounds us, it is necessary to internally know the IAMC, a fundamental aspect for the study of costs. Together with the definition, an attempt will be made to mention the different types of companies, the services they provide, the sources of financing and their internal composition.
Definition. A fairly accepted definition of IAMC is the one that says:
“… An IAMC is a pre-paid health insurance in which an institution, at least partially run by doctors, undertakes to organize access to a very broad and comprehensive set of health services provided to its members by its own medical staff. or hired in own facilities or hired but indicated and managed by the institution… "
At the beginning, the IAMC operated as an insurance company, that is, they paid a fee and when they needed care, they went to their trusted doctor, they attended and then the doctor collected their fees from the institution.
Later, the IAMC began to offer their services in their own facilities and integrated those doctors to work there. From that moment on, the members paid a fee and, if they needed care, they went to the place where the IAMC operated and the doctor, now an IAMC employee, was seen.
IAMCs differ from Partial Insurance and IAMPP because the assistance they provide is comprehensive; instead, these institutions provide certain types of services or certain types of medical coverage, but never comprehensive. Furthermore, the IAMC are not for profit and those are.
In turn, they differ from Sanatoriums and Hospitals (speaking in the private area, given that the situation in publics is somewhat different) by virtue of the purpose pursued and the bases on which they are based. While the IAMC have associates who pay a monthly fee and when they require medical assistance they go to their facilities, in the sanitariums there are no associates, but rather institutions whose objective is to sell a health service. Many IAMCs even buy services from sanitariums. So the base with which they were created is not the same, the IAMC are supported by the help and solidarity among its members and do not pursue a lucrative purpose, and the Sanatoriums and Hospitals are a company, where what is sought is the sale of services.
Types of IAMC. Now that we locate ourselves not only in the external environment but also in the internal one since we differentiate these institutions from the rest of the private ones and we saw that they are different, let's see what types of IAMC exist.
Legally, Law 15,181 regulates three types of IAMC: Assistance Associations, Professional Cooperatives and Assistance Services, and defines them as follows:
Healthcare Associations. Those that, inspired by the principles of mutualism and through mutual insurance, provide their members with medical assistance and whose assets are exclusively affected for this purpose.
Cooperative of Professionals. Those that provide medical assistance to their affiliates and partners and in which the social capital is contributed by the professionals who work in them.
Assistance Services. Created and financed by private or mixed economy companies to provide non-profit medical care to the personnel of said companies and eventually to their relatives.
The most widespread are the first two types. Regarding the legal nature, the IAMC are Civil Associations and the Professional Cooperatives have the character of Production Cooperatives.
These institutions enjoy tax and fiscal exemptions, but since 2000 they have been reached by IM.ESSA. (Specific Tax on Health Services) which taxes at a rate of 5% the provision of services related to human health as long as they are provided to final consumers.
Services they provide. As mentioned above, IAMCs provide comprehensive assistance. But what is comprehensive assistance? The services they provide can be summarized in the following words.
The coverage must be basic, complete and egalitarian, which in healthcare includes the application of the following activities: medicine, gynecotocology, surgery and pediatrics, as well as their complementary specialties.
Mandatory health care coverage includes actions for disease prevention, health repair and rehabilitation. They are not obliged to provide services in the area of mental health.
Financing. These institutions basically have three main forms or types of financing: a) Associates' Social Fees, b) Consultation orders and Ticket's for medicines and c) Sale of Services.
- Regarding dues, we have three types of Associates: 1) Individual: people who go by their own means and apply to join and pay a monthly fee; 2) Collective: agreements with companies through which the relatives of their employees become affiliates (employees are covered by social security); and from Social Security l: contribution made by the Social Security Bank that links low-income private sector workers and liabilities. Orders and tickets fulfill the function of a moderating rate in order not to be abused of the IAMC services, both in medical consultations and in consumption of medications (imagine how many people would see the doctor if the consultations were not charged).
Both the amounts of the quotas of the individual associates as well as the orders and tickets have to be authorized by the Ministry of Economy and Finance.
Internal composition. Finally, to close this introduction, let's look at the internal composition of the IAMC, that is, the main areas or departments.
As you can imagine, there are small differences between all the institutions, many times derived from their own legal nature, but now we will make an overview that, basically, can be seen in all the IAMC.
In the section referring to inventories of SINADI, a mention is made of the existing areas or departments in which there are assets that must be inventoried. Better yet, the aforementioned section mentions cost centers or areas of activity, which can be grouped primarily as follows:
- Governing Bodies. Senior Management. Internal Assistance. External Assistance. Emergency Services. Diagnostic and Treatment Services. Support Services. Production Centers.
The governing bodies include all the bodies of authorities of an elective nature of the Institution and the offices, permanent or not, that are directly related to them. Examples: Representative Assembly, Tax Commission, Board of Directors, Advisors, Public Relations Office, etc.
The upper management depends directly on said organs, where the General Management and the Technical-Medical Direction of the institution stand out. Generally, all the administrative departments report to the Management and all the assistance areas to the Technical Directorate; in turn, General Management reports directly to the Technical Directorate.
In turn, all the support services (7) depend on the general management, which includes the accounting, personnel, computing, supply, etc. departments. and the production centers (8), where we find the kitchen, laundry, maintenance, etc. departments.
On the other hand, all the healthcare sectors depend on the Technical-Medical Directorate (3 to 6). These sectors are divided into four main areas, which are named above. Internal care includes everything related to inpatient services (simple, intermediate and intensive) as well as all the healthcare departments linked to it, such as the management of inpatient services.
In the external assistance it includes everything concerning patient care in clinics and doctors ' offices, both at headquarters and in decentralized polyclinics.
In emergency services emergency and home emergencies are included. Finally, all the services that the IAMC provides and have not been named are included in the techniques of diagnosis, treatment and medical support, that is, the Delivery and Nursery Room (newborns), the Surgical Block, the Laboratory of Clinical Analysis, Electrocardiology and Electroencephalography, Radiology, Ultrasonography, Computed Tomography, Nuclear Medicine, Radiotherapy, Inhalterapia, Physical Medicine (Physiatry) and Rehabilitation, Blood Bank and fluid therapy, Pathology, Pharmacy, Clinical Archive.
After this summary, and to start thinking about costs, let's see what the mutual product is.
2) The definition of the product / service in the IAMC and its difficulties.
When someone wants to calculate the costs of their company, the first thing they do is define the cost object, which can be products / services, customers, etc., in traditional cost accounting is in most cases the first, that is, the articles produced by the company or the services provided. The IAMC are no stranger to this. Today, and always, their cost objective has been that: products / services.
The definition of the IAMC product (or mutual product) is conditioned by two fundamental characteristics:
- An IAMC is a Services company, and it works in a Health environment.
In the work "Cost systems and their relationship with decision-making in Collective Medical Assistance Institutions" it is mentioned that since the IAMC is a service company, the mutual product has the following characteristics:
- Intangible; Although there are material elements such as plates, x-rays, etc., but the most important product that is provided to the associate: medical attention and / or intervention, cannot be physically materialized. It is difficult to find a unit of measurement for the amount of services produced. They are made by hand, so they cannot be automated like in industries.
But a very relevant characteristic of the service companies and that is more accentuated in these institutions is that the mutual product is little or not at all homogeneous, for example, it is not the same to perform cardiac surgery on a person than to perform an operation on sight, and in turn two people who have cardiac surgery the resources used as well as the results may be different, and in fact they are.
2.1) Classification of mutual products / services.
Natividad Guadalajara in his book "Analysis of costs in Hospitals" mentions that a mutual service is made up of the main benefit and some secondary benefits. For example, a main benefit would be cardiac surgery, while the secondary benefit would be patient care, materials and medicines used, cleaning, food, etc.
Just as Natividad divided the mutual service into main and secondary services, it can also be divided into intermediate and final services.
In an IAMC there are many products / services, some physical and others intangible (most of them). The set of all these would be, under the classification mentioned in the previous paragraph, intermediate products. What we can define as the final product would be the set of intermediate products provided to each patient.
Even if we want to move a little further we can say that there are intermediate services that can be classified as support, such as maintenance departments, kitchen, laundry, etc., that although they are not provided directly to the patient, they are necessary for them to provide the intermediate service and therefore the final service.
Note then that we have certain mutual, intangible (medical care, diagnosis, etc.) and tangible products (clinical tests, radiological plates, etc.) which, with the necessary support, are combined in such a way that each combination can be defined as a service. final. This accounts for the difficulty and / or particularity of calculating costs in these institutions.
For example, an intermediate service is obtaining lung plates; another is Diagnosis. Therefore the final product / service will be the diagnosis of the patient based on the result of the plaque. It must be remembered that in addition to this, the maintenance of the machine that makes the plates, the cleaning of the plate rooms and the consulting room, all these support services were required.
In turn, the mutual product will present a great variety due to the diversity of patients treated. So not only do we have many products, but each product is very variable.
Although it seems easy, the qualification of the services in support, intermediate and final in many cases is not easy. In the aforementioned case, we tend to think that the Diagnostic service is intermediate, and it may be, but the doctor's personal attention can be classified as a final service as well.
Therefore, although it can be determined which is the mutual product it is not an easy task, and this is due to the characteristics of the same mentioned at the beginning of the section.
TABLE 4: Expenditure Graph.
2.2) Measurement and Cost of the mutual product / service.
As we do then to measure this product. The aforementioned Natividad Guadalajara says that one way to do this is through the enumeration of the services provided to the patient: diagnostic, therapeutic and rehabilitative means, clinical process and hotel services, and therefore, the measure of the mutual product would be based on the three.
It also mentions that the measurement could be carried out depending on the type of product / service that the IAMC provides: Hospitalization (the measure would be the hospitalization itself), the External Consultation (whose measure would be the number of visits) and Emergencies (the measure is given by the number of patients).
Three were mentioned but the IAMC may want to define more mutual products, or even have the aforementioned product under-defined, for example, the Internation product have it classified in: Room Internment, Intermediate Internment and CTI Internment
An important problem also arises when we want to pay for it, a topic that obviously has a close connection with the purpose of this work. Will traditional methods be effective? Which method and / or cost system will be the most appropriate based on the current situation of mutualism? Will the application of activity-based costing be possible? Trying to find the answers to these questions will be the challenge of this work.
Despite everything mentioned in this section in relation to the particularity of the calculation of costs in these institutions, nothing prevents it from being understood as just another company and therefore the cost system that the acting professional considers best based on the situation of each IAMC. But, in our opinion, first of all we must remember that we should not try to apply what conceptually seems to be the best cost system, but rather the system that best suits the company. Carlos M. Jiménez himself in his book "Costs for Entrepreneurs" states it:
"… Not all (referring to companies), even those in the same branch, share the same distinctive characteristics, and consequently, the registration and costing methods are different. The problem is to find the appropriate system that provides all the necessary information to prepare faithful and valid cost and results tables for any decision to be made in the future. Equal companies can choose different systems depending on the way of operating … ”“… Industries that are simple can have complicated cost mechanisms, and vice versa, very complex industries can base their costs on simple methods in the sense of their implementation and application.. The facts is to develop and know the processes well…and face a useful and practical costing method … ”
3) The cost systems applied in health.
This section will present, on the one hand, a brief summary of the current situation regarding the calculation of costs in the IAMC, and on the other hand, the proposed cost system.
3.1.) Current Situation.
In the work "Cost systems and their relationship with decision-making in the IAMC" a survey was made of the methodology that exists today in our country to calculate costs in these institutions. Basically, data was collected on: a) The cost systems used, b) the mechanisms for receiving information to calculate costs, since the issue is not only having a good cost system but having the necessary and reliable information to proceed to the calculation, and c) the use that was given to the results obtained, which at that time was the object of the work.
Therefore, the main conclusions obtained will be discussed below, which describe the current cost situation in these institutions. What is presented now is a conclusion obtained as a result of interviews with four of the largest IAMCs in the country, but we believe that the results can be extrapolated to the entire spectrum of the other institutions; Obviously there are always exceptions, although in this case they are minimal.
- A) In relation to the cost system used
From the survey carried out, the following stand out:
- The most widely used system is the cascade cost distribution, or cost system based on cost coordination sectors, which follows the guidelines of the process cost system, that is, cost centers are defined on the one hand and cost concentration sectors on the other: Final, Intermediate and Support, grouping each center in the corresponding sector. Subsequently, based on some criteria, all the costs of the Support centers in the Intermediates and Finals (may also be in other Support centers) and the Intermediates in the Finals are distributed, since the Ministry of Public Health established a certain format For the Financial Statements and does not establish an accounting plan that allows the application of Cost Accounting, the aforementioned system is applied in an Extra Accounting form, although in all cases reconciliations are made with accounting, which generally adds some reliability to the results since all these institutions are subject to external audits. Although the cost centers are quite standardized, differences can be established in cost centers, mainly those classified within the Final Sectors. For example, in one institution we find a center called hospitalization, where this service is fully paid for, but in another there are several hospitalization centers: Conventional, CTI, Intermediate Care, etc. Obviously, in the latter case, the costs found They will be more representative of reality than the former, although they will all be average costs.differences in the criteria used to distribute costs between the different centers in each sector.
- B) Reliability of the information for the calculation of costs.
Regarding the reliability of the information for decision-making, it is necessary to clarify an important concept: Although the cost system used is conceptually the best if the information collected for it is not reliable, the results are not reliable.
In the interviews carried out with the institutions, it was verified that the mechanisms for collecting the information for the calculation of costs, in most cases, presented serious deficiencies. This is because:
- As there is no department in charge of costs (for economic reasons) there is no prior control of cost informationIn other words, the data comes from the different sectors and is loaded into the system directly, with no prior checks being performed. On certain occasions the sectors themselves are not aware of the use that will be given to the data provided. The costs must be a reflection of the healthcare activity expressed in some type of currency; therefore, if the cost information is not collected at the precise moment in which the activity occurs, then it is very difficult to obtain it. But for this to happen, there must be a business conscience in all the members of the institution on the issue of costs; it was detected that in most cases it does not exist. For example, it is natural to hear from some healthcare worker at the institution (a doctor, a nurse, a nurse, etc.) affirm that their task is to care for the patient and they do not have to record their consumption. In summary,There is not a culture of costs generalized to all the members of the IAMC. In many cases the computer systems were not designed with the ideal of providing information for the calculation of costs, and therefore, it can be difficult to obtain the data exactly as It requires the cost system, not even when they are needed. Finally, there are certain data that are not directly available, and which are very necessary, especially for the distribution of costs, such as, for example, operating expenses, amortizations, etc.
- C) Decision making based on cost information
In this case, exactly those expressed in the aforementioned work will be cited:
“… When making decisions, the information that arises from the cost systems is taken into account in a generic way and not as a basis, due to all the shortcomings mentioned above.
Most institutions, when they need to know the cost of a department or an activity for a certain reason, carry out a specific study of costs without taking into account, often, the information provided by the cost systems … ”
The intention is that with this brief summary it is clear that today in most of the IAMC in our country there is no culture of costs, institutions for certain reasons do not calculate costs systematically, and when they do, the data they obtain does not It is reliable and therefore they do not dare to make important decisions based on them, with which the work carried out loses total validity.
3.2) The proposed cost system: COSTS PER PATIENT / PATHOLOGY.
3.2.1) The Objective and Philosophy of the proposed system.
In chapter two, all the characteristics of the mutual product were mentioned, where it was highlighted that the two main ones were its intangibility and heterogeneity. Intangible because, although there are material elements, the final product of care cannot materialize. Heterogeneity because the same service provided to two patients may be different and also have different results.
Why patient costs? For the second characteristic of the mutual product; it is the only viable answer from which reliable data can be obtained to make safe decisions. By means of the process cost system, average costs of sectors or even activities are obtained, but with these data I cannot distinguish the particular situations of each patient with respect to costs and therefore make the correct decisions.
Why for pathology? Basically for two reasons. Firstly, heterogeneity, the same that was mentioned so far in this section. Secondly, due to a characteristic of this institution that until now has not been mentioned in the work but which we all know: insurance companies, because they charge a fee and cover certain benefits. In this sense, many people in the sector think that the difference in the quota is in the age because it is spent more as the person ages, but it is not only the age, but also the pathology presented by each associate is important. A 20-year-old who is asthmatic is not going to spend the same as a 20-year-old who does not have any particular pathology, nor a 20-year-old who had a kidney transplant.Therefore, it is very important to take pathology into account when calculating costs.
On the other hand, our health system is not applied worldwide. In the most developed countries there are insurers, where health institutions when they make an intervention already know what they are going to charge because it pays them according to the patient's pathology; They do this because they have the costs calculated by this methodology and the only thing they add is a% profit for the company that performs the medical act.
In our opinion, this methodology is the most suitable for calculating costs in the IAMC because it is the one that provides the information in the most convenient way for decision-making.
Finally, a comment that we believe supports the opinion. In our country, the possibility of changing the current health system for a new National Health System (SNS) is being studied, in which it has been specified that the institutions will not collect more but that the SNS will do so and will allocate the money to each IAMC based on the type of associates it has. For example, two IAMCs that have the same number of affiliates but in one the population has an average of 30 years and in the other 60, they will not receive the same income because the costs per patient are different. But to do this, it is necessary to know the costs per patient and also per pathology, otherwise we will never find the economic-financial balance that allows the institution to continue working.
3.2.2) The calculation methodology
The methodology proposed here starts from a classification into two main types of costs: Variable and Fixed; that is, on the one hand, the system must calculate the variable costs per patient, which will be all those expenses that originate from patient care, for example, medications, material for medical use, analysis, fees specifically for that patient, etc.
On the other hand, the fixed costs or costs for the use of the IAMC services must be calculated, such as the cost of the day / bed in each type of room (conventional, intermediate, intensive, etc.), the cost of use of the surgical block, the cost of the consultation by specialty, etc.
There is no exact correlation between the proposed cost system and a specific existing cost system, but this system is a combination of methodologies: Production order costs, process costs and activity-based costing.
For the calculation of variable costs, the methodology of the production order cost system is used, where the order is, so to speak, the patient. When each individual is served, it is as if a production order was opened, all the inputs that are consumed are recorded from the moment they enter until they leave.
For the calculation of fixed costs, the process cost system is applicable, since it allows obtaining the average cost of using the IAMC services, using the costing methodology for the allocation of indirect costs between the cost centers. based on activities.
Therefore, as we said at the beginning, we have two main types of costs: Variable Costs that we can call Assignable Costs to Patients and Fixed (or Structural) Costs for using services.
3.2.2.1) Costs Directly Assignable to Patients / Pathology
These are the expenses that, as the definition of variable costs indicates, originate if the patient is treated, otherwise no variable expense originates only fixed costs, which, as previously mentioned, are calculated by another mechanism.
TABLE 5: Diagram of resource consumption per patient.
Here is an important clarification. It is not all the variable costs that are included here, but only those that can be directly associated with the patient at the time the service is provided; that is, there are costs that can be classified as variables but it is difficult to put into practice when registering them by patients, such as the cost of the food served or the kg. of washed clothes, although these are variable costs, it is proposed to register them together with the structural or fixed costs. It should be noted that these costs are not significant.
Let's make a brief summary of the costs that are included under this classification (directly assignable to patients).
Remuneration and Fees. Only those labor costs generated by specific patient care will be included; in other words, piecework or fees. In cases in which a fixed remuneration is paid for care, it must be classified as a structural cost or a fixed cost for the provision of a service, since the same is paid if one or twenty acts are performed.
In an institution of this type we can find different situations; Generally, the remunerations are fixed and the number of patients attended is not taken into account, especially in non-technical (non-medical) officials, therefore they will not be part of the variable cost but rather of the structural cost. With technicians there are two situations; There are doctors who charge for acts performed and others a figure per month, the former will be charged directly to the patient, while the latter will be calculated using the methodology of calculating structural costs.
In summary, non-technicians who charge piecework and technicians who charge for a medical act must be included as labor costs directly assignable to patients. If someone is paid a fixed amount plus a% per act performed, only the% should be included because it is the component that varies according to the patients attended.
Medicines, materials for medical use and other goods. Only the goods of this type consumed specifically by each patient should be registered. In no way should the consumption of goods in a sector be incorporated into the variable cost to provide a service to several patients.
For example, the serum consumed by a patient is associated with and charged to it, but the gauze and tape used to heal a wound cannot be attributed to it because a patient does not consume a roll of tape or a pack of gauze pads; these costs are considered within the fixed costs (it is an example that all the semi-variable costs are not included in the variable cost).
Services: Laboratory analysis, other studies and services in general. This item includes all diagnostic services such as studies performed using plates, laboratory analysis, hospitalization services that the patient requires outside the institution (for example, psychiatric hospitalization if the institution does not have it), fees of professionals outside the IAMC for specific medical consultations, and all other types of services required to care for a patient.
As in the aforementioned items, the services required to care for a patient will be recorded as a variable cost.
In this area, special consideration should be made in the event that the IAMC provides these services itself. In the case of hospitalization services, there is no problem because its use is calculated as a fixed cost by the process cost system, but in the case of analyzes and other studies , the cost of providing it must be calculated.. For example, a patient needs to have a computed tomography scan and the institution does it because it has a CT scanner; In this case, we must calculate the pure cost of conducting the study and charge this value as a variable cost per patient multiplied by the number of studies that were done. If the tomography had been performed outside the institution, the cost of the invoice or counted ballot of the company that carried it out would be charged.
The calculation of the cost of the diagnostic service is carried out by the process cost system, it is the same as calculating the cost of using the hospitalization service.
These are basically the costs that must be specifically attributed to each patient; Let us now look at the methodology for calculating costs for service utilization.
3.2.2.2) Costs for using IAMC services
As we said before, the costs are basically fixed costs, although as explained in the previous section, other costs are also included, such as kitchen and laundry expenses, which are difficult to impute to patients and are not very significant.
The costs calculated here are all those that cannot be directly assigned to patients. We have, among others, the following costs:
- Hospitalization day / bed: ward, intermediate care, intensive care, psychiatric, maternity and others Use of the Polyclinic Office (Central and Decentralized). Use of the surgical block. Emergency consultations. Diagnostic services: Unit of Relative Value, Tomography, Mammography, others.
The calculation methodology is the same as the process cost system, but with an important variant: the allocation of indirect costs will be based on the activities.
Let's clarify. First, by the system's own methodology, after knowing what costs we want to calculate, cost centers must be defined, which will be classified into Final, Intermediate or Support centers depending on the function that each center fulfills in the company with in relation to its objective.
Second, the costs of the Intermediate and Support departments in the Finals must be assigned. This is where the cost allocation occurs. Generally, in companies that have used the process cost system, general allocation criteria based on production volumes have been used, which seems to be quite unfair since they tend to be over-applied to products / services of higher volume, subsidizing those of lower volume. volume; What the proposed methodology indicates is that the allocation of costs is made based on the activities consumed by the final cost centers of the Intermediates and Support.
Table 1 shows the process for calculating costs for using services.
Once all costs have been assigned and distributed in the final centers, the unit value of the aforementioned services must be calculated (value day / bed, Block quir., Etc.). For this it is necessary that the statistics department provides us with the production data of each service. The following production measures are generally used:
| Service | Production unit |
| Internment | Days / Bed occupied |
| Surgical Block | Qty. Interventions by type |
| Polyclinic Consultations | Number of Polyclinic Consultations |
| Emergency | Number of Emergency Queries |
Despite being a simple mathematical operation given that it is obtained by the quotient between total costs per center and production, it must be taken into account that the costs involved are all fixed and by dividing them by units we are unifying them. To make the data reasonable, it is necessary: a) as is normal in each cost study, to be carried out in a period where production is normal and not in exceptional periods (such as the April-June quarter), and b) verify that the percentages of use of the services are relatively constant.
Until now, the cost calculation methodology has been broadly determined. It has already been clear that variable costs should be attributed to patients (except in situations where this is almost impossible, such as in the case of laundry and kitchen) and Fixed costs are calculated in another way, establishing a methodology that concentrates them by cost centers and assigns them based on the activities carried out in them and that the rest of the centers consume.
Let us now look at the requirements at the administrative and computer system level that are required.
3.2.3) The system from the administrative and computer systems point of view.
An attempt will be made to explain the method for capturing, processing and calculating, on the one hand the variable costs, on the other the fixed costs and finally, an interaction system that will request data and display the results. The computer system will be one but, as in the previously explained methodology, there will be a calculation method for variable costs and another for fixed costs.
TABLE 6: Process for calculating costs for the use of services
Collection and recording of cost data assignable to patients. Variable costs must be captured at the time they occur, otherwise it is impossible to know them; they must be processed in such a way that all the data required by the system is included, and then the information the user wants is provided.
The idea is to have a PC in each physical place where costs occur and when they are generated, register them in the system. The use of the barcode is a useful tool for this purpose. That is, we should have a PC in the Surgical Block and in each intervention enter what each patient spent in the system; another one in the hospitalization rooms (be it conventional, intermediate or intensive care) and during the patient's stay recording the costs that originate from the patient's care; another in the pharmacy, and registering in the system the medications that are provided to the patient, and so on in all the places where patients are treated and variable costs are generated.
The issue is that nowadays due to the economic situation that the AMIs are going through, it is difficult to have a PC in all those areas, so what is done is the following: a) in each area in which a patient is treated and consumes resources, a spreadsheet is filled with all the data on what was spent. Each spreadsheet is recorded in adequate detail by type of resource consumed, specifying quantities, and one is filled for each patient; b) in some area, whether healthcare or administrative, data is received and entered into the system.
Whether there is a PC in each area where patients consume resources or that forms are filled out and then someone enters them into the system, what has to be clear is that the information must be entered in its entirety trying to avoid that it is not produce no data omission because otherwise the information that the system will provide to the user will not be adequate, and therefore, the decisions made will not be the right ones.
TABLE 7: System screen where costs assignable to patients are recorded. Esp.-Tipo is where the pathology is recorded. Destination is the sector where the patient is hospitalized.
How should information be recorded in the system to meet the requirements of the proposed cost methodology? It is an easy question to answer; Since we want to obtain costs per patient and pathology, the consumption of resources per patient and pathology must be entered into the system. For this it is necessary that when entering the data to the system the following information is entered:
- Affiliate number or admission number if you are not a member of the institution Pathology Detailed consumption (for example, name of medications and amounts provided, etc.) Other information such as name of the doctor who treated you and who indicated the treatment or intervened (This will allow us to obtain medical costs).
Regarding point b), it is necessary to have the pathologies already established in advance and not leave the treating doctor the name because sometimes the same pathology can be called in two different ways and that would cause problems when it comes to obtaining results. Therefore, pathologies must be established by the institution's medical authorities and will be registered in the system in the same way; In this way we ensure that a pathology is not expressed in two different ways.
The input of these data is essential to successfully meet the objectives of the cost system per patient / pathology. Where only one of the data is not entered into the system in the aforementioned manner will result in inaccurate information from the computer system; therefore, the necessary control mechanisms must be created in the sectors, establishing penalties for those who do not comply with the aforementioned guidelines.
Collection and registration of costs for the use of services. There are two ways to calculate structural or fixed costs, by cost accounting or off-the-shelf. As required by the MSP, the IAMCs have a chart of accounts to comply with, which does not have the aspects of cost accounting, therefore, before touching the chart of accounts, it is better to calculate them off-account.
It is necessary to remember that the calculation methodology is that of costs by processes using as criteria for the distribution of indirect costs the concepts of costing based on activities.
For this, cost centers must be defined and their classification into cost concentration sectors by Final, Intermediate and Support Activities. Importantly, only fixed costs and never variables will be assigned to cost centers.
TABLE 8: Screen of the accounting system where the entries are recorded. See the field where you ask the assistant to enter the cost center.
It is not necessary to elaborate too much because the process cost system has already been widely used. What if it is interesting would be to mention some criteria guidelines in order to obtain the information with more agility, because here in Uruguay it has been developed basically at an extra-accounting level and manually, while the idea is to structure the mechanisms so that the information of Fixed costs are obtained by computer systems.
For the remuneration part, it would be convenient for each official to code the cost center to which he belongs. If you work for several cost centers, you must specify their codes and every month the number of hours worked in each center. In this way, the personnel department enters the information every month and a list of personnel costs by cost centers is obtained.
The rest of the fixed costs arise from accounting, but in order not to touch the chart of accounts, what has been done in some institution is to generate a report based on the accounting data that groups expenses by cost centers. To do this, all that is required is that a code be added to each accounting entry (which represents a cost center) depending on the expense that is being spent. The code does not touch the traditional accounting but the system generates a report with all the expenses by codes.
In this way, fixed costs are obtained by cost centers. Subsequently, the cost computer system requests the following information:
- Indirect cost allocation criteria, for which there is a toolkit where the data is loaded for the allocation based on the activities; yProduction of the period.
Therefore, the system must take the compensation data from the personnel system and the rest of the expenses from the accounting system report and must automatically distribute the direct costs to each cost center. Subsequently, by assigning costs between the sectors (final, intermediate and support), it will automatically calculate the total costs of the final cost centers. Once these are obtained, the unit costs will be calculated.
In this way, the costs for using IAMC services are obtained.
Finally, let's look at the general characteristics of the computer system.
The computer system - data input and information output. Like all computer systems, on the one hand it collects data and on the other it provides information.
Obviously the computer system calculates everything automatically. It is related to the affiliate system so that by entering a member number you can provide all the information about it and therefore can calculate costs by age range, by geographical area, etc. It is also related to the membership system. staff so that obtaining costs doctors can know immediately the specialty of the same and any other information that we consider necessary for analysis and billing system, as also requests a profit margin above the cost of mutual product if you want to invoice an individual.
Regarding daily operations, it is like if the system were a person, it asks for data, processes it in your mind and, depending on what is asked, gives an answer.
The entry of data related to fixed and variable costs has already been mentioned in previous lines; What remains to be seen are the data that the system provides and which are the following:
- The cost originated by the care of any patient for the desired period. The costs for patients classified by pathology, by age and both together. Obviously in the periods you want.Idem b) but also classified by the different sectors of the IAMC (Intensive care hospitalization, intermediate care, conventional, consultations, emergency, etc.). Show the variable costs for any modality a), b), c) Show the fixed costs for the use of the institution's services. Show the costs of a certain defined mutual product.
To finish, some clarifications are needed. In the first place, in the cost originated by the attention to any patient, the system not only provides the variable costs, but depending on the sector where it was attended, it also provides the cost for the use of the service. For example, the patient underwent vascular surgery; When we ask the system for cost data, it will not only provide the variable costs consumed, but will also add to the total cost the cost of using the surgical block (referred to in medical jargon as table right) and the cost of the day / bed occupied in the room that has been hospitalized. It will display the following:
Patient's name: Emilio Da Rosa Age: 58 years
Type of Medical Act Practiced: Intervention in Surgical Block
Medical act: Vascular Surgery
Consumed Costs 28,350
Assignable to Patients: 20,350
Block Utilization: 2,500
CTI hospitalization: 4,000
Conventional Hospitalization: 1,500
Obviously, the system can open more costs by showing the composition of each concept.
If it were not associated and you wanted to invoice, the system would take the total costs and multiply it by the established percentage and invoice.
Secondly, and we believe that for the purposes of decision-making it is important, the system calculates the costs of each mutual product; for example, what is the cost of a certain intervention with two days of hospitalization, with three or with those you want. Not only how much does the use of the Block cost, the day / hospitalization bed but how much does a mutual product cost. For this it is necessary that the mutual products are defined by the medical authorities and / or accountants or whoever is in charge of calculating costs.
This was a brief summary of what the system is capable of providing, but the basis of everything is given by the proposed cost system: Costs per patient / pathology.
BIBLIOGRAPHY
- Costs for entrepreneurs. Carlos Mª Gimenez et al. Macchi 2000 Editions. Cost System and its relationship with decision-making in collective healthcare institutions. Cr. Martín Velarde, Cr. Ana Testa and Cr. Federico Antúnez. Coordinator: Cr. Alfredo Kaplan. Monographic research work. University of the Republic. Year 2001. Cost analysis in Hospitals (1st Edition). Guadalajara Nativity. M / C / Q editions. 1994. Management and Costs - Increasing profit, continuous improvement. Carlos Mª Gimenez and others. Macchi editions. 2001. Health: a state policy. Towards a national health system. Dr. Hugo Villar. Publication of the Medical Union of Uruguay. Year 2003.The health of Uruguayans. Dr. Álvaro Harretche. Cost Accounting Treaty (5th Edition). Carlos M. Gimenez et al. Law No. 15,181: New standards for collective and private medical care are established. IAMC: Uniform Information System and Audit Procedures ”. Ministry of Public Health.
