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Title: The Role of Cost Accounting in U.S. Health Systems' Transformation
Subject: The Role of Cost Accounting in U.S. Health Systems' Transformation
Keywords: IDC, analyst report, cost accounting, health
Author: IDC Health Insights
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Business Strategy
Business Strategy: Getting to Goal -- The Role of Cost
Accounting in U.S. Health Systems' Transformation
Judy Hanover
IDC HEALTH INSIGHTS OPINION
This IDC Health Insights report discusses the growing importance of cost accounting in U.S. health
systems' analytics and IT strategy and important considerations hospitals should make when adopting
cost accounting tools. Cost accounting is playing an increasingly important role in U.S. health systems
and hospitals, as they make the transformation to value-based care. Cost is one of the key goals for
health systems making this transition; the oft-cited triple aim is, after all, to increase access and value
while reducing cost. But most cost accounting approaches in healthcare have been minimally effective,
and the new emphasis on value-based care in the industry has called them into question, as health
systems begin to demand rigorous and accurate approaches to understanding their costs that they can
apply to pricing, contracting, operational decision making, measuring outcomes, planning strategy,
interacting with payers, and even the value of the care itself when cost is linked to outcome. Providers
making cost accounting investments should consider:
Cost accounting is a type of analytics. Most U.S. provider organizations have been investing
heavily in analytics over the past few years, and cost accounting is another type of analytics
that will be essential to their operations. But like other types of analytics, it is important for IT to
differentiate between platforms and tools when guiding investment; providers making cost
accounting investments should seek to build on existing analytics platforms where possible, to
provide the tools needed for cost accounting.
Top-down models and bottom-up costing approaches. Two main approaches to cost
accounting can be described as top-down and bottom-up approaches. Top-down models
essentially take the operating expenses of the hospital and seek to attribute them to service
lines, departments, and eventually individual events; these are prone to error introduced by
their assumptions along the way. Bottom-up models get into the minutiae and seek to
determine cost by considering each and every expense involved in an activity and can get
bogged down in the details, making cost accounting highly complex, incredibly costly and, in
the end, still inaccurate, as many expenses in a hospital are tough to determine and attribute.
Newer solutions emerging and gaining traction in the industry have elements of both in their
approaches; hospitals should consider the data they have available when choosing a specific
approach.
Centralized and distributed approaches. Classic hospital cost accounting systems are based
on RVU models assembled from the top down. Models aren't necessarily a bad approach, but
it should be considered that centralized finance departments don't always understand costs at
the department or procedure level. Successful cost accounting approaches will involve both
centralized information stewardship and distributed input into models and their application.
October 2014, IDC Health Insights #HI251771
IN THIS STUDY
This IDC Health Insights report is based on primary and secondary research with cost accounting
suppliers, including established players and new entrants, and cost accounting end users in the industry.
The primary and secondary research for this report was conducted from May to September 2014 and
includes observations of both implementations in progress and established technology in the industry.
SITUATION OVERVIEW
The importance of cost accounting had been growing over the years but came into focus following the
introduction of the Patient Protection and Affordable Care Act (PPACA) in 2010. PPACA offered a
number of mechanisms and approaches as well as programs for achieving its aim, to improve the
quality of care and outcomes for patients, while increasing access and decreasing the cost of care.
The end goal was to improve value for payers and patients by improving results while lowering costs.
Initial efforts surrounding PPACA focused on population health management to facilitate the goal of
improving outcomes and quality, but it quickly became apparent to providers that they also needed
information from analytics to facilitate population health management and to more accurately
understand their costs to reduce variation in costs and improve value across the board. Cost
containment cannot be accomplished without an accurate and detailed understanding of cost, and the
factors that influence it, to understand opportunities for cost containment, an essential component of
success in accountable care. These market drivers create a need for better and more robust cost
accounting systems in provider organizations.
Cost accounting is not new to healthcare, but the complexity of the modern health system -- with its many
inpatient and ambulatory departments, staff and consulting physicians, multiple entry points, payer
relationships, and service lines -- has long eluded efforts to better understand the cost of care. Most cost
accounting approaches thus far in healthcare have been of two basic types: high-level cost models
based on the relative-value unit (RVU), established by Medicare as part of its resource-based relative
value scale (RBRVS) for determining payment, and more complicated approaches that attempt to
understand cost based on often incomplete, inconsistently collected, and complex direct costing data
from within hospitals. Both are largely understood to be flawed approaches when used in isolation.
Cost accounting is increasingly critical to making good business decisions and remaining competitive
under accountable care. Many efforts have been made, and key strategies for accomplishing cost
accounting include leveraging Medicare's implementation of the RBRVS and its RVUs, one of the first
widespread approaches to cost accounting, as well as more recent efforts to conduct activity-based
costing, in combined models.
Medicare, RVUs, and RCCs
Medicare's RBRVS and its units of value, RVUs, were introduced into healthcare in the United States
with the Omnibus Budget Reconciliation Act of 1989. The RBRVS was one of the first attempts by the
government to instill an element of cost and subsequently equitable cost containment into Medicare
reimbursement policies; prior to the implementation of the RBRVS, most payments were made on the
basis of the usual, customary, and reasonable (UCR) billing amount for a service in an area. The
?2014 IDC Health Insights #HI251771 1
RBRVS and its RVU calculation includes components for physician work, practice (overhead), and
malpractice (insurance) expense, with an adjustment for geographical variation in payment. RVUs tend
to be seen as weighing complexity too highly and thereby biased toward specialist providers and in-
person visits, and the methodology used to set the rates has been questioned, among other issues
with the RBRVS. Further problems arise when Medicare payment calculations like RVUs or derivations
of them are extended to commercial settings.
However, the RVU represents a strong basis for many forms of cost accounting and, outside of its use
in determining payment, is used extensively to evaluate potential fee schedules, analyze contracts,
and determine physician compensation in healthcare organizations. Using RVUs in cost accounting is
a top-down methodology -- mostly derived from the assumption that, if a healthcare organization
knows its total operating cost and has data on volume that allows it to determine the total RVUs its
provider delivered, the cost per RVU can be calculated and basic cost accounting can be performed.
The RVU model can be extended if data about costs can be allocated to individual departments and
service line. In a less complex business model like a single-specialty ambulatory practice involved in
fee-for-service arrangement, RVU-based cost accounting can be sufficient. However, changes in the
healthcare system as value-based care evolves have made the methodology problematic for most
providers; the underlying issues with the determination of RVUs as well as assumptions as to resource
nature, intensity, and distribution are all reflected in the accuracy of cost accounting solely using
RVUs.
The Ratio of Cost to Charges (RCC) is another method for approaching cost accounting, with or
without the use of RVUs. RCC can be calculated quite easily as a simple ratio of cost/charge but does
not have the advantage of taking the complexity and resource consumption into account that the RVU
does. The two are often used together, with the RCC taking the place of the RVU in areas for which
RVUs are not available. However, even when used together in a hybrid model, both RVUs and RCCs
have disadvantages, especially when working with large, complex, multilocation, and multiple service
line health systems. While the RVU's issues are mainly around calculation and determination,
allocation of costs are an issue with both RVUs and RCCs. RCCs are further disadvantaged by the
assumption that cost will be proportional to charge; as most organizations that go further along into
activity-based costing will find, this is not always the case. For this reason, most cost accounting
environments seek to evolve past PCCs and RVUs to include activity-based costing, either in
combination with RVU- or RCC-based models or on its own.
THE APPROACH
Activity-Based Costing
Activity-based costing was developed in the manufacturing industry to allow companies to focus on
profitability by identifying and eliminating unnecessary costs. Activity-based costing techniques identify
the relationships between activities and the resources needed to delivery them -- in healthcare, this
would be healthcare services. Activity-based costing needs to take into account the contribution of all
the resources consumed in the delivery of care in order to be most effective. But healthcare is not as
clear-cut as manufacturing. Ideally, activity-based costing should attribute supply, labor, resources,
and overhead, as well as all the discrete costs that go into each interaction supplied by individuals and
departments in the hospital. However, the complexity of healthcare costs creates many issues for
?2014 IDC Health Insights #HI251771 2
health systems that wish to implement comprehensive activity-based costing systems, particularly in
these three critical areas:
Labor. A health system's largest cost, labor, is the first thing we need to address when
entering the activity-based costing realm. Healthcare workers work in shifts to provide 24 x 7
care in the hospital and are often assigned to floors or groups of patients who may be
hospitalized for a variety reasons like observation to monitor a condition, a planned procedure
and its pre- and postcare, or an acute emergency. Multiple reasons for admission create
multiple levels of acuity within the responsibility of a staff member. This means that even
though a nurse may be assigned to six patients on a medical unit, she may spend 50% of her
time with one patient and only 10% with the other five, if one requires more attention than
others, and ideally this should be reflected in the cost attributed to caring for a specific patient.
Cost allocation approaches seek to address this unevenness in resource consumption by
patients. Many different approaches are used in cost accounting attempts to answer this
question by leveraging data from sources like RFID badges, security and authentication
systems, acuity scoring, and other methods of allocation. Some labor expense, like that of
physicians and other skilled professionals, can be accounted for by tracking orders and
procedures completed; however, many health systems will want to get more specific by
tracking time spent on completing orders and procedures, to compare productivity of providers
and optimize capacity planning and scheduling.
Supply. Supply is the second-largest cost for most health systems. In a manufacturing
environment, cost accounting systems will attempt to attribute the cost of every component, no
matter how small, to a product. In a health system, this approach translates to attributing the
cost of supplies to individual patients, physicians, and procedures, but doing this for all
supplies can be unnecessary as some are used more uniformly than others are. Large,
expensive consumable items, like implantable devices, need to be tracked very carefully. Use
of reusable medical devices like infusion pumps and bedside monitors should also be tracked
and attributed to the costs of services. RFID and barcoding can be used for tracking and
incorporating these items into cost records. When we get into smaller items, like gloves and
bandages, hospitals need to determine the value of actual costing when compared with
modeled approaches to cost accounting and containment.
Overhead. Overhead can be quite difficult for health systems to ascertain and attribute to
individual procedures and services. Overhead costs that need to be attributed include the
physical plant and utilities and the overhead costs associated with maintenance and
availability of the emergency room, operating rooms, procedure rooms, laboratory, pharmacy,
and other specialized spaces that serve the population. Costs that need to be attributed
include both supplies that are actually used and those that cannot be used, like expired drugs
and injectables but must remain on hand. Service-based overhead costs include cleaning,
dietary, and therapeutic services, among others. IT costs also need to be attributed. Overhead
is complicated further for acute care centers that not only need to offer capacity to meet day-
to-day requirements in a community but also must remain prepared to expand capacity quickly
in the event of a public health emergency. RVU-based systems make attempts to attribute
overhead, and continued use of components of this model and similar ones are not
unreasonable for calculations of overhead, even if activity-based models are used for costs
like labor and supply in a hybrid model. The lack of alignment between the actual cost of
delivering a single healthcare service and the fee schedules of hospitals have come under
attention lately, with public criticism of fee schedules that seem arbitrary or excessive. Some of
this complaint is related to the lack of availability of accurate cost data, while some component
?2014 IDC Health Insights #HI251771 3
of it is certainly due to the significant overhead associated with the full spectrum of services a
hospital delivers to the community.
Activity-based costing information can then be combined with historical and actuarial data to calculate
expected procedure volumes and forecast cost. Activity-based costing provides an important
component for provider organizations that want deeper insight into their costs, to identify opportunities
to address waste and lower costs, and compete under their growing share of accountable delivery
contracts. Activity-based costing is perhaps most effective when used in hybrid models, with rigorous
costing methodology applied to high-value data and cost components, while relatively low-value data
and areas where RVUs and RCCs apply well can continue to be modeled using tools like RVUs and
RCCs. In the remainder of this report, hybrid costing models refer to those techniques that include
elements of RVU- and/or RCC-based models alongside activity-based costing applied selectively to
different areas of the business.
Vendors to Watch
With the evolution of the need for more rigorous cost accounting, many suppliers are adding new cost
analytics capabilities to enterprise data warehouse environments and introducing new cost analytics
tools. The methodologies and data requirements for these tools vary; some are firmly rooted in
historical healthcare approaches like the use of RVUs and RCCs, and others come straight out of pure
activity-based costing environments. Health systems selecting costing solutions should consider the fit
of the methodology of a tool to the data they have accessible and their goals. Vendors with existing
and new functionality under development include, but are not limited to:
Allscripts. With approximately 300 customers representing over 900 hospitals, Allscripts EPSi
is one of the most established and widely used financial planning and cost accounting
applications in U.S. health systems. EPSi was founded as an independent company in 1999
and acquired by Eclipsys in 2008, which then was acquired by Allscripts in 2010. Allscripts has
continued to support and enhance the product for use both in integration with its HIS and EHR
systems and for standalone use by clients of other HIS and EHR systems. EPSi is a Web-
based performance analytics and operational optimization solution that aggregates data from
multiple sources. The solution includes business intelligence, planning and decision support
functionality that incorporates analytics, product line forecasting, strategic planning, cost
accounting, reimbursement modeling, operational and capital budgeting, and productivity
analysis. While EPSi has been in use for over 15 years, recent years have seen the focus of
users shift from its planning and budgeting capabilities to its long underutilized cost accounting
capabilities. Allscripts has responded to customer demand for extended support of core
functionality and cost accounting functionality by extending its patient data model to allow for
more hybrid and detailed attribution capabilities, much of which will be delivered in its 8.0
release, anticipated in November 2014.
Explorys. Explorys is a healthcare data warehouse supplier founded in 2009 as an innovation
spinoff from the Cleveland Clinic and currently used by 19 integrated delivery networks at 300
hospital sites. Explorys offers a cloud-based data warehouse solution that offers high
performance via the incorporation of big data infrastructure into its platform, with an emphasis
on data security and integrity. Explorys' analytics tools have a strong focus on the cost, risk
management, and performance associated with clinical encounters, with clinical cost a
component of its existing analytics and decision support tools. Explorys plans to expand cost
accounting capabilities with product releases for its customers in 2015.
?2014 IDC Health Insights #HI251771 4
Health Catalyst. Health Catalyst was founded in 2008 and is headquartered in Salt Lake City,
Utah. Catalyst has 19 health system clients serving over 150 hospitals and an aggressive
innovation strategy including close collaboration with clients in developing both the enterprise
data warehouse platform and advanced application tools. Catalyst offers a unique late-binding
approach to the EDW that leads to rapid implementation for its structured, actionable analytics.
Catalyst's core functionality includes an environmental scan capability that the company refers
to as its initial key process evaluation as well as extensive models for evaluating clinical costs,
variation, and waste. The company has activity-based costing functionality in development
with a pilot customer and expects a general release of the functionality in 2014.
Oracle. Oracle offers cost accounting capabilities to healthcare providers via its Enterprise
Healthcare Analytics (EHA) data warehouse platform and Hyperion business intelligence suite.
Oracle's Hyperion cost accounting solution is currently available, but Oracle is working in
collaboration with key health system clients to deliver healthcare-specific models and best
practice-based approaches for cost accounting to its healthcare clients. Oracle EHA and
Hyperion tools are most commonly installed on-premise but can be delivered via the cloud.
With its origin in other industries and strength in manufacturing, Oracle offers an activity-based
costing capability that uses a distributed model to attribute costs with contributions to the
models from individual departments in the health system. Oracle's installed base with human
capital management and enterprise resource planning systems in hospitals gives the
horizontal vendor a strong position with which to enter provider cost accounting, given the
importance of labor and supply to cost models.
Strata Decision Technology. Strata Decision Technology was founded in 1996 and offers
financial analytics and performance management systems to 175 health systems representing
approximately 1,000 U.S. hospitals. Strata's product suite, StrataJazz, is an entirely cloud-
based SaaS platform with modular capabilities for financial planning, decision support, and
cost management. Strata is not typically used as a data warehouse, but it integrates with ERP,
EDW, and EHR solutions, and the company has relationships with multiple data warehouse
providers and HIS/EHR systems including Epic. As demand has increased for cost accounting,
Strata's product road map has evolved accordingly, and the current offering includes cost
accounting via a hybrid model in its decision support module as well as additional capabilities
for rolling forecasting, strategic planning, budgeting, capital planning, reporting, and
performance management. A planned major release in October of a new Continuous Cost
Improvement (CCI) module will make additional algorithms and workflow for cost management
available.
Other vendors. The cost analytics space is growing quickly, driven by need from providers that
wish to add capabilities to their environments and the wide array of capabilities under demand.
Additional suppliers with cost accounting capabilities currently available and/or under
development include Infor, McKesson, and Cerner. Established vendors are constantly making
new capabilities available to customers, and new suppliers are emerging, particularly in the
cloud-based analytics-as-a-service space, to serve the growing need for cost accounting
applications.
FUTURE OUTLOOK
Going forward, health systems will be increasingly focused on value and providing the outcomes
patients and payers want at the lowest cost. The shift away from fee-for-service medicine will lead to
value or outcomes-based payments, and in this environment, cost is a critical component of health
?2014 IDC Health Insights #HI251771 5

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