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SELF-TEST 1. What is the difference in goals between investor-owned and not-QUESTION for-profit businesses?

Healthcare Reform and Finance The Patient Protection and Affordable Care Act (ACA) of 2010 has been called the most significant healthcare legislation since Medicare and Medicaid in 1965. The law, which was enacted on March 23, 2010, was designed to provide all US citizens and legal residents with access to affordable health insurance, to reduce healthcare costs, and to improve care and quality. This legislation puts in place comprehensive health insurance exchanges to expand coverage, hold insurance companies accountable for product cost and quality, lower costs across the system, guarantee more choices, and enhance the quality of care all of which are intended to transform the US healthcare system and make it more sustainable.

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The ACA has numerous major aims. However, the central goal is to expand healthcare coverage through shared responsibility between government, Accountable care organization (ACO) A network of healthcare providers joined together for the purpose of increasing patient service quality and reducing costs.

individuals, and employers. This involves requiring all US citizens and legal residents to have health insurance coverage, which may be obtained through health insurance exchanges at an affordable cost if the individual does not have health insurance available from other sources.

Some of the benefits of the ACA include free preventive care, the banning of preexisting-condition coverage limitations, prescription discounts for seniors, extended coverage for young adults, lifetime coverage on most benefits, prevention of coverage cancellation by insurers, transparency on increases in insurance premium rates, and patient selection (rather than insurer assignment) of primary care doctors from the provider network.

The major implications of the ACA for health insurance are addressed in Chapter 2, while the major implications for the delivery of healthcare services, and hence healthcare finance, are discussed in the following sections.

Accountable Care Organizations One of the ways the ACA seeks to decrease healthcare costs and increase quality is by encouraging providers to form accountable care organizations (ACOs). An ACO is a network of physicians, other clinicians, and hospitals and clinics that shares responsibility for providing coordinated care to patients.

Providers in an ACO not only are jointly accountable for the health of their patients but also receive financial incentives to cooperate and reduce costs by avoiding unnecessary tests and procedures, eliminating duplication of services, and coordinating patient care.

An ACO can take one of many forms, such as the following:

An integrated delivery system that has common ownership of hospitals and physician practices and uses electronic health records, offers team- based care, and makes available resources to support cost-effective care A multispecialty group practice that has strong affiliations with hospitals and contracts with multiple health plans A physician hospital organization that is a subset of a hospital s medical staff and that functions like a multispecialty group practice An independent practice association composed of individual physician practices that come together to contract with health plans A virtual physician organization that sometimes includes physicians in rural areas ACOs are paid through the traditional fee-for-service system (see Chapter 2); however, they are offered bonuses as an incentive to reduce the cost of care.

Doctors and hospitals have to meet specific quality benchmarks that focus on prevention and careful management of patients with chronic diseases. In other words, providers get paid more for keeping patients healthy and out of the hospital. If an ACO is unable to save money, it could be liable for the costs of the investments made to improve care; it also may have to pay a penalty if it does not meet performance and cost-savings benchmarks.

Medical Homes A medical home (or patient-centered medical home) is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient s lifetime with the goal of maximizing health outcomes.

The medical home is responsible for providing all of a patient s healthcare needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illnesses, and assistance with end-of-life issues. It is a model of practice in which a team of healthcare professionals, coordinated by a personal physician, works collaboratively to ensure coordinated and integrated care, patient access and communication, quality, and safety. The medical home model is independent of the ACO concept, but it is anticipated that ACOs will provide an organizational setting that facilitates implementation of the model.

Supporters of the model claim that it will allow better access to healthcare, increase patient satisfaction, and improve health. Although the development and implementation of the medical home model is in its infancy, its key characteristics at this time are the following:

Personal physician. Each patient has an ongoing relationship with a personal physician trained to provide first-contact, continuous, and comprehensive care.

Whole-person orientation. The personal physician is responsible for providing all of a patient s healthcare needs or for appropriately arranging care with other qualified professionals. In effect, the personal physician leads a team of clinicians who collectively take responsibility for patient care.

Coordination and integration. The personal physician coordinates care across specialists, hospitals, home health agencies, nursing homes, and hospices.

Quality and safety. Quality and patient safety are ensured by a care- planning process, evidence-based medicine, clinical decision support tools, performance measurement, active participation of patients in decision making, use of information technology, and quality improvement activities.

Enhanced access. Medical care and information are available at all times through open scheduling, expanded hours of service, and new and innovative communications technologies.

Payment-for-value methodologies. It is essential that payment methodologies recognize the added value provided to patients.

Payments should reflect the value of work that falls outside of Medical home A team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient s lifetime with a goal of maximizing health outcomes.

Population health management The concept that the health of all individuals is improved when the health of the entire population is improved.

face-to-face visits, should support adoption and use of health information technology for quality improvement, and should recognize differences in the patient populations treated within the practice.

Industry Consolidation The ACA is driving the consolidation of healthcare organizations. It has accelerated health systems acquisition of hospitals and hospitals acquisition of physician practices, and that trend is likely to continue for many years. With the greater focus on clinical integration, quality of care, and changing reimbursement methodologies, healthcare organizations are seeking to restructure healthcare delivery to operate more efficiently and improve coordination between patients and providers. Healthcare organizations are looking to gain a competitive advantage from combining assets, staff, and resources. Consolidation not only provides organizations access to capital, economies of scale, and market share but also may lead to improvement in patient care by making it easier to share patient information, adhere to clinical practice guidelines (thus reducing variations in care), and access high-quality specialist physicians.

Population Health The ACA is moving providers toward the population health management approach to care provision. The goal of population health management is to shift from focusing on treating illness to maintaining or improving health. The idea is to prevent costly illnesses when possible and hence avoid unnecessary care, which is encouraged by reimbursement models such as capitation, payment bundling, and shared savings (discussed in Chapter 2). Instead of just providing preventive and chronic care when patients come in for acute problems, ACOs track and monitor the health status of the entire patient population, requiring greater use of health information technology. The keys to success in population health management are greater awareness of the health status of the population and proactive intervention to reduce the use of provider resources and to achieve the best population outcomes.

Clinical Integration A fundamental component to achieving the goals of the ACA is clinical integration.

Clinical integration aims to coordinate patient care across conditions, providers, settings, and time to achieve care that is safe, timely, effective, efficient, and patient focused. New payment models and advances in health information systems are used to facilitate the transition to the clinical integration model and to manage the continuum of care for patients. Provider payments are tied to results for quality, access, and efficiency with the objective of establishing coordination between hospitals and physicians. Health information technology aims to capture patient information and make it accessible to authorized providers at the point of care. Complete patient information facilitates optimal treatment strategies and reduces the chance of medication errors and conflicting treatment plans. There will be requirements for new and more comprehensive policies and procedures that protect patient privacy and that guarantee the security of data that are transferred between patients, caregivers, and organizations.

Data Analytics The emergence of ACOs and an increased emphasis on collaboration between clinicians and on quality patient care are making it necessary for healthcare organizations to invest in integrated information systems technology to collect large quantities of patient and provider data (so-called big data). Data analytic systems are capable of analyzing large amounts of patient data to better understand clinical processes and to identify problems and opportunities for improvement in the provision of healthcare services. New, complex information technology will facilitate analysis of care coordination, patient safety, and utilization of healthcare services.

Staffing Shortages The ACA is expected to increase the number of patients who can access the healthcare system. Healthcare organizations will see an influx of formerly uninsured patients now seeking care because they have insurance or better coverage. As a result, the demand for healthcare professionals especially physicians, nurse practitioners, and physician assistants will likely increase.

The ACA is also driving changes in hospital staffing by emphasizing prevention and value-based care, creating demand for primary care providers, emergency physicians, clinical pharmacists, and health information technology and data specialists. Some professional and industry associations are predicting that current shortages of various healthcare staff will worsen in the face of this growing demand. The ACA has identified several strategies to increase the supply of health professionals (including primary care physicians), such as scholarships and flexible loan repayment programs to help fund their education.

However, many healthcare organizations likely will face great competition for some healthcare staff.

SELF-TEST QUESTIONS 1. What is the primary purpose of healthcare reform?

2. Will reform have a greater impact on insurers or providers?

3. What is an accountable care organization (ACO), and what is it designed to accomplish?

4. What is the medical home model, and what is its purpose?

Key Concepts This chapter provided an introduction to healthcare finance. The key concepts of this chapter are as follows:

The term healthcare finance, as it is used in this book, means the accounting and financial management principles and practices used within health services organizations to ensure the financial wellbeing of the enterprise.

A business maintains its financial viability by selling goods or services, while a pure charity relies solely on contributions.

The primary role of finance in health services organizations, as in all businesses, is to plan for, acquire, and use resources to maximize the efficiency and value of the enterprise.

Finance activities generally include (1) planning and budgeting, (2) financial reporting, (3) capital investment decisions, (4) financing decisions, (5) revenue cycle and current accounts management, (6) contract management, and (7) financial risk management. These activities can be summarized by the four Cs: costs, cash, capital, and control.

The size and structure of the finance department within a health services organization depend on the type of provider and its size. Still, the finance department within a larger provider organization generally consists of a chief financial officer (CFO), who typically reports directly to the chief executive officer (CEO) and is responsible for all finance activities within the organization.

Reporting to the CFO are the comptroller, who is responsible for accounting and reporting activities, and the treasurer, who is responsible for the acquisition and management of capital (funds).

In larger organizations, the comptroller and treasurer direct managers who have responsibility for specific functions, such as the patient accounts manager, who reports to the comptroller, and the cash manager, who reports to the treasurer.

In small health services organizations, the finance responsibilities are combined and assigned to one individual, often called the business (practice) manager.

All business decisions have financial implications, so all managers whether in operations, marketing, personnel, or facilities must know enough about finance to incorporate those implications into their own specialized decision-making processes.

Healthcare services are provided in numerous settings, including hospitals, ambulatory care facilities, long-term care facilities, and even at home.

Recent surveys of health services executives confirm the fact that healthcare managers view financial concerns as the most important current issue they face.

The three main forms of business organization are proprietorship, partnership, and corporation. Although each form of organization has its own unique advantages and disadvantages, most large organizations, and all not-for-profit entities, are organized as corporations.

Investor-owned corporations have stockholders who are the owners of the corporation. As owners, stockholders have claim on the residual earnings of the corporation. Investor-owned corporations are fully taxable.

Charitable organizations that meet certain criteria can be organized as not-for-profit corporations. Rather than having a well- defined set of owners, such organizations have a large number of stakeholders who have an interest in the organization. Not-forprofit corporations do not pay taxes; they can accept tax-deductible contributions, and they can issue tax-exempt debt.

In lieu of tax filings, not-for-profit corporations must file Form 990, which reports on an organization s governance structure and community benefit services, with the Internal Revenue Service.

From a financial management perspective, the primary goal of investor-owned corporations is shareholder wealth maximization, which translates to stock price maximization. For not-for-profit corporations, a reasonable goal for financial management is to ensure that the organization can fulfill its mission, which translates to maintaining financial viability.

Healthcare reform is federal legislation that was signed into law in 2010 and is expected to have a significant impact on health insurers and providers.

Accountable care organizations (ACOs) are a method of integrating local physicians with other members of the healthcare community and rewarding them for controlling costs and improving quality.

A medical home (or patient-centered medical home) is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient s lifetime to maximize health outcomes.

In the next chapter, we continue the discussion of the healthcare environment, with emphasis on health insurance and reimbursement methodologies.

Questions and Problems 1.1 Briefly describe the purpose and organization of this book and the learning tools embedded in each chapter.

1.2 a. What are some of the industries in the healthcare sector?

b. What is meant by the term healthcare finance as used in this book?

c. What are the two broad areas of healthcare finance?

d. Why is it necessary to have a book on healthcare finance as opposed to a generic finance book?

1.3 What is the difference between a business and a pure charity?

1.4 a. Briefly discuss the role of finance in the health services industry.

b. Has this role increased or decreased in importance in recent years?

1.5 What is the structure of the finance department within health services organizations?

1.6 a. (Hint: the material reviewed in this question is covered in the Chapter Supplement.) Briefly describe the following health services settings:

Hospitals Ambulatory care Home health care Long-term care Integrated delivery systems b. What are the benefits attributed to integrated delivery systems?

1.7 What are the major current concerns of healthcare managers?

1.8 What are the three primary forms of business organization? Describe their advantages and disadvantages.

1.9 What are the primary differences between investor-owned and not- for-profit corporations?

1.10 a. What is the primary goal of investor-owned corporations?

b. What is the primary goal of most not-for-profit healthcare corporations?

c. Are there substantial differences between the finance goals of investor-owned and not-for-profit corporations? Explain.

1.11 Briefly describe the main provisions of healthcare reform and its implications for the practice of healthcare finance.

1.12 Describe the primary features of accountable care organizations (ACOs) and medical homes. What benefits are attributed to them?

Resources For a general introduction to the healthcare system in the United States, see Barton, P. L. 2010. Understanding the U.S. Health Services System. Chicago: Health Administration Press.

Shi, L., and D. A. Singh. 2013. Essentials of the U.S. Health Care System. Burlington, MA: Jones and Bartlett Learning.

For the latest information on events that affect health services organizations, see Modern Healthcare, published weekly by Crain Communications Inc., Chicago.

For ideas on the future of healthcare in the United States and other information pertinent to this chapter, see Bisognano, M. 2011. Finance is Key to Achieving Quality and Cost Goals. Healthcare Financial Management (April): 68 71.

Giniat, E. J. 2009. Finance Needs to Sit at the Head Table. Healthcare Financial Management (May): 80 82.

Kim, C., D. Majka, and J. H. Sussman. 2011. Modeling the Impact of Healthcare Reform. Healthcare Financial Management (January): 51 60.

Lee, J. G., G. Dayal, and D. Fontaine. 2011. Starting a Medical Home: Better Health at Lower Cost. Healthcare Financial Management (June): 71 80.

Mulvany, C. 2011. Medicare ACOs No Longer Mythical Creatures. Healthcare Financial Management (June): 96 104.

Nguyen, J., and B. Choi. 2011. Accountable Care: Are You Ready? Healthcare Financial Management (August): 92 100.

Reynolds, M. 2011. Managing the Risks of Accountable Care. Healthcare Financial Management (July): 49 56.

Selvam, A. 2013. Reform Unease Fading Among CEOs: But Financial Challenges Remain Top Concern in ACHE s Annual Survey. Modern Healthcare (January 14): 22 23.

Smith, P. C., and K. Noe. 2012. New Requirements for Hospitals to Maintain Tax- Exempt Status. Journal of Health Care Finance (Spring): 16 21.

Song, P. H., S. D. Lee, J. A. Alexander, and E. E. Seiber. 2013. Hospital Ownership and Community Benefit: Looking Beyond Uncompensated Care. Journal of Healthcare Management (March/April): 126 42.

For current information on how the Internet affects health and the provision of health services, see Journal of Medical Internet Research,

1 HEALTH SERVICES SETTINGS Introduction Health services are provided in numerous settings, including hospitals, ambulatory care facilities, long-term care facilities, and even at home. Before the 1980s, most health services organizations were freestanding and not formally linked with other organizations. Those that were linked tended to be part of horizontally integrated systems that controlled a single type of healthcare facility, such as hospitals or nursing homes. Recently, however, many health services organizations have diversified and become vertically integrated either through direct ownership or contractual arrangements.

Settings Hospitals Hospitals provide diagnostic and therapeutic services to individuals who require more than several hours of care, although most hospitals are actively engaged in ambulatory (walk-in) services as well. To ensure a minimum standard of safety and quality, hospitals must be licensed by the state and undergo inspections for compliance with state regulations. In addition, most hospitals are accredited by The Joint Commission. Joint Commission accreditation is a voluntary process that is intended to promote high standards of care. Although the cost to achieve and maintain compliance with Joint Commission standards can be substantial, accreditation provides eligibility for participation in the Medicare program, and hence most hospitals seek accreditation.

Recent environmental and operational changes have created significant challenges for hospital managers. For example, many hospitals are experiencing decreasing admission rates and shorter lengths of stay, which result in excess capacity. At the same time, hospitals have been pressured to give discounts to private third-party payers, governmental payments have failed to keep up with the cost of providing services, and indigent care and bad debt losses have increased. Because of the changing payer environment and resultant cost containment pressures, the number of hospitals (and beds) has declined in recent years.

Hospitals differ in function, average length of patient stay, size, and ownership. These factors affect the type and quantity of assets, services offered, and management requirements and often determine the type and level of reimbursement. Hospitals are classified as either general acute care facilities or specialty facilities. General acute care hospitals, which provide general medical and surgical services and selected acute specialty services, are short-stay facilities and account for the majority of hospitals. Specialty hospitals, such as psychiatric, children s, women s, rehabilitation, and cancer facilities, limit admission of patients to specific ages, sexes, illnesses, or conditions. The number of specialty hospitals has grown significantly in the past few decades because of the increased need for such services.

Hospitals vary in size, from fewer than 25 beds to more than 1,000 beds; general acute care hospitals tend to be larger than specialty hospitals.

Small hospitals, those with fewer than 100 beds, usually are located in rural areas. Many rural hospitals have experienced financial difficulties in recent years because they have less ability than larger hospitals to lower costs in response to ever-tighter reimbursement rates. Most of the largest hospitals are academic health centers or teaching hospitals, which offer a wide range of services, including tertiary services. (Tertiary care is highly specialized and technical in nature, with services for patients with unusually severe, complex, or uncommon problems.) Hospitals are classified by ownership as private not-for-profit, investor owned, and governmental. Governmental hospitals, which make up 25 percent of all hospitals, are broken down into federal and public (nonfederal) entities.

Federal hospitals, such as those operated by the military services or the US Department of Veterans Affairs, serve special populations.

Public hospitals are funded wholly or in part by a city, county, tax district, or state. In general, federal and public hospitals provide substantial services to indigent patients. In recent years, many public hospitals have converted to other ownership categories primarily private not-for-profit because local governments have found it increasingly difficult to fund healthcare services and still provide other necessary public services. In addition, the inability of politically governed organizations to respond quickly to the changing healthcare environment has contributed to many conversions as managers try to create organizations that are more responsive to external change.

Private not-for-profit hospitals are nongovernmental entities organized for the sole purpose of providing inpatient healthcare services. Because of the charitable origins of US hospitals and a tradition of community service, roughly 80 percent of all private hospitals (60 percent of all hospitals) are not-for-profit entities. In return for serving a charitable purpose, these hospitals receive numerous benefits, including exemption from federal and state income taxes, exemption from property and sales taxes, eligibility to receive tax-deductible charitable contributions, favorable postal rates, favorable tax-exempt financing, and tax-favored annuities for employees.

Chapter 1 Supplement Chapter 1 Supplement Chapter 1 Supplement The remaining 20 percent of private hospitals (15 percent of all hospitals) are investor owned. This means that they have owners (typically shareholders) that benefit directly from the profits generated by the business. Historically, most investor-owned hospitals were owned by physicians, but now most are owned by large corporations such as HCA, which owns about 160 hospitals; Community Health Systems, which owns about 130 hospitals; and Tenet Healthcare, which owns about 80 hospitals.

Unlike not-for-profit hospitals, investor-owned hospitals pay taxes and forgo the other benefits of not-for-profit status. However, investor-owned hospitals typically do not embrace the charitable mission of not-for-profit hospitals. Despite the expressed differences in mission between investor-owned and not-for-profit hospitals, not-for-profit hospitals are being forced to place greater emphasis on the financial implications of operating decisions than in the past. This trend has raised concerns in some quarters that many not-for-profit hospitals are now failing to meet their charitable mission. As this perception grows, some people argue that these hospitals should lose some, if not all, of the benefits associated with their not-for-profit status.

Hospitals are labor intensive because of their need to provide continuous nursing supervision to patients, in addition to the other services they provide through professional and semiprofessional staffs. Physicians petition for privileges to practice in hospitals. While they admit and provide care to hospitalized patients, physicians, for the most part, are not hospital employees and hence are not directly accountable to hospital management. However, physicians retain a major responsibility for determining which hospital services are provided to patients and how long patients are hospitalized, so physicians play a critical role in determining a hospital s costs and revenues and hence its financial condition.

Ambulatory (Outpatient) Care Ambulatory care, also known as outpatient care, encompasses services provided to noninstitutionalized patients. Traditional outpatient settings include medical practices, hospital outpatient departments, and emergency departments. In addition, the 1980s and early 1990s witnessed substantial growth in nontraditional ambulatory care settings such as home health care, ambulatory surgery centers, urgent care centers, diagnostic imaging centers, rehabilitation/sports medicine centers, and clinical laboratories. In general, the new settings offer patients increased amenities and convenience compared with hospital-based services and, in many situations, provide services at a lower cost than hospitals do. For example, urgent care and ambulatory surgery centers are typically less expensive than their hospital counterparts because hospitals have higher overhead costs.

Many factors have contributed to the expansion of ambulatory services, but technology has been a leading factor. Often, patients who once required hospitalization because of the complexity, intensity, invasiveness, or risk associated with certain procedures can now be treated in outpatient settings. In addition, third-party payers have encouraged providers to expand their outpatient services through mandatory authorization for inpatient services and by payment mechanisms that provide incentives to perform services on an outpatient basis. Finally, fewer entry barriers to developing outpatient services relative to institutional care exist. Ordinarily, ambulatory facilities are less costly and less often subject to licensure and certificate-of-need regulations (exceptions are hospital outpatient units and ambulatory surgery centers).

As outpatient care consumes an increasing portion of the healthcare dollar and as efforts to control outpatient spending are enhanced, the traditional role of the ambulatory care manager is changing. Ambulatory care managers historically have focused on such routine management tasks as billing, collections, staffing, scheduling, and patient relations, while the owners, often physicians, have tended to make the more important business decisions.

However, reimbursement changes and increased affiliations with insurers and other providers are requiring a higher level of management expertise. This increasing environmental complexity, along with increasing competition, is forcing managers of ambulatory care facilities to become more sophisticated in making business decisions, including finance decisions.

Long-Term Care Long-term care entails the provision of healthcare services, as well as some personal services, to individuals who lack some degree of functional ability.

It usually covers an extended period of time and includes both inpatient and outpatient services, which often focus on mental health, rehabilitation, and nursing home care. Although the greatest use is among the elderly, long-term care services are used by individuals of all ages.

Long-term care is concerned with levels of independent functioning, specifically activities of daily living such as eating, bathing, and locomotion.

Individuals become candidates for long-term care when they become too mentally or physically incapacitated to perform necessary tasks and when their family members are unable to provide needed services. Long-term care is a hybrid of healthcare services and social services; nursing homes are a major source of such care.

Three levels of nursing home care exist: (1) skilled nursing facilities, (2) intermediate care facilities, and (3) residential care facilities. Skilled nursing facilities (SNFs) provide the level of care closest to hospital care. Services must be provided under the supervision of a physician and must include 24-hour daily nursing care. Intermediate care facilities (ICFs) are intended for individuals who do not require hospital or SNF care but whose mental or physical conditions require daily continuity of one or more medical services. Residential care facilities are sheltered environments that do not provide professional Chapter 1 Supplement Chapter 1 Supplement Chapter 1 Supplement healthcare services and thus for which most health insurance programs do not provide coverage.

Nursing homes are more abundant than hospitals and are smaller, with an average bed size of about 100 beds, compared with about 170 beds for hospitals. Nursing homes are licensed by states, and nursing home administrators are licensed as well. Although The Joint Commission accredits nursing homes, only a small percentage participate because accreditation is not required for reimbursement and the standards to achieve accreditation are much higher than they are for licensure requirements.

The long-term care industry has experienced tremendous growth in the past 50 years. Long-term care accounted for only 1 percent of healthcare expenditures in 1960, but by 2010 it accounted for about 6 percent of expenditures.

Further demand increases are anticipated, as the percentage of the US population aged 65 or older increases, from less than 15 percent in 2013 to a forecasted 20 percent in 2030. The elderly are disproportionately high users of healthcare services and are major users of long-term care.

Although long-term care is often perceived as nursing home care, many new services are being developed to meet society s needs in less institutional surroundings, such as adult day care, life care centers, and hospice programs.

These services tend to offer a higher quality of life, although they are not necessarily less expensive than institutional care. Home health care, provided for an extended time period, can be an alternative to nursing home care for many patients, but it is not as readily available as nursing home care in many rural areas. Furthermore, third-party payers, especially Medicare, have sent mixed signals about their willingness to adequately pay for home health care.

In fact, many home health care businesses have been forced to close in recent years as a result of a new, less generous Medicare payment system.

Integrated Delivery Systems Many healthcare experts have extolled the benefits of providing hospital care, ambulatory care, long-term care, and business support services through a single entity called an integrated delivery system. The hypothesized benefits of such systems include the following:

Patients are kept in the corporate network of services (patient capture).

Providers have access to managerial and functional specialists (e.g., reimbursement and marketing professionals).

Information systems that track all aspects of patient care, as well as insurance and other data, can be developed more easily, and the costs to develop them are shared.

Linked organizations have better access to capital.

The ability to recruit and retain management and professional staff is enhanced.

Integrated delivery systems are able to offer payers a complete package of services ( one-stop shopping ).

Integrated delivery systems are better able to plan for and deliver a full range of healthcare services to meet the needs of a defined population, including chronic disease management and health improvement programs. Many of these population-based efforts typically are not offered by stand-alone providers.

Incentives can be created that encourage all providers in the system to work together for the common good of the system, which has the potential to improve quality and control costs.

Although integrated delivery systems can be structured in many different ways, the defining characteristic of such systems is that the organization has the ability to assume full clinical responsibility for the healthcare needs of a defined population. Because of current state laws, which typically mandate that the insurance function be assumed only by licensed insurers, integrated delivery systems typically contract with insurers rather than directly with employers.

Sometimes, the insurer, often a managed care plan, is owned by the integrated delivery system itself, but generally it is separately owned. In contracts with managed care plans, the integrated delivery system often receives a fixed payment per plan member and hence assumes both the financial and clinical risks associated with providing healthcare services.

To be an effective competitor, integrated delivery systems must minimize the provision of unnecessary services because additional services create added costs but do not necessarily result in additional revenues. Thus, the objective of integrated delivery systems is to provide all needed services to its member population in the lowest-cost setting. To achieve this goal, integrated delivery systems invest heavily in primary care services, especially prevention, early intervention, and wellness programs. The primary care gatekeeper concept is frequently used to control utilization and hence costs. While hospitals continue to be centers of technology, integrated delivery systems have the incentive to shift patients toward lower-cost settings. Thus, clinical integration among the various providers and components of care is essential to achieving quality, cost efficiency, and patient satisfaction.

1. What are some different types of hospitals, and what trends are occurring in the hospital industry?

2. What trends are occurring in outpatient and long-term care?

3. What is an integrated delivery system?

4. Do you think that integrated delivery systems will be more or less prevalent in the future? Explain your answer.

SELF-TEST QUESTIONS Chapter 1 Supplement HEALTHCARE INSURANCE AND 2 REIMBURSEMENT METHODOLOGIES Learning Objectives After studying this chapter, readers will be able to Explain the overall concept of insurance, including adverse selection and moral hazard.

Briefly describe the third-party payer system.

Explain the different types of generic payment methods.

Describe the incentives created by the different payment methods and their impact on provider risk.

Describe the purpose and organization of managed care plans.

Explain the impact of healthcare reform on insurance and reimbursement methodologies.

Explain the importance and types of medical coding.

Introduction For the most part, the provision of healthcare services takes place in a unique way. First, often only a few providers of a particular service exist in a given area. Next, it is difficult, if not impossible, to judge the quality of competing services. Then, the decision about which services to purchase is usually not made by the consumer but by a physician or some other clinician. Also, full payment to the provider is not normally made by the user of the services but by a healthcare insurer. Finally, for most individuals, health insurance from third-party payers is totally paid for or heavily subsidized by employers or government agencies, so many patients are partially insulated from the costs of healthcare.

This highly unusual marketplace for healthcare services has a profound effect on the supply of, and demand for, such services. In this chapter, we discuss the concept of insurance, the major providers of healthcare insurance, and the methods used by insurers to pay for health services.

Insurance Concepts Healthcare services are supported by an insurance system composed of a wide variety of insurers of all types and sizes. Some are investor owned, while others are not-for-profit or government sponsored. Some insurers require their policyholders, who may or may not be the beneficiaries of the insurance, to make the policy payments, while other insurers collect partial or total payments from society at large. Because insurance is the cornerstone of the healthcare system, an appreciation of the nature of insurance will help you better understand the marketplace for healthcare services.

A Simple Illustration To better understand insurance concepts, consider a simple example. Assume that no health insurance exists and you face only two medical outcomes in the coming year:

Outcome Probability Cost Stay healthy 0.99 $ 0 Get sick 0.01 20,000 Furthermore, assume that everyone else faces the same medical outcomes at the same odds and with the same associated costs. What is your expected healthcare cost E(Cost) for the coming year? To find the answer, we multiply the cost of each outcome by its probability of occurrence and then sum the products:

E(Cost) = (Probability of outcome 1 . Cost of outcome 1) + (Probability of outcome 2 . Cost of outcome 2) = (0.99 . $0) + (0.01 . $20,000) = $0 + $200 = $200.

Now, assume that you, and everyone else, make $20,000 a year. With this salary, you can easily afford the $200 expected healthcare cost. The problem is, however, that no one s actual bill will be $200. If you stay healthy, your bill will be zero, but if you are unlucky and get sick, your bill will be $20,000. This cost will force you, and most people who get sick, into personal bankruptcy.

Next, suppose an insurance policy that pays all of your healthcare costs for the coming year is available for $250. Would you purchase the policy, even though it costs $50 more than your expected healthcare costs? Most people would. In general, individuals are risk averse, so they would be willing to pay a $50 premium over their expected costs to eliminate the risk of financial ruin. In effect, policyholders are passing to the insurer the costs associated with the risk of getting sick.

Would an insurer be willing to offer the policy for $250? If an insurance company sells a million policies, its expected total policy payout is 1 million times the expected payout for each policy, or 1 million . $200 = $200 million.

If there were no uncertainty about the $20,000 estimated medical cost per claim, the insurer could forecast its total claims precisely. It would collect 1 million . $250 = $250 million in health insurance premiums; pay out roughly $200 million in claims; and hence have about $50 million to cover administrative costs, create a reserve in case realized claims are greater than predicted by its actuaries, and make a profit.

Basic Characteristics of Insurance The simple example of health insurance we just provided illustrates why individuals would seek health insurance and why insurance companies would be formed to provide such insurance. Needless to say, the concept of insurance becomes much more complicated in the real world. Insurance is typically defined as having four distinct characteristics:

1. Pooling of losses. The pooling, or sharing, of losses is the heart of insurance. Pooling means that losses are spread over a large group of individuals so that each individual realizes the average loss of the pool (plus administrative expenses) rather than the actual loss incurred.

In addition, pooling involves the grouping of a large number of homogeneous exposure units people or things having the same risk characteristics so that the law of large numbers can apply. (In statistics, the law of large numbers states that as the size of the sample increases, the sample mean gets closer and closer to the population mean.) Thus, pooling implies (1) the sharing of losses by the entire group and (2) the prediction of future losses with some accuracy.

2. Payment only for random losses. A random loss is one that is unforeseen and unexpected and occurs as a result of chance. Insurance is based on the premise that payments are made only for losses that are random. We discuss the moral hazard problem, which concerns losses that are not random, in a later section.

3. Risk transfer. An insurance plan almost always involves risk transfer.

The sole exception to the element of risk transfer is self-insurance, which is the assumption of a risk by a business (or an individual) itself rather than by an insurance company. (Self-insurance is discussed in a later section.) Risk transfer is transfer of a risk from an insured to an insurer, which typically is in a better financial position to bear the risk than the insured because of the law of large numbers.

Adverse selection The problem faced by insurance companies because individuals who are more likely to have claims are also more likely to purchase insurance.

Moral hazard The problem faced by insurance companies because individuals are more likely to use unneeded health services when they are not paying the full cost of those services.

4. Indemnification. The final characteristic of insurance is indemnification for losses that is, reimbursement to the insured if a loss occurs. In the context of health insurance, indemnification takes place when the insurer pays the insured, or the provider, in whole or in part for the expenses related to an insured s illness or injury.

Adverse Selection One of the major problems facing healthcare insurers is adverse selection.

Adverse selection occurs because individuals and businesses that are more likely to have claims are more inclined to purchase insurance than those that are less likely to have claims. For example, an individual without insurance who needs a costly surgical procedure will likely seek health insurance if she can afford it, whereas an individual who does not need surgery is much less likely to purchase insurance. Similarly, consider the likelihood of a 20-year-old to seek health insurance versus the likelihood of a 60-year-old to do so. The older individual, with much greater health risk due to age, is more likely to seek insurance.

If this tendency toward adverse selection goes unchecked, a disproportionate number of sick people, or those most likely to become sick, will seek health insurance, and the insurer will experience higher-than-expected claims.

This increase in claims will trigger a premium increase, which only worsens the problem, because the healthier members of the plan will seek insurance from other firms at a lower cost or may totally forgo insurance. The adverse- selection problem exists because of asymmetric information, which occurs when individual buyers of health insurance know more about their health status than do insurers.

In today s world of health reform, ushered in by the Patient Protection and Affordable Care Act (ACA; introduced in Chapter 1), which requires insurers to take on patients regardless of preexisting conditions, the best strategy for healthcare insurers to combat adverse selection is to create a large, well- diversified pool of subscribers. If the pool is sufficiently large and diversified, the costs of adverse selection can be absorbed by the large number of enrollees.

Moral Hazard Insurance is based on the premise that payments are made only for random losses, and from this premise stems the problem of moral hazard. The most common case of moral hazard in a casualty insurance setting is the owner who deliberately sets a failing business on fire to collect the insurance. Moral hazard is also present in health insurance, but it typically takes a less dramatic form; few people are willing to voluntarily sustain injury or illness for the purpose of collecting health insurance. However, undoubtedly there are people who purposely use healthcare services that are not medically required. For example, some people might visit a physician or a walk-in clinic for the social value of human companionship rather than to address a medical necessity. Also, some hospital discharges might be delayed for the convenience of the patient rather than for medical purposes.

Finally, when insurance covers the full cost or most of the cost of healthcare services, individuals often are quick to agree to an expensive MRI (magnetic resonance imaging) scan or other high-cost procedure that may not be necessary. If the same test required total out-of-pocket payment, individuals would think twice before agreeing to such an expensive procedure unless they clearly understood the medical necessity involved.

All in all, when somebody else is paying the costs, patients consume more healthcare services.

Even more insidious is the impact of insurance on individual behavior. Individuals are more likely to forgo preventive actions and embrace unhealthy behaviors when the costs of not taking those actions will be borne by insurers. Why stop smoking if the monetary costs associated with cancer treatment are carried by the insurer? Why lose weight if others will pay for the adverse health consequences likely to result?

The primary weapon that insurers have against the moral hazard problem is coinsurance, which requires insured individuals to pay a certain percentage of eligible medical expenses say, 20 percent in excess of the deductible amount. (Insurers also use copayments, which are similar to coinsurance but are expressed as a dollar amount: $20 per primary care visit, for example.) To illustrate coinsurance, assume that George Maynard, who has employer- provided medical insurance that pays 80 percent of eligible expenses after the $100 deductible is satisfied, incurs $10,000 in medical expenses during the year. The insurer will pay 0.80 . ($10,000 . $100) = 0.80 . $9,900 = $7,920, so George s responsibility is $10,000 . $7,920 = $2,080.

The purposes of coinsurance and copayments are to reduce premiums to employers For Your Consideration Who Should Pay for Health Services?

Users or Insurers?

One of the most confounding questions that arises when discussing healthcare services is who should bear the responsibility for payment.

Should the patient be responsible, or should some third party such as the government or an insurance company foot the bill?

Many people argue that when individuals bear the cost of their own healthcare, they will be responsible consumers and only pay for necessary services. In addition, they will choose providers on the basis of cost and quality and hence create the incentive for providers to offer better yet less expensive services. It is estimated that this action alone would reduce total healthcare costs in the United States by some 20 30 percent, or even more.

Other people argue that individuals cannot make rational decisions regarding their own healthcare because they do not sufficiently understand the nature of illness and injury. Furthermore, there is insufficient information about provider quality and costs available to guide individuals to good decisions. Finally, individuals would skimp on routine preventive healthcare services to save money, which would create healthcare problems down the road and ultimately lead to higher future costs.

What do you think? Should individuals be held more responsible for their own costs of healthcare services? What about the arguments stated above? Is there some way of balancing the need for more consumerism in healthcare service purchases with the need to protect individuals against the very high costs of many services?

SELF-TEST QUESTIONS Third-party payer A generic term for any outside party, typically an insurance company or a government program, that pays for part or all of a patient s healthcare services.

and to prevent overutilization of healthcare services. Because insured individuals pay part of the cost, premiums can be reduced. Additionally, by being forced to pay some of the costs, insured individuals will presumably seek fewer and more cost-effective treatments and embrace a healthier lifestyle.

1. Briefly explain the following characteristics of insurance:

a. Pooling of losses b. Payment only for random losses c. Risk transfer d. Indemnification 2. What is adverse selection, and how do insurers deal with the problem?

3. What is the moral hazard problem, and how do insurers mitigate the problem?

Third-Party Payers Up to this point in the chapter, we have focused on basic insurance concepts because a large proportion of the health services industry receives its revenues not directly from the users of their services the patients but from insurers known collectively as third-party payers. Because an organization s revenues are critical to its financial viability, this section contains a brief examination of the sources of most revenues in the health services industry. In the next section, the reimbursement methodologies employed by these payers are reviewed in more detail.

Health insurance originated in Europe in the early 1800s when mutual benefit societies were formed to reduce the financial burden associated with illness or injury. Since then, the concept of health insurance has changed dramatically. Today, health insurers fall into two broad categories: private insurers and public programs.

Private Insurers In the United States, the concept of public, or government, health insurance is relatively new, while private health insurance has been in existence since the early 1900s. In this section, the major private insurers are discussed: Blue Cross/Blue Shield, commercial insurers, and self-insurers.

Blue Cross/Blue Shield Blue Cross/Blue Shield organizations trace their roots to the Great Depression, when both hospitals and physicians were concerned about their patients ability to pay healthcare bills. One example is Florida Blue (formerly Blue Cross and Blue Shield of Florida), which offers healthcare insurance to individuals and families, Medicare beneficiaries, and business groups that reside in Florida.

Blue Cross originated as a number of separate insurance programs offered by individual hospitals. At that time, many patients were unable to pay their hospital bills, but most people, except the poorest, could afford to purchase some type of hospitalization insurance. Thus, the programs were initially designed to benefit hospitals as well as patients. The programs were all similar in structure: Hospitals agreed to provide a certain amount of services to program members who made periodic payments of fixed amounts to the hospitals whether services were used or not. In a short time, these programs were expanded from single hospital programs to community-wide, multihospital plans that were called hospital service plans. The Blue Cross name was officially adopted by most of these plans in 1939.

Blue Shield plans developed in a manner similar to Blue Cross plans, except that the providers were physicians instead of hospitals. Today, there are 37 Blue Cross/Blue Shield ( the Blues ) organizations. Some offer only one of the two plans, but most offer both plans. The Blues are organized as independent corporations, including some for-profit entities, but all belong to a single national association that sets standards that must be met to use the Blue Cross/Blue Shield name. Collectively, the Blues provide healthcare coverage for more than 100 million individuals in all 50 states, the District of Columbia, and Puerto Rico.

Commercial Insurers Commercial health insurance is issued by life insurance companies, by casualty insurance companies, and by companies that were formed exclusively to offer healthcare insurance. Examples of commercial insurers include Aetna, Humana, and UnitedHealth Group. All commercial insurance companies are taxable (for-profit) entities. Commercial insurers moved strongly into health insurance following World War II. At that time, the United Auto Workers negotiated the first contract with employers in which fringe benefits were a major part of the contract. Like the Blues, the majority of individuals with commercial health insurance are covered under group policies with employee groups, professional and other associations, and labor unions.

Self-Insurers The third major form of private insurance is self-insurance. Although it might seem as if all individuals who do not have some form of health insurance are self-insurers, this is not the case. Self-insurers make a conscious decision to bear the risks associated with healthcare costs and then set aside (or have available) funds to pay future costs as they occur. Individuals, except the very Medicare A federal government health insurance program that primarily provides benefits to individuals aged 65 or older.

wealthy, are not good candidates for self-insurance because they face too much uncertainty concerning healthcare expenses. On the other hand, large groups, especially employers, are good candidates for self-insurance. Today, most large groups are self-insured. For example, employees of the State of Florida are covered by health insurance, the costs of which are paid directly by the state.

Florida Blue is paid a fee to administer the plan, but the state bears all risks associated with cost and utilization uncertainty.

Public Insurers Government is a major insurer as well as a direct provider of healthcare services.

For example, the federal government provides healthcare services directly to qualifying individuals through the medical facilities of the US Department of Veterans Affairs; the US Department of Defense and its TRICARE program (health insurance for uniformed service members and their families); and the Public Health Service, part of the US Department of Health and Human Services (HHS). In addition, government either provides or mandates a variety of insurance programs, such as workers compensation. In this section, however, the focus is on the two major government insurance programs: Medicare and Medicaid.

Medicare Medicare was established by Congress in 1965 primarily to provide medical benefits to individuals aged 65 or older. About 50 million people have Medicare coverage, which pays for about 17 percent of all US healthcare services.

Over the decades, Medicare has evolved to include four major coverages:

(1) Part A, which provides hospital and some skilled nursing facility coverage; (2) Part B, which covers physician services, ambulatory surgical services, outpatient services, and other miscellaneous services; (3) Part C, which is managed care coverage offered by private insurance companies and can be selected in lieu of Parts A and B; and (4) Part D, which covers prescription drugs. In addition, Medicare covers healthcare costs associated with selected disabilities and illnesses, such as kidney failure, regardless of age.

Part A coverage is free to all individuals eligible for Social Security benefits.

Individuals who are not eligible for Social Security benefits can obtain Part A medical benefits by paying monthly premiums. Part B is optional to all individuals who have Part A coverage, and it requires a monthly premium from enrollees that varies with income level. About 97 percent of Part A participants purchase Part B coverage, while about 20 percent of Medicare enrollees elect to participate in Part C, also called Medicare Advantage Plans, rather than Parts A and B. Part D offers prescription drug coverage through plans offered by private companies. Each Part D plan offers somewhat different coverage, so the cost of Part D coverage varies widely.

The Medicare program falls under HHS, which creates the specific rules of the program on the basis of enabling legislation. Medicare is administered by an agency in HHS called the Centers for Medicare & Medicaid Services (CMS). CMS has eight regional offices that oversee the Medicare program and ensure that regulations are followed. Medicare payments to providers are not made directly by CMS but by contractors for 12 Medicare Administrative Contractor (MAC) jurisdictions.

Before we close our discussion of Medicare, note that many private insurers offer coverage called Medicare supplement insurance, or Medigap. Such insurance is designed to help pay some of the healthcare costs that traditional Medicare does not cover, such as copayments, coinsurance, and deductibles.

In addition, some Medigap policies offer coverage for services that Medicare doesn t include, for example, medical care when traveling outside of the United States. When an individual buys Medigap coverage, Medicare will first pay its share of the Medicare-approved amount for covered costs, and then the Medigap policy pays its share.

Medicaid Medicaid began in 1966 as a modest program to be jointly funded and operated Medicaid A federal and by the states and the federal government that would provide a medical safety state government net for low-income mothers and children and for elderly, blind, and disabled health insurance individuals who receive benefits from the Supplemental Security Income (SSI) program that program. Congress mandated that Medicaid cover hospital and physician care, provides benefits to low-income but states were encouraged to expand on the basic package of benefits either by individuals.

increasing the range of benefits or extending the program to cover more people.

States with large tax bases were quick to expand coverage to many groups, while states with limited abilities to raise funds for Medicaid were forced to construct more limited programs. A mandatory nursing home benefit was added in 1972.

Over the years, Medicaid has provided access to healthcare services for many low-income individuals who otherwise would have no insurance coverage.

Furthermore, Medicaid has become an important source of revenue for healthcare providers, especially for nursing homes and other providers that treat large numbers of indigent patients. However, Medicaid expenditures have been growing at an alarming rate, which has forced both federal and state policymakers to search for more effective ways to improve the program s access, quality, and cost.

SELF-TEST QUESTIONS 1. What are some different types of private insurers?

2. Briefly, what are the origins and purpose of Medicare?

3. What is Medicaid, and how is it administered?

Managed care plan A combined effort by an insurer and a group of providers with the purpose of both increasing quality of care and decreasing costs.

Managed Care Plans Managed care plans strive to combine the provision of healthcare services and the insurance function into a single entity. Traditional plans are created by insurers who either directly own a provider network or create one through contractual arrangements with independent providers.

One type of managed care plan is the health maintenance organization (HMO). HMOs are based on the premise that the traditional insurer provider relationship creates perverse incentives that reward providers for treating patients illnesses while offering little incentive for providing prevention and rehabilitation services. By combining the financing and delivery of comprehensive healthcare services into a single system, HMOs theoretically have as strong an incentive to prevent illnesses as to treat them. However, from a patient perspective, HMOs have several drawbacks, including a limited network of providers and the assignment of a primary care physician who acts as the initial contact and authorizes all services received from the HMO.

Another type of managed care plan, the preferred provider organization (PPO), evolved during the early 1980s. PPOs are a hybrid of HMOs and traditional health insurance plans that use many of the cost-saving strategies developed by HMOs. PPOs do not mandate that beneficiaries use specific providers, although financial incentives are created that encourage members to use those providers that are part of the provider panel those providers that have contracts (usually at discounted prices) with the PPO. Furthermore, PPOs do not require beneficiaries to use preselected gatekeeper physicians. In general, PPOs are less likely than HMOs to provide preventive services and do not assume any responsibility for quality assurance because enrollees are not constrained to use only the PPO panel of providers.

In an effort to achieve the potential cost savings of managed care plans, most insurance companies now apply managed care strategies to their conventional plans. Such plans, which are called managed fee-for-service plans, use preadmission certification, utilization review, and second surgical opinions to control inappropriate utilization.

Although the distinctions between managed care and conventional plans were once quite apparent, considerable overlap now exists in the strategies and incentives employed. Thus, the term managed care now describes a continuum of plans, which can vary significantly in their approaches to providing combined insurance and healthcare services. The common feature in managed care plans is that the insurer has a mechanism by which it controls, or at least influences, patients utilization of healthcare services.

1. What is meant by the term managed care?

2. What are some different types of managed care plans?

SELF-TEST QUESTIONS Healthcare Reform and Insurance The ACA introduced a number of provisions to expand insurance coverage and improve insurance affordability and access. Here are some of the act s provisions that focus on healthcare insurance.

Insurance Standards A number of new insurance standards have been specified in the ACA. In terms of coverage, these include the following:

Children and dependents are permitted to remain on their parents insurance plans until their twenty-sixth birthday.

Insurance companies are prohibited from dropping policyholders if they become sick and from denying coverage to individuals due to preexisting conditions.

Individuals have a right to appeal and request that the insurer review denial of payment.

In terms of costs, the standards include the following:

Insurers are required to charge the same premium rate to all applicants of the same age and geographic location, regardless of preexisting conditions or sex.

Insurers are required to spend at least 80 percent of premium dollars on health costs and claims instead of on administrative costs and profits. If the insurer violates this standard, it must issue rebates to policyholders.

Lifetime limits on most benefits are prohibited for all new health insurance plans.

In terms of care, the standards include the following:

All plans must now include essential benefits, such as ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; laboratory services; preventive and wellness services; chronic disease management; and pediatric services, including oral and vision care.

Preventive services, such as childhood immunizations, adult vaccinations, and basic medical screenings, must be available to patients free of charge.

Individuals are permitted to choose a primary care doctor outside the plan s network.

Health insurance exchange (HIE) An online marketplace created primarily by the states or the federal government that insurers use to post plan details and consumers use to purchase healthcare insurance.

Individuals can seek emergency care at a hospital outside the health plan s network.

Individual Mandate All eligible individuals (US citizens and legal residents) who are not covered by an employer-sponsored health plan, Medicaid, or Medicare are required to have a health insurance policy. If they do not maintain minimum essential coverage for themselves and their dependents, they face tax penalties assessed by the Internal Revenue Services at the end of each tax year.

Health Insurance Exchanges Health insurance exchanges (HIEs) are an important part of ensuring that healthcare access is available to all Americans and legal immigrants. People who have no employer-sponsored insurance, the unemployed, or the self-employed can purchase coverage through an exchange. HIEs are online marketplaces where people can research and review their options and purchase health insurance.

It is estimated that more than 10 million people are using HIEs to buy healthcare insurance coverage. To ensure price transparency, all participating insurance companies are required to post on HIEs the rates for their various health insurance plans. This mandate permits individuals and businesses shopping for insurance to compare all plans and rates side by side and select plans that are affordable and meet their needs.

There are different types of HIEs. Public exchanges are created by state or federal government and are open to both individuals seeking personal insurance and small-group employers seeking insurance for their workers. All plans listed on an HIE are required to offer core benefits called essential health benefits such as preventive and wellness services, prescription drugs, and hospital stays. Private exchanges, on the other hand, are created by private- sector firms, such as health insurance companies. Private HIEs are expected to increase in number over time as more employers offer defined healthcare contribution plans (discussed in a later section in this chapter) to their employees, who then must purchase health insurance on their own.

Medicaid Expansion One of the provisions of the ACA is the expansion of Medicaid. Nearly all US citizens and legal residents between the ages of 19 and 64 who have household incomes below 133 percent of the federal poverty level now qualify for Medicaid. This expansion benefits childless adults who previously did not qualify for Medicaid regardless of their income level as well as low-income parents who previously did not qualify even if their children did qualify. As a result, it is estimated that an additional 16 million people will receive coverage through Medicaid.

Originally, under the ACA, Medicaid expansion was mandatory for all states; states that did not comply were to be penalized by the federal government.

However, the US Supreme Court ruled that states can opt out of the Medicaid expansion, leaving this decision to participate in the hands of the state s leaders. As of 2015, 31 states have participated in the Medicaid expansion program. The managed Medicaid market may be an area of high growth potential for insurance companies as more states move Medicaid beneficiaries into managed care plans.

High-Deductible Health Plans Many individuals are now choosing high-deductible health plans (HDHPs) for their health insurance coverage. HDHPs are growing in popularity because they are among the least expensive options available on HIEs. In fact, the rate of enrollment in HDHPs has more than doubled since 2009. These plans have low premiums and high deductibles and are linked with savings accounts established to pay for healthcare services. HDHPs aim to provide individuals more control over their healthcare expenditures and hence may offer an incentive to control healthcare costs.

New Insurance Markets Before health reform, the health insurance industry focused on selling group plans to employers. Now it must re-create itself to cater to an entirely new, huge market of individual consumers. Many insurers have little idea how costly it is to provide coverage to these new customers, many of whom are not working and have not been insured for a long time (or even at all). One of the biggest challenges that insurance companies will face is attempting to accurately price and administer these plans without dramatic premium increases.

Another problem is that the newly insured often need education about how to use their health plan effectively and how to access different types of care.

Focus on Chronic Care As insurers and providers continue to partner in new accountable care organizations (ACOs), the shared savings programs will likely increasingly focus on consumers with chronic conditions. That means implementing more patient- centered medical homes that aim to manage chronic conditions with specific care pathways that address behavioral health needs and decrease hospital admissions and emergency department visits. ACOs and medical homes will also increasingly make use of personal health coaches, who motivate patients on a one-on-one basis and help coordinate patient care with all caregivers.

SELF-TEST 1. Briefly describe the impact of the ACA on health insurance. QUESTIONS 2. What is a health insurance exchange (HIE)?

Generic Reimbursement Methodologies Fee-for-service A reimbursement methodology that provides payment each time a service is provided.

Capitation A reimbursement methodology that is based on the number of covered lives as opposed to the amount of services provided.

Cost-based reimbursement A fee-for-service reimbursement method based on the costs incurred in providing services.

Charge-based reimbursement A fee-for-service reimbursement method based on charges (chargemaster prices).

Chargemaster A list of all items and services provided by a health services organization containing their gross (list) prices.

Regardless of the payer for a particular healthcare service, only a limited number of payment methodologies are used to reimburse providers. Payment methodologies fall into two broad classifications: fee-for-service and capitation.

In fee-for-service payment, of which many variations exist, the greater the amount of services provided, the higher the amount of reimbursement.

Under capitation, a fixed payment is made to providers for each covered life, or enrollee, that is independent of the amount of services provided. In this section, we discuss the mechanics, incentives created, and risk implications of alternative reimbursement methodologies.

Fee-for-Service Methods The three primary fee-for-service methods of reimbursement are cost based, charge based, and prospective payment.

Cost-Based Reimbursement Under cost-based reimbursement, the payer agrees to reimburse the provider for the costs incurred in providing services to the insured population. Reimbursement is limited to allowable costs, usually defined as those costs directly related to the provision of healthcare services. Nevertheless, for all practical purposes, cost-based reimbursement guarantees that a provider s costs will be covered by payments from the payer. Typically, the payer makes periodic interim payments (PIPs) to the provider, and a final reconciliation is made after the contract period expires and all costs have been processed through the provider s managerial (cost) accounting system.

During its early years (1966 1982), Medicare reimbursed hospitals on the basis of costs incurred. Now most hospitals are reimbursed by Medicare, and other payers, using a per diagnosis prospective payment system (see the later subsection on this topic). However, critical access hospitals, which are small rural hospitals that provide services to remote populations that do not have easy access to other hospitals, are still reimbursed on a cost basis by Medicare.

Charge-Based Reimbursement When payers pay billed charges, or simply charges, they pay according to a rate schedule established by the provider, called a chargemaster. To a certain extent, this reimbursement system places payers at the mercy of providers in regards to the cost of healthcare services, especially in markets where competition is limited. In the early days of health insurance, all payers reimbursed providers on the basis of billed charges. Some insurers still reimburse providers according to billed charges, but the trend for payers is toward other, less generous reimbursement methods. If this trend continues, the only payers that will be expected to pay billed charges are self-pay, or private-pay, patients. Even then, low-income patients often are billed at rates less than charges.

Some payers that historically have reimbursed providers on the basis of billed charges now pay by negotiated, or discounted, charges. This is especially true for insurers that have established managed care plans. Additionally, many conventional insurers have bargaining power because of the large number of patients that they bring to a provider, so they can negotiate discounts from billed charges. Such discounts generally range from 20 to 50 percent, or even more, of billed charges. The effect of these discounts is to create a system similar to hotel or airline pricing, where there are listed rates (chargemaster prices for providers, and rack rates or full fares for hotels and airlines) that few people pay.

Prospective Payment In a prospective payment system, the rates paid by payers are established by the payer before the services are provided. Furthermore, payments are not directly related to either costs or chargemaster rates. Here are some common units of payment used in prospective payment systems:

Per procedure. Under per procedure reimbursement, a separate payment is made for each procedure performed on a patient. Because of the high administrative costs associated with this method when applied to complex diagnoses, per procedure reimbursement is more commonly used in outpatient than in inpatient settings.

Per diagnosis. In the per diagnosis reimbursement method, the provider is paid a rate that depends on the patient s diagnosis.

Diagnoses that require higher resource utilization, and hence are more costly to treat, have higher reimbursement rates. Medicare pioneered this basis of payment in its diagnosis-related group (DRG) system, which it first used for hospital inpatient reimbursement in 1983.

Per day (per diem). If reimbursement is based on a per diem payment, the provider is paid a fixed amount for each day that service is provided, regardless of the nature of the service. Note that per diem rates, which are applicable only to inpatient settings, can be stratified.

For example, a hospital may be paid one rate for a medical/surgical day, a higher rate for a critical care unit day, and yet a different rate for an obstetrics day. Stratified per diems recognize that providers incur widely different daily costs for providing different types of care.

Bundled. Under bundled payment, payers make a single prospective payment that covers all services delivered in a single episode, whether the services are rendered by a single provider or by multiple providers.

For example, a bundled payment may be made for all obstetric services Prospective payment A fee-for-service reimbursement method that is established beforehand by the third-party payer and, in theory, not related to costs or charges.

Per diem payment A fee-for-service reimbursement method that pays a set amount for each inpatient day.

Bundled (global) payment The fee-for-service payment of a single amount for the complete set of services required to treat a single episode.

For Your Consideration Creating the Proper Provider Incentives An article in the Wall Street Journal (February 18, 2015, page A1) describes how one patient in a Kindred Healthcare long-term care hospital was discharged after 23 days of treatment for complications from a previous knee surgery. According to family members, the timing of his release did not appear to be related to any improvement in his medical condition. However, it did result in a higher reimbursement that the hospital received for his stay.

According to billing documents, Kindred collected $35,887.79 from Medicare for his treatment, the maximum amount it could earn for treating patients with his condition. Under Medicare s reimbursement rules, if the patient had left the hospital one day earlier, Kindred would have received a per diem rate that would have resulted in a total payment of roughly $20,000. If he had stayed longer than 23 days, the hospital likely would not have received any additional reimbursement other than the $35,887.79 single payment for an extended stay.

What do you think? What incentives are created for providers under the reimbursement method used by Medicare for long-term (as opposed to acute care) hospitals? Can you think of a payment system that would encourage longterm care hospitals to discharge patients at the appropriate time?

associated with a pregnancy provided by a single physician, including all prenatal and postnatal visits as well as the delivery.

For another example, a bundled payment may be made for all physician and hospital services associated with a cardiac bypass operation. Finally, note that, at the extreme, a bundled payment may cover an entire population. In this situation, the payment becomes a global payment, which, in effect, is a capitation payment as described in the next section.

Capitation Up to this point, the prospective payment methods presented have been fee-for-service methods that is, providers are reimbursed on the basis of the amount of services provided.

The service may be defined as a visit, a diagnosis, a hospital day, an episode, or in some other manner, but the key feature is that the more services that are performed, the greater the reimbursement amount.

Capitation, although a form of prospective payment, is an entirely different approach to reimbursement and hence deserves to be treated as a separate category. Under capitated reimbursement, the provider is paid a fixed amount per covered life per period (usually a month) regardless of the amount of services provided. For example, a primary care physician might be paid $15 per member per month for handling 100 members of an HMO plan.

Capitation payment, which is used primarily by managed care plans, dra matically changes the financial environment of healthcare providers. It has implica tions for financial accounting, managerial accounting, and financial management.

Discussion of how capitation, as opposed to fee-for-service reimbursement, affects healthcare finance is provided throughout the remainder of this book.

SELF-TEST QUESTIONS 1. Briefly explain the following payment methods:

Cost based Charge based and discounted charges Per procedure Per diagnosis Per diem Bundled Capitation 2. What is the major difference between fee-for-service reimbursement and capitation?

Provider Incentives Under Alternative Reimbursement Methodologies Providers, like individuals and businesses, react to the incentives created by the financial environment. For example, individuals can deduct mortgage interest from income for tax purposes, but they cannot deduct interest payments on personal loans. Loan companies have responded by offering home equity loans that are a type of second mortgage. The intent is not that such loans would always be used to finance home ownership, as the tax laws assumed, but that the funds could be used for other purposes, including paying for vacations and purchasing cars or appliances. In this situation, tax laws created incentives for consumers to have mortgage debt rather than personal debt, and the mortgage loan industry responded accordingly.

In the same vein, it is interesting to examine the incentives that alternative reimbursement methods have on provider behavior. Under cost-based reimbursement, providers are given a blank check in regard to acquiring facilities and equipment and incurring operating costs. If payers reimburse providers for all costs, the incentive is to incur costs. Facilities will be lavish and conveniently located, and staff will be available to ensure that patients are given deluxe treatment. Furthermore, as in billed charges reimbursement, services that may not truly be required will be provided because more services lead to higher costs and hence lead to higher revenues.

Under charge-based reimbursement, providers have the incentive to set high charge rates, which lead to high revenues. However, in competitive markets, there will be a constraint on how high providers can go. But, to the extent that insurers, rather than patients, are footing the bill, there is often considerable leeway in setting charges. Because billed charges is a fee-forservice type of reimbursement in which more services result in higher revenue, a strong incentive exists to provide the highest possible amount of services.

In essence, providers can increase utilization, and hence revenues, by churning creating more visits, ordering more tests, extending inpatient stays, and SELF-TEST QUESTIONS so on. Charge-based reimbursement does encourage providers to contain costs because (1) the spread between charges and costs represents profits, and the more the better, and (2) lower costs can lead to lower charges, which can increase volume. Still, the incentive to contain costs is weak because charges can be increased more easily than costs can be reduced. Note, however, that discounted charge reimbursement places additional pressure on profitability and hence increases the incentive for providers to lower costs.

Under prospective payment reimbursement, provider incentives are For Your Consideration Value-Based Purchasing Value-based purchasing rests on the concept that buyers of healthcare services should hold providers accountable for quality of care as well as costs. In April 2011, HHS launched the Hospital Value-Based Purchasing program, which marks the beginning of a historic change in how Medicare pays healthcare providers. For the first time, 3,500 hospitals across the country are being paid for inpatient acute care services based on care quality, not just the quantity of the services provided.

Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us, said former HHS Secretary Kathleen Sebelius. Under this initiative, Medicare will reward hospitals that provide high- quality care and keep their patients healthy. It s an important part of our work to improve the health of our nation and drive down costs. As hospitals work to improve quality, all patients not just Medicare patients will benefit. The initial measures to determine quality focus on how closely hospitals follow best clinical practices and how well hospitals enhance patients care experiences.

The better a hospital does on its quality measures, the greater the reward it will receive from Medicare.

What do you think? Should providers be reimbursed based on quality of care? How should quality be measured? Should the additional reimbursement to high-quality providers be obtained by reductions in reimbursement to low- quality providers?

altered. First, under per procedure reimbursement, the profitability of individual procedures varies depending on the relationship between the actual costs incurred and the payment for that procedure. Providers, usually physicians, have the incentive to perform procedures that have the highest profit potential. Furthermore, the more procedures the better, because each procedure typically generates additional profit. The incentives under per diagnosis reimbursement are similar. Providers, usually hospitals, will seek patients with those diagnoses that have the greatest profit potential and discourage (or even discontinue) those services that have the least potential. Furthermore, to the extent that providers have some flexibility in selecting procedures (or assigning diagnoses) to patients, an incentive exists to up code procedures (or diagnoses) to ones that provide the greatest reimbursement.

In all prospective payment methods, providers have the incentive to reduce costs because the amount of reimbursement is fixed and independent of the costs actually incurred. For example, when hospitals are paid under per diagnosis reimbursement, they have the incentive to reduce length of stay and hence costs. Note, however, when per diem reimbursement is used, hospitals have an incentive to increase length of stay.

Because the early days of a hospitalization typically are more costly than the later days, the later days are more profitable. However, as mentioned previously, hospitals have the incentive to reduce costs during each day of a patient stay.

Under bundled pricing, providers do not have the opportunity to be reimbursed for a series of separate services, which is called unbundling. For example, a physician s treatment of a fracture could be bundled, and hence billed as one episode, or it could be unbundled with separate bills submitted for making the diagnosis, taking x-rays, setting the fracture, removing the cast, and so on. The rationale for unbundling is usually to provide more detailed records of treatments rendered, but often the result is higher total charges for the parts than would be charged for the entire package. Also, bundled pricing, when applied to multiple providers for a single episode of care, forces involved providers (e.g., physicians and a hospital) to jointly offer the most cost-effective treatment. Such a joint view of cost containment may be more effective than each provider separately attempting to minimize its treatment costs because lowering costs in one phase of treatment could increase costs in another.

Finally, capitation reimbursement totally changes the playing field by completely reversing the actions that providers must take to ensure financial success. Under all fee-for-service methods, the key to provider success is to work harder, increase utilization, and hence increase profits; under capitation, the key to profitability is to work smarter and decrease utilization. As with prospective payment, capitated providers have the incentive to reduce costs, but now they also have the incentive to reduce utilization. Thus, only those procedures that are truly medically necessary should be performed, and treatment should take place in the lowest-cost setting that can provide the appropriate quality of care. Furthermore, providers have the incentive to promote health, rather than just treat illness and injury, because a healthier population consumes fewer healthcare services.

SELF-TEST 1. What are the provider incentives created under fee-for-service QUESTION reimbursement? Under capitation?

Medical Coding: The Foundation of Fee-for-Service Reimbursement Medical coding Medical coding, or medical classification, is the process of transforming The process of descriptions of medical diagnoses and procedures into code numbers that transforming can be universally recognized and interpreted. The diagnoses and procedures medical diagnoses and procedures are usually taken from a variety of sources within the medical record, such into universally as doctor s notes, laboratory results, and radiological tests. In practice, the recognized basis for most fee-for-service reimbursement is the patient s diagnosis (in the numerical codes.

International Classification of Diseases (ICD) codes Numerical codes for designating diseases plus a variety of signs, symptoms, and external causes of injury.

Current Procedural Terminology (CPT) codes Codes applied to medical, surgical, and diagnostic procedures.

case of inpatient settings) or the procedures performed on the patient (in the case of outpatient settings). Thus, a brief background on clinical coding will enhance your understanding of the reimbursement process.

Diagnosis Codes The International Classification of Diseases (most commonly known by the abbreviation ICD) is the standard for designating diseases plus a wide variety of signs, symptoms, and external causes of injury. Published by the World Health Organization, ICD codes are used internationally to record many types of health events, including hospital inpatient stays and death certificates. (ICD codes were first used in 1893 to report death statistics.) The codes are periodically revised; the most recent version is ICD-10.

However, US hospitals are still using a modified version of the ninth revision, called ICD-9-CM, where CM stands for Clinical Modification. The ICD-9 codes consist of three, four, or five digits. The first three digits denote the disease category, and the fourth and fifth digits provide additional information. For example, code 410 describes an acute myocardial infarction (heart attack), while code 410.1 is an attack involving the anterior wall of the heart. (However, the conversion to ICD-10 codes will occur October 1, 2015, although hospitals will not be penalized if they continue to use ICD-9 codes for one additional year. The conversion process is consuming and costly because there are more than five times as many individual codes in ICD-10 as in ICD-9. Of course, the information provided by the new code set will be more detailed and complete.) In practice, the application of ICD codes to diagnoses is complicated and technical. Hospital coders have to understand the coding system and the medical terminology and abbreviations used by clinicians. Because of this complexity, and because proper coding can mean higher reimbursement from third-party payers, ICD coders require a great deal of training and experience to be most effective.

Procedure Codes While ICD codes are used to specify diseases, Current Procedural Terminology (CPT) codes are used to specify medical procedures (treatments). CPT codes were developed and are copyrighted by the American Medical Association.

The purpose of CPT is to create a uniform language (set of descriptive terms and codes) that accurately describes medical, surgical, and diagnostic procedures. CPT and its corresponding codes are revised periodically to reflect current trends in clinical treatments. To increase standardization and the use of electronic health records, federal law requires that physicians and other clinical providers, including laboratory and diagnostic services, use CPT for the coding and transfer of healthcare information. (The same law also requires that ICD codes be used for hospital inpatient services.) To illustrate CPT codes, there are ten codes for physician office visits.

Five of the codes apply to new patients, while the other five apply to established patients (repeat visits). The differences among the five codes in each category are based on the complexity of the visit, as indicated by three components: (1) extent of patient history review, (2) extent of examination, and (3) difficulty of medical decision making. For repeat patients, the least complex (typically shortest) office visit is coded 99211, while the most complex (typically longest) is coded 99215.

Because government payers (Medicare and Medicaid) as well as other insurers require additional information from providers beyond that contained in CPT codes, an enhanced version called the Healthcare Common Procedure Coding System (HCPCS, commonly pronounced hick picks ) was developed. This system expands the set of CPT codes to include nonphysician services and durable medical equipment such as ambulance services and prosthetic devices.

Although CPT and HCPCS codes are not as complex as the ICD codes, coders still must have a high level of training and experience to use them correctly.

As in ICD coding, correct CPT coding ensures correct reimbursement.

Coding is so important that many businesses offer services, such as books, software, education, and consulting, to hospitals and medical practices to improve coding efficiency.

1. Briefly describe the coding system used in hospitals (ICD codes) and medical practices (CPT codes).

2. What is the link between coding and reimbursement?

Specific Reimbursement Methods There are many specific reimbursement methods in use today. Typically, the methods differ from one insurer to another. In addition, insurers use different methods for different types of providers and services, such as hospitals versus physicians or even hospital inpatients versus outpatients. In this section, we discuss the specific methods used by Medicare to reimburse hospitals for inpatient services and physicians for all services. We discuss other specific reimbursement methods used by Medicare in the chapter supplement.

Hospital Inpatient Services The Medicare inpatient prospective payment system (IPPS) is a prospective payment methodology based on an inpatient s diagnosis at discharge. It starts with two national base payment rates (operating and capital expenses), which Healthcare Common Procedure Coding System (HCPCS) A medical coding system that expands the CPT codes to include nonphysician services and durable medical equipment.

SELF-TEST QUESTIONS Inpatient prospective payment system (IPPS) The method, based on diagnosis, that Medicare uses to reimburse providers for inpatient services.

are then adjusted to account for two factors that affect the costs of providing care: (1) the patient s condition and treatment and (2) market conditions in the facility s geographic location (Exhibit 2.1).

Discharges are assigned to one of 751 Medicare severity diagnosis-related groups (MS DRGs), which designate the diagnoses of patients with similar clinical problems and, hence, who are expected to consume similar amounts of hospital resources. Each MS DRG has a relative weight that reflects the expected cost of inpatients in that group. The payment rates for MS DRGs in each local market are determined by adjusting the base payment rates to reflect the local input price level and then multiplying them by the relative weight for each MS DRG. The operating and capital payment rates are increased for facilities that operate an approved resident training program EXHIBIT 2.1 Medicare Adjusted for geographic factors Hospital Acute Inpatient Services Payment System + .

1.0 Hospital wage index MS DRG Patient characteristics for area wages Principal diagnosis Procedure Complications and comorbidities Adjusted for case mixWage index 1.0 Wage index Operating base payment rate Adjusted base payment rate 69.6% adjusted for area wages 62% adjusted Non-labor- related portion Base rate adjusted for geographic factors MS DRG weight Adjustment for transfers Policy adjustments for hospitals that qualify + + Indirect medical education payment Disproportionate share payment = If case is extraordinarily costly Full LOS Short LOS and discharged Payment** to other acute IPPS hospital diem or post-acute care* Per case payment rate rate Per payment Adjusted base payment rate High- cost outlier (payment + outlier payment) Note: MS DRG (Medicare severity diagnosis-related group), LOS (length of stay), IPPS (inpatient prospective payment system). Capital payments are determined by a similar system.

* Transfer policy for cases discharged to post-acute care settings applies for cases in 275 selected MS DRGs.

** Additional payment made for certain rural hospitals.

Source: Reprinted from MedPAC. 2014. Hospital Acute Inpatient Services Payment System. Figure 1. Revised October. inpatient-services-payment-system-14.pdf.

or that treat a disproportionate share of low-income patients. Rates are reduced for various transfer cases, and outlier payments are added for cases that are extraordinarily costly to protect providers from large financial losses due to unusually expensive cases.

Both operating and capital payment rates are updated annually.

The IPPS rates are intended to cover the costs that reasonably efficient providers would incur in providing high-quality care. If the hospital is able to provide the services for less than the fixed reimbursement amount, it can keep the difference.

Conversely, if a Medicare patient s treatment costs are more than the reimbursement amount but do not meet the definition of an outlier, the hospital must bear the loss.

Physician Services Medicare pays for physician services using a resource-based relative value scale (RBRVS) system. In the RBRVS system, payments for services are determined by the resource costs needed to provide them as measured by weights called relative value units (RVUs).

RVUs consist of three components: (1) a work RVU, which includes the skill level and training required along with the intensity and time required for the service; (2) a practice expense RVU, which includes equipment and supplies costs as well as office support costs, including labor; and (3) a malpractice expense RVU, which accounts for the relative risk and cost of potential malpractice claims. To illustrate, the (total) RVU is 0.52 for a minimal office visit, 1.32 for an average office visit, and 3.06 for a comprehensive office visit. Furthermore, the average office visit RVU is composed of a work RVU of 0.67, a practice expense RVU of 0.62, and a malpractice expense RVU of 0.03.

The RVU values then are adjusted to reflect variations in local input prices, and the total is multiplied by a standard dollar value called the conversion factor to arrive at the payment amount. Medicare s payment rates may also be adjusted to reflect provider characteristics, geographic Industry Practice Using RVUs for Physician Compensation Traditionally, there have been a number of ways of estimating physician productivity when tying compensation to performance. For many years, productivity was measured by volume-based metrics such as number of patients seen or amount of revenue billed.

Today, however, physician productivity measures and compensation models are rapidly moving toward models based on relative value units (RVUs).

Work RVUs, which are one of three components of RVUs, measure the relative level of time, skill, training, and intensity required of a physician to provide a given service. As such, they are a good proxy for the training required and volume of work expended by a physician in treating patients. A routine well-patient visit, for example, would be assigned a lower RVU than an invasive surgical procedure would. Given this relative scale, a physician seeing two or three complex or high-acuity patients per day could accumulate more RVUs than a physician seeing ten or more low- acuity patients per day. Thus, the nature of the work, rather than number of patients or billings, is being measured and hence used for compensation levels.

According to the Medical Group Management Association (MGMA), well over half of all physicians are compensated, at least in part, on the basis of productivity as measured by work RVUs. Usually, work RVUs are combined with other productivity and quality measures in determining productivity and compensation, but there is little doubt that work RVUs have the dominant role.

Relative value unit (RVU) A measure of the amount of resources consumed to provide a particular service.

When applied to physicians, a measure of the amount of work, practice expenses, and liability costs associated with a particular service.

EXHIBIT 2.2 Medicare Total RVUs from physician fee schedule Physician Work GPCI PLI GPCI PE GPCI Conversion factor Work RVU PE RVU PLI RVU Complexity Services of service and expenses Payment Adjusted .




+ + for:

System Geographic factors Payment modifier Adjusted fee schedule payment rate SELF-TEST QUESTIONS Adjusted fee schedule payment rate Note: RVU (relative value unit), GPCI (geographic practice cost index), PE (practice expense), PLI (professional liability insurance), HPSA (health professional shortage area). This figure depicts Medicare payments only. The fee schedule lists separate PE RVUs for facility and nonfacility settings. Fee schedule payments are reduced when specified nonphysician practitioners bill Medicare separately, but not when services are provided incident to a physician.

Source: Reprinted from MedPAC. 2014. Physician and Other Health Professionals Payment System. Figure 1. Revised October. other-health-professionals-payment-system-14.pdf.

designations, and other factors. The provider is paid the final amount, less any beneficiary coinsurance (Exhibit 2.2).

1. Briefly describe the method used by Medicare to reimburse for inpatient services.

2. Explain the method used by Medicare to reimburse for physician services.

Healthcare Reform and Reimbursement Methods In addition to improving healthcare delivery through focusing on access and quality, the ACA has significantly changed the way providers are reimbursed.

The key reforms include a move from a fee-for-service model to a prospective payment model, which may include bundled payments or capitation. These new payment methods aim to move reimbursement from that based on the amount of services provided (volume) to that based on value and better outcomes.

Policy adjustments (multiplicative) Provider type Geographic Service type HPSA bonus Primary Major surgical care procedures = (decreases) (increases) (increases) Nonphysician Nonparticipating Payment The new payment methods are specifically designed to accomplish the following:

Encourage providers to deliver care in a high-quality, cost-efficient manner Support coordination of care among multiple providers Adopt evidence-based care standards and protocols that result in the best outcomes for patients Provide accountability and transparency Discourage overtreatment and medically unnecessary procedures Eliminate or reduce the occurrence of adverse events Discourage cost shifting The sections that follow describe a few of the important implications for provider payments.

Value-Based Purchasing Value-based purchasing (VBP) is a Medicare initiative that rewards acute care hospitals with incentive payments for providing high-quality care to Medicare beneficiaries, which should lead to better clinical outcomes for all hospitalized patients. The amounts of these payments are based on how closely the institution followed best clinical practices, how well it enhanced patients care experiences, how well it achieved quality goals, and how much it improved on each measure compared to its performance during the baseline period. Note that some VBP programs are paired with shared savings programs (discussed later) to reward cost reduction as well as quality of care.

Quality-Based Clinician Compensation In addition to VBP for hospitals, the ACA requires Medicare to factor quality into payments for physicians and most other clinicians. Quality-based compensation is part of Medicare s effort to shift medicine away from the volume- based focus, where clinicians are paid for each service regardless of quality.

Clinicians can earn additional compensation based on the quality of care they provide to their patients. Bonuses and penalties are calculated on the basis of performance on quality measures, which vary by specialty. As with VBP programs for hospitals, quality-based clinician reimbursement programs can be paired with shared savings programs.

Shared Savings Programs Shared savings is an approach to reducing healthcare costs and, potentially, a mechanism for encouraging the creation of ACOs. Under shared savings, if a provider reduces total healthcare spending for its patients below the level Value-based purchasing (VBP) An approach to provider reimbursement that rewards quality of care rather than quantity of care.

that the payer expected, the provider is then rewarded with a portion of the savings. The benefits are twofold: (1) The payer spends less than it would otherwise, and (2) the provider gets more revenue than it expected. The savings can arise from the more efficient, cost-effective use of hospital or outpatient services that enhance quality, reduce costs over time, and improve outcomes.

It can be applied to hospital episodes of care, including physician services, or to physician office care.

New Bundled Payment Models Bundled payment models are a form of fee-for-service reimbursement in which a single sum covers all healthcare services related to a specific procedure. The objective of bundled payments is to promote more efficient use of resources and reward providers for improving the coordination, quality, and efficiency of care. If the cost of services is less than the bundled payment, the physicians and other providers retain the difference. But if the costs exceed the bundled payment, physicians and other providers are not compensated for the difference.

In some circumstances, an ACO may receive the bundled payment and subsequently divide the payment among participating physicians and providers.

In other situations, the payer may pay participating physicians and providers independently, but it may adjust each payment according to negotiated predefined rules to ensure that the total payments to all the providers do not exceed the total bundled payment amount. This type of reimbursement is called virtual bundling. For providers, the challenges of bundled payments include determining who owns the episode of care and apportioning the payment among the various providers.

Readmission Reduction Program With the passage of the ACA, Medicare now has the authority to penalize hospitals if they experience excessive readmission rates compared to expected levels of readmission. The readmissions are based on a 30-day readmission measure for heart attack, heart failure, and pneumonia.

Hospital-Acquired Conditions In a relatively new initiative, hospitals will be penalized by Medicare for hospital- acquired conditions. Hospital-acquired conditions include bedsores, infections, complications from extended use of catheters, and injuries caused by falls.

Hospitals will face a 1 percent reduction in Medicare inpatient payments for all discharges if they rank in the top 25 percent of hospital-acquired conditions for all hospitals in the previous year.

SELF-TEST QUESTION 1. Briefly describe the impact of the ACA on payments to providers.

Key Concepts This chapter covers important background material related to healthcare insurance and provider reimbursement. The key concepts of this chapter are as follows:

Health insurance is widely used in the United States because individuals are risk averse and insurance firms can take advantage of the law of large numbers.

Insurance is based on four key characteristics: (1) pooling of losses, (2) payment for random losses, (3) risk transfer, and (4) indemnification.

Adverse selection occurs when individuals most likely to have claims purchase insurance while those least likely to have claims do not.

Moral hazard occurs when an insured individual purposely sustains a loss, as opposed to a random loss. In a health insurance setting, moral hazard is more subtle, producing such behaviors as seeking more services than needed and engaging in unhealthy behavior because the costs of the potential consequences are borne by the insurer.

Most provider revenue is not obtained directly from patients but from healthcare insurers, known collectively as third-party payers.

Third-party payers are classified as private insurers (Blue Cross/ Blue Shield, commercial, and self-insurers) and public insurers (Medicare and Medicaid).

Managed care plans, such as health maintenance organizations (HMOs), strive to combine the insurance function and the provision of healthcare services.

Third-party payers use many different payment methods that fall into two broad classifications: fee-for-service and capitation. Each payment method creates a unique set of incentives and risk for providers.

When payers pay billed charges, they pay according to a schedule of rates established by the provider called a chargemaster.

Negotiated charges, which are discounted from billed charges, are used by insurers with sufficient market power to demand price reductions.

Under a cost-based reimbursement system, payers agree to pay providers certain allowable costs incurred when providing services to the payers enrollees.

(continued) (continued from previous page) In a prospective payment system, the rates paid by payers are determined in advance and are not tied directly to reimbursable costs or billed charges. Typically, prospective payments are made on the basis of the following service definitions: (1) per procedure, (2) per diagnosis, (3) per diem (per day), or (4) bundled pricing.

Capitation is a flat periodic payment to a physician or another healthcare provider; it is the sole reimbursement for providing services to a defined population. Capitation payments are generally expressed as some dollar amount per member per month, where the word member typically refers to an enrollee in some managed care plan.

Medical coding is the foundation of fee-for-service reimbursement systems. In inpatient settings, ICD codes are used to designate diagnoses, while in outpatient settings, CPT codes are used to specify procedures.

Medicare uses the inpatient prospective payment system (IPPS) for hospital inpatient reimbursement. Under IPPS, the amount of the payment is determined by the patient s Medicare severity diagnosis- related group (MS DRG).

To provide some cushion for the high costs associated with severely ill patients within each diagnosis, IPPS includes a provision for outlier payments.

Physicians are reimbursed by Medicare using the resource-based relative value scale (RBRVS). Under RBRVS, reimbursement is based on relative value units (RVUs), which consist of three resource components: (1) physician work, (2) practice expenses, and (3) malpractice insurance expenses. The RVU for each service is multiplied by a dollar conversion factor to determine the payment amount.

The ACA is having a significant impact on health insurance and on the way providers are reimbursed. More people now have access to insurance coverage, and the new provider payment methods emphasize value and patient outcomes over volume.

Because the managers of health services organizations must make financial decisions within the constraints imposed by the economic environment, the insurance and reimbursement concepts discussed in this chapter will be used over and over throughout the remainder of the book.

Questions 2.1 Briefly explain the following characteristics of insurance:

a. Pooling of losses b. Payment only for random losses c. Risk transfer d. Indemnification 2.2 What is adverse selection, and how do insurers deal with the problem?

2.3 What is the moral hazard problem?

2.4 Briefly describe the major third-party payers.

2.5 a. What are the primary characteristics of managed care plans?

b. Describe different types of managed care plans.

2.6 What is the difference between fee-for-service reimbursement and capitation?

2.7 Describe the provider incentives under each of the following reimbursement methods:

a. Cost based b. Charge based (including discounted charges) c. Per procedure d. Per diagnosis e. Per diem f. Bundled payment g. Capitation 2.8 What medical coding systems are used to support fee-for-service payment methodologies?

2.9 Briefly describe how Medicare pays for the following:

a. Inpatient services b. Physician services 2.10 What are some features of the ACA that affect healthcare insurance and reimbursement?

Resources For the latest information on events that affect the healthcare sector, see Modern Healthcare, published weekly by Crain Communications Inc., Chicago.

Other resources pertaining to this chapter include Beagle, J. T. 2010. Episode-Based Payment: Bundling for Better Results. Healthcare Financial Management (February): 36 39.

D Cruz, M. J., and T. L. Welter. 2010. Is Your Organization Ready for Value-Based Payments? Healthcare Financial Management (January): 64 72.

. 2008. Major Trends Affecting Hospital Payment. Healthcare Financial Management (January): 53 60.

Harris, J., I. Elizondo, and A. Isdaner. 2014. Medicare Bundled Payment: What Is It Worth to You? Healthcare Financial Management (January): 76 82.

Kentros, C., and C. Barbato. 2013. Using Normalized RVU Reporting to Evaluate Physician Productivity. Healthcare Financial Management (August): 98 105.

Kim, C., D. Majka, and J. H. Sussman. 2011. Modeling the Impact of Healthcare Reform. Healthcare Financial Management (January): 51 60.

Mulvany, C. 2013. Insurance Market Reform: The Grand Experiment. Healthcare Financial Management (April): 82 88.

. 2010. Healthcare Reform: The Good, the Bad, and the Transformational. Healthcare Financial Management (June): 52 57.

Patton, T. L. 2009. The IRS s Version of Community Benefit: A Look at the Redesigned Form 990 and New Schedule H. Healthcare Financial Management (February): 50 54.

Pearce, J. W., and J. M. Harris. 2010. The Medicare Bundled Payment Pilot Program:

Participation Considerations. Healthcare Financial Management (September):

52 60.

Ronning, P. L. 2011. ICD-10: Obligations and Opportunities. Healthcare Financial Management (August): 48 51.

Saqr, H., O. Mikhail, and J. Langabeer. 2008. The Financial Impact of the Medicare Prospective Payment System on Long-Term Acute Care Hospitals. Journal of Health Care Finance (Fall): 58 69.

Shoemaker, P. 2011. What Value-Based Purchasing Means to Your Hospital. Healthcare Financial Management (August): 61 68.

Tyson, P. 2010. Preparing for the New Landscape of Payment Reform. Healthcare Financial Management (December): 42 48.

Wilensky, G. R. 2011. Continuing Uncertainty Dominates the Healthcare Landscape. Healthcare Financial Management (March): 34 35.

Williams, J. 2013. A New Model for Care: Population Management. Healthcare Financial Management (March): 69 76.

Woodson, W., and S. Jenkins. 2010. Payment Reform: How Should Your Organization Prepare? Healthcare Financial Management (January): 74 79.

ADDITIONAL MEDICARE PAYMENT 2 METHODS Introduction In Chapter 2, we discussed the inpatient prospective payment system (IPPS) and the resource-based relative value scale (RBRVS) system used by Medicare to reimburse hospitals for inpatient services and physicians for all services. In this supplement, we provide information on the other primary reimbursement methods used by Medicare.

Outpatient Hospital Services The outpatient prospective payment system (OPPS) is essentially a fee schedule.

The unit of payment under the OPPS is the individual service as identified by the Healthcare Common Procedure Coding System (HCPCS), which contains codes for about 6,700 distinct services. Medicare groups services into ambulatory payment classifications (APCs) on the basis of clinical and cost similarity. Each APC has a relative weight that measures the resource requirements of the service and is based on the median cost of services in that APC. The Centers for Medicare & Medicaid Services (CMS) sets payments for individual APCs using a conversion factor that translates the relative weights into dollar payment rates with adjustments for geographic differences in input prices. Hospitals also can receive additional payments in the form of outlier adjustments for extraordinarily high-cost services and pass-through payments for selected new technologies (Exhibit S2.1).

Ambulatory Surgery Centers Medicare pays for surgery-related facility services provided in ambulatory surgery centers (ASCs) based on the individual surgical procedure. Each of the nearly 3,600 approved procedures is assigned an APC from the same payment groups as used for hospital outpatient services. The relative weights for most procedures in the ASC payment system are the same as the relative weights used in the OPPS. Like the OPPS, the ambulatory surgical center payment system sets payments for individual services using a conversion factor and adjustments for geographic differences in input prices. Note that the payment for facilities services is separate from the payment for physician services.

EXHIBIT S2.1 Medicare Adjusted for Payment adjusted for Policy adjustments for geographic factors complexity of service hospitals that qualify Outpatient Hospital Services Hospital wage index Conversion factor 60% adjusted 40% for area wages related non-labor- portion = .

+ + + APC Conversion factor adjusted for APC geographic factors weight relative 7.1% add-on for rural SCHs + Payment System Hold harmless for cancer and children s hospitals Payment If patient is extraordinarily costly High- cost outlier (payment + outlier payment) Chapter 2 Supplement Measures resource requirements of service Note: APC (ambulatory payment classification), SCH (sole community hospital). The APC is the service classification system for the outpatient prospective payment system. Medicare adjusts outpatient prospective payment system payment rates for 11 cancer hospitals so that the payment-to-cost ratio (PCR) for each cancer hospital is equal to the average PCR for all hospitals.

Source: Reprinted from MedPAC. 2014. Outpatient Hospital Services Payment System. Figure 1.

Revised October. system.pdf.

Inpatient Rehabilitation Facilities Inpatient rehabilitation facilities are paid predetermined, per discharge rates based primarily on the patient s condition (diagnoses, functional and cognitive status, and age) and market area wages. Discharges are assigned to one of 92 intensive rehabilitation categories called case-mix groups (CMGs), which are groups of patients with similar clinical problems. Within each of these CMGs, patients are further categorized into one of four tiers on the basis of comorbidities, with each tier having a specific payment that reflects the costliness of patients in that tier relative to others in the CMG.

Psychiatric Hospital Services Medicare uses the inpatient psychiatric facility prospective payment system for psychiatric hospital services, which is based on a per diem rate plus additional payments for ancillary services and capital costs. A base per diem payment is adjusted to account for cost-of-care differences related to patient characteristics, such as age, diagnosis, comorbidities, and length of stay, and facility characteristics, such as local wages, geographic location, teaching status, and emergency department status.

Skilled Nursing Facility Services Medicare uses a prospective payment system for skilled nursing facilities (SNFs) that pays facilities a predetermined daily rate for each day of care, up to 100 days. The rates are expected to cover all operating (nursing care, rehabilitation services, and other goods and services) and capital costs that efficient facilities would incur in providing SNF services. Various high-cost, low-probability ancillary services are covered separately. Patients are assigned to one of 66 categories, called resource utilization groups (RUGs), on the basis of patient characteristics and services used that are expected to require similar resources. Nursing and therapy weights are applied to the base payment rates of each RUG. Daily base payment rates are also adjusted to account for geographic differences in labor costs.

Home Health Care Services Medicare uses a prospective payment system that pays home health agencies a predetermined rate for each 60-day episode of home health care. If fewer than five visits are delivered during a 60-day episode, the home health agency is paid per visit, by visit type. Patients who receive five or more visits are assigned to one of 153 home health resource groups, which are based on clinical and functional status and service use as measured by the Outcome and Assessment Information Set (OASIS). The payment rates are adjusted to reflect local market input prices and special circumstances, such as high-cost outliers.

Critical Access Hospitals The Balanced Budget Act of 1997 created a new category of hospitals called critical access hospitals (CAHs), which operate primarily in rural areas. Each of the approximately 1,300 CAHs is limited to 25 beds, and patients are limited to a four-day length of stay. The limited size and short length-of-stay requirements are designed to encourage CAHs to focus on providing inpatient and outpatient care for common, less complex conditions while referring more complex patients to larger, more distant hospitals. Unlike most other acute care hospitals (which are paid using prospective payment systems), Medicare pays CAHs on the basis of reported costs. As of this writing, each CAH receives 99 percent of the costs it incurs in providing outpatient, inpatient, laboratory, and therapy services and post-acute care. The cost of treating Medicare patients is estimated using cost accounting data from Medicare cost reports. The purpose of the different reimbursement system for CAHs is to enhance the financial performance of small rural hospitals and thus reduce hospital closures.

Chapter 2 Supplement Chapter 2 Supplement Chapter 2 Supplement Hospice Services Medicare pays hospice providers a daily rate for each day a beneficiary is enrolled in the hospice program, regardless of the amount of services provided, even on days when no services are provided. The daily payment rates are intended to cover costs of providing services included in patients care plans. Payments are made according to a fee schedule for four different categories of care: routine home care, continuous home care, inpatient respite care, and general inpatient care. The four categories of care differ by the location and intensity of the services provided, and the base payments for each category reflect variation in expected input cost differences.

Ambulance Services Medicare pays for ambulance services using a dedicated fee schedule, which has set rates for nine payment categories of ground and air ambulance transport.

Historical costs are used as the basis to establish relative values for each payment category. These relative values are multiplied by a dollar amount that is standard across all nine categories and then adjusted for geographic differences. This amount is added to a mileage payment to arrive at the total ambulance payment amount. Medicare payments for ambulance services may also be adjusted by one of several add-on payments based on additional geographic characteristics of the transport.

II FINANCIAL ACCOUNTING Part I discusses the unique environment that creates the framework for the practice of healthcare finance. Now, in Part II, we begin the actual coverage of healthcare finance by discussing financial accounting, which involves the preparation of a business s financial statements. These statements are designed to provide pertinent financial information about an organization both to its managers and to the public at large.

The coverage of financial accounting extends over several chapters.

Chapter 3 begins the coverage with an introduction to basic financial accounting concepts and an explanation of how organizations report financial performance, specifically revenues, expenses, and profits. Then, in Chapter 4, the discussion is extended to the reporting of financial status, which includes an organization s assets, liabilities, and equity. In addition, Chapter 4 covers the way in which organizations report cash flows. Finally, note that Chapter 17 is related to financial accounting in that it also discusses financial statements, but the focus is on how interested parties use financial statement data to assess the financial condition of an organization. That material has purposely been placed at the end of the book because the nuances of financial statement analysis can be better understood after learning more about the financial workings of a business. Part II and Chapter 17, taken together, will provide readers with a basic understanding of how financial statements are created and used to make judgments regarding the operational status and financial condition of health services organizations.

THE INCOME STATEMENT AND STATEMENT 3 OF CHANGES IN EQUITY Learning Objectives After studying this chapter, readers will be able to Explain why financial statements are so important both to managers and to outside parties.

Describe the standard-setting process under which financial accounting information is created and reported, as well as the underlying principles applied.

Describe the components of the income statement revenues, expenses, and profitability and the relationships within and among these components.

Explain the differences between operating income and net income, and between net income and cash flow.

Describe the format and use of the statement of changes in equity.

Introduction Financial accounting involves identifying, measuring, recording, and communicating in dollar terms the economic events and status of an organization.

This information is summarized and presented in a set of financial statements, or just financials. Because these statements communicate important information about an organization, financial accounting is often called the language of business. Managers of health services organizations must understand the basics of financial accounting because financial statements are the best way to summarize a business s financial status and performance.

Historical Foundations of Financial Accounting It is all too easy to think of financial statements merely as pieces of paper with numbers written on them, rather than in terms of the economic events and physical assets such as land, buildings, and equipment that underlie the Financial accounting The field of accounting that focuses on the measurement and communication of the economic events and status of an entire organization.

numbers. If readers of financial statements understand how and why financial accounting began and how financial statements are used, they can better visualize what is happening within a business and why financial accounting information is so important.

Many thousands of years ago, individuals and families were self-contained in the sense that they gathered their own food, made their own clothes, and built their own shelters. When specialization began, some individuals or families became good at hunting, others at making spearheads, others at making clothing, and so on. With specialization came trade, initially by bartering one type of goods for another. At first, each producer worked alone, and trade was strictly local. Over time, some people set up production shops that employed workers, simple forms of money were used, and trade expanded beyond the local area. As these simple economies expanded, more formal forms of money developed and a primitive form of banking began, with wealthy merchants lending profits from past dealings to enterprising shop owners and traders who needed money to expand their operations.

When the first loans were made, lenders could physically inspect borrowers assets and judge the likelihood of repayment. Eventually, though, lending became much more complex. Industrial borrowers were developing large factories, merchants were acquiring fleets of ships and wagons, and loans were being made to finance business activities at distant locations. At that point, lenders could no longer easily inspect the assets that backed their loans, and they needed a practical way of summarizing the value of those assets. Also, certain loans were made on the basis of a share of the profits of the business, so a uniform, widely accepted method for expressing income was required. In addition, owners required reports to see how effectively their own enterprises were being operated, and governments needed information to assess taxes. For all these reasons, a need arose for financial statements, for accountants to prepare the statements, and for auditors to verify the accuracy of the accountants work.

The economic systems of industrialized countries have grown enormously since the early days of trade, and financial accounting has become much more complex. However, the original reasons for accounting statements still apply:

Bankers and other investors need accounting information to make intelligent investment decisions; managers need it to operate their organizations efficiently; and taxing authorities need it to assess taxes in an equitable manner.

It should be no surprise that problems can arise when translating physical assets and economic events into accounting numbers. Nevertheless, that is what accountants must do when they construct financial statements. To illustrate the translation problem, the numbers shown on the balance sheet to reflect a business s assets and liabilities generally reflect historical costs and prices. However, inventories may be spoiled, obsolete, or even missing; land, buildings, and equipment may have current values that are much higher or lower than their historical costs; and money owed to the business may be uncollectible. Also, some liabilities, such as obligations to make lease payments, may not even show up in the numbers. Similarly, costs reported on an income statement may be understated or overstated, and some costs, such as depreciation (the loss of value of buildings and equipment), do not even represent current cash expenses. When examining a set of financial statements, it is best to keep in mind the physical reality that underlies the numbers and to recognize that many problems occur in the translation process.

SELF-TEST 1. What are the historical foundations of financial accounting QUESTIONS statements?

2. Do any problems arise when translating physical assets and economic events into monetary units? Give one or two illustrations to support your answer.

The Users of Financial Accounting Information The predominant users of financial accounting information are those parties that have a financial interest in the organization and hence are concerned with its economic status. All organizations, whether not-for-profit or investor owned, have stakeholders that have an interest in the business. In a not-for-Stakeholder profit organization, such as a community hospital, the stakeholders include A party that managers, staff physicians, employees, suppliers, creditors, patients, and even has an interest, often financial, the community at large. Investor-owned hospitals have essentially the same in a business.

set of stakeholders, plus owners. Because all stakeholders, by definition, have Stakeholders can an interest in the organization, all stakeholders have an interest in its financial condition.

be affected by the business s actions, objectives, or Of all the outside stakeholders, investors, who supply the capital (funds) policies.

needed by businesses, typically have the greatest financial interest in health services organizations. Investors fall into two categories: (1) owners who supply equity capital to investor-owned businesses and (2) creditors (or lenders) who supply debt capital to both investor-owned and not-for-profit businesses.

(In a sense, communities supply equity capital to not-for-profit organizations, so they, too, are investors.) In general, there is only one category of owners.

However, creditors constitute a diverse group of investors that includes banks, suppliers granting trade credit, and bondholders. Because of their direct financial interest in healthcare businesses, investors are the primary outside users of financial accounting information. They use the information to make judgments about whether to make a particular investment as well as to set SELF-TEST QUESTIONS Securities and Exchange Commission (SEC) The federal government agency that regulates the sale of securities and the operations of securities exchanges.

Also has overall responsibility for the format and content of financial statements.

the return required on the investment. (Investor-supplied capital is covered in greater detail in chapters 11, 12, and 13.) Although the field of financial accounting developed primarily to meet the information needs of outside parties, the managers of an organization, including its board of directors (trustees), also are important users of the information. After all, managers are charged with ensuring that the organization has the financial capability to accomplish its mission, whether that mission is to maximize the wealth of its owners or to provide healthcare services to the community at large.

Thus, an organization s managers not only are involved with creating financial statements but also are important users of the statements, both to assess the current financial condition of the organization and to formulate plans to ensure that the future financial condition of the organization will support its goals.

In summary, investors and managers are the predominant users of financial accounting information as a result of their direct financial interest in the organization. Furthermore, investors are not merely passive users of financial accounting information; they do more than just read and interpret the statements.

Often, they create financial targets based on the numbers reported in financial statements that managers must attain or suffer some undesirable consequence. For example, many debt agreements require borrowers to maintain stated financial standards, such as a minimum earnings level, to keep the debt in force. If the standards are not met, the lender can demand that the business immediately repay the full amount of the loan. If the business fails to do so, it may be forced into bankruptcy.

1. What is a stakeholder?

2. Who are the primary users of financial accounting information?

3. Are investors passive users of this information?

Regulation and Standards in Financial Accounting As a consequence of the Great Depression of the 1930s, which caused many businesses to fail and almost brought down the entire securities industry, the federal government began regulating the form and disclosure of information related to publicly traded securities. The regulation is based on the theory that financial information constructed and presented according to standardized rules allows investors to make the best-informed decisions. The newly formed (at that time) Securities and Exchange Commission (SEC), an independent regulatory agency of the US government, was given the authority to establish and enforce the form and content of financial statements. Nonconforming companies are prohibited from selling securities to the public, so many businesses comply to gain better access to capital. Not-for-profit corporations that do not sell securities still must file financial statements with state authorities that conform to SEC standards. Finally, most for-profit businesses that do not sell securities to the public are willing to follow the SEC-established guidelines to ensure uniformity of presentation of financial data. The end result is that all businesses, except for the smallest, create SEC-conforming financial statements.

Rather than directly manage the process, the SEC designates other organizations to create and implement the standards system. For the most part, the SEC has delegated the responsibility for establishing reporting standards to the Financial Accounting Standards Board (FASB) a private organization whose mission is to establish and improve standards of financial accounting and reporting for private businesses. (The Government Accounting Standards Board [GASB] has the identical responsibility for businesses that are partially or totally funded by a government entity.) Typically, the guidance issued by FASB, which is promulgated by numbered statements, applies across a wide range of industries and, by design, is somewhat general in nature. More specific implementation guidance, especially when industry- unique circumstances must be addressed, is provided by industry committees established by the American Institute of Certified Public Accountants (AICPA) the professional association of public (financial) accountants. For example, financial statements in the health services industry are based on the AICPA Audit and Accounting Guide titled Health Care Entities, which was published most recently on September 1, 2014.

Because of the large number of statements and pronouncements that have been issued by FASB and other standard-setting organizations, FASB combined all of the previously issued standards into a single set called the FASB Accounting Standards Codification, which became effective on September 15, 2009. The purpose of the codification is to simplify access to accounting standards by placing them in a single source and creating a system that allows users to more easily research and reference accounting standards data.

When even more specific guidance is required than provided by the standards, other professional organizations may participate in the process, although such work does not have the same degree of influence as codification has. For example, the Healthcare Financial Management Association has established the Principles and Practices Board, which develops position statements and analyses on issues that require further guidance for example, its statement regarding the valuation and financial statement presentation of charity care and bad debt losses, which was issued in 2006 and revised in 2012.

When taken together, all the guidance contained in the codification and the amplifying information constitute a set of guidelines called generally accepted accounting principles (GAAP). GAAP can be thought of as a set of objectives, conventions, and principles that have evolved through the years to guide the preparation and presentation of financial statements. In essence, GAAP sets the rules for the financial statement preparation game.

Financial Accounting Standards Board (FASB) A private organization whose mission is to establish and improve the standards of financial accounting and reporting for private businesses.

American Institute of Certified Public Accountants (AICPA) The professional association of public (financial) accountants.

Generally accepted accounting principles (GAAP) The set of guidelines that has evolved to foster the consistent preparation and presentation of financial statements.

Note, however, that GAAP applies only to the area of financial accounting (financial statements), as distinct from other areas of accounting, such as managerial accounting (discussed in later chapters) and tax accounting.

It should be no surprise that the field of financial accounting is typically classified as a social science rather than a physical science. Financial accounting is as much an art as a science, and the end result represents negotiation, compromise, and interpretation. The organizations involved in setting standards are continuously reviewing and revising GAAP to ensure the best possible development and presentation of financial data. This task, which is essential to economic prosperity, is motivated by the fact that the US economy is constantly evolving, with new types of business arrangements and securities being created almost daily.

For large organizations, the final link in the financial statement quality assurance process is the external audit, which is performed by an independent (outside) auditor usually one of the major accounting firms. The results of For Your Consideration International Financial Reporting Standards As the globalization of business continues, it becomes more and more important for financial accounting standards to be uniform across countries.

At this time, FASB and the International Accounting Standards Board (IASB) are working jointly on convergence, a process to develop a common set of standards that would be accepted worldwide. These standards, called International Financial Reporting Standards (IFRS), ultimately will be applicable to for-profit businesses in more than 150 countries, including the United States.

Currently, over 100 countries have adopted IFRS standards, but not the United States.

Needless to say, a large number of details must be worked out, and differences between current US and international standards must be resolved. Thus, it is expected that total convergence will not occur for a number of years. Also, the impact of international standards on not-forprofit organizations is uncertain at this time.

What do you think? Should financial accounting standards be applicable to for-profit businesses worldwide as opposed to country by country? What is the rationale behind your opinion? Should not-for-profit organizations be subject to international standards? Support your position.

the external audit are reported in the auditor s opinion, which is a letter attached to the financial statements stating whether or not the statements are a fair presentation of the business s operations, cash flows, and financial position as specified by GAAP.

There are several categories of opinions given by auditors. The most favorable, which is essentially a clean bill of health, is called an unqualified opinion. Such an opinion means that, in the auditor s opinion, the financial statements conform to GAAP, are presented fairly and consistently, and contain all necessary disclosures. A qualified opinion means that the auditor has some reservations about the statements, while an adverse opinion means that the auditor believes that the statements do not present a fair picture of the financial status of the business. The entire audit process, which is performed by the organization s internal auditors and the external auditor, is a means of verifying and validating the organization s financial statements. Of course, an unqualified opinion gives users, especially those external to the organization, more confidence that the statements truly represent the business s current financial condition.

Although one would think that the guidance given under GAAP, along with auditing rules, would be sufficient to prevent fraudulent financial statements, in the early 2000s several large companies, including HealthSouth, which operates the nation s largest network of rehabilitation services, were found to be cooking the books. Because the US financial system is so dependent on the reliability of financial statements, in 2002 Congress passed the Sarbanes- Oxley Act, generally known as SOX, as a measure to improve transparency in financial accounting and to prevent fraud. (According to the SEC, transparency means the timely, meaningful, and reliable disclosure of a business s financial information.) Here are just a few of the more important provisions of SOX:

An independent body, the Public Accounting Oversight Board, was created to oversee the entire audit process.

Auditors can no longer provide non-auditing (consulting) services to the companies that they audit.

The lead partners of the audit team for any company must rotate off the team every five years (or more often).

Senior managers involved in the audits of their companies cannot have been employed by the auditing firm during the one-year period preceding the audit.

Each member of the audit committee shall be a member of the company s board of directors and shall otherwise be independent of the audit function.

The chief executive officer (CEO) and chief financial officer (CFO) shall personally certify that the business s financial statements are complete and accurate. Penalties for certifying reports that are known to be false range up to a $5 million fine, 20 years in prison, or both. In addition, if the financial statements must be restated because they are false, certain bonuses and equity-based compensation that certifying executives earned must be returned to the company.

It is hoped that these provisions, along with others in SOX, will deter future fraudulent behavior by managers and auditors. So far, so good.

SELF-TEST QUESTIONS 1. Why are widely accepted principles important for the measurement and recording of economic events?

2. What entities are involved in regulating the development and presentation of financial statements?

3. What does GAAP stand for, and what is its primary purpose?

4. What is the purpose of the auditor s opinion?

5. What is the purpose of SOX, and what are some of its provisions?

Accounting entity The entity (business) for which a set of accounting statements applies.

Conceptual Framework of Financial Reporting Because the actual preparation of financial statements is done by accountants, a detailed presentation of accounting theory is not required in this book.

However, to better understand the content of financial statements, it is useful to discuss some aspects of the conceptual framework that accountants apply when they develop financial accounting data and prepare an organization s financial statements. By understanding this framework, readers will be better prepared to understand and interpret the financial statements of healthcare organizations.

The goal of financial accounting is to provide information about organizations that is useful to present and future investors and other users in making rational financial and investment decisions. To achieve this objective, GAAP specifies recognition and measurement concepts that include four assumptions, four principles, and two constraints.

Assumptions Accounting Entity The first assumption is the ability to define the accounting entity, which is important for two reasons. First, for investor-owned businesses, financial accounting data must be pertinent to the business activity as opposed to the personal affairs of the owners. Second, within any business, the accounting entity defines the specific areas of the business to be included in the statements.

For example, a healthcare system may create one set of financial statements for the system as a whole and separate sets of statements for its subsidiary hospitals. In effect, the accounting entity specification establishes boundaries that tell readers what business (or businesses) is being reported on.

Going Concern It is assumed that the accounting entity will operate as a going concern and hence will have an indefinite life. This means that assets, in general, should be valued on the basis of their contribution to an ongoing business as opposed to their current fair market value. For example, the land, buildings, and equipment of a hospital may have a value of $50 million when used to provide patient services, but if they are sold to an outside party for other purposes, the value of these assets might only be $20 million. Furthermore, short-term events should not be allowed to unduly influence the data presented in financial statements.

The going concern assumption, coupled with the fact that financial statements must be prepared for relatively short periods (as explained next), means that financial accounting data are not exact but represent logical and systematic approaches applied to complex measurement problems.

Periodicity Because accounting entities are assumed to have an indefinite life but users of financial statements require timely information, it is common to report financial results on a relatively short periodic basis. The period covered, called an accounting period, can be any length of time over which an organization s managers, or outside parties, want to evaluate operational and financial results.

Most health services organizations use calendar periods months, quarters, and years as their accounting periods. However, occasionally an organization will use a fiscal year (financial year) that does not coincide with the calendar year. For example, the federal government has a fiscal year that runs from October 1 to September 30, and the State of Florida has a fiscal year that runs from July 1 to June 30. Although annual accounting periods are typically used for illustrations in this book, financial statements commonly are prepared for periods shorter than one year. For example, many organizations prepare semiannual and quarterly financial statements in addition to annual statements.

Monetary Unit The monetary unit provides the common basis by which economic events are measured. In the United States, this unit is the dollar, unadjusted for inflation or deflation. Thus, all transactions and events must be expressed in dollar terms.

Principles Historical Costs The historical cost principle requires organizations to report the values of most assets based on acquisition costs rather than fair market value, which implies that the dollar has constant purchasing power over time. In other words, land that cost $1 million 20 years ago might be worth $2 million today, but it is still reported at its initial cost of $1 million. The accounting profession has grappled with the inflation impact problem for years but has not yet developed a feasible solution. The historical cost principle ensures reliable information, which removes subjectivity, but it does not provide the most current information.

We should note, however, that some items (primarily security holdings) are reported at fair market value.

Revenue Recognition The revenue recognition principle requires that revenues be recognized in the period in which they are realizable and earned. Generally, this is the period in which the service is rendered, because at that point the price is known (realizable) and the service has been provided (earned). However, in some instances, difficulties in revenue recognition arise, primarily when there are uncertainties surrounding the revenue amount or the completion of the service.

Accounting period The period (amount of time) covered by a set of financial statements often a year, but sometimes a quarter or another time period.

Fiscal year The year covered by an organization s financial statements.

It usually, but not necessarily, coincides with a calendar year.

Historical cost In accounting, the purchase price of an asset.

Revenue recognition principle The concept that revenues must be recognized in the accounting period in which they are realizable and earned.

Expense Matching The expense-matching principle requires that an organization s expenses be matched, to the extent possible, with the revenues to which they are related.

In essence, after the revenues have been allocated to a particular accounting period, all expenses associated with producing those revenues should be matched to the same period. Although the concept is straightforward, implementation of the matching principle creates many problems. For example, consider long-lived assets such as buildings and equipment. Because such assets for example, an MRI machine provide revenues for several years, the expense- matching principle dictates that its acquisition cost should be spread over the same number of years. However, there are many alternative ways to do this, and no single method is clearly best.

Full Disclosure Financial statements must contain a complete picture of the economic events of the business. Anything less would be misleading by omission. Furthermore, because financial statements must be relevant to a diversity of users, the full-disclosure principle pushes preparers to include even more information in financial statements. However, the complexity of the information presented can be mitigated to some extent by placing some information in the notes or supplementary information sections as opposed to the body of the financial statements.

Constraints Materiality If the financial statements contained all possible information, they would be so long and detailed that making inferences about the organization would be difficult without a great deal of analysis. Thus, to keep the statements manageable, only entries that are important to the operational and financial status of the organization need to be separately identified. For example, medical equipment manufacturers carry large inventories of materials that are both substantial in dollar value relative to other assets and instrumental to their core business, so such businesses report inventories as a separate asset item on the balance sheet. Hospitals, on the other hand, carry a relatively small amount of inventories. Thus, many hospitals and other healthcare providers do not report inventories separately but combine them with other assets. In general, the materiality constraint affects the presentation of the financial statements rather than their aggregate financial content (i.e., the final numbers).

Cost Benefit There are costs associated with financial statement information for both the preparers of the statements and the users. Preparers must collect, record, verify, and report financial information, while users must analyze and interpret the information. As a result, financial statements cannot report all possible information that every potential user might find relevant. When deciding what information should be reported, and how that information should be reported, standards setters and accountants must determine whether the benefits of the information outweigh the associated costs.

1. Why is it important to understand the basic accounting concepts that underlie the preparation of financial statements?

2. What is the goal of financial accounting?

3. Briefly explain the following assumptions, principles, and constraints as they apply to the preparation of financial statements:

Accounting entity Going concern Accounting period Monetary unit Historical cost Revenue recognition Expense matching Full disclosure Materiality Cost benefit Accounting Methods: Cash Versus Accrual In the implementation of the conceptual framework discussed in the previous section, two different methods have been applied: cash accounting and accrual accounting. Although, as we discuss below, each method has its own set of advantages and disadvantages, GAAP specifies that only the accrual method can receive an unqualified auditor s opinion, so accrual accounting dominates the preparation of financial statements. Still, many small businesses that do not require audited financial statements use the cash method, and knowledge of the cash method helps our understanding of the accrual method, so we discuss both methods here.

Cash Accounting Under cash accounting, often called cash basis accounting, economic events are recognized put into the financial statements when the cash transaction SELF-TEST QUESTIONS Cash accounting The recording of economic events when a cash exchange takes place.

Accrual accounting The recording of economic events in the periods in which the events occur, even if the associated cash receipts or payments happen in a different period.

occurs. For example, suppose Sunnyvale Clinic, a large multispecialty group practice, provided services to a patient in December 2015. At that time, the clinic billed Florida Blue (Blue Cross and Blue Shield of Florida) $700, the full amount that the insurer was obligated to pay. However, Sunnyvale did not receive payment from the insurer until February 2016. If it used cash accounting, the $700 obligation on the part of Florida Blue would not appear in Sunnyvale s 2015 financial statements. Rather, the revenue would be recognized when the cash was actually received in February 2016.

The core argument in favor of cash accounting is that the most important event to record on the financial statements is the receipt of cash, not the provision of the service (i.e., the obligation to pay). Similarly, Sunnyvale s costs of providing services would be recognized as the cash is physically paid out:

Inventory costs would be recognized as supplies are purchased, labor costs would be recognized when employees are paid, new equipment purchases would be recognized when the invoices are paid, and so on. To put it simply, cash accounting records the actual flow of money into and out of a business.

There are two advantages to cash accounting. First, it is simple and easy to understand. No complex accounting rules are required for the preparation of financial statements. Second, cash accounting is closely aligned to accounting for tax purposes, and hence it is easy to translate cash accounting statements into income tax filing data. Because of these advantages, about 80 percent of all medical practices, typically the smaller ones, use cash accounting. However, cash accounting has its disadvantages, primarily the fact that in its pure form it does not present information on revenues owed to a business by payers or the business s existing payment obligations.

Before closing our discussion of cash accounting, we should note that most businesses that use cash accounting do not use the pure method described here but use a hybrid method called modified cash basis accounting.

The modified statements combine some features of cash accounting, usually to report revenues and expenses, with some features of accrual accounting, usually to report assets and liabilities. Still, the cash method presents an incomplete picture of the financial status of a business and hence the preference by GAAP for accrual accounting.

Accrual Accounting Under accrual accounting, often called accrual basis accounting, the economic event that creates the financial transaction, rather than the transaction itself, provides the basis for the accounting entry. When applied to revenues, the accrual concept implies that revenue earned does not necessarily correspond to the receipt of cash. Why? Earned revenue is recognized in financial statements when a service has been provided that creates a payment obligation on the part of the payer, rather than when the payment is actually received.

For healthcare providers, the payment obligation typically falls on the patient, a third-party payer, or both. If the obligation is satisfied immediately, such as when a patient makes full payment at the time the service is rendered, the revenue is in the form of cash. In such cases, the revenue is recorded at the time of service whether cash or accrual accounting is used.

However, in most cases, the bulk of the payment for services comes from third-party payers and is not received until later, perhaps several months after the service is provided. In this situation, the revenue created by the service does not create an immediate cash payment. If the payment is received within an accounting period one year, for our purposes the conversion of revenues to cash will be completed, and as far as the financial statements are concerned, the reported revenue is cash. However, when the revenue is recorded (i.e., services are provided) in one accounting period and payment does not occur until the next period, the revenue reported has not been collected.

Consider the Sunnyvale Clinic example presented in our discussion of cash accounting. Although the services were provided in December 2015, the clinic did not receive its $700 payment until February 2016. Because Sunnyvale s accounting year ended on December 31 and the clinic actually uses accrual accounting, the clinic s books were closed after the revenue had been recorded but before the cash was received. Thus, Sunnyvale reported this $700 of revenue on its 2015 financial statements, even though no cash was collected. When accrual accounting is used, the amount of revenues not collected is listed as a receivable (the amount due to Sunnyvale) in the financial statements, so users will know that not all reported revenues represent cash receipts.

The accrual accounting concept also applies to expenses. To illustrate, assume that Sunnyvale had payroll obligations of $20,000 for employees work during the last week of 2015 that would not be paid until the first payday in 2016. Because the employees actually performed the work, the obligation to pay the salaries was created in 2015. An expense will be recorded in 2015 even though no cash payment will be made until 2016. Under cash basis accounting, Sunnyvale would not recognize the labor expense until it was paid, in this case in 2016. But under accrual accounting, the $20,000 will be shown as an expense on the financial statements in 2015 and, at the same time, the statements will indicate that a $20,000 liability (or obligation to pay employees) exists.

SELF-TEST QUESTIONS 1. Briefly explain the differences between cash and accrual accounting, and give an example of each.

2. What is modified cash basis accounting?

3. Why does GAAP favor accrual over cash accounting?

General ledger The master listing of an organization s primary accounts, which record the transactions that ultimately are used to create a business s financial statements.

Chart of accounts A document that assigns a unique numerical identifier to every account of an organization.

Recording and Compiling Financial Accounting Data The ultimate goal of a business s financial accounting system is to produce financial statements. However, the road from the recording of basic accounting data to the completion of the financial statements is long and arduous, especially for large, complex organizations. The starting point for the identification and recording of financial accounting information is a transaction, which is defined as an exchange of goods or services from one individual or enterprise to another. To ensure that the transaction is faithfully represented and verifiable two qualitative characteristics of useful financial information under the conceptual framework each transaction must be supported by relevant documentation, which is retained for some required length of time.

Once a transaction is identified, it must be recorded, or posted, to an account, which is a record of transactions for one uniquely identified activity.

For example, under the general heading of cash, separate accounts might be established for till cash, payroll checks, vendor checks, other checks, and the like. A large business can easily have hundreds, or even thousands, of separate primary accounts, which are combined to form the general ledger, plus subsidiary accounts that support the primary accounts. The subsidiary accounts, which pertain to specific assets or liabilities or to individual patients or vendors, are aggregated to create data for a primary (general ledger) account. For example, individual patient charges, which are carried in subsidiary accounts, are aggregated into one or more general ledger revenue accounts.

To help manage the large number of accounts, businesses have a document called a chart of accounts, which assigns a unique numeric code to each account. For example, the till cash account might have the code 1-1000-00, while the account for checks written might have the code 1-1100-00. The first 1 indicates that the account is an asset account; the second 1 indicates a cash account; and the next digit, 0 or 1, indicates the specific cash account.

Further numbers are available should the organization decide to subdivide either the till cash or the checks-written accounts into subsidiary accounts.

For example, the next digit of the checks-written account might indicate the purpose of the check: 1 for payroll, 2 for vendor payments, and so on. Because everyone who deals with the accounts is familiar with the business s chart of accounts, transactions can be easily sorted by account code to ensure that they are posted to the correct account.

Within the system of primary and subsidiary accounts, accounts are further classified as follows:

Permanent accounts include items that must be carried from one accounting period to another. Thus, permanent accounts remain active until the items in the account are no longer on the books of the business. For example, an account might be created, or opened, to contain all transactions related to a five-year bank loan. The account would remain open to record transactions relating to the loan say, annual interest payments until the loan was paid off in five years, at which time the account would be closed.

Temporary accounts are for those items that will automatically be closed at the end of each accounting period. For example, a business s revenue and expense accounts typically are closed at the end of the accounting period, and then new accounts are opened, with a zero balance, at the beginning of the next period.

Contra accounts are special accounts that convert the gross value of some other account into a net value. As you will see in the next chapter, there is a contra account associated with depreciation expense, which accounts for the loss of value of buildings and equipment due to wear and tear. Each transaction is recorded in an account by a journal entry. The system used in making journal entries is called the double entry system because each transaction must be entered in at least two different accounts once as a debit and once as a credit. Such a system ensures consistency among the financial statements. Because accounts have both debit and credit entries, they traditionally have been set up in a T format and hence are called T accounts, with debits entered on the left side of the vertical line and credits entered on the right side. To illustrate the double entry system, assume that Sunnyvale Clinic receives $100 in cash from a self-pay patient at the time of the visit. A debit entry would be made in the cash account indicating a $100 receipt, while a credit entry would be made in the equity account indicating that the business s value has increased by the amount of the cash revenue.

Note that whether an entry is a debit or a credit depends both on the nature of the entry (revenue or expense) and the type of account, so these entries may be counterintuitive to someone not familiar with the double entry system.

Ultimately, the journal entries are verified, consolidated, and reconciled in a trial balance, and the trial balance is formatted into the business s financial statements. Often, the primary means for disseminating this information to outsiders is the business s annual report. It typically begins with a descriptive section that discusses, in general terms, the organization s operating results over the past year as well as developments that are expected to affect future operations.

The descriptive section is followed by the business s financial statements.

Because the actual financial statements cannot possibly contain all relevant information, additional information is provided in the notes section.

For health services organizations, these notes contain information on such topics as inventory accounting practices, the composition of long-term debt, pension plan status, the amount of charity care provided, and the cost of malpractice insurance.

Double entry system The system used to make accounting journal entries. Called double entry because each transaction has to be entered in at least two different accounts.

Annual report A report issued annually by an organization to its stakeholders that contains descriptive information and historical financial statements.

In addition to the body of the financial statements and the notes section, GAAP requires organizations to provide certain supplementary information.

Other supplementary information may be voluntarily provided by the reporting organization. For example, a healthcare system may report the revenues of its primary subsidiaries as supplementary data even though the statements focus on the aggregate revenues of the entire system. Because the notes and supplementary information sections contain a great deal of information essential to a good understanding of the financial statements, a thorough examination always considers the information contained in these two sections.

SELF-TEST QUESTIONS 1. Briefly explain the following terms used in the recording and compiling of accounting data:

Transaction Account Posting Chart of accounts General ledger T account Double entry system 2. Why are the notes and supplementary information sections important parts of the financial statements?

Income Statement Basics In this section, we begin our coverage of the four primary financial statements by discussing the income statement. Then, in a later section, we discuss the statement of changes in equity. In Chapter 4, the remaining two statements the balance sheet and the statement of cash flows are discussed. Unfortunately, the names of the statements are not consistent across types of organizations.

We will introduce the alternative names of each statement as it is discussed.

The purpose of our financial accounting discussion is to provide readers with a basic understanding of the preparation, content, and interpretation of a business s financial statements. Unfortunately, the financial statements of large organizations can be long and complex, and there is significant leeway regarding the format used, even within health services organizations. Thus, in our discussion of the statements, we use simplified illustrations that focus on key issues. In a sense, the financial statements presented here are summaries of actual financial statements, but this is the best way to learn the basics; the nuances must be left to other books that focus exclusively on accounting issues.

Perhaps the most frequently asked, and the most important, question about a business is this: Is it making money? The income statement summarizes the operations (activities) of an organization with a focus on its revenues, expenses, and profitability. Thus, the income statement is also called the statement of operations, statement of activities, or statement of revenues and expenses.

The income statements of Sunnyvale Clinic are presented in Exhibit 3.1.

Most financial statements contain two or three years of data, with the most recent year presented first. The title section tells us that these are annual income statements, ending on December 31, for the years 2015 and 2014. Whereas the balance sheet, which is covered in Chapter 4, reports a business s financial position at a single point in time, the income statement contains operational results over a specified period of time. Because these income statements are part of Sunnyvale s annual report, the time (accounting) period is one year. Also, the dollar amounts reported are listed in thousands of dollars, so the $148,118 listed as net patient service revenue for 2015 is actually $148,118,000.

The core components of the income statement are straightforward:

revenues, expenses, and profitability (net operating income and net income).

Revenues, as discussed previously in the section on cash versus accrual accounting, represent both the cash received and the unpaid obligations of payers for 2015 2014 Operating Revenues:

Patient service revenue Less: Provision for bad debts Net patient service revenue Premium revenue Other revenue Net operating revenues Expenses:

Salaries and benefits Supplies Insurance Lease Depreciation Interest Total expenses Operating income Nonoperating income:

Contributions Investment income Total nonoperating income Net income $ 150,118 2,000 $ 148,118 18,782 3,079 $ 169,979 $ 126,223 20,568 4,518 3,189 6,405 5,329 $ 166,232 $ 3,747 $ 243 3,870 $ 4,113 $ 7,860 $123,565 1,800 $ 121,765 16,455 2,704 $140,924 $ 102,334 18,673 3,710 2,603 5,798 3,476 $ 136,594 $ 4,330 $ 198 3,678 $ 3,876 $ 8,206 Income statement A financial statement, prepared in accordance with generally accepted accounting principles (GAAP), that summarizes a business s revenues, expenses, and profitability.

EXHIBIT 3.1 Sunnyvale Clinic:

Statements of Operations, Years Ended December 31, 2015 and 2014 (in thousands) services provided during each year presented. For healthcare providers, the revenues result mostly from the provision of patient services. However, in addition to revenues from patient and patient-related services, some revenues, designated contributions and investment income in Exhibit 3.1, stem from donations and securities investments, respectively, and hence have nothing to do with patient services.

To produce revenues, organizations must incur expenses, which are classified as operating or capital (financial). Although not separately broken out on the income statement, operating expenses consist of salaries, supplies, insurance, and other costs directly related to providing services. Capital costs are the costs associated with the buildings and equipment used by the organization, such as depreciation, lease, and interest expenses. Expenses decrease the profitability of a business, so expenses are subtracted from revenues to determine an organization s profitability. Sunnyvale s income statement reports two different measures of profitability: operating income and net income.

The income statement, then, summarizes the ability of an organization to generate profits. Basically, it lists the organization s revenues (and income), the expenses that must be incurred to produce the revenues, and the differences between the two. In the following sections, the major components of the income statement are discussed in detail.

SELF-TEST QUESTIONS 1. What is the primary purpose of the income statement?

2. In regard to time, how do the income statement and balance sheet differ?

3. What are the major components of the income statement?

Revenues Revenues can be shown on the income statement in several different formats.

In fact, there is more latitude in the construction of the income statement than there is in that of the balance sheet, so the income statements for different types of healthcare providers tend to differ more in presentation than do their balance sheets. (See problems 3.2 and 3.3, as well as Exhibit 17.1, for examples of income statements from other types of providers.) Sunnyvale s operating revenues section (see Exhibit 3.1) focuses on revenues that stem from the provision of patient services; in other words, they derive from operations. As we discuss in a later section, Sunnyvale also has revenues from contributions and securities investments (nonoperating income), but because such income is not related to core business activities, it is reported separately on the income statement.

The first line of the operating revenues section reports patient service revenue of $150,118,000 for 2015. The key term here is patient service. This line contains revenues that stem solely from patient services, as opposed to revenues that stem from related sources, such as parking fees or food services, which are reported on a separate line in the operating revenues section. Also, as discussed later, patient service revenue that stems from capitated patients may be reported separately. If this is the case, the $150,118,000 reported by Sunnyvale as patient service revenue includes only revenue from fee-forservice patients.

Sunnyvale, like all healthcare providers, has a charge description master file, or chargemaster, that contains the charge code and gross price for each item and service that it provides. However, the chargemaster price rarely represents the amount the clinic expects to be paid for a particular service. For example, the price for a particular service might be $800, while the contract with a particular payer might specify a 40 percent discount from charges, which would result in a reimbursement of only $480. In addition to negotiated discounts, governmental payers such as Medicare and Medicaid reimburse providers a set amount that often is well below the chargemaster (gross) price.

Because recorded revenue must reflect only amounts that are realizable (collectible), differences between chargemaster prices and actual reimbursement amounts are incorporated before the revenue is recorded on the patient service revenue line. Thus, the patient service revenue shown on the income statement is reported after contractual allowances have been considered and hence represents the actual reimbursement amount expected.

To add to the complexity of revenue reporting, some services have been provided as charity care to indigent patients. (Indigent patients are those who presumably are willing to pay for services provided but do not have the ability to do so.) Sunnyvale has no expectation of ever collecting for these services, so, like contractual allowances, charges for charity care services are not reflected in the $150,118,000 patient service revenue reported for 2015.

Finally, some payments for patient services that are owed, and hence reported as patient service revenue, will never be collected and ultimately will become bad debt losses. To recognize that Sunnyvale does not really expect to collect the entire $150,118,000 patient service revenue reported, the second entry in the operating revenues section for 2015 lists a $2,000,000 provision for bad debts. When this amount is subtracted, the result is a net patient service revenue of $148,118,000 for 2015. Note the distinction between charity care and bad debt losses. Charity care represents services that are provided to patients who do not have the capacity to pay. Typically, such patients are identified before the service is rendered. Bad debt losses result from the failure to collect revenues from patients or third-party payers who do have the capacity to pay.

Patient service revenue Revenue that stems solely from the provision of patient services. In some situations, may only reflect revenue from fee-for-service patients.

Industry Practice Revenue Reporting in the Good Old Days About 20 years ago, hospital revenues were reported differently from today. Back then, the revenues section would begin with gross patient services revenue based on chargemaster prices.

In other words, every service provided would be recorded at its chargemaster price and those prices would be aggregated to calculate reported revenues.

Then, the total amount of discounts and allowances would be listed, followed by the total amount of charity care provided, and these values would be subtracted from gross patient service revenue to obtain net patient service revenue.

In this format, discounts and allowances and charity care were prominently displayed at the top of the income statement. Today, however, if these amounts are listed at all, they typically are listed in the notes to the financial statements as opposed to the income statement itself.

Also, the treatment of bad debt losses has recently changed. Whereas the provision for bad debts had been listed on the income statement as an expense, it is now listed as a deduction to patient service revenue.

What do you think? Is the old way or the current system best? Why do you think GAAP was changed to report only the net amount expected to be collected, as opposed to the gross amount billed? Also, why was the provision for bad debt losses moved from an expense item to the revenues section?

Premium revenue Patient service revenue that stems from capitated patients as opposed to fee-forservice patients.

A description of policies regarding discounts and charity care often appears in the notes to the financial statements. Sunnyvale s financial statements include the following two notes:

Revenues. Sunnyvale has entered into agreements with third-party payers, including governmental programs, under which it is paid for services on the basis of established charges, the cost of providing services, predetermined rates, or discounts from established charges.

Revenues are recorded at estimated amounts due from patients and third-party payers for the services provided. Settlements under reimbursement agreements with third-party payers are estimated and recorded in the period the related services are rendered and are adjusted in future periods, as final settlements are determined. The adjustments to estimated settlements for prior years are not considered material and thus are not shown in the financial statements or footnotes.

Charity care. Sunnyvale has a policy of providing charity care to indigent patients in emergency situations. These services, which are not reported as revenues, amounted to $67,541 in 2015 and $51,344 in 2014.

Even though Sunnyvale ultimately expects to collect all of its reported net patient service revenue not yet received, the clinic did not actually receive $148,118,000 in cash payments from fee- for-service patients and insurers in 2015. Rather, some of the revenue has not yet been collected. As readers will learn in Chapter 4, the yet-to-be-collected portion of the net patient service revenue $28,509,000 appears on the balance sheet (see Exhibit 4.1) as net patient accounts receivable.

If a provider has a significant amount of revenue stemming from capita tion contracts, it is often reported separately in the operating revenues section as premium revenue. Sunnyvale reported premium revenue of $18,782,000 for 2015. The key difference is that patient service revenue is reported when services are provided, but premium revenue is reported at the start of each contract payment period typically the beginning of each month. Thus, premium revenue implies an obligation on the part of the reporting organization to provide future services, while patient service revenue represents an obligation on the part of payers to pay the reporting organization for services already provided. Also, different types of providers may use different terminology for revenues; for example, some nursing homes report resident service revenue.

Most health services organizations have revenue related to, but not arising directly from, patient services, and Sunnyvale is no exception. In 2015, Sunnyvale reported other revenue of $3,079,000. Examples of other revenue include parking fees; nonpatient food service charges; office and concession rentals; and sales of pharmaceuticals to employees, staff, and visitors.

When all the revenue associated with patient services is totaled, the amount reported as net operating revenues for 2015 is $169,979,000. This amount represents the net amount of revenue that stems from a provider s core operations the provision of patient services. Income that results from noncore activities primarily contributions and securities investments will be reported at the bottom of the income statement.

1. What categories of revenue are reported on the income statement?

2. Briefly, what is the difference between gross patient service revenue and net patient service revenue?

3. Describe how the following types of revenue are reported on the income statement:

Contractual discounts and allowances Charity care Bad debt losses 4. Is income from securities investments included in the revenue section? If not, why not?

Expenses Expenses are the costs of doing business. As shown in Exhibit 3.1, Sunnyvale reports its expenses in categories such as salaries and benefits, supplies, insurance, and so on. According to GAAP, expenses may be reported using either a natural classification, which classifies expenses by the nature of the expense, as Sunnyvale does, or a functional classification, which classifies expenses by purpose, such as inpatient services, outpatient services, and administrative.

SELF-TEST QUESTIONS Expenses The costs of doing business. Or, the dollar amount of resources used in providing services.

The number and nature of expense items reported on the income statement can vary widely depending on the nature and complexity of the organization. For example, some businesses, typically smaller ones, may report only two categories of expenses: health services and administrative. Others may report a whole host of categories. Sunnyvale takes a middle-of-the-road approach to the number of expense categories. Most users of financial statements would prefer more, as well as a mixing of classifications, rather than less because more insights can be gleaned if an organization reports revenues and expenses both by service breakdown (e.g., inpatient versus outpatient) and by type (e.g., salaries versus supplies). To assist readers, some organizations present additional detail on expenses in the notes to the financial statements.

Sunnyvale is typical of most healthcare providers in that the dominant portion of its cost structure is related to labor. The clinic reported salaries and benefits of $126,223,000 for 2015, which amounts to 75 percent of Sunnyvale s total expenses. The detail of how these expenses are broken down by department or contract, or the relationship of these expenses to the volume or type of services provided, is not part of the financial accounting information system. However, such information, which is very important to managers, is available in Sunnyvale s managerial accounting system. Chapters 5 through 8 focus on managerial accounting matters.

The expense item titled supplies represents the cost of supplies (primarily medical) used in providing patient services. Sunnyvale does not order and pay for supplies when a particular patient service requires them. Rather, the clinic s manager estimates the usage of individual supply items, orders them beforehand, and then maintains a supplies inventory. As readers will see in Chapter 4, the amount of supplies on hand is reported on the balance sheet. The income statement expense reported by Sunnyvale represents the cost $20,568,000 of the supplies actually consumed in providing patient services for 2015. Thus, the expense reported for supplies does not reflect the actual cash spent by Sunnyvale on supplies purchased during the year. In theory, Sunnyvale could have several years worth of supplies in its inventories at the beginning of 2015, could have used some of these supplies without replenishing the stocks, and hence might not have actually spent one dime on supplies during 2015.

Sunnyvale uses commercial insurance to protect against many risks, including property risks, such as fire and damaging weather, and liability risks, such as managerial malfeasance and professional (medical) liability. The cost of this protection is reported on the income statement as insurance expense, which for 2015 amounted to $4,518,000.

Sunnyvale owns all of its land and buildings but leases (rents) much of its diagnostic equipment. The total amount of lease payments $3,189,000 for 2015 is reported as lease expense on the income statement. There are many reasons that health services organizations lease rather than purchase equipment, including protection against technological obsolescence. Chapter 18, which is available online, contains more information on leases and how they are analyzed.

The next expense category, depreciation, requires closer examination.

Businesses require property and equipment (fixed assets) to provide goods and services. Although some of these assets are leased, Sunnyvale owns most of the fixed assets necessary to support its mission. When fixed assets are initially purchased, Sunnyvale does not report their cost as an expense on the income statement. The reason is found in the expense-matching principle, which dictates that such costs be matched to the accounting periods during which the asset produces revenues. A more pragmatic reason for not reporting the costs of fixed assets when they are acquired is that reported earnings would fluctuate widely from year to year on the basis of the amount of fixed assets acquired.

To match the cost of fixed assets to the revenues produced by such long-lived assets, accountants use the concept of depreciation expense, which spreads the cost of a fixed asset over many years. Note that most people use the terms cost and expense interchangeably. To accountants, however, the terms can have different meanings. Depreciation expense is a good example. Here, the term cost is applied to the actual cash outlay for a fixed asset, while the term expense is used to describe the allocation of that cost over time.

The calculation of depreciation expense is somewhat arbitrary, so the amount of depreciation expense applied to a fixed asset in any year generally is not closely related to the actual usage of the asset or its loss in fair market value. To illustrate, Sunnyvale owns a piece of diagnostic equipment that it uses infrequently. In 2014 it was used 23 times, while in 2015 it was used only nine times. Still, the depreciation expense associated with this equipment was the same $7,725 in both years. Also, the clinic owns another piece of equipment that could be sold today for about the same price that Sunnyvale paid for it four years ago, yet each year the clinic reports a depreciation expense for that equipment, which implies loss of value.

Depreciation expense, like all other financial statement entries, is calculated in accordance with GAAP. The calculation typically uses the straight-line method that is, the depreciation expense is obtained by dividing the historical cost of the asset, less its estimated salvage value, by the number of years of its estimated useful life. (Salvage value is the amount, if any, expected to be received when final disposition occurs at the end of an asset s useful life.) The result is the asset s annual depreciation expense, which is the charge reflected in each year s income statement over the estimated life of the asset and, as readers will discover in Chapter 4, accumulated over time on the organization s balance sheet. (The term straight line stems from the fact that the depreciation expense is constant in each year, and hence the implied value of the asset Depreciation A noncash charge against earnings on the income statement that reflects the wear and tear on a business s fixed assets (property and equipment).

declines evenly like a straight line over time.) In 2015, Sunnyvale reported a depreciation expense of $6,405,000, which represents the total amount of deprecation taken on all of the clinic s fixed assets during the year.

In addition to depreciation calculated for financial statement purposes, which is called book depreciation, for-profit businesses must calculate depreciation for tax purposes. Tax depreciation is calculated in accordance with IRS regulations, as opposed to GAAP. Also, note that land is not depreciated for either financial reporting or tax purposes.

In closing our discussion of depreciation expense, note that depreciation is a noncash expense, meaning there is no actual payment associated with the expense. The cash payment was made some time, possibly many years, before the expense appears on the income statement. The impact of noncash expenses on a business s cash flows will be covered in a later section.

Key Equation: Straight-Line Depreciation Calculation Suppose Sunnyvale Clinic purchases an X-ray machine for $150,000. Its useful life, according to accounting guidelines, is ten years, and the machine s expected value at that time is $25,000. The annual depreciation expense, calculated as follows, is $12,500:

Annual depreciation expense = (Initial cost . Salvage value) Useful life = ($150,000 . $25,000) 10 years = $125,000 10 = $12,500.

The final expense line reports interest expense. Sunnyvale owes or paid its lenders $5,329,000 in interest expense for debt capital supplied during 2015.

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