ReviewCost accounting models used for price-setting of health services: An international review
Introduction
Pricing policy in most industries is part of internal management decisions and, ultimately, the price is formed on the basis of supply and demand. Characteristics of healthcare reported widely in the literature – mainly its social value and the occurrence of market failures (e.g. [1], [2]) – cause that the process of determining the price of health services is regulated. The regulations include the following aspects:
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how the products subject to funding are defined,
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what the rules for price calculation are,
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how the rules for updating the prices are defined.
Increasing expenditure on healthcare around the world [3] caused that the economic aspects, including the costs of health services, play an increasingly important role in each of these stages of pricing of health services [4]. The accurate estimation of the costs of specific health services is critical to prevent undesired consequences affecting the quality of healthcare [5], [6]. The importance of cost information increased particularly in those areas where pricing is based on diagnosis related groups (DRGs), as the effective operation of this concept depends largely on the proper cost accounting system, which ensures the cost homogeneity of individual groups [7].
Comparative research on DRG costing standards started in 2006 [8], [9] and has been continued in different countries around the world [10], [11]. The subject of cost accounting comparability is particularly important within the European Union (EU). Increasing patient mobility transforms into the need for the uniform definition of health services. Information on how much these services cost and what their price is forms the basis for setting health policy goals, making decisions as well as searching for the ‘best practice’ examples from other countries. However, there is still a lack of consensus on how to measure health costs and collect this information for the price-setting process.
The article presents a set of examples from different countries of the European Union, Australia and the United States. The analysis covered those European countries that took part in at least one of two projects that compared costing and pricing regulations – HealthBasket or EuroDRG – and use cost information collected from providers as the basis of price-setting purpose. Additionally, the US solutions implemented in Medicare program as well as Australian solutions were included into the review.
The article provides an in-depth review of cost accounting methods used in different countries with respect to price-setting. It is based on a thorough analysis of costing and pricing practices described in costing instructions published in several countries as well as country reports provided within HealthBasket (directed by the European Health Management Association) and EuroDRG (directed by the European Observatory on Health Systems and Policies) projects.
The limitation of this study is that it relies deeply on secondary sources. In the case of six countries (Australia, Austria, England, Germany, Sweden and the United States) the analysis based on both primary as well as secondary sources. In case of seven other countries (Denmark, Estonia, Finland, France, Hungary, Italy, Netherlands) the analysis was limited to secondary sources only. Due to the fact that reports used have been prepared within research projects held by recognizes institutions, the secondary data are seen to be sufficient to describe the role of cost data in the price-setting process in individual countries. Future research in this area would add to the discussion on how cost accounting should be organized to best serve the process of price-setting.
Practical experience indicates significant differences in the following areas of cost accounting:
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The process of collecting and verifying information about the costs.
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The scope and nature of the regulations relating to cost accounting system.
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Costing methodology used.
All countries are briefly presented and their costing systems are analysed in the light of the above three points. In case of the first two criteria descriptive analysis has been provided to point out the differences between the countries. The last criterion – the costing methodology – has been assessed using point evaluation. Points have been allocated for each country depending on the costing method used for: allocation of support cost centres, calculation of intermediate products and calculation of final products. The more accurate costing method the more points have been allocated. On this step only accuracy of costing aspects was considered. Other factors, e.g. time and cost effectiveness, were consciously neglected.
The purpose of this article is to identify the differences and evaluate each model of collecting and calculating cost information. From these experiences, the article concludes with appropriate lessons for other countries and areas.
Section snippets
Meaning of cost information in different hospital payment systems
Cost information is used for the purpose of price-setting and reimbursing healthcare providers. In case of services which are subject to regulations it means that the prices of health services are defined by an external regulatory institution using cost information either collected from the service providers operating in that country or obtained from other sources (e.g. abroad). Nowadays the basic unit used for pricing purposes are diagnosis-related groups (DRGs). Patient episodes are grouped
Overview of cost accounting in individual countries
A brief description of the cost accounting models used for pricing of health services is presented below. The solutions differ in many ways, what is clear from their initial analysis. A more detailed comparison is provided later.
Collection and verification of cost information
The diagnosis-related groups and cost-based pricing were historically first implemented in the area of inpatient services [43], [44], [45]. Increased cost control in the area of hospital services coincided with a sharp increase in the amounts of outpatient services. The possible solution was the implementation of the DRG concept in the field of ambulatory care [46]. There are still differences between countries regarding the scope of cost-based pricing, as shown in Table 2.
In most countries,
Regulations in the area of cost accounting
The use of cost data for pricing is only possible when all providers use uniform methods of cost calculation, uniformly define products and consistently apply cost drivers for allocation of indirect costs. Otherwise the compilation of cost data from different providers would be like ‘comparing apples and oranges’. The introduction of uniform regulations is a guarantee of greater coherence of the data received.
In some countries, such as England and the United States, mandatory cost accounting
Methodology of cost accounting
Different models of cost accounting provide different levels of accuracy. Generally speaking, it depends on how cost components are identified and how they are valued. Each of these dimensions can take two values. Identification of cost components can be developed using gross costing or microcosting, and their valuation – using the top-down or bottom-up approach. Combining these dimensions gives a matrix which is presented in Fig. 1. It reflects the four theoretic approaches to cost accounting,
Conclusion
Bottom-up approach is more accurate than top-down methods (especially when used at both stages of calculation) because in the bottom-up model costs are allocated to individual health services based on the actual used of resources [62], [65], [66], [67], [68]. Detailed and actual cost information obtained in bottom-up approach enables the analysis of cost categories that have the greatest share in the total cost of the health service and factors that influence it. Analysis of cost drivers is
References (73)
- et al.
Pricing health services for purchasers—a review of methods and experiences
Health Policy
(2004) Using computerised patient-level costing data for setting DRG weights: the Victorian (Australia) cost weight studies
Health Policy
(2001)Improving patient-level costing in the English and the German ‘DRG’ system
Health Policy
(2013)- et al.
Changes in hospital service mix and cost allocations in response to changes in Medicare reimbursement schemes
Journal of Accounting and Economics
(1997) - et al.
Comparison of cost accounting methods from different DRG systems and their effect on health care quality
Health Policy
(2005) Economics of the public sector
(2000)- et al.
Public finance
(2008) - WHO. Global health expenditure atlas. http://www.who.int/nha/atlas.pdf [accessed...
- et al.
Comparing methodologies for the cost estimation of hospital services
European Journal of Health Economics
(2009) - et al.
Equivalence of two healthcare costing methods: bottom-up and top-down
Health Economics
(2009)
Cost unit accounting based on a clinical pathway: a practical tool for DRG implementation
Thoracic and Cardiovascular Surgeon
Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries
Health Care Management Science
Editorial: hospital case payment systems in Europe
Health Care Management Science
How to solve the cost crisis in health care
Harvard Business Review
Australian hospital patient costing standards
HealthBasket Work Package 6: health benefits and service costs in Europe, SP21-CT-2004-501588
Approaches for cost and price assessment in the Danish health sector
HealthBasket Work Package 6: health benefits and service costs in Europe, SP21-CT-2004-501588
Work Package 6: approaches for cost assessment & price setting in practice, Hungary
The provider reimbursement manual
HealthBasket – health benefits and service costs in Europe, SP21-CT-2004-501588
Approaches for cost/price assessment in practice
Austria: inpatient care and the LKF framework
Handbuch zur Dokumentation von Kostendaten in landesgesundheitsfondsfinanzierten Krankenanstalten
Variable prospective financing in the Danish hospital sector and the development of a Danish case-mix system
Health Care Management Science
Costs and prices for inpatient care in England: mirror twins or distant cousins?
Health Care Management Science
Estonia: developing NordDRGs within social health insurance
Paying for hospital care: the experience with implementing activity-based funding in five European countries
Health Economics, Policy and Law
Finland DRGs in a decentralized health care system
HealthBasket Work Package 6: health benefits and service costs in Europe, SP21-CT-2004-501588
Work Package 6: approaches for cost assessment & price setting in practice, France
Accounting and reimbursement schemes for inpatient care in France
Health Care Management Science
France: implementing homogeneous patient groups in a mixed market
HealthBasket Work Package 6: health benefits and service costs in Europe, SP21-CT-2004-501588
Work Package 6: approaches for costing and pricing in practice, Germany
Kalkulation von Fallkosten Handbuch zur Anwendung in Krankenhäusern
Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system?
Health Care Management Science
Cost accounting methodologies in price setting of acute inpatient services in Hungary
Health Care Management Science
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