1. Purpose of the Study
At present, hospitals are forced to operate in a severe financial environment due to the continued suppression of medical fees, and at the same time, they are forced to continuously invest large amounts of money due to the rapid progress of medical technology, and it is necessary to accumulate minimum profits for investment. Therefore, it is increasingly necessary to grasp and manage profits and losses not only for the hospital as a whole but also for each “department” such as departments of internal medicine and surgery, central medical departments such as laboratories and surgery departments, and support management departments such as medical affairs and accounting departments.
Under these circumstances, it is extremely important to verify whether departmental profit and loss accounting and management effectively improve profitability, which is their main purpose. On the other hand, it is also important to examine whether there are any adverse effects (so to speak, side effects) on the results of medical care, which is more important for hospitals as non-profit organizations whose main purpose is not to improve profitability. In addition, it is also interesting to see what kind of effects can be observed in the utilization of wards and the implementation of important medical treatments, which are related to the processes before the results are achieved, in addition to the financial and medical results.
Therefore, this study evaluates the effectiveness of departmental P&L management practices, such as breakeven analysis, which have not been verified in previous studies, based on objective performance data by utilizing data from a questionnaire survey on departmental P&L management conducted for a group of hospitals (FY2021) consisting of various establishment entities. The difference in business performance with and without the implementation of departmental profit and loss accounting has already been verified by Sangwan et al. (2017), as will be clarified in the next section, but we will attempt to evaluate its effectiveness again. We will also examine whether the implementation of departmental profit and loss accounting is still effective in improving profitability in FY2021 and whether the effectiveness of the implementation of departmental profit and loss accounting is robust.
The difference in performance between companies with and without the implementation of departmental P&L accounting has already been examined by Sangwan et al. (2017), as will be clarified in the next section, but we will attempt to evaluate the effectiveness again.
First, previous studies on the effectiveness of departmental profit and loss accounting and management in enhancing profitability are discussed in this paper, and the characteristics of this study are clarified in comparison to the previous studies. The methodology for this investigation is then detailed in-depth, followed by the analysis results. Then, depending on the analysis results, a discussion is added, and lastly, the study is summarized as a conclusion.
2. Prior Research
In the past, the evaluation of the effectiveness of departmental profit and loss accounting and management in hospitals in improving profitability has not been completely unattempted (Harsvardhan et al., 2014; Ganai et al., 2016; Sangwan et al., 2017; Endri et al., 2020; Fuadah et al., 2020; Langroudi et al., 2017). However, Ganai et al. (2016) is a study of medical corporations that manage hospitals, not of hospitals of various establishments, including national, public, and medical corporations, and only evaluates profitability. Harsvardhan et al. (2014) is a study of a group of hospitals with excellent business management capabilities, and the number of hospitals subject to analysis is extremely small. In addition, due to the limitations of data available at the time, the assessment of the impact on outcomes and process aspects of health care is very limited.
Sangwan et al. (2017), on the other hand, focused on a large number of hospitals (1619), did not target a set of hospitals with exceptional management capabilities, and did not analyze a limited number of hospitals. The impact assessment’s scope ranges from financial and medical outcomes to procedural considerations. However, because the report covers management accounting methods in general, it is limited to evaluating the effects of departmental profit-and- loss accounting management by whether or not departmental profit-and-loss accounting is implemented, and it does not evaluate the effects of differences in profit-and-loss monitoring frequency (monthly or not) or differences in the degree of profit-and-loss accounting use when departmental profit-and-loss accounting is implemented. Furthermore, the usefulness of break-even analysis has yet to be determined, as there has been no assessment of whether or not break-even analysis, a primary tool for controlling profit and loss by department, is used or the extent to which it is used.
However, the relationship between profit and loss accounting and profitability improvement (Chatterjee et al., 2013), in for-profit companies is not necessarily the same as that in hospitals, which are not-for-profit organizations. This is because improving profitability, which is the purpose of profit and loss management, is not the main objective of nonprofit organizations, and the consciousness and behavior of the employees working there are often different from those of employees in for-profit companies. Moreover, hospitals do not necessarily have a high sense of belonging to an organization, and they are also characterized as a group of professionals with a high degree of autonomy. Therefore, it is indispensable to conduct this study in hospitals.
3. Research Methodology
This paper evaluates the effectiveness of departmental P&L management by combining the data from the questionnaire survey on departmental P&L management conducted for hospitals in fiscal 2021 and the financial data of the hospitals that responded to the survey, which were obtained separately. Specifically, among the 286 hospitals (response rate: 17.2%) that responded to the survey conducted in 2021 targeting hospitals (1667 hospitals), we will examine differences in profitability and medical outcomes due to differences in various practices related to departmental P&L management, targeting 169 hospitals for which financial data, etc. are available and can be used for analysis. The following is a more specific description of the research methodology.
3.1. Performance Data Collection Methods
First, for this study, hospitals that responded to the questionnaire survey on departmental P&L management conducted in 2021 were the target hospitals for performance data collection. This is because this study can only be conducted in hospitals where departmental P&L management practices are known.
Next, financial performance data, which is essential for verifying the effectiveness of the departmental profit and loss accounting management, was obtained through additional surveys of financial data at the hospitals that responded to the survey, as well as through the yearbooks of local public corporations and the websites of the National Health Portal and the Ministry of Health & Family Welfare. As a result, we were able to obtain the financial performance data of 177 hospitals. In addition, we tested whether any outliers would have a significant impact on the analysis of the medical profit margin and medical profit per hospital bed (calculated using the total number of hospital beds of each hospital), which were calculated from the medical revenues and medical expenses obtained above. Specifically, we conducted an outlier test (Smirnov- Grubbs test) and identified the data (hospitals) that were determined to be outliers at a significance level of 0.1%. As a result of excluding the outlier hospitals from the analysis, 169 hospitals remained in the analysis.
On the other hand, for these 169 hospitals, we obtained performance data on discharge outcomes, readmissions, ward utilization, and implementation of key therapeutic activities.
As a result, 19 national hospitals, 98 public hospitals, 19 Indian Red Cross Society, 24 medical corporations, and 9 other corporations were included in the analysis. In this study, we will analyze all of these hospitals. However, for the analysis of the impact of the implementation of departmental profit and loss accounting on financial and non-financial performance, we will limit the analysis to the group of public hospitals in a broad sense (national, etc., public, etc., and the Indian Red Cross), excluding private hospitals in a broader sense (medical corporations and other corporations), because a certain number of samples are available.
3.2. Selection of Performance Indicators for Analysis and Basic Statistics
In this study, to evaluate the effectiveness of departmental P&L management, we first analyzed the performance related to profitability, which is the main objective of this management. As aspects of performance other than profitability, we analyzed performance related to the results of medical care, such as discharge outcomes and readmissions, and performance related to the efficiency and productivity of inpatient operations, such as ward utilization and implementation of important therapeutic activities. The following indices were selected as specific indicators to measure each performance aspect.
First, the medical profit margin and medical profit per bed were selected as indicators of profitability.
Next, as indicators of the results of medical care, the improvement rate of the outcome at discharge and the worsening rate of the outcome at discharge were included in the analysis as indicators related to the outcome at discharge. The study classifies each patient as having one of the following discharge outcomes: “cured or mildly recovered, ” “remission, ” “unchanged, ” “exacerbation, ” “death from the injury or disease for which the most medical resources were invested, ” “death from the injury or disease for which the least medical resources were invested, ” and “other.” The improvement rate at discharge is the percentage of patients whose outcome at discharge was either “cure” or “remission.” The opposite is the worsening rate, which is the percentage of patients whose outcome at discharge was either “exacerbation, ” “death due to the injury or disease for which the most medical resources were invested, ” or “death due to an injury or disease other than the one for which the most medical resources were invested.” As an indicator related to readmission status, the rate of unplanned readmissions within 4 weeks under the same name as the previous hospitalization (hereafter, unplanned readmission rate) was included in the analysis. Although these indicators of medical outcomes do not cover all aspects of medical outcomes, they are the only indicators of medical outcomes that are available as commonly defined indicators across a wide range of hospitals today.
In addition, as indicators of ward utilization, we used the bed utilization rate and the average length of stay as the objects of analysis. Bed utilization is a performance indicator that indicates high or low occupancy of wards, and the average length of stay is a performance indicator that indicates efficient use of hospital beds (efficiency of the healthcare delivery process). The hospital bed utilization rate was calculated based on the total number of inpatients, the average length of stay, and the number of beds and patients in each hospital (total number of inpatients × average length of stay ÷ number of beds × 365). On the other hand, the average length of stay without correction, which is based on the actual disease composition of the hospital and the actual length of stay for each disease, is first used as a reference index for analysis. The average length of stay after correction for disease composition, which is calculated by changing the actual disease composition of each hospital to the national average disease composition and applying the actual length of stay for each disease to each hospital, will be used as the main indicator for analyzing the performance of efficient use of hospital beds.
In addition, the number of patients with surgery per hospital bed per year and the number of patients with surgery/chemotherapy/radiation therapy per hospital bed per year (number of patients with critical care) were analyzed as indicators of the implementation of critical care activities. The basic statistics of each performance indicator are described below (Table 1).
Table 1: Basic Statistics of Performance Indicators
3.3. Content Analysis
In this study, first of all, in the questionnaire, “The accounting and management of profit and loss by ‘department’ refers to the accounting and management of profit and loss by each of the four medical departments such as internal medicine and surgery, four departments in the central medical care system such as laboratory, pharmacy, surgery, and rehabilitation departments, and four departments in the support management system such as the medical affairs department, accounting department, and information system department. In this study, we will first evaluate the effectiveness of departmental profit and loss accounting by examining the differences in financial and medical outcomes, as well as the differences in the utilization of wards and the implementation of important medical treatments, which are related to the processes leading to the outcomes, depending on whether or not departmental profit and loss accounting based on this definition is implemented.
In the previous studies, when examining the difference in profitability depending on whether or not departmental P&L is implemented, a comparative analysis was conducted not only by simply comparing whether or not departmental P&L is implemented but also by considering the year in which departmental P&L was introduced (started). It is known that many hospitals decide to introduce departmental profit and loss accounting because they are in the red and unprofitable, and therefore hospitals immediately after the start of departmental profit and loss accounting are often in the red. The reason is that it is not necessarily appropriate from the perspective of evaluating the effect of departmental profit and loss accounting to compare the profitability of hospitals with and without the implementation of departmental profit and loss accounting, including hospitals immediately after the start of implementation. Even if departmental profit and loss accounting affects improving profitability, it is not considered that it will improve as soon as it starts. In many cases, business managers first grasp the situation of profit and loss, think about countermeasures based on the information, ask for action change at the site, and after a short time after the actual action change is convinced by the field medical staff, it leads to improvement of profitability. Therefore, even if it is effective, there is a certain time lag from the start to the manifestation of the financial results (Harsvardhan et al., 2014). Therefore, in this study, as in the previous studies, we also conducted an analysis in which the hospitals whose departmental profit and loss accounting started in 2021, the year of this questionnaire survey, and in 2020, the year before that, were excluded from the analysis for reference. In other words, we also attempted to examine the difference in financial performance in 2021 between the two groups of hospitals: those that started departmental P&L accounting by 2019 and those that did not start departmental P&L accounting.
Next, we will examine whether the effects and impacts of departmental profit and loss accounting differ depending on whether the frequency (interval) of the implementation of departmental profit and loss accounting is monthly (quarterly, half-yearly, yearly, or irregularly (as needed)), that is, whether profit and loss are grasped and managed on a high frequency and regular basis or not. We will also examine whether differences in the degree of use of departmental profit and loss accounting make a difference in the effects and impacts when departmental profit and loss accounting is implemented. In the questionnaire survey on which this study relies, the degree of use of P&L by department is divided into two categories: (1) use by management for business analysis (business diagnosis, policy formulation, and decision making), and (2) use by front-line managers and staff (to raise awareness of business management and promote autonomy). We asked the respondents to rate the degree of use on a 7-point scale: not used at all (1), not used much (2), used a little (3), used (4), used a lot (5), used fairly often (6), and used very often (7). In this study, considering the sample size of each usage category to be compared, we will examine the differences in the effects and impacts of the different usage levels by comparing the hospitals with usage levels of 3 (little usage) or higher for both analytical usage and approach usage (23 samples) with the other hospitals (29 samples). The following is a summary of the results.
Finally, we will examine the differences in financial and medical outcomes due to whether or not departmental breakeven analysis is implemented, as well as the differences in ward utilization and the implementation of key therapeutic actions related to the processes leading to the outcomes. We will also examine whether differences in the degree of use of break-even analysis by the department, if implemented, make a difference in financial and other results. In the questionnaire survey on which this study relies, respondents were asked to rate the degree of use of break-even analysis on the same seven-point scale as above, according to whether it is used (1) for analysis by management, (2) for encouraging front-line workers, (3) for unit price improvement, or (4) for cost structure improvement. Therefore, in this study, taking into account the sample size of each utilization category to be compared, we will examine the difference in the effect and impact of different levels of utilization by comparing the hospital group (sample size: 19), which has a utilization level of 2 or higher in any of the four utilization methods (i.e., no utilization at all (1) in any utilization method), with the other hospital group (sample size: 17).
The t-test (Welch’s test) was used to verify the difference between the means of each category.
4. Results
First, we examined the relationship between departmental P&L implementation and financial outcomes improvement, which is the fundamental goal of this strategy. Although the link was proportional to the deficit area, we discovered that hospitals that implemented P&L were much better in both medical profit margin and medical profit per bed (Table 2). For comparison, after accounting for the start year of departmental profit and loss accounting, we found that hospitals that implemented the system performed much better in both profitability measures. The profitability index of the group of adopting hospitals was better in the case of the analysis considering the start year than in the case of the analysis not considering the start year, as in the previous study (Sangwan et al., 2017).
Significant differences were observed in the previous study only when hospitals that had just started departmental profit and loss accounting were excluded. In contrast, significant disparities were identified in this study regardless of the year of introduction, depending on whether or not it was applied. Because the analysis will be limited to the group of implementing hospitals as indicated later in this study, the following analysis does not take into consideration the start year of the departmental profit and loss accounting to avoid reducing the sample size.
We also conducted an analysis limited to public hospitals and public hospital groups in a broad sense for reference and found no difference in the effect of implementing departmental profit and loss accounting on improving profitability compared to the case of all hospital groups (Table 3).
Then we examined the relationship between departmental P&L implementation and the outcomes of medical care, which is the primary goal of hospitals, and discovered that the group of hospitals that implemented departmental P&L had no worse results in any of the medical care outcome indicators (Table 4). In the implementation hospital group, however, the results of poor discharge outcomes and unplanned readmission rates were much better. At least in terms of these three health care outcome measures, the introduction of departmental P&L does not appear to have a negative influence on health care results. In addition, for reference, a study confined to public hospitals and public hospital groups, in general, was conducted. However, there was no difference from the case of all hospital groups.
Table 2: Implementation of Departmental Profit and Loss Accounting and Financial Results (All Hospital Groups)
Table 3: Implementation and Financial Results of Departmental Profit and Loss Accounting (Public and Public Hospital Groups in the Broad Sense)
Table 4: Departmental P&L Implementation and Medical Outcomes
In addition, we examined whether there were differences in the utilization of wards and the implementation of important medical treatments, which are related to the processes leading to financial and medical results, depending on whether or not departmental profit and loss accounting was implemented. Although there was no significant difference in the utilization rate of hospital wards, which indicates the efficient utilization of hospital wards, there was a significant difference in the adjusted average length of stay, which indicates the efficient utilization of hospital wards, at the 10% level (there was a significant difference in the normal average length of stay at the 5% level). Table 5. On the other hand, there was a significant difference in both indices for the implementation of critical care, and it was found that the number of patients who underwent critical care such as surgery per hospital bed per year was higher in the group of hospitals that implemented departmental profit and loss accounting. In addition, we also conducted an analysis limited to public hospitals and public hospital groups in a broad sense, but the results were the same for all hospital groups. In other words, the group of hospitals that implemented departmental profit-and-loss accounting had a significantly higher number of patients who underwent important treatment procedures in both indicators, and the group of hospitals that implemented profit-and-loss accounting was more efficient in all indicators in the respondent hospitals, although the utilization of wards was not significant due to the reduced sample size.
Table 5: Calculation of Profit and Loss by Department, Use of Ward, and Implementation of Important Treatment Actions
Then we examined whether there was a difference in the financial results of hospitals that used departmental profit and loss accounting, whether it was done monthly or on a more frequent basis and whether there was a difference in the performance of hospitals that didn’t. In terms of financial results, it was discovered that hospitals that adopted the monthly programs were much more profitable than hospitals that did not, although the difference was only 10%. (Table 6). In terms of medical care outcomes, there was no significant difference in any of the variables depending on whether it was completed monthly or not. Furthermore, the hospitals that implemented monthly care had a much higher bed utilization rate and a more significant number of patients with surgery per bed per year, both are tied to the process before the results are accomplished. There was no significant change in the average length of stay before and after disease composition correction, nor in the annual number of patients treated with surgery, chemotherapy, or radiotherapy per hospital bed.
Table 6: Relationship between the Frequency of Performing Departmental Profit and Loss Accounting and Hospital Performance
We also examined whether disparities in the extent to which departmental profit and loss accounting was used resulted in variances in hospital performance, such as financial results. First and foremost, in terms of financial results, the group of hospitals with high utilization was shown to be significantly more profitable than the group of hospitals with low utilization in terms of both profitability metrics (Table 7). In terms of medical care outcomes, there was no significant difference in any of the variables between hospitals with high and low usage levels. Furthermore, while there was no significant difference in ward utilization for any of the indices, the number of critical therapeutic practices was significantly higher in the group of institutions with high utilization for both indices.
Table 7: Relationship between the Degree of Use of Departmental Profit and Loss Accounting and Hospital Performance
Then we examined whether financial results and other hospital performance differed depending on whether the department completed a break-even analysis or not. In terms of the relationship between break-even analysis by the department and improved profitability, it was confirmed that hospitals that implemented break-even analysis by the department were significantly better in terms of medical profit margin and medical profit per hospital bed. However, the relationship was relative to the deficit area (Table 8). In terms of the relationship with the outcomes of medical care, which is the primary goal of a hospital, there was no significant difference in any of the indicators depending on whether the department used break-even analysis or not. Furthermore, whether or not the department’s break-even analysis was applied, there was no substantial difference in the usage of wards and the execution of critical medical treatments, which are related to the procedures before the financial and medical outcomes.
Table 8: Relationship between Implementation of Break-Even Analysis by Department and Hospital Performance
Finally, we examined whether differences in the degree to which departments applied the break-even analysis resulted in disparities in hospital performance, such as financial results when it was implemented. First and foremost, in terms of financial results, hospitals with a high usage rate were found to be significantly more profitable in terms of both profitability indices (Table 9). In terms of medical treatment outcomes, only the rate of improvement in outcome at discharge was considerably lower in the group of institutions with high use, though it remained around 10%. Furthermore, there were no significant differences in any of the indices for hospital ward utilization or the implementation of critical treatment activities.
Table 9: Relationship between the Degree of Use of Break-Even Analysis by Department and Hospital Performance
5. Discussion and Recommendations
The fact that departmental profit and loss accounting is effective in boosting profitability was reconfirmed, and the certainty of the effectiveness of departmental profit and loss accounting was increased, as in the previous study (Sangwan et al., 2017). We also examined the impact of departmental P&L on financial results, both with and without considering the initial year of implementation. We found that P&L increased profitability in both circumstances, but when the first year of implementation was evaluated, the profitability index of the group of hospitals that implemented P&L was higher. When the year of implementation was taken into account, however, the profitability index of the implemented hospital group was higher. This indicates that many hospitals began implementing departmental profit and loss accounting at a time when their profitability was declining. Furthermore, even if limited to public hospitals and public hospital groups in a broad sense, the effect of implementing departmental profit and loss accounting on improving profitability was confirmed, and it became clear that even public hospital groups with a low implementation rate of this method had the same financial effect as other established hospital groups when this method was implemented.
In addition, the implementation of the departmental profit and loss accounting confirmed that the indicators analyzed in this study did not have any negative impact on the results of medical care, which is the purpose of the hospital.
In addition, it became clear that the departmental profit and loss accounting is expected to improve the utilization of wards, focusing on the efficient use of hospital beds. It can be inferred that the implementing hospital group is trying to improve profitability by increasing the total revenue by increasing the number of patients while shortening the average length of stay and improving the unit cost of treatment. Furthermore, while the corrected average length of stay (and the normal average length of stay), which represents the efficient use of hospital beds, is significantly shorter, the utilization rate of hospital beds, which represents the utilization status of hospital wards, shows no significant difference (the utilization rate of hospital beds is higher in the implementation hospital group than in the response hospital group). In addition to reducing the length of stay, the number of patients increased to the point that the bed utilization rate was maintained. From the perspective of the major purpose of departmental profit and loss accounting, which is to increase profitability, it can be said that departmental profit and loss accounting has had a positive effect on the process of ward utilization.
In contrast to the previous study (Sangwan et al., 2017), which found no significant difference in the effect of departmental profit and loss accounting on the implementation of important therapeutic activities, it became clear that departmental profit and loss accounting was considered to significantly promote the implementation of important therapeutic activities such as surgery. Important therapeutic activities such as surgery are generally well reimbursed, which leads to an increase in the unit cost of medical treatment and an increase in the hospital’s overall revenue. As a result, given the cost structure of hospitals, which has a high fixed cost ratio, encouraging the implementation of vital medical treatments will result in increased profitability. As a result, departmental profit-and-loss accounting has a positive effect on the process of conducting significant treatment operations from the standpoint of increasing profitability.
Then, even when departmental profit and loss accounting was established, the effect of profit and loss accounting on improving profitability tended to be larger in hospitals that grasped profit and loss by the department on a monthly and frequent basis and executed the PDCA cycle often. Furthermore, it was confirmed that the high frequency of PDCA management had no negative impact on medical care outcomes. Furthermore, it was found that hospitals that used monthly PDCA management had a greater bed utilization rate and improved their ward occupancy status, as well as a higher rate of critical therapeutic activities, particularly surgery. In other words, the high frequency of PDCA management by grasping the profit and loss of each department improved and promoted the utilization of wards and the implementation of important treatment procedures, and enhanced the effect of improving profitability, but did not have a negative impact on the results of medical care.
In addition, the effect of increasing profitability was proven when the degree of utilization was high, in addition to the department’s implementation of profit and loss accounting. Furthermore, it was found that the higher the utilization level, the larger the impact on profitability. It was also established that the higher the level of usage, the less negative impact on medical outcomes. Furthermore, it was found that the higher the utilization level, the more critical therapy actions were promoted. To put it another way, expanding the use of departmental profit-and-loss accounting encourages the implementation of important treatments and boosts the effect of boosting profitability, although it is unlikely to have a negative influence on medical outcomes.
Finally, it was established that the department’s use of break-even analysis has an effect on improving profitability, which is the objective of the analysis, but it has no negative impact on medical care outcomes. Furthermore, it became obvious that not only implementing the break-even analysis by the department but also increasing the level to which the analysis was used, had a positive influence on profitability. On the other hand, as the level of use is raised, the possibility of certain negative effects on medical care outcomes has been suggested, and it has also been advised that when actively using departmental break-even analysis, close attention to side effects is required.
6. Conclusion
This study reconfirmed that the implementation of departmental profit and loss accounting has a positive effect on the objective financial performance of hospitals and that the effect of improving profitability is enhanced not only by implementing it but also by implementing it monthly with high frequency and regularity, and by using the accounting results more actively. It is also clear that the department’s implementation of break-even analysis improves financial performance and that the effect of increasing profitability is enhanced not just by applying the analysis but also by using it more actively. Furthermore, it was discovered that this style of departmental P&L management had no negative effects on the results of medical care.
Based on the assumption that we are in a financially challenging business environment, active income statement management would be an appropriate management activity for a hospital organization, not only for the hospital as a whole but also for each department. However, because medical care outcomes have many different aspects, and the indicators used in this study cannot be considered to encompass all aspects of medical care outcomes, the side effects of departmental P&L management must constantly be closely monitored.
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