Costing of Medical Services
Costing of medical work has gained popularity in hospitals that are
working under the purchaser provider split and contracts. Purchasers generally
want to know from what services they are paying for. As a consequence, the
providers must calculate the cost of these services for pricing and contracting
purposes. However, price setting is not the only reason for cost calculations.
Costs are calculated also for managerial purposes along different hospital
departments. This is because the allocation of costs to products or services is
not particularly useful for cost control purposes. Instead, costs should be
traced to departments and to the person who is accountable for controlling
costs within that department i.e. head of department.
Bookkeeping and cost accounting
The book keeping (financial accounting) provides the main
information base for cost accounting (management accounting) but can not
replace it. Bookkeeping and cost accounting together are identifying, measuring
and communicating economic information to permit informed judgements and
decisions. Bookkeeping provides information for the owners and other external
parties outside the organisation like tax authorities but cost accounting is
made for the internal use only.
The major differences between book keeping and cost accounting are
that book keeping is a compulsory requirement for public and private
enterprises to produce annual financial accounts but there is no legal
requirement for cost accounting. Bookkeeping reports and describes the whole of
the organisation when cost accounting focuses on reporting information for
different units of it. Also, book keeping must be prepared in accordance with
generally accepted accounting principles and it deals with historical
information. Cost accounting places greater emphasis on reporting estimated
future costs and revenues.
Consequently, cost accounting in hospitals has two different
functions. First, provide relevant information to help managers make better
decisions when analysing profitability, pricing products or services, deciding
to make or buy and, finally, when deciding what to produce and how much.
Second, provide information for planning, control and performance measurement
where we can separate long -term and short-term planning (budgeting) and
periodic performance reports for feedback and control.
How to calculate costs
A cost accounting system normally accounts for costs in two broad
stages: Accumulating costs by classifying them into certain categories e.g.
labour, materials and services and overheads and then assigning costs to cost
objects. These objects can be cost centres/departments, services, products and
customers. The calculation of the cost of the different departments is called
cost centre accounting. It is done for management purposes only. Today in
hospitals in Europe we generally have at least two management levels (whole
hospital and subordinated clinical departments) and, consequently, two levels
of budgets. The second class of cost objects is the actual services and
products. The product and service costing is based on the information derived
from a cost centre accounting. Product and service cost accounting is needed
when a hospital start to sell services for customers e.g. rayon health
administration, health insurance companies or patients. Therefore, cost centre
accounting is also relevant in budget organisations but they hardly need a
service costing because they derive incomes trough budget and not trough
For cost accounting different hospital departments are usually
classified in three categories: first, administrative and support services,
second, clinical services (clinical laboratory, imaging, intensive care,
operation theatres and pharmacy) and third, clinical departments. Inpatient and
outpatient clinical departments are in hospital cost accounting called as final
cost centres because they are producing services to clients outside hospitals.
Support services are called initial or intermediate cost centres because they
are producing services (mostly) for final cost centres only.
There are two main costing approaches. The first one is called the
direct costing where the indirect costs are not assigned to cost objects. This
method is appropriate where the majority of costs are direct that today is very
seldom the case. Therefore, even being simple, the direct costing is mostly
outdated. The second approach is called indirect costing method where a
two-stage allocation procedure is required. In first stage overheads are
assigned into initial cost centres. In second stage, cost centre overheads are
allocated to cost objects (e.g. products or services) using second stage
allocation bases/cost drivers. Applying the two-stage allocation process
requires four steps. First, assigning all overheads to final production and
service cost centres, second, reallocating the costs assigned to service cost
centres to production (final) cost centres, third computing separate overhead
rates for each production cost centre and finally, assigning cost centre
overheads to products or other chosen cost objects.
Costing services, patients and patient groups
Evident precondition for costing of any medical services is that
these services are defined. A medical service can be whatever activity aiming
to maintain the patient vital functions, to provide knowledge about his or her
health status or/and to improve it. These services are many: examinations,
treatments, operations, tests, medications and hotel services like meals or
bed-days. However, treated patient (or solved medical problem) can be defined
to be the "final product" of hospitals and to be the main base of cost control
- not the outputs- being they in days, laboratory examinations or operations.
These services are only intermediate inputs for the final service.
If we want to get a accurate picture on the cost of the individual
treatment all the directly patient related services must be registered on the
patient level when they pass through various intermediate stages from the time
they enter the hospital to the time they are assigned to patients. These
intermediate stages must be identified to understand the true sources of
hospital costs. However, for most practical purposes the services can be
defined by broader categories related to the medical problem at hand and
treatment delivered because of it. Instead of the individual patient cost are
related different treatment/patient groups. The most well known grouping system
today is the Diagnosis Related Groups (DRG) that is widely used for hospital
management and reimbursement purposes in Europe and USA.
Above two levels - individual treatment or treatment group -
define how the costs can be calculated and we, therefore, have two main
approaches to the costing of medical services. The first can be defined as
bottom up or micro costing method that relies on the costing of all individual
services and use of these services by individual patients. This is mostly based
on the computerised information systems that capture all data about the use of
internal services by the patient. The data needed includes e.g. services
provided by operating theatres, laboratories, radiology departments, wards,
laundry, kitchen etc. This costing model does not come without cost and is
relatively expensive to implement because of extensive need of information and
data. However, that kind of costing approach is now under development in pilot
hospitals of our project.
The second approach can be called as cost modelling. As compared
with micro costing, cost modelling does not normally require the collection of
additional service utilisation data by individual patients and this is today
the case in most Ukrainian hospitals. The process used is a "top-down" one in
which the total costs associated with a hospital's operations are distributed
instead of the individual patient first, to the clinical cost centres like
surgical or gynaecological departments and then to service groups (e.g.
diagnostic related groups, DRG) using a variety of indicators and indexes of
activity and costs from hospital statistics. The relationships between costs,
activities and service groups are modelled. This means that a group of
simplifying assumptions has to be made about these relationships to find out
the service cost estimates.
In top-dawn costing exercise the way to control and monitor
healthcare costs take place through the standard cost system (point and point
values). A standard cost approach develops estimates for what a service should
cost at the given desired/planned levels of quality and quantity of care. Once
standard costs have been developed, we can compare actual total costs incurred
and case mix standardised cost. The resulting differences, called variances,
can be used to evaluate a hospital performance. Three major inputs needed in a
standard costing process are: identification services (disease groups like
DRG), their estimated resource requirements (based on medical standards) and
costing of the resources identified. That kind of process is already on the way
in Ukraine. Within EU project, based on existing Ukrainian medical standards,
four categories of diagnosis related groups where derived for inpatient,
policlinics, primary care and dental care. This grouping will be incorporated
into the information system in pilot hospitals.
Standard costs (relative value units) are developed by measuring
the intensity-of-care. There exist workload measurement systems to introduce
e.g. cost weights and unit values for each service that are based on e.g. time
average studies. The unit value might be the average number of productive
minutes of technical, clerical and idle time required to complete the defined
service. When the major determinant of cost is the time used, per hourly rate
approach has been used for costing: total costs are divided by the number of
hours or minutes to get the average cost of one time unit. Multiplying this
average cost by the units of time for a specific procedure gives the cost of
Often in practice the costing projects of medical services
incorporate elements both from micro costing and top down models. However,
neither cost modelling nor micro costing will provide the "true" costs of
treating the patients included in each group. The purpose of top down cost
modelling is to provide estimates of average costs of services only on a
consistent and systematic basis. This will ensure that the results are
comparable between institutions, and that the results are useful for management
and reimbursement purposes. Each costing model must state which cost-items are
included and which are excluded. Also, we have to know how the costs that are
not directly associated with patient care should be allocated, and how joint
production costs are to be distributed between the various products.
Relevance of cost information
Fortunately, for management purposes the crucial issue is not
whether costs are calculated precisely. More important is whether the quantity
is measured correctly. With a good measure of quantity consumed, the cost
measure would have to be substantially in error before it would adversely
affect managerial decisions. As long as clinical managers are charged based on
an accurate quantity measure, they will probably not spend much time arguing
about minor fluctuations in its unit price. Instead they will act to use the
quantity of the resource they consume efficiently and effectively.
If, however, we measure the quantity inaccurately managers are not
rewarded or punished for the quantity of the demands they place on service
departments. In this case, the use of a surrogate measure of quantity has
caused the cost signal to be ineffective in motivating operating efficiencies.
Thus, cost attribution to clinical departments can be performed when an
accurate quantity measure exists. Fortunately, in hospitals most of the
quantity measures are related to the patients treated and modern IT technology
offers economic way for registration of these activities.
Consequently, if hospital management or owners or purchasing
authorities wants clinical managers to promote efficiency, improve
productivity, and learn more about the characteristics of production processes
under their control, then they must send them accurate measures of quantities
and good estimates of cost of resources consumed.