Healthcare Economics for Executives and Managers

The type of budgeting and the tools used to develop the budget are administrative decisions. Before developing an adequate budget, information and training should be supplied to those creating the budget. The information should provide historical financial activities, show the past revenue sources, anticipated sources, and any potential uncertainties related to revenue streams; this allows for discussions to deal with future challenges related to the budget (Rundio, 2020). The data tends to be spread across the year, usually by months.

Managers will be asked to provide their rationale to defend their proposed budget, sometimes in writing or a presentation. It is a give-and-take negotiation between managers and finance personnel (Rundio, 2020). Ensure you agree with the budget the finance department sends to the administration.

When developing the budget, a timeline is needed to create a preliminary, revised, and final budget consistent with the organization's practices and goals. After the budget is developed, there is usually a review and approval process. The goal is to ensure that once the final budget is confirmed and released, it serves as a guide for everyone.

A fixed budget is a financial plan based on the estimates of selling specific amounts of goods during a period. In other words, fixed budgets are based on a set sales volume or revenues. A fixed volume, like the number of patient days or procedures performed, can be used to calculate the annual budget. Annual totals are divided by 12 to reach a monthly average. The fixed budget does not make provisions for monthly or seasonal variations. Other budgeting forms are flexible and are usually adjusted based on significant variables, like the volume of services provided or seasonal variations.

The administration determines budget reporting tools and time frames. The managers and executives in charge of budgets are expected to monitor budget reports, which are usually generated monthly. The process helps them better and more appropriately manage their units and services. Managers need to be knowledgeable of current trends within their organization and industry. Over-or-under variance correction can result due to a lack of knowledge of the current trends and unexpected difficulties in the future (Rundio, 2020).

Budgetary reports are sent to managers and executives, usually monthly and annually. The overall financial status of the organization, determined by the financial department and administrators, is also sent out. Most executives and managers receive their financial reports electronically using the sophisticated software the hospital or healthcare facility has purchased. Managers and Executives all need to know how to use paper spreadsheets and software as part of their practice.

Once received, reports must be checked and analyzed for accuracy and hidden content to justify increased expenses (Rundio, 2020). Reports allow the manager to justify deviations and make necessary adjustments. Many organizations have a justification plan that often requires a business case to justify the expenditure. Some expenses may put the organization into a negative variance but are justifiable because of the long-term return on investment, yielding a financial benefit.

Because budgets are projections that change over time, line items are rarely on target. Therefore, variance analysis is an essential part of the budgeting process. Variance analysis is a tool applied to financial and operational data to identify and determine the cause of the variance. In project management, variance analysis helps maintain control over a project's expenses by monitoring planned versus actual costs (Rundio, 2020).

Effective variance analysis can help companies spot trends, issues, opportunities, and threats to short-term or long-term success (Rundio, 2020). Variances between planned and actual costs might lead to adjusting business goals, objectives, or strategies.

Variances may be characterized as volume, efficiency, rate, or non-salary expenditure:

• Volume variances in the hospital are due to fluctuations in patient days.
• Efficiency variances are changes from the anticipated hours per patient day (HPPD).
• Rate variances reflect the differences between the budgeted and paid hourly rates.
• Non-salary expenditure variances are due to patient mix and volume changes, supply quantities and costs, the price paid, and new technology or regulations.

Revenue is the total amount of income anticipated during a defined period.

Three revenue streams for healthcare organizations include but are not limited to the following (Syntellis, 2023):

• Reimbursement for patient care
• Sales of goods and products
• Membership dues like direct-member health maintenance companies or organizations

Revenue generation is seldom under the direct control of managers. However, a certain percentage of anticipated or actual revenue is allocated to specific cost centers under the manager's direction. The extent to which the manager can control fixed expenses is often limited.

The executives and managers are responsible for operating within the revenue allocation by controlling expenses or creating services to generate revenue. Payroll costs are the most significant influence for those working within budgetary constraints.

An expense is an outflow of resources or cash. The expense budget includes salary and non-salary items. Managers manage expenses or cash inflow within their cost center. Operating expense (OPEX) appears in budgeting and spending and as an income statement term in financial accounting (Syntellis, 2023). Operating expenses do not result in capital assets. Instead, they include most of the expenses for operating the firm's usual line of business. In general, it is all expenses that are not capital spending. In most organizations, employee wages and salary expenses account for a large percentage of the operating budget.

• Fixed costs are constant for the organization regardless of fluctuations in activity levels, such as loans, contract fees, or rental fees.
• Semi-fixed costs run at a certain level for a given period and then increase or decrease.
• Variable costs fluctuate in response to external or internal changes, such as changes in the census, staff mix, patient acuity, or product costs.
• Direct costs are linked to a specific source, such as treatments or medications.
• Indirect costs like housekeeping cannot be directly linked to a specific area and may be spread among different cost centers.

The capital budget includes equipment and renovation expenses designated to pay for long-term projects. Capital budgeting is how a business determines and evaluates potential significant expenses or investments.

The process includes the specific criteria organizations have when purchasing certain equipment. These items must have an expected lifespan of one year or more and exceed a specific dollar value. The lifespan is the expected time the equipment should work well. Additional costs also need to be determined, such as installation, delivery charges, and service contracts (Syntellis, 2023).

Managers must understand the capital budgeting process to work effectively within their organization. Part of the capital budgeting process understands amortization, which includes assigning costs to the capital item for its lifetime. Knowing the life expectancy of equipment, programs, or services is vital to plan a replacement strategy; this can be built into the capital budgeting process.

The environmental needs of many healthcare organizations require constant capital planning, including providing space and buildings needed to conduct business while ensuring regulatory requirements are implemented as required. The rate of technological innovation has put a greater demand on construction schedules. The challenge is that building regulatory plan requirements need a long lead time. Because of this, it has become outdated by the time the building is constructed to house designated clinical services.

An operating or annual budget is a plan to monitor anticipated day-to-day activities, resources, personnel, and supplies, typically over one year. Revenue and expenses are separated to calculate bottom-line profit or loss easily. The operating budget is revised annually to monitor the organization's progress toward financial goals. Management practices directly impact the success of the operating budget (Syntellis, 2023).

Sarah, the night charge nurse on the hospice unit, had to work 12 hours of overtime. During the same time frame, James, another RN, had to work a double to cover the hospice unit. Two nursing assistants also worked two extra shifts to meet the needs of the patients.

Sharon, the nurse manager, was informed that five staff members had influenza and could not work during this period. They also did not want to infect the already sick hospice patients and other staff team members. Sharon discussed the problem with the staff involved to ensure there were no better cost-effective solutions than overtime.

Due to the short staffing, there were more expenses in staffing for the month. Although Sharon's cost center exceeded budget, she could justify the added expense and overtime; this is a standard way of handling temporary unplanned staffing shortages. Since a virus caused it, other units were probably in the same situation.

If this is a recurring problem, management may want to look at alternative scheduling and staffing options.

Classification systems assign patients to categories based on variables such as care intensity, care level, or utilization of resources (American Nurses Association [ANA], n.d.). Patient classification systems (PCS) are also known as patient acuity systems. Acuity has become a reference for estimating nurse staffing allocations and budget determinations. The classification used in a facility should be applied to forecasting staffing needs within each department. Charge nurses should be informed of the patient care ratios relevant to each department and understand how to predict staffing needs based on the system utilized by the organization.

There are different kinds of PCS available. The three most commonly used PCS are:

1. Descriptive: This classification system is purely subjective. A nurse selects which category best suits the patient.
2. Checklist: This is another subjective system. The acuity level of a patient is assigned as a numerical value based on the level of activity in the specific pre-set categories. The numerical value is then added to give the nurse an overall rating of the patient's needs. The assigned acuity is based on this rating.
3. Time standards: This acuity determination method is created when the charge nurse assigns a time value based on the patient's various and specific activities that need to be completed. The time value is then totaled and converted to an acuity level.
4. Acuities assist a nurse leader in determining workload requirements and staffing needs. Most acuity systems are automated and provide support services (ANA, n.d.).

Some organizations do not use a specific PCS system. Charge nurses are taught that the fewer patients can do for themselves, the more activities are needed for the patient, and the higher the acuity. Naturally, the higher the acuity, the more staff are needed.

The challenge is that whatever the approach is to determine acuity, there is a consistent practice in decision-making, regardless of the charge nurse, shift, and department they work in. Thus, specific guidelines still need to be established and implemented by all, resulting in improved patient care and the use of resources within an established budget.

Staff mix assigns defined categories of staff to care for a specific group of patients. The staff mix includes registered nurses (RNs), licensed practical nurses (LPN), unlicensed assistive personnel, and other direct and indirect caregivers. A shift on one unit may have 40% RNs, 40% LPNs, and 20% other personnel. However, this ratio may not work in other departments. To determine the best and safest staff mix, specific personnel should be determined by a patient's overall condition, the intensity of needs, and the competence of the staff (Butler et al., 2019). Staffing distribution is a determination of the number of personnel allocated per shift. (e.g., 50% day shift, 30% evening shift, 20% night shift).

Managed care, in terms of healthcare, means a person agrees only to visit certain doctors and specialists contracted with their healthcare plan. In turn, for this agreement, the costs are kept low by a managing company that oversees all healthcare interactions of their clients. These costs are significantly lower because the company contracts with specific healthcare providers and hospitals. An entity with a financial interest oversees provider practices and patient utilization. Three different types of managed care plans are available (Heaton & Tadi, 2023):

1. Health maintenance organizations (HMOs)
2. Preferred provider organizations (PPOs)
3. Point of service plans (POSs)

Each is different from the others but provides the same essential services.

Initially, advocates of managed care expected that it would do the following:

• Optimize resource use by avoiding over and under-use.
• Ensure better outcomes of care.
• Increase accountability at all levels.
• Reduce variations in practice.
• Contain or reduce expenses.
• Focuses on disease prevention and health maintenance instead of acute care and crisis intervention.

Advantages of managed care:

1. Lower cost
2. Accredited care
3. Cheaper prescriptions

Disadvantages of managed care:

1. Restricted care
2. Strict approval
3. Referral difficulties

While many people criticize the quality of care and the ethical practices of managed care providers, they still provide an excellent service to a large population without healthcare until they become extremely sick, have no other recourse, and become deathly ill. Even the most minor illnesses can cause incredible financial stress without health insurance (Heaton & Tadi, 2023).

Costs can be contained through reduced force strategies (RIF) and cutting back or eliminating services not critical to the organization's goals, including maintaining fiscal viability. A frequent practice is outsourcing specific food, housekeeping, and linen services. Outsourcing means another company is contracted to provide the services at a lower cost than the facility could provide. Some organizations contract out their payroll, transcription, and other business services. As with both practices, hidden costs may outstrip the anticipated cost savings (Visier, n.d.).

Before the initiation of a RIF to contain costs, the following needs to be considered:

1. Are there potential ethical issues that will affect safe patient care?
2. Will there be more preventable accidents and the intrusion of regulatory agencies and sanctions?
3. Do present contracts for members of the organization and their organized labor have a stipulation that there will be no layoffs?

Thus ethical, legal, and contractual issues must be considered when RIFs are considered a means of reducing costs.

Administrators, unit managers, economists, efficiency experts, and front-line staff believe resources can be better managed by developing and applying better business information and successful care systems (Listl et al., 2019). A "competitive bidding" process controls the cost of supplies and equipment—organizations get discounts on products from various vendors. Cost discounts are available when products are purchased in larger quantities. So, hospitals will work to make buying relationships that increase the purchase volume and lower costs. These relationships are to the reduced cost advantage of large hospital systems. Most hospital employees and patients have no idea of the cost of supplies and equipment and the cost of processing.

Cost control of supplies and equipment is ongoing. Inventory control systems match supply and demand. They decrease resource use and loss of theft (Listl et al., 2019). When staff is informed of the pricing or cost of frequently used items on their unit, they may compare shops for the most cost-effective products and supplies to use in their department.

Some departments end up sharing some high-priced equipment and have set up processes. Monthly, managers receive reports detailing material costs for their units or department.

The original Medicare program included Part A (hospital insurance) and Part B (medical insurance). Medicare was expanded to cover disabled people with end-stage renal disease (ESRD) requiring dialysis or kidney transplant and more benefits, like prescription drug coverage.

Private health plans approved by Medicare are Medicare Advantage Plans. These plans are sometimes called Part C or MA plans. Medicare also expanded to include an optional prescription drug benefit named Part D (Kagan, 2022).

Medicaid provides medical insurance to people getting financial assistance. Today, a much larger group is covered and includes the following:

• Low-income families
• Pregnant women
• People of all ages with disabilities
• People who need long-term care

States tailor their Medicaid programs to serve the people in their state best, so there is a wide variation in the services offered. Federal and state governments fund Medicaid together. Matching federal funds are determined by the state's per capita income.

Capitation is a payment arrangement for healthcare service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per a specific, agreed-upon period, whether that person seeks care or not. As a payment model, capitation offers opportunities for primary care physicians to influence the future of healthcare by improving the management of resources at a local level (Listl et al., 2019). HMOs, PPOs, and Medical Service Organizations (MSOs) are examples of capitation.

Organizations financed under capitation must provide needed and contracted care by managing resources and practices. The risks are spread across the providers and organizations. The care is focused on the prevention of illness and health maintenance. Acute care is expected to be based on standard and proven therapy.

When organizations provide care beyond the agreed-upon plan, they face considerable financial risk. The regulations governing managed care require that only the agreed-upon services are given to patients; if an organization goes beyond the agreed-upon services, it can become in financial and regulatory jeopardy (Listl et al., 2019). The public finds this concept difficult to understand and often places the healthcare organization in a negative light.

Various income streams, including capitated contracts, must be evaluated during budgeting. Healthcare organizations decide if a specific population group should be given discounted rates for services and if it would be reasonable and profitable to do so. The organization must evaluate the potential financial risk before deciding.