V

U.S. ARMY-BAYLOR UNIVERSITY

A COST ANALYSIS OF EMERGENCY MEDICAL SERVICES

AT WILLIAM BEAUMONT ARMY MEDICAL CENTER

A GRADUATE MANAGEMENT PROJECT

SUBMITTED TO

THE FACULTY OF BAYLOR UNIVERSITY

IN PARTIAL FULFILLMENT OF THE

DEGREE OF MHA FOR THE

GRADUATE PROGRAM IN HEALTH CARE ADMINISTRATION

BY

CAPTAIN SHAWN A. WAGNER, M.S., CHE

EL PASO, TEXAS

MARCH 1997

20000111 130

""««"»»«i»,

ACKNOWLEDGMENTS

I would like to take this opportunity to thank those individuals who have significantly supported my efforts to complete this project. Firstly, my appreciation extends to my preceptor, COL Gordon W. Cho, who has given me guidance and vision through-out my residency. To Mr. Alan Napier for planting a seed which eventually became my methodology. He has been a sound-board for many financial conversations. To LTC Margaret Rivera for extending her leadership and friendship to me. To LTC Bice-Stevens for her acedemic assistance with this project. To my faculty advisor, MAJ Mark Perry, for continually reminding me of the objective and his sound advice for my methodology.

To the Patient Administration Division statisticians for the endless reports and helpful interpretation of those reports.

Lastly, to my loving wife and children whom have endured not only the completion of this project but the entire Baylor educational process. Without my family's support, I would not have been able to succeed at such a rigorous program.

11

ABSTRACT

The purpose of this graduate management project was to prepare an estimate of the full cost of providing inpatient care for emergency department admissions for the military and civilian community of El Paso, Texas for fiscal year 1995. It was found to be an efficient, reliable methodology which can be applied to any military treatment facility. By understanding how costs are accumulated within the MTF, management may make more informed decisions as to the provision of health services. This methodology combines a product line costing approach with the current step down process of MEPRS. The end result places a price tag on the product line in question.

111

TABLE OF CONTENTS

ACKNOWLEGDEMENTS Ü

ABSTRACT iii

LIST OF ILLUSTRATIONS V

LIST OF TABLES vi

INTRODUCTION 1 CONDITIONS WHICH PROMPTED THE STUDY 2 STATEMENT OF THE PROBLEM 3 REVIEW OF THE LITERATURE 3 PURPOSE STATEMENT 18

METHOD AND PROCEDURE 19 VALIDITY AND RELIABILITY 24

RESULTS 27

DISCUSSION 30 DEVELOPMENT OF THE MODEL 31 ANALYSIS AND INTERPRETATION 33 LIMITATIONS 35

RECOMMENDATIONS 38

CONCLUSIONS 41

WORKS CITED 43

APPENDIX A: FLOW CHART OF ED PATIENTS 46

APPENDIX B: SAMPLE OF COST CALCULATIONS 47

APPENDIX C: PASBA2 PATIENT CATEGORY CODES 56

IV

LIST OF ILLUSTRATIONS

Figure Page

1. MEPRS Cost Allocation, a step-down methodology 16

2. Basic Full Cost Formula 19

3 . Patient Categories 20

4 . Weighted Relative Product 21

5. Calculation of the Conversion Factor 22

6 . Average Cost per DRG 23

7 . Methodology Check 23

8. Total Cost of Each Patient Category-through ED 24

Chart Page

1. Break-out of Patient Category Costs 34

2 . Length of Stay and Cost Allocation 36

LIST OF TABLES

Table Page

1. Patient Costs; including Medicare in each Category... 28

2. Patient Costs; excluding Medicare in each Category... 28

3. Sample: Inpatient DRG Cost Calculation 47

4. Sample: Cost Calculation of Active Duty Admissions from ED 48

5. Sample: Cost Calculation of Active Duty Dependent Admissions from ED 49

6. Sample: Cost Calculation of Non-Active Duty Admissions from ED 50

7. Sample: Cost Calculation of Non-Active Duty Dependent Admissions from ED 51

8. Sample: Cost Calculation of Veteran's Affairs Admissions from ED 52

9. Sample: Cost Calculation of Indigent Patient Admissions from ED 53

10. Sample: Cost Calculation of Medicare Eligible Patient Admissions from ED 54

11. Sample: Cost Calculation of All Other Patient Admissions from ED 55

12 . PASBA2 Patient Category Codes 56

VI

CHAPTER 1

INTRODUCTION

The exponential growth in health care expenditures over the

past two decades has continued annually to consume greater

amounts of the gross domestic product (GDP). In 1970, healthcare

expenditures accounted for approximately seven percent of the GDP

and by 1994, those expenditures have nearly doubled to fourteen

percent (Healthcare Executive 1996). It is estimated that by the

year 2065 healthcare will account for approximately thirty-three

to fifty percent of the GDP (Warshawsky 1994). This rise in

healthcare expenditures has pushed cost-containment and even cost

reductions to the forefront of the healthcare delivery systems'

agenda.

Military, as well as civilian healthcare systems, are

feeling the impact of cost containment strategies. While

civilian organizations have seen an evolution in reimbursement

mechanisms used by Medicare and Medicaid, the Department of

Defense (DoD) and Department of the Army (DA) have also been

active in changing funding mechanism. The DA's shift from

workload reimbursement to capitation and to its current system of

TRICARE lends itself to accurate cost accounting systems. The

Army Medical Department (AMEDD) medical treatment facilities

2

(MTFs) must have accurate cost information to make informed

decisions.

It is equally important that MTFs understand associated

revenue streams. In addition to funding allocated by the Office

of the Assistant Secretary of Defense (Health Affairs)

(OASD(HA)), new revenue streams are appearing. Recent

negotiations in Lead Agent Region VI have yielded partial

reimbursement for trauma services provided by Brooke Army Medical

Center and Wilford Hall Medical Center in San Antonio, Texas

(Yoshihashi 1996). Additionally, a simulated demonstration

project between OASD(HA), DoD, and the Department of Health and

Human Services (DHHS) will allow Medicare to treat the Military

Health Services System (MHSS) similar to a risk-type health

maintenance organization (HMO) (Memorandum of Agreement 1996).

This demonstration project will make it possible for Medicare

payments to MTFs to offset the cost of care associated with some

Medicare eligible beneficiaries who are treated in military

facilities. Most recently DHHS and the Health Care Financing

Administration (HCFA) are initiating mechanisms for Medicaid

reimbursements (Vega 1996).

CONDITIONS WHICH PROMPTED THE STUDY

The historical changes, as outlined above, have had

considerable impact on William Beaumont Army Medical Center

(WBAMC), El Paso, Texas. Trend analysis has revealed declining

3

inpatient census and reduced lengths of stay (LOS) at WBAMC in

recent years (Williams 1996). Corresponding budget decrements

and possible elimination of the current graduate medical

education programs necessitate the need for WBAMC to have a more

precise financial picture. Additionally, recent discussions

concerning the sale of Thomason General Hospital, a county owned

entity and the only other trauma-capable hospital in the local

area, to a for-profit organization, raise the possibility of

increased emergency medical services workload at WBAMC.

Therefore, it is in the interest of survivability that WBAMC

conduct cost analysis on traditionally expensive services such as

those provided through the portal of the emergency department.

STATEMENT OF THE PROBLEM

What is the average full cost per patient, per beneficiary

category1, of the healthcare services provided to those who enter

WBAMC through the Emergency Room Department?

REVIEW OF THE LITERATURE

Although this analysis is an economic tool to be used by

the WBAMC executive staff, it is important that the non-financial

impacts of this study are understood. There are ethical and

'Beneficiary categories: Active duty, Active Duty Dependent, Non- Active Duty, Non-Active Duty Dependent, MEDICARE eligible, MEDICAID, Veteran's beneficiaries, and others. To be discussed in the Methodology section.

legal issues that surround the matter.

LEGAL AND ETHICAL ISSUES

Currently, there are no trauma centers, as defined by the

American College of Surgeons (ACS), in the local and surrounding

areas of El Paso (Schreiber 1996). However, WBAMC and Thomason

operate as trauma centers without certification by the ACS.

WBAMC's trauma capabilities are within the ACS guidelines for a

level II treatment facility and could easily be upgraded to a

level I trauma center (Schreiber 1996). Accompanying these

notable designations are federal mandates concerning the

accessibility of emergency room services. The Omnibus

Reconciliation Act of 1985 gave uncontested access of patients to

emergency care services (Koehler, 1992). Hospitals that are

equipped to treat people who present at their emergency room are

required to provide emergency care within the facility's and

staff's capability regardless of the patient's ability to pay for

services rendered. Additionally, a disproportionate percentage

of trauma patients are uninsured, and of those that are covered

by programs such as Medicare and Medicaid, the actual costs of

the health services provided are not fully covered. In 1990,

Mount Saini spent approximately $12,000 per trauma case and was

only reimbursed around $4,200 per Medicaid beneficiary (Skolnick

1992) .

There is an ethical problem if support is not provided

5

to those within the community where trauma and emergency medical

services are necessary. It is estimated that effective regional

trauma systems have reduced preventable death rates by fifty

percent (Koehler 1992). It is therefore important to understand

the effects on the community if a trauma service were to close in

any community.

COST ACCOUNTING REVIEW

Cost accounting is an element of financial management that

generates information about the costs of an organization and its

components (Finkler 1994). The advent of the prospective payment

system necessitated the use of more sophisticated cost accounting

systems (Young and Pearlman 1993, Rezaee 1993). Increased

financial pressure on hospitals and heightened competition in

local markets have facilitated the use of accurate cost

accounting information to aid management decision-making (Orloff

et al. 1990). The cost of the healthcare services is unrelated

to billed charges, such as those calculated by diagnosis related

groups (DRG). Services may in fact cost more or less than the

actual billed charges resulting in a profit or loss.

There are numerous accounting techniques available to

managers to correctly identify healthcare service costs. Older

methods of cost accounting, such as cost to charge ratio,

weighted procedure surcharge, and per diem costing, are

considered inaccurate and obsolete (Loop 1995, Thorely and Jones

6

1994). Currently, cost accounting systems are grouped into

product costing, standard costing, microcosting, and a relatively

new methodology termed activity based cost (ABC) accounting

(Finkler 1994).

Product Costing

Most cost accounting systems stem from product or

"traditional" cost accounting approaches (Finkler 1994).

Traditional cost accounting is further broken into process, job

order, and hybrid methodologies.

Job Order Costing

This is normally associated with custom project accounting.

Each item or "job" that is produced has identifiable costs

matched to that unit of production. It is a complex form of cost

accounting, time consuming, and is best suited for products that

vary from order to order (Eastaugh 1987).

Process Costing

This method is the most basic approach to cost accounting.

It involves averaging the accumulated costs according to a

specific cost center's processes and dividing cost by volume, to

arrive at a unit cost per item (Eastaugh 1987). Costs may then

be aggregated using cost allocation methods to determine an

average cost per patient.

7

Hybrid Approach

Most organizations do not use pure job order or process

costing. A mixture of job order and process systems exist to

mesh the demands of information costs with the need for accuracy.

In high cost procedures such as a computerized tomography (CT)

scan, a job order system might yield the best decision-making

information at an acceptable cost. However, a laboratory that

conducts thousands of similar procedures might use a process

costing system. In this case, the necessary cost information is

considered adequate for the decision-maker and is usually less

expensive to gather than a job order methodology (Eastaugh 1987,

Finkler 1994).

These techniques of product costing may then be applied to

determine departmental or product line costs. That is, services

may be viewed as either a departmental service or a series of

tasks (intermediate steps) that form a product line. For

example, managers can perceive a radiology appointment as a

departmental cost or as an intermediate cost of a product line

associated with the treatment of a broken leg. Cooper and Surver

(1988) contend that product line costing is a powerful tool in

estimating and evaluating product mix to determine which services

should be eliminated or what intermediate products are most

costly.

Product line costing involves knowing an accurate cost for

8

each patient for a particular product. It accounts for the

variation of the degree of complexity which an individual patient

inherently maintains. This allows managers to conduct "what if"

analyses under varying market conditions (Cooper and Surver

1988).

Departmental costing, on the other hand, only considers the

type of patient. This is regardless of the complexity of the

patient diagnosis. An ambulatory patient needing a particular

procedure would cost the same as a non-ambulatory patient needing

the exact same procedure. This method would not account for the

possible increased work of providing the service to the non-

ambulatory patient (Finkler 1994).

Yee-Ching notes a significant problem with these

traditional cost accounting systems. Yee-Ching (1993) describes

them as volume-based accounting systems. Consequently, low-

volume products are consistently undercosted and high-volume

products are consistently overcosted by such systems. This is

enigmatic, as it is widely held that as volume increases

efficiencies are gained through economies of scale (Yee-Ching

1993) .

Standard Costing

Standard costing is an adjunct product costing methodology

sometimes referred to as the Cleverly model. In 1987, William

Cleverly proposed a product costing methodology based on the

9

accumulation of standard units (SU). Standard units are

intermediate products which when totaled will yield a cost for a

given procedure. Treatments are outlined through standard

treatment protocols (STP) and thus give management a fairly

accurate and predictable cost analysis (Cleverly 1987).

Finkier (1994) contends that while it is argued that each

patient is unique and standards are not possible, reimbursement

systems do group patients together for payment. It is therefore

obligatory for managers to group patients together for costing as

well.

Microcosting

Microcosting is the process of closely monitoring and

examining the actual resources consumed by a particular patient

or service (Finkler 1994). Microcosting was developed at the

University of Pittsburgh to correct the inadequacies of

macrocosting (Shuman and Wolfe 1992). Shuman and Wolfe (1992)

developed the following five steps for microcosting from 1969-

1972 shortly after the initiation of the cost based reimbursement

methods used by Medicare and Medicaid:

1. All direct and indirect costs of a unit would be

allocated to its revenue producing services according to a

rational, consistent basis.

2. It would result in an accurate representation of the

"true" cost for each service provided in the revenue center of

10

interest.

3. Cost analysis models must be transferable among

institutions with only minor modification.

4. Models must be computerized and usable in a dynamic

manner.

5. A major technological change would only require an

examination of the factors affected and not the entire system.

Microcosting is an extremely time intensive process and can

be cost prohibitive. Microcosting is usually implemented where

specific cost data is necessary and the accuracy of the data

outweighs the costs associated with the collection process.

Normally, this is the case with special study programs (Finkler

1994).

Activity Based Cost (ABC) Accounting

Activity based cost (ABC) accounting has its origins in

industrial entity's product lines (Baker 1995). According to

James Canby (1995), ABC accounting defines costs in terms of an

organization's processes or activities and determines costs

associated with significant activities or events. Those

activities represent the orchestration of technology, people, raw

materials, and skills that go into the delivery of healthcare.

ABC focuses on the cost drivers (any causal factor that increases

total costs) to apply costs to cost objects (Ramsey 1994). Cost

objects are the activities which are defined and subsequently

11

aggregated based on the cost driver to determine an activity cost

(Yee-Ching 1993). The ultimate goal of this method is to more

accurately distribute overhead to an associated activity. Rather

than applying a pure volume based relationship, which is

misleading, an actual weight is assigned to each overhead cost

object and is then applied to the cumulative total. The result

is an accurate picture of those services which are more costly

than the revenue they generate. However, as Yee-Ching (1993)

points out this information is provided at a significant cost and

therefore, should initially be applied only to those more

expensive services. The value of this method is readily

acknowledged by the DoD. A briefing at the Resource Managers

conference in San Antonio, Texas (1996) described the need to

adopt an ABC approach to cost analysis within the Military Health

Services System (Spicer 1996). The goal under the new Expense

Assignment System IV (EAS IV) will be the transition from

determining what is spent to how it is spent. It is DoD's

ultimate intent to tie together or link the human resource

system, financial system, logistical system, and clinical systems

under the umbrella of a centralized executive information system

(Spicer 1996).

Cost Accounting Mechanics

All of the above cost accounting methodologies have

similarities in how costs are defined. The application of the

12

definitions are the nuances of the methodology. All cost

accounting systems deal with various types of costs, whether

direct, indirect, relevant, full, fixed, variable, or other. It

is therefore important to discuss basic cost terminology.

Direct and Indirect Costs

Direct costs are those costs clearly associated with the

cost objective (destination of an assigned cost). They are

normally under control of the manager within the department or

cost center. Indirect costs are more nebulous in their

assignment. Indirect costs are also called overhead costs and as

discussed above are allocated to cost centers in numerous

fashions (Finkler 1994). In any organization, a cost not

classified as a direct cost is, by default, an indirect cost

(Needles, Anderson, and Caldwell 1984).

Fixed, Variable, Semi-Variable (Mixed), Semi-Fixed (Step-Fixed) Costs, and Full Costs

Fixed cost will not vary within a relevant range of volume

or activity (Needles, Anderson, and Caldwell 1984). They remain

relatively constant over time and over the amount of relevant

activity. Variable costs, however, change with the provision of

service to each individual patient. They will increase or

decrease in direct proportion as the volume of patients

fluctuates. For example, a facility's rent or mortgage cost is a

stable monthly expense. It will remain the same regardless of

13

the number of patients seen within its walls. It is therefore a

fixed cost. Supplies on the other hand would be a variable cost.

As the number of patients seen increases, the volume of supplies

will generally increase at a proportional rate (Finkler 1994).

The sum of fixed and variable costs is the total or full

cost (McConnell 1984). The term "full cost" is a measurement,

expressed in monetary units, of all resources used for a given

cost objective (Broyles and Rosko 1986). Full costs, while not

normally important when making program evaluation decisions, are

necessary when attempting to determine the maximum justifiable

price for reimbursement (Holmes 1996).

There are costs that contain characteristics of both fixed

and variable costs. Mixed costs are those in which the fixed and

variable components cannot be separated. A telephone bill is a

realistic example. Monthly telephone charges are made up of a

service charge (fixed) plus extra charges for extra telephones

and long-distance charges (variable) (Needles, Anderson, and

Caldwell 1984). Step-fixed costs relates to the concept of

volume to the fixed cost object. For example, the rent as a

fixed cost is correct up to a set volume. If the facility can

only support servicing a finite number (full capacity) of

patients and the organization wants to see more than the

allowable capacity, it must add additional resources and thus

increase its fixed costs (Holmes 1996). Holmes (1996) also

14

points out that all costs are variable over time. A building,

although new today, will someday be replaced. For the life of.

the building the cost is relatively fixed, perhaps with the

exception of the inflation placed on property taxes and potential

physical plant upgrades. Ultimately, the life of the

organization could exceed the life of the building and therefore

necessitate a new building and new costs.

Marginal Costs and Opportunity Costs

According to Brown and Howard (1975) marginal costing is

one of the most controversial subjects within the sphere of

management accounting. To the economist, marginal costs are

those which are associated with the addition of one more unit of

production (McConnell 1984, Brown and Howard 1975). To the

accountant, marginal costs represent a technique with which

management can measure the profitability of an undertaking by

considering the behavior of costs (Brown and Howard 1975).

Marginal cost is calculated by dividing the change in total costs

by the change in quantity (McConnell 1984)

An equally important concept is that of opportunity costs.

Because resources are limited, choices between competing

alternatives must be made. The value of other alternatives which

must be foregone or sacrificed to obtain a unit of any given

product is called the opportunity cost for that particular good

(McConnell 1984, Finkler 1994). Managers must understand the

15

economic impact of competing alternatives when using cost

information for decision making.

Medical Expense and Performance Reporting System

The purpose of the Medical Expense and Performance

Reporting System (MEPRS) is to provide a uniform healthcare cost

management system for the DoD. The MEPRS also provides detailed,

uniform performance indicators, common expense classification by

work centers, uniform reporting of personnel utilization data by

work centers, and a cost assignment methodology. Additionally,

MEPRS defines work centers, applies performance measures, assigns

costs, and gives standardized reports(DoD 6010.13-M 1995). MEPRS

produces full costs for each work center. Full costs are

determined utilizing a traditional step-down methodology (Figure

1 below). These allocations are based on a workload measure.

They might be allocated by the number of minutes used, pounds of

laundry, number of visits seen, or man hours spent. These are

computed as a ratio of the total expense for the cost center.

One can easily identify inherent problems with this system.

Watkins (1995) noted the inequity in the MEPRS cost assignment.

She explained that an operating room procedure which lasted 60

minutes was twice as expensive as a procedure which lasted 30

minutes. This methodology ignored the fact that the shorter

procedure might require more expensive, sophisticated equipment

than a longer less costly procedure (Watkins 1995). An acuity

16

Depreciation

w Cmd,Mgt,Adm ^

*\ Other Support

i Ptk Ancillary • ~^h"

fe V Inpatient ^

^ Outpatient

Figure 1. MEPRS cost allocation, a step-down methodology. Source: Holmes, Richard L. 1996. Relevant Cost Decision-Making. U.S. Army Medical Department Journal. Feb/Mar, 8-15

adjustment is necessary when using this data for decision-making

purposes, regardless of whether using full cost data or looking

for relevant costs.

CASE MIX INDICES, PATIENT ACUITY AND DIAGNOSTIC RELATED GROUPS

Under the Prospective Payment System (PPS), Medicare uses

six variables to determine the payment for a case (Jencks and

Dobson 1987):

1. Urban or Rural location (based on Metropolitan

Statistical Area).

2. Labor costs (area wage index)

3. Indirect teaching costs (interns and residents)

17

4. Disproportionate share (the number of Medicaid or

Supplemental Security Income eligibles)

5. The DRG assigned to the patient

6. Outlier Status (supplemental payments for those cases

that fall outside the norm)

These variables combine to form hospital billed charges.

The billed charges represent a prospective payment for a hospital

service regardless of the resources consumed. The Medicare

payment is derived from the expected resource consumption, rather

than actual consumption. If a hospital can discharge a patient

in less time and with less resources than the expected

consumption requirements, it will make a profit. The opposite is

then true in this regard as well (St. Anthony's 1995).

This study necessitates an understanding of DRGs. The DRG

system, designed at Yale University, groups patients by diagnosis

(Kasten 1987). Linking similar procedures and their respective

complexity produces a relative weight per procedure. This

methodology accounts for complications and comorbidity.

Furthermore, for cases that lie more than three standard

deviations from the norm, an outlier adjustment factor is

calculated to account for the increase in resource consumption

(St Anthony's 1995). Consider this simple example. A patient

presents at a community hospital for human immunodeficiency virus

(HIV) with a major related condition. This case would be coded

18

into DRG 489. DRG 489 has a corresponding arithmetic length of

stay (ALOS) of 12.5 days and a relative weight of 1.8158. The

hospital's base rate for reimbursement is $4,000. The resultant

payment to the hospital for the treatment would be $7,263,

irrespective of whether the patient stayed longer or shorter than

12.5 days. That is, $4,000 multiplied by 1.8158 is equal to the

hospital payment of $7,263 (St. Anthony's 1995). Thus, the

higher the relative weight the greater the payment to the

hospital. The relative weight is intended to reflect the

resources consumed by the corresponding principal diagnosis.

PURPOSE STATEMENT

The purpose of this graduate management project is to

prepare an estimate of the full cost of providing inpatient

emergency department services to the military and civilian

community of El Paso, Texas for fiscal year 1995. This project

will establish a methodology which will allow MTFs to determine

an estimated full cost per beneficiary category for emergency

medical services. The results of this study may be utilized to

conduct negotiations with the local and state government, as well

as other non-DoD users, for reimbursement to offset costs

associated with the provision of services.

19

CHAPTER 2

METHOD AND PROCEDURE

The method to assign costs to the various beneficiary

categories is problematic. Since no single system in the

facility can provide the desired information, the researcher must

develop an acceptable procedure to determine full costs. The

full cost of emergency department care is described in its most

basic form in the formula below (Figure 2).

Full costs = £ Full Patient Category Costs ] Figure 2. Basic full cost formula

The calculation of full beneficiary category costs is the

end result of determining how many patients, by DRG and category,

were admitted from the emergency department for fiscal year 1995.

The following steps outline the process of full cost

determination for those patients who are admitted into the system

via the emergency department.

20

Step 1: Outline the patient flow

The first step is to identify how patients flow through the

facility once they present at the emergency department. By flow

charting this process one can better understand where and how the

patients are treated. Appendix A shows the possible

matriculation through WBAMC to final disposition. The possible

work centers or cost centers are locations where the patient is

treated and will accumulate costs.

Step 2: Determine Patient Categories

Patients are categorized into like groupings by Army

Regulation 40-3 (1985). This regulation additionally prioritizes

the beneficiaries with respect to access to care. For the

purpose of this study the researcher has categorized patients in

the following manner(Figure 3).

Active Duty (AD) Active Duty Dependent (ADD) Non-Active Duty (NAD) Non- Active Duty Dependent (NADD) Medicare Eligible (age>65) Medicaid Eligible Indigent Care Veterans' Affairs Beneficiary Others

Figure 3. Patient Categories

21

Step 3: Determine Pull Costs for All Inpatient Cost Centers

From a MEPRS Part-One Analysis the total amount spent on

all inpatient services can be determined. This full cost is

necessary to calculate the allocation of costs to each patient.

As discussed in the literature review, for decisions involving

program cuts, full costs may not be relevant. However, decisions

involving pricing require full cost data.

Step 4: Calculate the Average Cost per Diagnosis Related Group

The calculation of an average cost per DRG is a three-step

process. The first step is to develop a relative weighted

product (RWP) so that the severity and number of each type of

admission is accounted. The Retrospective Case Mix Analysis

System (RCMAS) provides the number of cases, by CHAMPUS DRG2,

RWP=£(Cases*WT)

RWP=Relative weighted product

Cases=The number of cases per DRG

WT=The assigned CHAMPUS weight for each DRG

Figure 4. Relative Weighted Product

2CHAMPUS DRG- The weights of CHAMPUS DRGs are reflective of those admissions in the civilian healthcare setting, based on non-availability statements (NASs), and not based on resources consumed within the military health services system (MHSS).

22

which are necessary to compute the average cost per DRG. The

figure above shows the formula to calculate the RWP.

The second step is to calculate a conversion factor. The

conversion factor is the average cost per relative weighted unit

which is similar to a hospital base rate. The hospital base

rate, as reviewed in the literature, is a standard reimbursable

charge which is multiplied by each DRG to determine the billed

charge for each hospital admission. The conversion factor can be

used similarly. It can be multiplied by the DRG's relative

weight and will arrive at an average cost per DRG for that

admission. Figure 5 below demonstrates the calculation of the

conversion factor.

CF^Inpatienteosfc/RWP

CF=Conversion Factor

Inpatient^^The Full MEPRS cost of All Inpatient Accounts

RWP=Relative weighted product

Figure 5. Calculation of the Conversion Factor

The final step in calculating the average cost per DRG is

applying the conversion factor to each individual DRG weight.

For example, if the researcher determines a conversion factor

equal to $1,000 and wants to calculate the cost of DRG 489 (HIV);

simply multiply the $1,000 by the DRG's relative weight of

23

2.7957. This yields a cost to the hospital of $2,796 based on an

average length of stay. Figure 6 shows how to determine the cost

per DRG. Figure 7 gives the researcher a mathmatical formula to

check the methodology.

AVG00St=CF*WT

AVGC0St= Average cost per DRG

CF=Conversion Factor

WT= The assigned HCFA weight for each DRG

Figure 6: Average Cost per DRG

METHOD CHECK Inpatient00Sts=£(AVGC0St*Cases)

InpatientC0Sts=The Full MEPRS cost of All Inpatient Accounts

AVGC0St=Average cost per DRG

Cases=Number of cases per DRG

Figure 7: Methodology Check

The methodology check should produce an answer equal to the

total inpatient costs which were given by the MEPRS part-one

analysis. The results of the method is the redistribution of

24

costs based on the acuity of the patients.

Step 5: Calculation of Emergency Room Costs by Patient Category and DRG

Since the cost of each individual DRG has already been

calculated, the researcher only needs to determine those ED

admissions by patient category. The Patient Administration

System and Biostatistical Activity (PASBA) will categorize the

facility's admissions. It will determine the number of patients,

by category and DRG, admitted from the ED. Once this information

is captured, each beneficiary category's costs may be calculated

using the following formula (Figure 7).

Categorycosts=i;(Cases*AVGcost)

Category^^The Total Cost of Each Patient Category, Admitted through ED

Cases=Number of cases per DRG

AVGC0St= Average cost per DRG

Figure 7. Total Cost of Each Patient Category-through ED

Validity and Reliability

The value of any research product is limited to the quality

of the data collected and the methodology employed. This study

required no original data collection. A detailed cost analysis

with the generation of new data would yield a significantly more

accurate product, however, the time to conduct such a project

25

would be prohibitive.

All data was acquired through existing sources. Each data

source can have questionable or suspect values. The researcher

did find all data sources to be reliable. The repeatability of

the data generation is not in question. However, the validity

could be suspect. The researcher extracted data from the

Retrospective Case Mix Analysis System (RCMAS), the Standard

Inpatient Data Record (SIDR), and the Medical Expense Performance

and Reporting System (MEPRS).

Validity of the Data Systems

The questionability of the MEPRS data lies in understanding

how the data is compiled and entered into the system. For

example, the allocation of labor costs is driven through the

Uniform Chart of Accounts Performance Expense Reporting System

(UCAPERS). This system, similar to a time card system, feeds

labor allocation information to the MEPRS database. Each

physician, nurse, and administrator reports the number of hours

worked and location of the work performed. Costs can be mis-

allocated if the UCAPERS data is not properly reported to the

data entry clerks. For example, if a pediatrician provides

inpatient care or on-call duty and does not properly report it to

the clerks, a standard entry of forty clinic hours is reported.

This ultimately will reduce the reported cost of care provided to

inpatients. This is because all of the pediatrician's labor will

26

count only as outpatient clinic time.

The Patient Administration System and Biostatistical

Activity (PASBA) compiles the admissions and dispositions from

each medical treatment facility within the Medical Command

(MEDCOM). The PASBA2 software system extracts the information

from the composite healthcare computer system (CHCS) to develop

the Standard Inpatient Data Record (SIDR). Simultaneously,

Vector Research Corporation analyzes the SIDR to exclude those

items which do not accurately reflect true admissions and

dispositions. Removed from the database are incomplete records,

those coded "Carded Record Only"3 and "Absent Sick"4 (Frazier

1997).

Faults in the PASBA system are readily apparent. Civilian

institutions must accurately code each diagnosis in order to

receive proper reimbursement for the admission. While military

treatment facilities do bill third party payors, the billing to

these revenue sources has historically not been seen necessary

for the survival of the organization. The lack of financial

motivation for accurate coding of inpatient records leaves the

system open for suspicion.

3Carded Record Only- Used for those procedures which are not a patient admission but must be recorded; such as an autopsy.

"Absent Sick- Used to classify active duty military who are admitted to a civilian facility. This accounts for the expenditure of supplemental funds.

27

CHAPTER 3

RESULTS

The application of the presented methodology yielded to the

researcher the expected outcome. The research revealed that there

were 13,027 (RCMAS) admissions to WBAMC in 1995, of which, 2,998

(SIDR) originated from the emergency department (ED) .

Correspondingly, the full costs of all admissions totaled

$63,884,196 (MEPRS). Research also indicated ED admissions

generated $18,510,557, or approximately 29% of all inpatient

costs.

Table 1 (below) reveals the break-out of the ED costs by

patient category. The table shows each category inclusive of

those beneficiaries over 65 years of age. For instance, an

individual who is an Active Duty Dependent (ADD) and over 65

years old could be double counted as an ADD and also as a

Medicare eligible. Because the Medicare eligibles are rolled-up

into each category, the table does not give an accurate cost of

Medicare patients admitted through the ED but does demonstrate

how much of the resources are being consumed by each patient

category.

28

Patient Category Total Costs AVG Cost

Active Duty $1,932,665 $4,423

AD Dependent $1,924,002 $3,825

Non-Active Duty $5,971,022 $7,482

NAD Dependent $3,656,719 $5,841

Veterans $2,655,696 $7,397

Indigent $1,800,955 $8,700

MEDICARE $289,934 $15,260

Others $279,565 $5,705

Total Costs $18,510,557 Table 1: Patient Cosl ;s; Including Medicare in each Categ

However, in Table 2, those individuals over 65 years of age

are removed from each patient category, reflecting only those

patients for whom Medicare could not be billed. Thus, those over

65 years of age are calculated as Medicare eligible and would

fall strictly in the Medicare patient category. The costs of

Medicare eligible patients in this table also include the

$289,934 which was reflected in Table 1, Medicare Category.

Patient Category Total Costs AVG Cost

Active Duty $1,928,338 $4,423

AD Dependent $1,855,044 $3,778

Non-Active Duty $2,993,515 $7,695

NAD Dependent $1,964,574 $5,550

29

Veterans $1,587,405 $6,902

Indigent $1,725,893 $8,806

MEDICARE $6,186,130 $7,226

Others $269,658 $5,737

Total Costs $18,510,557 Table 2: Patient Costs; Excluding Medicare in each Category

30

CHAPTER 4

DISCUSSION

This methodology provides the researcher with a macro-cost

accounting technique to easily identify cost drivers within any

military medical treatment facility.

A typical admission from the ED might occur in the

following manner: An elderly patient who has fallen at home is

brought to the ED by their spouse. The ED physician evaluates

the patient and determines the need for a surgical consult. The

"Surgeon of the Day" examines the patient, identifies the need

for hip surgery and admits him or her. This admission is then

counted as a "Surgical Clinic" admission, despite the origin of

the admission. MEPRS is designed to allocate these costs to the

admitting physician's clinic. While it is important to determine

these clinic costs and hold department chiefs responsible for the

allocation of scarce resources, it is equally important to

understand the resource consumption patterns of the patients.

With the push to health promotion and prevention, the ED appears

to be a likely candidate for monitoring the effectiveness of DoD

and MTF health promotion programs.

31

DEVELOPMENT OF THE MODEL

A RCMAS report was completed to identify all admissions for

FY 1995. The data, which consisted of the DRG code, average

length of stay, and the number of cases for each DRG code, were

imported into an MICROSOFT EXCEL* spreadsheet. The CHAMPUS

relative weighted product (RWP), also known as a DRG weight, was

manually typed into the spreadsheet next to the corresponding DRG

code (APPENDIX B, Table 3).

Initially the researcher attempted to use the Medicare DRGs

produced by the Health Care Financing Administration (HCFA).

However, the RCMAS analysts were unable to pull the data in the

HCFA format. On the other hand, the PASBA2 clerks were able to

produce data in both HCFA and CHAMPUS formats. Interestingly,

the RCMAS and PASBA2 systems stem from the same database origin

(CHCS) and probably should have produced similar outputs. The

limitation of the WBAMC systems necessitated the use of the

CHAMPUS weights, rather than the use of the HCFA weights. The

spreadsheet sample in Appendix B, Table 3, shows the first

fifteen DRGs, the last two DRGs, total admissions, total

inpatient costs, and the corresponding calculations for all

inpatient admissions for FY 1995.

Once the cost for each admission by DRG was estimated for

FY 1995, the next step was to correctly identify which DRGs were

admitted from the ED. The PASBA2 system easily allowed queries

of the SIDR as to the patient category, admission location (ED),

32

DRG code, number of cases, and the average length of stay.

Currently, the DoD does not bill Medicare. Since Medicare

is not a revenue source there is limited classification of these

type patients. There were only nineteen admissions actually

classified as Medicare or other Federal beneficiaries for FY

1995. Therefore it was necessary to remove those patients over

65 years of age from each patient category to determine an

estimated cost for this group. To alleviate any confusion as to

how the patients were classified, Appendix C shows each patient

category by PASBA2 codes.

Additionally, it was noted that Medicaid patients were not

being coded as such during FY 1995, although they did have a

PASBA2 assignment code. In 1995 and previous years, WBAMC would

submit a bill to the Defense Finance and Accounting System (DFAS)

for those patients who were non-eligible for DoD care and for

whom payment for services rendered was not received. DFAS would

then reimburse WBAMC with DoD funds. DoD would then try to

collect on those outstanding debts (Vega 1996). Like the

Medicare coding situation, there was no incentive to classify

patients as Medicaid eligible. The Indigent patient category

included all Medicaid eligible patients. Therefore, the Medicaid

patient category was removed as a distinct patient category.

Indigent patients should be classified as those patients without

insurance, whether Medicaid, Medicare, or private health

insurance, or lacking the ability to pay with private funds.

33

This definition will be applied in the future to WBAMC patients.

As of fiscal year 1997, WBAMC will have the legal authority to

directly bill Medicaid for services rendered to Medicaid eligible

beneficiaries (Vega 1996).

After identifying the above difficulties, the researcher

manually entered the number of admissions for each DRG and

patient category. Appendix B (Tables 4-11) shows a sample of

each patient category, adjusted for Medicare eligible (over 65

years old) patients. The summation of each patient category

represents the total costs generated by the ED in FY 1995.

ANALYSIS AND INTERPRETATION

Overall, WBAMC spent approximately $18.5 million on

admissions through the ED in fiscal year 1995. The ED produced

2,998 of the 12,027 inpatient admissions during the year,

accounting for approximately 25% of all inpatient workload.

However, the ED was responsible for 29% of all inpatient costs

for the year. These numbers substantiate the researcher's belief

that ED patients are generally more sick and may consume more

resources than most who enter the facility through other portals.

The chart below shows how the $18 million dollars of ED generated

costs were produced by the corresponding patient categories. The

red bar indicates the dollar amount expended on that patient

category with the inclusion of all Medicare eligible patients.

The blue bar represents the dollar amount of each patient

34

ED Costs by Patient Category $7,000,000

$6,000,000

$5,000,000

$4,000,000

$3,000,000

$2,000,000

$1,000,000

$0 AD ADD NAD NADD VAB indigent Medicare Others

W/ Medicare W/Out Medicare

Chart 1: Break-out of Patient Category Costs

category with the Medicare eligibles removed. The difference

between the two bars would equate to the amount of resources

consumed by Medicare eligible patients. The patient category

"Medicare eligible" (sum of all Medicare eligibles) combined to

account for the largest expenditure of funds by patient category.

However, the primary cost driver of ED costs is the non-active

duty patient (NAD) category. As a population, they consumed over

$5.9 million dollars in healthcare, by far the greatest amount of

any patient category. They had 798 admissions for the year, with

an average cost of $7,482. While they were the greatest consumer

of resources, they did not have the highest average cost per

35

admission.

From Table 1 it would appear that Medicare patients were

much more acute than the other categories. Medicare yielded an

average cost per admission of $15,260. This was an inaccurate

picture of Medicare costs because it was only averaged over

nineteen patients. When the Medicare category was adjusted to

include all 856 admissions, the average cost per admission

dropped to $7,231 each. Overall, the Indigent patients were a

much more expensive admission. Each admission averaged $8,700

before the removal of the Medicare patients and each admission

actually increased to $8,806 per admission after the Medicare

eligible patients were removed.

LIMITATIONS

This study applies costs to DRGs based on the acuity levels

as determined by the CHAMPUS relative weighted units. It does

not account for variation in the length of stay.

To better understand this variation, consider two patients

with equal diagnosis and hence equal DRG assignments. Both

patients are admitted for a Craniotomy (CHAMPUS DRG 001). Under

the current methodology both patients would be allocated a cost

of $19,475. This disregards the possibility that one patient

stays only six days, while the other stays eight days. Although

both of the procedures performed are similar, the patient who

stays for the extra two days would not cost anymore, under this

methodology, than the other patient. Inherently, this is false.

36

The patient who stays longer, with a similar procedure performed,

would be expected to consume more resources than the shorter stay

patient.

The methodology presented calculates the average cost of a

DRG, rather than adjusting it for length of stay. It must also

be noted that the variation in the allocation of the costs is not

linear but rather curvilinear. For example, DRG 001 on the chart

below has an average length of stay of 13.5 days. If the patient

40000 -

35000 -

30000 -

25000 -

20000 -

15000 -

10000 -

5000-

0-1

1

Length of Stay - Costs

—- -"

^ ^t,*^\__^^^^m^^^m^

^^^^

r i i 5 10

i 13.5 15 20 2!

Chart 2: Length of Stay and Cost Allocation

was discharged on day 7, before the average of 13.5 days, the

resources consumed would be significantly less than someone who

was admitted exactly on the average. Conversely, if the patient

stays longer, there would be more resources consumed. Upon

reaching day 14, there would only be incremental increases in

37

costs attributable to the patient staying longer. The leveling

off of DRG 001 beyond day 14 represents the decreasing cost of

caring for a patient once the primary admission diagnosis is

treated. The continued increase of the average cost represents

the limitation of this methodology, as it does not adjust for the

variation in the length of stay.

Furthermore, this study does not include the outpatient

visit cost of an ED admission. Prior to any admission from the

ED, an exam is conducted. A routinely scheduled admission from a

clinic would include a series of outpatient appointments prior to

the day of admission. The ED operates in a similar manner,

except the outpatient visit can occur within hours, minutes, or

simultaneously with the admission. Although cost of an ED

outpatient visit is easily obtained from MEPRS ($140 per visit),

the cost per visit is not adjusted for patient acuity and would

provide cost information of minimal value. Significantly more

research would be necessary to accurately allocate the cost of an

outpatient visit prior to an admission.

38

CHAPTER 5

RECOMMENDATIONS

This study was designed to yield full cost information on

all admissions for fiscal year 1995 from the emergency

department. The full cost data allows management the opportunity

to determine where the cost drivers are within their facility.

The costs produced by this study must only be used for pricing

decisions. The non-active duty and non-active duty dependents

are the most likely individuals to have third party insurance.

They provide a unique opportunity for a revenue source. As of

this fiscal year, the Medicaid beneficiaries will be removed from

the Indigent patient category. The remaining indigent

individuals will, for the time being, be paid for by passing the

bill to (DFAS). DFAS is expected to cease payment for these

services which are considered the responsibility of local

government (Williams 1997). WBAMC should view the local

governing body as a revenue source for all indigent patients.

This study could assist in the justification of such an endeavor.

This study has created the opportunity for continued

research in this area of study. The extension of this project by

applying an adjustment factor for variation in the average length

of stay would yield more accurate results. Another continuation

39

of this study would be an investigation of the relationship of

the outcomes of this methodology as compared to the interagency

rates. An analysis of the variances between the researcher's

identified costs per DRG and the DoD Interagency rates would

assist in determining the efficiencies of providing health care

services. For example, DRG 001 has been identified as costing

WBAMC $19,475 per admission. The interagency rate shows a

corresponding price of $20,647. Theoretically, WBAMC should have

lower costs than the interagency rate in all DRGs. Further study

could determine if WBAMC's resources are being wisely allocated.

Furthermore, a slight modification of this methodology could

produce a relevant cost (Holmes 1996) decision-making tool.

The costs of adding an additional product line could be

determined by identifying those relevant costs which vary with

the decision. The sum of those costs could replace the

wInpatientcosts=The Full MEPRS cost of All Inpatient Accounts"

portion of the formula to produce a relevant cost decision.

Initially the researcher would identify and apply the relevant

costs and with the current methodology produce a relevant cost

per DRG. The identification of product line specific DRGs would

illustrate how much it would cost to produce those DRGs. This of

course does not account for the possible addition of more

resources to produce more volume within the product line. But

some modifications would again simplify the process of applying

costs to product line wmake-buy" decisions.

40

Lastly, it is recommended that further study be initiated

to determine each patient categories' most frequent and most

costly DRGs. This will allow for the development of utilization

management initiatives which, in time, could possibly save scarce

resources and have a positive effect on the fiscal outcomes of

the medical center.

41

CHAPTER 6

CONCLUSIONS

The purpose of this graduate management project was to

prepare an estimate of the full cost of providing inpatient care

to emergency department admissions for the military and civilian

community of El Paso, Texas for fiscal year 1995. It was found

to be an efficient, reliable methodology which can be applied to

any military treatment facility. By understanding how costs are

accumulated within the MTF, management may make more informed

decisions as to the provision of health services. This

methodology combines a product line costing approach with the

current step down process of MEPRS. The end result places a

price tag on the product line in question.

This study illustrates, with relative accuracy, which

patients, by category, are driving costs within the ED. It shows

that the emergency department generates costs beyond those

outpatient visits, determined and reported by MEPRS. Almost 30%

of all inpatient costs can be traced to one portal of entry and

that portal should be properly monitored to enhance correct

utilization of limited resources.

If local communities wish to continue receiving care within

DoD MTFs, they must be expected to reimburse the cost of that

care. William Beaumont Army Medical Center provides significant

resources to the community of El Paso. Administrators must

pursue revenue streams whenever and wherever they appear. The

survival of any organization, whether military or civilian, lies

in the ability to manage limited resources. At a recent

healthcare seminar, the speaker stated, "When competition is

tight, quality is assumed, and the differentiating factor is

cost" (Hernandez 1997). William Beaumont Army Medical Center

must continue to pursue and refine its cost accounting techniques

to determine which product lines need refinement, thereby

remaining solvent in an increasingly complex health care arena.

42

WORKS CITED

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Assistant Secretary of Defense for Health Affairs. 1995. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities. DoD 6010.13-M. Department of Defense.

Baker, Judith J. 1995. Activity-based costing for integrated delivery systems. Journal of Health Care Finance 22 (2, Winter):57-61.

Brown, Lewis J., and Leslie R. Howard. 1975. Principles and Practice of Management Accountancy. 3rd. London, England: Macdonald & Evans Limited.

Broyles, Robert W., and Michael D. Rosko. 1986. Full cost determiniation: an application of pricing and patient mix policies under DRGs. Healt Care Management Review 11 (3, Summer).

Canby, James B., IV. 1995. Applying activity-based costing to healthcare settings. Healthcare Financial Management (Feburary):5 0-5 6 .

Cleverley, William 0. 1987. Product costing for health care firms. Health Care Management Review 12 (4, Fall):39-48.

Cooper, Jean C, and James D. Suver. 1988. Product line cost estimation: A standard cost approach. Healthcare Financial Management, April, 60-70.

Eastaugh, Steven R. 1987. Has PPS affected the sophistication of cost accounting? Healthcare Financial Management, November, 50-52.

Finkler, Steven A. 1994. Essentials of Cost Accounting for Health Care Organizations. Gaithersburg, MD: Aspen.

Holmes, Richard L. 1996. Relevant Cost Decision-Making. Army Medical Department Journal, Feb/Mar, 8-15.

Hernandez, Hank. Interview by author, William Beaumont Army Medical Center, January 23, 1996.

43

Jencks, Stephen F., and Allen Dobson. 1987. Refining Case-Mix Adjustment. The New England Journal of Medicine 311 (11, September):679-86.

Kasten, Bernard L. 1987. The Physician's DRG Handbook. Stow, OH: Lexi-Comp Inc.

Koehler, Corinne Z. 1992. Issues and legislation surrounding trauma care. AORN Journal 56 (2, August):331-37.

Loop, Floyd D. 1995. You are in charge of cost. Annuals of Thorac Surgery 60:1509-12.

McConnell, Campbell R. 1984. Economics: principles, problems, and policies. UNK: McGraw-Hill.

Needles, Belverd E., Henry R. Anderson. 1984. Principles of Accounting. 2d. Boston, MA: Houghton Mifflin Company.

Orloff, Tracy M., Candace L. Littell. 1990. Hospital cost accounting: Who's doing what and why. Health Care Management Review 15 (4, Fall):73-78.

Ramsey, Ralph H. 1994. Activitybased costing for hospitals. Hospital & Health Services Administration 39 (3, Fall):385-96.

Rezaee, Zabihollah. 1993. Examining the effect of PPS on cost accounting systems. Healthcare Financial Management 47 (3, March):58-61.

Schrieber, Martin M.D.. 1996. Interview by author, William Beaumont Army Medical Center, September 12.

Skolnick, Andrew A. 1992. Congress Acts to Resuscitate Nation's Financially Ailing Trauma Systems. Journal of the American Medical Association 267 (22, June):2994,2996.

Spicer, Pat. 1996. Department of Defense Resource Management Conference (March 1996). Ed. Captain Shawn Wagner. William Beaumont Army Medical Center, September 19.

St. Anthony's. 1995. St. Anthony's Diagnostic Related Groups.

44

Thorley, Nancy and, Edith L. Johns. 1994. Adoption of costing systems by U.S. hospitals. Hospital & Health Services Administration 39 (4, Winter):521-37.

Vega, Carlos. Interview by author. William Beaumont Army Medical Center, October 15, 1996.

Warshawsky, Mark J. 1994. Projections of Health Care Expenditures as a Share of the GDP: Actuarial and Macroeconomic Approaches. HSR: Health Services Research 29 (3, August):293-313.

Williams, Calvin. 1996. Interview by author, William Beaumont Army Medical Center, 15 September.

Yee-Ching Lilian C. 1993. Improving hospital cost accounting with activity-based costing. Health Care Management Review 18 (1, Winter):71-77.

Yoshihashi, Eric. 1996. Telephone interview. Ed. Captain Shawn Wagner. William Beaumont Army Medical Center, September 17.

Young, David W., and Leslie K. Pearlman. 1993. Managing the stages of hospital cost accounting. Healthcare Financial Management 47 (4, April):58-80.

45

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APPENDIX C

PASBA2 PATIENT CATEGORY CODES Active Duty Army

A11 Active Duty Army

Active Duty Dependent

A41 Dependent AD, Excluding Former Spouse F41 Dependent AD, Excluding Former Spouse N41 Dependent AD, Excluding Former Spouse

Non-Active Duty

A31 Length of Service- Retiree A32 Permanent Disabled Retirement List C31 Length of Service- Retiree F31 Length of Service- Retiree F32 Permanent Disabled Retirement List M31 Length of Service- Retiree N31 Length of Service- Retiree

Non-Active Duty Dependent

A43 Dependent-Living Retired, Excluding Former Spouse A45 Dependent-Deceased AD, Excluding Former Spouse A47 Dependent-Deceased Retired, Excluding Former Spouse C43 Dependent-Living Retired, Excluding Former Spouse C47 Dependent-Deceased Retired, Excluding Former Spouse F43 Dependent-Living Retired, Excluding Former Spouse F47 Dependent-Deceased Retired, Excluding Former Spouse M47 Dependent-Deceased Retired, Excluding Former Spouse N43 Dependent-Living Retired, Excluding Former Spouse N45 Dependent-Deceased AD, Excluding Former Spouse N47 Dependent-Deceased Retired, Excluding Former Spouse

Veteran's

K61

i Affairs Beneficiary

Veterans Administration

Indigent

K92 Civilian Emergencies

Medicare

K64 Other Federal Agencies

Others

A48 Unremarried Former Spouses Source: PASBA2 System, 1996

56

REPORT DOCUMENTATION PAGE OMB No -oroj-oisft

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1. AGENCY USE ONLY (Ledve ö/an*; 2. REPORT DATE

March 1997 3. REPORT TYPE AND DATES COVERED

FINAL REPORT (08-96 to 03-97

4. TITLE AND SUBTITLE

A Cost Analysis of Emergency Medical Services at William Beaumont Army Medical Center

6. AUTHOR(S)

Captain Shawn A. Wagner, Medical Service Corps

7. PERFORMING ORGANIZATION NAME(S) AND ADCRESS(ES) William Beaumont Army Medical Center 5005 N. Piedras Street El Paso, Texas 79920-5001

9. SPONSORING-MONITORING AGENCY NAME(S) AND ADDRESS(ES)

U.S. Army Medical Department Center and School BLDG 2841 (MCCS-HRA) U.S. Army-Baylor PGM in HCA 3151 Scott Road Fort Sam Houston, Texas 78234-6135

11. SUPPLEMENTARY NOTES

5. FUNDING NUMBERS

8. PERFORMING ORGANIZATION REPORT N'JMBLR

1-97 \

10. SPONSORING MONITORING AGENCY REPORT NUMBER

{ 123. DISTRIBUTION AVAILABILITY STATEMENT j

\ Approved for Public Release; Distribution is unlimited

I 12b. DISTRIBUTION CC

.M.---:^u^ yccv.

The purpose of this graduate management project was to oreoare an estimate of the full cost of providing inpatient care ?orPemer^ncy department admissions for the military and c.vxlxan community of El Paso, Texas for fiscal year 1995. It was found toTe^an efficient, reliable methodology which can be applied to any miUtary treatment facility. By understanding how costs are accumulated within the MTF, management may make more informed decisions as to the provision of health servxces. This _ methodology combines a product line costing^approach with the current step down process of MEPRS. The end result places a price tag on the product line in question.

Cost Analysis, Military healthcare, cost and.acuity : ''']■*.: ■■'"'■ 63' :. 116 PR>C£ -:o::-'

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