Textbook solution for Survey of Accounting (Accounting I) 8th Edition Carl Warren Chapter 13 Problem 13.6.2P. These activities are conducted on state-of-the-art equipment. Indirect or overhead costs cannot be identified with or traced to a specific cost object (17). Measure costs right: make the right decisions, Improved financial management of the radiology department with a microcosting system, The costs of CT procedures in an academic radiology department determined by an activity-based costing (ABC) method, Activity-based cost analysis: a method of analyzing the financial and operating performance of academic radiology departments, Cost identification of abdominal aortic aneurysm imaging by using time and motion analyses, Time-motion analysis of emergency radiologists and emergency physicians at an urban academic medical center, Time-driven activity-based costing in an outpatient clinic environment: development, relevance and managerial impact, The role of physicians in controlling medical care costs and reducing waste, Measuring the value of process improvement initiatives in a preoperative assessment center using time-driven activity-based costing, A new costing model in hospital management: time-driven activity-based costing system, How Cleveland Clinic used TDABC to improve value, Using time-driven activity-based costing to identify value improvement opportunities in healthcare, Time-driven activity-based costing in emergency medicine, Time-driven activity-based costing: a driver for provider engagement in costing activities and redesign initiatives, Utilizing time-driven activity-based costing to understand the short- and long-term costs of treating localized, low-risk prostate cancer, Quality initiatives: lean approach to improving performance and efficiency in a radiology department. Classically, ABC is a two-stage process that first assigns resource costs to discrete tasks or “activities” and then assigns the costs to final products or services based on their use of the activities (Fig 5). In a study of costing at seven hospitals, RCC-derived hospitalization costs differed by more than 15% from the reference standard in 35% of hospitalizations (26). For example, the expenses associated with an MRI of the brain with contrast could be found by costing out the number of milliliters of contrast needed per procedure, then estimating the average time to perform the procedure and using this to assign the cost of staff. Unlike the top-down methods, product-level costing requires engagement of a broad constituency of care providers, midlevel managers, and finance personnel and is enabled by activity-based costing (ABC). Glimpse through the lens of costs, and you will see why and how medical centers and health systems make decisions. With approximately 75% of hospital costs being fixed direct or overhead costs, the allocation of these costs across the breadth of medical activities is a huge challenge. The benefits of a systematic approach to product-level costing as a basis for strategic decision making in a radiology department were recognized almost 30 years ago (30). Figure 4: RCC and RVU methods of costing. Evert H. This article is concerned with establishing a revenue and expense budget for a diagnostic radiology department. How can the health system ensure that the negotiated rate of its contract to manage full episodes of care is sufficient to support a diverse blend of expenses with sufficient margin? Radiology and Imaging Sciences Radiology. The insurer’s cost will be the portion of the price that the insurer pays to the provider plus their costs to process the claim and an allocation of overhead costs. The RCC method has no direct linkages to resource costs or utilization rates. Hospital Radiology Departments Outpatient Centers . Variable cost units are consumed entirely by a cost object and thus in aggregate vary with the volume of an activity. (b) Factors influencing the cost of imaging for the various links in the value chain illustrate the central role of the referring provider on both upstream and downstream links while experiencing no costs themselves. Bell and Associates, 3660 Dove Hollow Road, Encinitas, CA 92024, e-mail. MR technologists sitting at an idle scanner while waiting for patient transport could reflect a combination of waste and excess capacity. Fragmentation of budgets across an organization can further exacerbate unproductive cost cutting when cross-departmental effects are not considered. In contrast to immediate cost savings through variable cost reductions, the “fixed cost dilemma” reflects the challenge of achieving real savings from cost management efforts that target fixed costs. II. Our service includes general radiology, covering imaging such as x-ray, and cardiothoracic radiology which deals with scans and images of the chest and heart. In the short run, most health care and in particular imaging costs are fixed, and thus variable costs such as supplies and flexible labor are the only targets for immediate cost savings. 38, No. Lack of a purchasing relationship at adjacent points along the industry value chain is atypical for most businesses. The central role of nonradiology providers in deriving value and influencing the costs of others, while experiencing no costs of their own, supports the principles of bundled payments, where imaging costs directly influence the margins of all providers. After reading the article and taking the test, the reader will be able to: ■ Describe how costs differ depending on the perspective of the stakeholder, ■ Explain why radiologists must understand costs and costing methods to articulate the value of their work, ■ Describe the factors that influence indirect cost allocation, ■ Describe the advantages and disadvantages of various methods for measuring and reporting costs. Consequently, when diagnostically equivalent, CT is preferable to MRI in terms of costs for hospitals. Thus value, a measure that articulates a balance between health outcomes and costs from the patient’s perspective, has arisen as a core metric of health care effectiveness across a spectrum of conceptual frameworks for defining health outcomes (4–7). Select and describe two different Revenue sources that are important … Within the high fixed cost and high overhead cost environment of health care provider organizations, stakeholders must understand the implications of misaligned top-down cost management approaches that can both paradoxically shift effort from low-cost workers to much costlier professionals and allocate overhead costs counterproductively. A final limitation that traditional ABC shares with top-down costing methods is its failure to discretely identify waste and unused capacity, which can be important drivers of excess cost (17). If the address matches an existing account you will receive an email with instructions to reset your password. A CT technologist earning $130 000 per year in salary and fringe benefits is estimated to have a practical capacity of 80% of a theoretical full-time annual capacity of 2080 hours. While a single manager might create a process map for acquiring a CT scan in the course of an hour, mapping an entire episode of care requires a structured process to coordinate multifunctional and multi-hierarchical teams, which may comprise 60 or more physicians, clinical staff, and administrators. In the United States, recent payment trends directing value-based payments for bundles of care advance the imperative for radiology providers to articulate their value. Figure 6 diagrams a 10-step process to apply TDABC in health care, which is enabled by the development of a detailed process map of all activities included in a procedure or care bundle (step 4), an undertaking that shares similarities and may realize synergies with “value stream mapping” in lean management (47). From the perspective of a professional radiology practice, a hospital department, or an entire health system, without margin there is no growth and no future. Stay Connected. Beyond the rationale described for radiology-specific scenarios, bundled payments further extend the importance of accurate costing for health system strategy and decision making. While the cost of health care is defined relative to who is paying, there is little disagreement that it is too high and growing at an unsustainable rate (51). Under an episode-of-care bundle, there is a single aggregate provider bill. Utter the word “cost,” and the mind swells with snickering associations to bean counters, number crunchers, and bureaucrats. By imposing a single-driver rate for each activity, traditional ABC does not accommodate services with multiple cost drivers such as patient registration, where both patient number and case complexity determine resource requirements (37). Medical imaging providers perform imaging studies in a hospital, a hospital-affiliated facility (separate from the hospital), or free-standing imaging centers. Most U.S. physicians are familiar with work RVUs as weighting factors that are set by the CMS and intended to reflect relative effort across medical procedures (27). RVU method costs are calculated as RVU times cost per RVU. The central role of nonradiology providers in deriving value and influencing the costs of others, while experiencing no costs of their own, supports the principles of bundled payments, where imaging costs directly influence the margins of all providers. At the level of costs attributable to an episode of care, an important source of waste includes medical procedures that cost more than the value they create (38) and imaging studies that are not indicated by the patient’s condition. Because CMS sets prices for Medicare and Medicaid, radiology providers have little direct influence on government payer costs. Charges evolve over time based on strategies directed toward revenue generation across payer contracts. Full management of 7 acute care hospital radiology departments . While physicians’ professional responsibilities and societal priorities make the study and management of patients’ costs a critical task, fiscally vital health care organizations and their operating units are a requirement for effective and efficient health care delivery. Because CMS sets prices for Medicare and Medicaid, radiology providers have little direct influence on government payer costs. If the address matches an existing account you will receive an email with instructions to reset your password. One important activity in the Radiology Department is transcribing digitally recorded analyses of images into a written report. Reference points for costing can be established with respect to a firm’s value chain operating within the industry’s value chain (Fig 1). For example, they suggest that if underutilized equipment were sold and excess space were repurposed, sold, or subleased, then these traditionally fixed costs would become variable costs. A per-bill method might be logical if per-bill labor utilization is constant within the revenue cycle management department. It requires the committed support and engagement of multiple stakeholders, particularly radiologists and radiology administrators. This analogy can be extended beyond the organization through the industry value chain where greater alignment between providers, patients, and payers could enhance accountability and incentivize reductions in downstream costs at the point where costs are generated. Cost drivers are identified and quantified for each activity that contributes to a final product or service. … The firm value chain lists the primary activities of the firm that sequentially add value to the final product or service, as well as the key support or indirect activities, which have applicability across the firm’s value chain. The manager of the Radiology Department determined that the average transcriptionist could type 700 lines of a report in an hour. In addition to the expense of equipment purchases, the expense of equipment maintainance (i.e., service contracts) must be considered a significant component of any budget of a radiology department. RVUs are derived from published national benchmarks. First, because cost driver selection for overhead cost allocation can have a profound impact on production department expense, clinical departmental managers should seek to partner with hospital finance and accounting departments when they are establishing overhead allocation methods. Because service departments do not generate revenue, their costs are allocated to “production” centers such as radiology, surgery, laboratory, and emergency services as overhead expense where they can be offset by revenue production. Hypothetical calculation of costs for two radiology departments in the same city, each performing 350 000 examinations per year. The widespread adoption of ABC has revealed common distortions of traditional costing methods, including tendencies toward over-allocation of overhead expense to high-volume products and services and under-allocation to low-volume products (29). In each of these scenarios, understanding the cost of providing service and ensuring that it does not exceed the associated revenue is critical to maintaining or preferably growing margin. Taking Team STEPPS on the Road to Patient Safety: What's Taking Us So Long? While all radiologists should seek to understand the costs that imaging procedures impose on themselves and their various customers and stakeholders and while CMS’s fees contribute to CMS’s costs, they do not fully represent anyone’s “imaging study costs.” One other easily overlooked source of costs for patients and payers is imaging overutilization (2,15). How can a radiology department ensure that the transferred revenue covers the cost of high-quality care? Demonstrated in Figure 7 are overhead allocations of revenue cycle expenses for departments of radiology, surgery, and all other departments using two cost drivers–bill count and revenue collected. Professional (oval) and facility (rectangular) providers have a direct relationship with the patient and payer when collecting revenue. While an intriguing construct, this view provides little guidance to the management of imaging departments or entire health systems operating within a context of annual budget cycles and performance expectations. Variable costs in a radiology department include catheters, contrast materials, and part-time or contract labor. Operational budgeting and budgetary control in diagnostic radiology. Surgery’s allocation is decreased by 12%, removing $200 000 in annual overhead expense. A decision to use bill count versus departmental revenue as the cost driver for overhead allocation increases radiology’s allocation by 167%, adding $1.5 million in additional annual overhead expense. In most industries, the purchaser of goods and services is the exclusive entity to derive value from that purchase. 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