Background
Healthcare delivery and financing aren’t getting any easier. Managed care requirements, the BBA, compliance, and outpatient prospective payment are all adding layers of complexity to the administrative burdens of healthcare providers. No longer is this only an administrative or bookkeeping exercise either. Now payors require that business office personnel also be clinicians who can discern whether or not a service is medically necessary and thus reimbursable. Some legal knowledge is also handy as personnel must sort through complex program compliance issues or deal with an account involving subrogation.
In order to continue to get paid and maintain cash flow, providers have set up further levels of specialization. The result has meant more handoffs, more delays, eroding financial positions, and a much more frustrated set of customers.
What can we do about this? So much of it seems beyond our control. When you factor in the maze of new technologies, it starts to get a bit overwhelming.
The ABC’s of Access Management
We have to start with the patient. At the hub of the patient experience is what is now commonly called Access Management, formerly referred to as Admitting or Registration. This group has the job of collecting enough information to satisfy the clinicians treating the patient, meeting the requirements of Joint Commission and other authoritative bodies, and getting the ball rolling on collecting and settling the account. In other words, the Access Management area has numerous customers in addition to the patient or family member sitting across from them.
Without the benefit of relevant information, providers have attempted to staff Access Management based on past history – namely, if patient and physician complaints aren’t too high, there is probably enough staff. However, staffing in Access Management has not kept up with the increased demands and complexity of the process, and thus other areas are suffering. Clinicians and medical records personnel deal with incomplete or incorrect information. Claims information is incomplete and left to back office to sort through. And all of these things make for a much more unhappy set of customers (both physicians and patients) as they continually have to live with the repercussions of inaccurate and incomplete information.
As the chart above shows, Access Management is the hub of the patient experience and kicks off several processes in the hospital setting: medical record documentation, patient flow, revenue capture, and billing and collections. In each of these areas, we are dealing with an inordinate amount of rework as information that should have been collected and verified in Access Management is corrected or added in other areas. This does not go unnoticed by patients and physicians as these situations erode their confidence in the hospital’s ability to get things right.
Access Management is the area that has the first chance to create the “emotional contract” with the patient that the hospital must have if it is going to be successful. It is here that the tone is set for the patient on the issues with respect to their hospitalization. And it is here that the provider has the chance to begin working on the patient’s behalf to get all the information correct so that the clinical outcomes are appropriate and the account is settled in a timely manner. All of this must happen in an environment that minimizes the likelihood of any of this occurring outside the realm of the complex legal requirements established by state and federal officials.
So why do we let unresolved issues out of the Access Management area? In a manufacturing environment, if there are problems on the front-end design or in the manufacturing process itself, huge problems ripple downstream in terms of recalls, warranty related expenses, lawsuits, and customers that abandon the company’s products. World-class manufacturers dealt with these issues with their TQM and Six Sigma programs during the 80’s and 90’s. Providers, however, are letting the issues in their manufacturing process (Access Management) create huge and costly problems for them in downstream processes.
The first step in understanding the overall implications of this is to analyze how much these non-value-added tasks of reworking are costing the hospital. The way to tackle this is using a discipline that manufacturing adopted in the 80’s and 90’s – activity based costing. In a relatively short period of time, the activities in Access Management and related areas can be identified and costed. The costing is done against relevant workload measures. Thus you can learn what each significant activity is costing in terms of the work that is being produced. Each activity is also identified as value or non-value-added, further identifying issues in the process.
Today, hospitals are looking for a silver bullet answer to their Access Management and Business Office problems. It is hoped that a new Internet technology or outsourcing partner can provide the missing piece of a complicated puzzle. However, it is hard to imagine planning for these types of changes without first going through the analysis of the activities that are consuming the resources of the hospital. That is exactly what activity based costing does. With the information on the cost of the activities, providers are armed with the information needed to make staffing, technology, and partnering decisions. The goal of each of these decisions is to lower the overall cost per workload measure and improve the quality of the process, including the downstream activities.
Getting Started
Every provider must take a proactive role in dealing with this trend. The next few years will prove pivotal in adapting to the new age of the empowered customers, Internet technologies, and more demanding payment plans. The first steps in this journey are assessment and planning.
The assessment is not a management engineering set of time studies aimed at micro costing every second of work. The information needed for this plan is collected in a few days by talking to the people performing the work. Estimates are gathered based on workers’ views about how they spend their time. This information is combined with available workload measures and general ledger cost information, and activity based reports are produced.
From there, it is an exercise in planning. Activity based information is used to look at areas where work can be restructured so errors and rework can be eliminated. New technologies that target problematic activities can be selected and implemented. Outside companies that can perform complex activities more economically can be evaluated.
Conclusion
Few doubt the clout that the consumer will have in the emerging healthcare environment. The customer’s experience with providers will play a much more important role in the future with regard to growing and sustaining market share. Thus, improvement efforts have to begin where we begin the customer relationship – in Access Management.
Activity based costing is a proven tool for analysis that can be applied easily to the Access Management area. It provides information that is essential to the critical decisions that must be made if the provider expects to provide excellent customer service in the coming years. Also, activity based costing and management tools can be applied in many other ways throughout the providers’ operations. TQM and budgeting programs benefit nicely from this type of analysis.
Manufacturing learned this a long time ago — you have to understand the activities that are occurring if you hope to make sustainable improvements in your operations. Providers rarely have the ability anymore to significantly grow the top line. It will be critical that these types of analysis begin to occur in the provider setting if they hope to lower cost and improve quality. And what better place to start than at the hub of the patient experience.
Contact: Lance Lott llott@infoad.com Tom Dugger tdugger@infoad.com
© Copyright 2000 InfoAdvantage, Inc.
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It would be prudent and smart for home medical equipment (HME) providers to create “separate checks” for their products, services and customers. Traditionally, HME owners have assumed that all overhead expenses apply equally to all products and customers. As an example in Table 1, this business owner would be led to assume that every dollar of revenue consumes 27 ½ cents of overhead expense. Intuitively, business owners recognize that certain sales transactions consume more overhead cost than others, e.g. a delivered order consumes more cost than a customer pick-up. But monthly accounting reports don’t report the “facts” to confirm these “feelings” (see Table 2).
To address the need for financial facts, home care firms are using Activity Based Costing (ABC) to create “separate overhead cost checks” for their different types of customers, services and product lines.
What is ABC? Activity Based Costing is based on a simple principle … activities consume resources and customers consume activities. Associating the labor and overhead expenses of the business with the activities that consume those resources provides valuable facts. Financial facts that can be used to improve decision-making and identify cost improvement opportunities.
The basic building blocks for ABC are activity accounting spreadsheets for each group of employees in the business. Typical groups in a home care company would be Delivery, Billing, Customer Service, Therapy, Repair, Sales & Marketing, Accounting, Purchasing and General Administration. Table 3 shows an activity accounting report for a typical home care billing department … the columns are the activities and the rows are the resources. The workload of each activity is measured resulting in a cost per output. As is often the case, the average cost of re-submitting a claim is more expensive than the initial submission.
Steps to Implement ABC Implementing ABC is a Five-Step Process:
Uses of ABC I have heard it said that the lottery is God’s way of punishing people who are bad at math skills. I believe the same can be said for the use of 1940’s-style accounting reports (Table 1) in 2000’s home care. The management of gross margin percentages is simple. But in today’s competitive marketplace, a focus on gross margin is simplistic. Traditional accounting reports are formatted for external compliance reporting, e.g. I.R.S., banks, etc. ABC is formatted for internal decision-making.
HME owners are increasingly discarding their monthly focus on traditional accounting reports and periodically using ABC to help make many types of decisions:
Here are some examples of “how to use” ABC:
Fire customers that consume more activities than their gross margin will cover! But before you “fire” any customer, add to the decision their accounts receivable balances and payment histories. What you will often find is that not only are you not making money on their orders, but you are also banking for them with your accounts receivable as well.
ABC customer profitability analysis not only identifies profitable and unprofitable customers, ABC also provides methods to turn losers into winners:
Many HME owners need more shelf-control when it comes to which products and services they should offer customers. Published gross margins can be misleading. For example, one home care firm met with a sales rep that wanted to demonstrate a useful new product. The new product had a recommended list sales price that results in a 20% gross margin. Normally the home care owner would not have carried the product because overhead costs are 27.5%, resulting in a pre-tax loss of 7.5%. But the business owner, using the principles of ABC, realized that many of the home care overhead activities would not be incurred with the sale of this new product. With this ABC knowledge, the owner decided to add the new product to the sales shelf. The product became a big seller for all the branches, adding significant profits to the company. ABC helped the owner make a good shelf decision.
Menu-based pricing is another popular use of ABC. The most costly activities of a home care company are typically services that are being performed for the customer. The higher cost, higher volume activities of the home care firm serve as a basis for a menu of services and prices, e.g. Make Delivery, Process Return Goods, etc. If customers are not charged for costly activities, they may incorrectly assume that you’re providing the service for free! Creating an ABC Bill of Activities will alert home care managers if they can afford to sell what they are currently offering customers on the firm’s menu of services.
A recent personal experience highlights the importance of using ABC to set policies. My 79-year old father recently had successful triple bypass surgery. The doctor prescribed an oxygen concentrator on the Sunday my dad was released from the hospital. Someone on the hospital staff selected a home care firm to make the delivery. If the selected home care owner subtracted the cost of the activities consumed in the two-hour roundtrip delivery and subsequent return two weeks later, I seriously doubt that any profit would be left from the $228 fee. Apparently the home care owner had a policy of accepting any business, no matter the distance from the store. While noble, it makes little or no sense.
Repeat Steps 3, 4 and 5 for product lines, service types, branches or any cost object needing analysis. ABC provides insight as to where you’re making money and where you’re not in your business.
Cost versus Benefit Implementing ABC can provide significant benefits … improved pricing, better marketing strategies and more profits despite lower reimbursement rates. But there is a cost of implementing ABC. There are three basic implementation options that vary in cost:
Conclusion
Zig Ziglar defines disappointment as the gap between expectation and delivery. Many home care business owners expecting a reasonable return on their investment are disappointed with their current financial condition. And while they may get some temporary pleasure in blaming others … such as Medicare, Medicaid, HMO’s, Health Care Financing Administration … for current financial problems, it is up to every business owner to close the gap of disappointment.
In the newly published “17 Lies that are Holding You Back & the Truth that will set You Free“, author Steve Chandler lists number 8 as “I worry because I care. We worry because worrying is what we do all day to avoid taking action.” Worrying will not improve your home care company. Action will! Implement ABC. Create “separate checks” for your products, services and customers. Convert your profitability “feelings” into “facts”. Use ABC as the basis for a fresh start to your firm’s improved financial future.
]]>How much overhead cost is enough for your business? Do you have too much or not enough? It is difficult to answer that important question using a traditional accounting report. The typical P&L format shown in Table 1 causes more questions than it answers:
To answer these questions and many others, home care firms are using Activity Based Management (ABM) to right-size their overhead costs.
What is ABM?
Activity Based Management is based on a simple principles … activities consume costs. Allocating overhead costs of a business to the activities that consume those resources provides valuable new facts. Facts that can be used to identify and eliminate non-value added waste.
Traditional accounting measures how much resource was consumed by a department or group of employees. ABM measures what they did with those resources.
ABM Quick Start
All it takes is approximately 90 minutes to quickly demonstrate the principles and benefits of ABM in your company. The basic building block for ABM is an activity accounting spreadsheet (Table 2). The columns are the activities; the rows are the resources. The workload of each activity is measured and costed. For example, it costs $37,700 to submit claims. Five hundred claims were filed. Therefore, on average it cost $75.40 to file a claim. This basic information can be used for improved decision-making and cost improvement.
Seven Quick Start Steps:
Traditional HME overhead accounting reports are two-dimensional:
To better meet the growing needs of HME managers, an Activity Based Management system is multi-dimensional. ABM provides seven new overhead cost perspectives:
Variety of Activities Activity classifications provide managers a multi-faceted tool to analyze and evaluate the business:
Seven Discontinuous Decisions Activity Based Management is a powerful new technology, but only when it is used. To be of value, ABM must be applied, not simply analyzed. After you’ve created your ABM Quick Start spreadsheet, find a quiet place and ponder these seven overhead changing decisions:
Action or Procrastination … which are you going to choose?
Most home care owners see the need for overhead cost reduction on their monthly accounting reports. Reimbursement reductions coupled with rising overheads result in shrinking profit margins. And even though most managers have heard of the benefits of using ABM to reduce overhead and ABC to improve decision-making, they put off implementation. The systematic and habitual putting off of important activities can usually be attributed to one or more root causes. The causes may differ but the effect is the same. You fail to accomplish something you want and need to do.
Why do HME managers procrastinate?
Conclusion In his number one best seller, Who Moved My Cheese?, author Spencer Johnson M.D. reminds us all that “the quicker you let go of old cheese, the sooner you find new cheese.” Are you praying for new and improved profits while still holding on to your old accounting reports? The quicker you let go of the old and move to the new principles of Activity Based Management, the more likely you’ll enjoy the benefits. ABM brings new clarity and creativity to the old topic of overhead.
How much overhead cost is enough for your business? Only you can effectively answer that question. But with ABM to clarify the decision, I am confident that your results will be much closer to your financial goals.
]]>The results are in! Based on the Institute of Management Accountant’s 1997 survey, service organizations are enjoying very positive results with ABM. ABM is no longer just a tool for the rich and famous manufacturing firms. “How To” workshops, books and ABM Software Tool Kits have made it possible and practical for all types and sizes of service organizations to successfully implement and enjoy the many benefits of ABM.
Typical Uses
There are five common uses of ABM by service organizations:
Multiply 20% times your annual overhead budget. Wouldn’t you like to redeploy that waste to your bottom line? You can with ABM. Many service organizations work on razor-thin profit margins. They need a “quick-fix” pickup for the bottom line. Within 30-60 days, an ABM implementer can identify 20%-30% waste in an overhead budget. A list of waste-reduction action plans can then be quickly prepared, approved and implemented.
How much does it cost to expedite a claim? Does it cost the same to serve high and low volume customers? What is the minimum order size to break even on a delivery? Service organizations that don’t understand the cost of daily transactions are living dangerously. A plumbing distributor that implemented ABM last year was shocked to find that their break-even for a delivered order was $150.00. The owner quickly instituted minimum order quantities and began an employee continuous improvement program to reduce overhead costs. What daily and weekly transactions do you need to analyze?
Gross margin pricing may be the K.I.S.S. of death. Pricing products and services to achieve a universal gross margin target percent is simple but dangerous. Gross margin pricing assumes that all overhead costs apply equally to every product, service or customer. As a service organization’s portfolio of services and customers grows, traditional gross margin-based pricing methods will lead you to overprice high volume products, services and customers and underprice low volume products, services and customers.
Can you afford to lose your high volume customers? If not, then you should evaluate ABC menu-based pricing. Your menu will be comprised of the significant activities (services) you offer customers. For example, distributors in several industries are separating the price of products from the price of delivery and other services (e.g. expedite, EDI, automatic replenishment). Implementing ABC is guaranteed to be an eye-opening experience!
All customers are not created equal. It is not uncommon to find with ABC customer profitability analysis that 80% of a service organization’s profit comes from 20% of its customers. It is crucial for any business owner to know where their business is making money and where they are not. ABC analysis highlights how much more profitable it is to keep and grow existing customers in lieu of the expense of constantly searching for new business. Who is your most profitable customer? Why? ABC customer profitability analysis answers those questions.
Distributors are under the gun. They are being asked by both manufacturers (supplier) and retailers (consumer): “What value are you adding to the supply chain?” ABM analysis provides the facts and figures to answer that question. Are your employees busy? Sure they are. But the real question is: “Doing what?” Traditional accounting reports tell the business owner: “Here is the cost of resources that you provided each manager last month.” ABM analysis tells the owner: “Here is what the manager and the employees did with those resources.” ABM highlights the value and the waste of resources.
Conclusion
Are you riding a dead horse accounting system? Dismount and end your frustration. Get answers to the important cost and profitability questions that confront your organization. Implement an ABM system in 90 days or less. Call Christine at 1-817-475-2945 for a free 90-day Self Implementation Plan.
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