Summary
Public hospitals are aware of the cost of paying attention to the costs of health-care services projects and the costs of disease, mainly as a result of policies at the national level and the reform of the drg/dip payment modality. In practice, the complexity of costing of medical services, the limitations of accounting for pathologies, difficulties in implementation and difficulties in translating accounting results have led to slow progress in cost management in public hospitals. Public hospitals should be flexible in using multiple accounting methods, with emphasis on data governance and informatization, enhancing the application of accounting results, and managing costs under clinical pathways, at a fee rate。
Zheng sun
As health care progresses, public hospitals need to face changes in policy norms, health insurance payments and the internal challenges of slower and unaffordable growth in income from operations in the post-disease era. Following the introduction of the cost accounting standard for public hospitals in 2020 (unpronaf 4), the pace of cost accounting in public hospitals has been accelerated in view of the importance of cost management. This paper analyses the history of cost management in public hospitals, as well as pain points and difficulties, and makes recommendations for their use。
01 cost management change in public hospitals
The cost management of our public hospitals, marked by the hospital finance system (cif 306) and the hospital accounting system (caf 27), which was promulgated in 2010, has been initially structured into a more comprehensive cost accounting system, which can be divided into three stages。
1. 1 the era of cost management 1. 0
During this period, the main policy was based on the hospital financial system, which for the first time clearly introduced the concepts of unit costs, medical service project costs, disease costs and bed-day costs, and clinical costs. However, with the exception of a clear method of subsuming and apportioning the costs of the sections, there are no specific guidelines and implementing rules for accounting for the costs and the costs of the medical services. In practice, hospitals are largely self-surveying. This is complemented by project-based payments, combined with dividends from the consumption of medicines, and the increased size of hospitals through broad collections, resulting in a lack of cost-conscious focus on overall income growth and health insurance payments。
1. 2 age of cost management 2. 0
During this period, an important landmark was the " guidance on strengthening financial and budgetary management of public hospitals " issued in 2015
For the first time, it was proposed that “project-by-sick costs be carried out in conjunction with the reform of health insurance payment modalities and the establishment of clinical pathways”. An important context for this policy is the comprehensive piloting of the cost of disease accounting in beijing's third-tier public hospital in 2012-2015, which led to the establishment of a cost accounting system led by the government, creating a more operational cost accounting path for the third-level public hospital. Another important indicator is that, as medical care progresses, medicines and consumables are added and eliminated, the competent authorities begin to control unreasonable medical expenses, and hospitals begin to focus on indicators such as the ratio of cost of medicines to cost, per capita cost, management cost rate and per capita output. In practice, however, medical personnel are passive and the medical behaviour pattern is not very different, often by cost, by controlling the cost of medicines per capita, by means of individual rewards or performance allocations. This is explained by the fact that the health insurance payments for this period are still based on project fees, that “more” is still available and that hospitals lack the incentive to carry out cost accounting。
1. 3 the era of cost management 3. 0
During this period, the state issued a circular on the publication of pilot cities lists of states paying by group for disease diagnostics (medical insurance)
2019334) and the circular on the issuance of the total budget of the regional points method and the programme of work for the pilot payment by disease (issued by the office of health insurance)
Two important policies, combined with the sudden new coronary pneumonia epidemic, have reduced the income from hospital operations and have had a marked impact on the economy, forcing not only public hospitals to improve their cost management, but also medical personnel to change their behaviour completely and move forward towards cost control。
02 pain and difficulty in cost management
In practice, cost accounting for public hospitals has progressed slowly, owing on the one hand to a lack of prior drivers and, on the other hand, to the pains and difficulties in establishing a cost management system。
2. 1 complex costing of medical services
Chen zhen (2001) first applied the operational cost method to the costing of hospitals in our country, and later it was widely applied to the costing of medical services projects, with high accuracy but complex operations. The main approach is time-driven operating costs, which are judged by statistical analysis and empirical judgement. The main disadvantages are also clear: first, the long implementation cycle, the high level of computerization of hospitals and the high level of capacity of accountants, and the fact that it often takes two to three years for large public hospitals to complete the costing of hospital-wide medical services; - it is the principle of the operational cost method, which is limited to the historical costs that are no longer applicable when resource drivers, such as operating processes, personnel and so forth, change significantly. When health services themselves are different from the standardized production in manufacturing, the individualization of clients varies greatly, the technology of health services is changing rapidly, and resources such as equipment, materials and so forth are rapidly being updated, many times the results are found to be detached from reality and unusable. In addition, the current costing of medical services is generally based on the cost of medical services, which is disconnected from the medical process and does not facilitate the development of a standard path based on medical behaviour. The current system of prices for medical services is not perfect, in particular the underestimation of the technical labour of medical personnel, the existence of a number of non-fee-free, resource-consumptioned medical services and the failure to achieve a dynamic adjustment in the price of the project, so that the billing items do not represent medical behaviour。
2. 2 limiting cost accounting for pathological species
Prior to the issuance of the latest edition of the public hospital cost accounting guidelines, the costing of diseases was largely project-based, so that the costing of medical services directly affected the costing of diseases. A number of hospitals, after accounting for unit costs, have stalled at the cost chain of medical services and are unable to implement the cost of the disease. Other accounting methods, such as the clinical path approach, depend on the level of clinical path development in hospitals, while the operational cost method is based on experience in hospitals abroad and is less operational in the country. Prior to the introduction of the diagnosis related groups (drg) and big data-based system, there was no commonly accepted definition of disease concept in the country, so that even if the project cost was completed, hospitals did not have a uniform basis for classifying disease costs。
2. 3 difficulties in implementing the cost-accounting system
2. 3. 1 participation the institutional set-up of hospital cost accounting is critical and requires a high level of accounting team, in addition to a cost leadership group and a cost accounting office. Owing to the special nature of medical operations, the operation of medical service projects, disease cost models, etc. Need to be operationally based and multidisciplinary in order to be completed, while cost accounting is often carried out only by financial personnel, who are less likely to understand both medical operations and management accounting, and whose results are difficult to obtain medical approval, to some extent hinder the advancement of cost accounting。
2. 3. 2 informationization issues cost accounting involves a variety of complex data and processes and must rely on a cost-accounting information system. This is not just a separate cost accounting software, but rather a need to link data from hospital information systems to break information isolation and to aggregate various cost data. In practice, however, not only is the direct extraction of cost data very difficult, but the system does not match cost data, with significant errors affecting the efficiency and effectiveness of cost accounting。
2. 3. 3 data quality issues. A study based on cost accounting by a beijing-based hospital found that about 70 per cent of accountants would need to process the raw data from the operational systems in the compound twice; about 80 per cent considered the poor quality of the data to be the biggest constraint on the application of the cost accounting results. Cost accounting requires, in addition to financial data, various types of operational data, whereas the fact is that data from the vast majority of hospitals cannot be directly extracted and need to be processed artificially; data are not matched and interconnected across systems, and many assessment parameters are largely based on experience and common sense; and the unit-based accounting module is subject to constant adjustments due to the consolidation of division of sections and changes in personnel, severely limiting the accuracy and timeliness of cost accounting。
2. 4 how cost-accounting results are translated into place is first and foremost an internal application, how hospitals conduct cost control and performance evaluations, such as whether the health-care payment criteria represent a cost base, whether the health-care loss pathologies are borne directly by the office or the doctor, how practical controls are developed, how to increase the motivation of doctors, how to conduct cost analysis, how to select cost performance indicators, how to integrate into existing performance programmes, and how to balance cost control and discipline development. Second, with regard to external applications, the slow development of the system of prices for medical services, especially for medical services that reflect medical values, is a result of varying levels of cost accounting at different levels, which makes it difficult for hospital cost accounting results to be reflected in service pricing; and the fact that health insurance payments are not based on hospital cost data owing to the introduction of regional lump sum advances, which makes it difficult to apply the cost accounting results of hospitals to payment rates owing to differences in health insurance balances。
03 public hospitals advance the idea of cost management
3. 1 a combination of accounting styles
One is a combination of methods. Owing to the complexity of medical operations and the limitations of the various accounting modalities, it is not only one method that can account for the cost of all medical services. At this stage of project cost accounting, where there is an operational cost method, a cost ratio factor method, a cost conversion method and a resource consumption classification method, hospitals have the flexibility to choose appropriate and efficient accounting methods, taking into account their operational characteristics and implementation needs, in combination with different types of sections, different categories of projects and different resource consumption modalities. In practice, multiple ways of doing so can be tried simultaneously, as long as basic data specifications do not affect the accuracy of cost results. The second is that the costs of the disease and the project are carried out simultaneously. The latest edition of the public hospitals costing guidelines defines the cost of the drg and, for the first time, includes a top-down and cost-income ratio. The former is a separate account for the cost of medicines, health materials and other costs of the costing module for patients, which is divided into bed days, time spent on consultations, etc., and is eventually folded into sick cost; the latter is a fee for patients divided by service modules and income converted to cost by calculating the cost-income margin for each service unit. Compared to the bottom-up project overlay, these two approaches allow for the completion of cost accounting for pathogens on the basis of section cost accounting, and advance the process of costing faster and more flexible。
3. 2 focus on data governance
The quality and standardization of data across business systems is crucial in establishing a cost-accounting system that, on the one hand, combes the flow of data and information within the college, and, on the other hand, links business processes through a standardized data dictionary, leading to connectivity of all cost data. In response, it was suggested that a multidisciplinary, multisectoral mechanism be established that would significantly enhance the efficiency and effectiveness of cost accounting。
3. 3 enhanced application of accounting results
The first is the establishment of a comprehensive cost analysis system that combines health insurance payments, discipline building and is not limited to the analysis of the financial results themselves, such as the boston matrix analysis of disease costs, which can be used to identify dominant groups and problem diseases。
The second is to track and resolve problems in a timely manner, for example, by conducting a single analysis of the medical services that have lost their accounting results, identifying the reasons, introducing cost controls over the internal combo process and making timely external declarations of price adjustments for services。
Third, integration into the in-house performance evaluation system and application of accounting results to hospital and unit operations management will accelerate the translation of results and give greater emphasis to cost work in hospitals。
3. 4 attempts to use medical advice as a starting point rather than as a fee item the current method of accounting for medical services is based on the sharing of cost drivers, such as time-consuming personnel services and the consumption of equipment and materials, without taking into account differences in the technical difficulties and exposure of medical personnel. At a later stage, it is possible to combine a medical programme, relying on standardized medical advice, increasing the weight of risk, intensity and exploring cost accounting methods that accurately reflect the content of medical behaviour。
3. 5 development of disease-specific resource consumption models
Maximizing the internal and external application of cost results will ultimately require the formation of standard clinical pathways corresponding to the disease, based on the consumption of medical resources and the degree of disease vulnerability, to regulate the clinical process. In conjunction with the diagnosis and treatment of diseases, each node in the course of the treatment is standardized through clinical route management, cost consumption is kept within a reasonable range and deviations are monitored, thus controlling resource consumption while ensuring medical quality。
In summary, changes in the way health insurance is paid by the drg/dip are a fundamental driver of cost management in public hospitals. At the time of the cost-accounting exercise, the complexity of the accounting methodology, the difficulty of implementation and the lack of results led to delays in moving forward and discounting effects. In practice, therefore, emphasis should be placed on data governance, improving data quality, forming multidisciplinary, complex teams to advance specific work in the context of information-based tools; strengthening analysis after the situation, focusing on problem resolution and the transformation of results, integrating into the performance evaluation system, leading to clinical route cost management in conjunction with clinical processes。
