There is no consistent, standardized cost accounting method for community healthcare institutions. The cost accounting in community healthcare institutions differ from that in public hospitals in that these institutions have a wider scope of function orientation, more difficulties in counting volume of services, higher demand for calculating the cost of new services, and relatively weaker informatization foundation, so it is necessary to explore a cost accounting method that is different from that used in public hospitals, and specially applicable to community healthcare institutions. We reviewed relevant literature, then summarized the development of cost accounting in community healthcare institutions, and systematically analyzed four common methods (proportionality coefficient, operating method, equivalent method, standardized workload method) and compared the similarities, differences and applicability of them. We found that the equivalent method and the standardized workload method are more widely used in practice because both of them are simple with "time" as the main accounting parameter, and can quickly calculate the cost of new services. Moreover, the two methods provide a unified "yardstick", which can provide a basis for performance management, financial compensation and personnel supplement for community healthcare institutions. So these two methods can be used for calculating performance and cost basis for community healthcare institutions obtaining the financial security (the first class public welfare institutions), and for those using a performance management system (the second class public welfare institutions), and are more applicable to community healthcare institutions at present. Standards and norms for cost accounting and management in community healthcare institutions should be formed to improve the self-management ability of these institutions and promote the overall high-quality development of community health services.
During the promotion of category-based management for community healthcare institutions (class 1 institutions obtain the financial security, and class 2 institutions implement a performance management system), how to appropriately determine the security level and scientifically evaluate the performance is a difficulty to tackle for health administrative departments.
To assess the operational efficiency of community healthcare institutions with the data envelopment analysis (DEA) using the information of costs of these institutions calculated using the equivalent method, then attempt to develop an input and management model of integrating cost accounting and performance management for these institutions, providing a theoretical basis for accurate and scientific input of various resources into the community through cost measurement with equivalent method, and a data basis for performance assessment in communities with different characteristics through efficiency evaluation.
The real data (financial status and staffing) of 14 community healthcare institutions during 2019 to 2020 were collected from their financial reports, hospital information system, maternal and child healthcare information system, chronic disease management information system, as well as focus group interviews. The equivalent method was used to calculate the total costs of medical services and public health services. The super-efficiency DEA was used to evaluate and analyze the operational efficiency of the 14 sample institutions.
(1) The average cost of one equivalent service (a general medical outpatient service lasting for 15 minutes was defined as one standard service equivalent unit) was 67.64 yuan in 2019 and 69.80 yuan in 2020 for the 14 institutions. The average cost of one equivalent essential medical service was higher than that of one equivalent public health service in both 2019 (167.14 yuan vs 18.86 yuan) and 2020 (215.43 yuan vs 19.78 yuan). The institutions demonstrated significant differences in the average cost of one equivalent essential medical service and the average cost of one equivalent public health service. (2) Each institution had its own peculiar characteristics. For example, S1 institution mainly provided essential medical services, and had higher total equivalent essential medical services and efficiency than other institutions, while S9 institution focused on providing public health services, and had the highest efficiency in delivering public health services. (3) In 2020, the 14 institutions provided 134 800 equivalent COVID-19-related services, with a cost of 1.037 8 million yuan. (4) In 2019 and 2020, only two institutions were relatively overall efficient, and ≥50.0% institutions were pure technically efficient. The institutions with overall operational inefficiency were mainly caused by scale inefficiency primarily due to increasing returns to scale.
The equivalent method provides a relatively unified "scale" to standardize the service efficiency of different types of community healthcare institutions, provides support for health administrative departments implementing category-based compensation for the institutions, benefiting the featured and high-level development of community healthcare institutions. Either institutions delivering essential medical services or those delivering public health services, mainly present increasing returns to scale, suggesting that the efficiency of these institutions can be improved by increasing the human/financial/material input into the institutions and providing precise compensation for them.
With the deepening of the new medical reform, the "short slabs" of the current financial compensation mechanism for primary care institutions has been gradually revealed. Compensation mechanism still needs to be further improved for the existence of painful and difficult problems such as insufficient "endogenous power" of primary care institutions, low efficiency in the use of financial funds, and the compensation mechanism still needs to be improved.
To explore and establish a service output, more simple and easy-to-use, scientific and reasonable financial compensation calculation model based on equivalent method, so as to provide a reference for the financial compensation of government-run community health service institutions.
Based on the cost calculation of the equivalent method, the policy analysis and literature review method were used to sort out the financial compensation policies, and the important parameters of the model were determined through expert consultation to build the financial compensation calculation model and financial compensation budget model. The application effect of the model was further evaluated by calculating the financial compensation of 14 community health care institutions in Beijing from 2019 to 2021.
The constructed financial compensation calculation model was mainly composed of three parts, including service equivalent (D), compensation standard per equivalent (PG) and adjustment coefficient (T), the financial compensation budget model was built on this basis. 14 institutions were taken as examples to calculate the financial compensation, the average calculated financial compensation amount of each institution in 2021 was 45.961 0 million yuan, and the average actual subsidy income of each institution was 44.546 8 million yuan, slightly lower than the calculated financial compensation amount. The average budgeted service equivalent for the 14 institutions in 2022 was 1 139 900 000 equivalents and the average budgeted financial compensation was 50.234 3 million yuan.
The data source of financial compensation calculation model based on equivalent method is standardized and easily available, which is convenient for promotion and use. It was suggested to explore a new model of financial compensation and flexibly use the adjustment coefficients, so that the financial compensation model can better meet the needs of high-quality development.
Problems existing in the operation of a family doctor team, such as unclear work content, inappropriate division of labor, and assigning a team member to a position below his true potential, restrict the overall development of the family doctor team.
To perform a standardized workload-based analysis of the services delivered by the family doctor team in a central urban community health institution in Shanghai, to understand the major factors associated with the development of the family doctor team, and to provide guidance for the improvement of the work pattern of the team.
The family doctor team of Xietu Subdistrict Community Health Center, Xuhui District, Shanghai was selected during July to Novermber 2021. The service projects, parameters of standardized workload and the number of services carried out by the team between August and September 2019, and between August and September 2021 were collected, respectively. The team services were analyzed from three aspects: 1. dividing the team services into essential medical services and public health services according to the nature of the service items, then calculating the total amount of standardized workload and total time used in performing the two kinds of services; 2. dividing the team services into five parts (involving community-based mobilization, screening, diagnosis, intervention and follow-up) according to the idea of integration of medical and preventive services, then calculating the total amount of standardized workload and total time used in performing each part; 3. using the TOPSIS method to comprehensively evaluate the value of all service items included in community-based mobilization, screening and follow-up.
The standardized workload of the team in delivering public health services increased to 16 961 in August 2021 from 11 486 in August 2019, and increased to 18 089 in September 2021 from 10 433 in September 2019, demonstrating an average increase of 59.9%. Pearson correlation analysis showed that the standardized workload involved in delivering essential medical services had no correlation with that involved in delivering public health services (r=-0.72, P=0.27). The total amount of standardized workload of the five parts of community health work was ranked as follows in a descending order: community-based diagnosis, community-based follow-up, community-based intervention, community-based mobilization, and community-based screening. The total standardized workload and total time used of the latter three were relatively less. According to TOPSIS evaluation results, 13 projects such as updating health records of patients with chronic diseases, follow-up management of patients with hypertension or diabetes, and information maintenance of contracted residents can be considered to be outsourced or to reduce the execution labor cost.
The family doctor team has not yet formed an effective work model to deliver integrated medical and preventive services, which leads to excessive waste of human resources in the implementation of public health services that need not to be performed by family doctors, affecting the delivery of essential medical services. It is suggested to strengthen the training of professional skills related to community-based interventions for family doctors, and increase relevant facilities and equipment, optimize the allocation of human resources in all parts of community health work, mainly reducing the implementation cost of community-based mobilization, screening and follow-up.
