"Healthcare Manager", 2008, N 3

METHODS FOR DISTRIBUTION OF COSTS OF MEDICAL INSTITUTIONS

GENERAL CONCEPTS ABOUT COST DISTRIBUTION

Each medical institution, as well as any manufacturer of goods or services, faces a number of questions related to the effectiveness of various areas of activity:

Which type of medical services brings more profit, and which types of services are unprofitable?

Which types of services should be expanded, and which services should be curtailed?

What are the optimal prices for services?

What are the most significant costs for each type of service, etc.?

To answer these and similar questions, it is necessary to clearly determine the costs for this area of ​​activity, for this type of service. The ideal option is when cost accounting and management accounting are identical. However, in practice there are large discrepancies between these types of accounting. These discrepancies are associated primarily with the inability of accounting (budget) accounting to solve management problems. In addition, there are discrepancies between regulations governing accounting itself and tax legislation, etc.

Let us add to this that a modern medical institution has a complex structure, provides a large number of different types of services, expends numerous types of resources, and receives funding from various sources. All this creates the problem of not only classifying costs, but also their ordering. For the purposes of economic analysis (as well as for the purposes of accounting, taxation, pricing, etc.), there is a need to distribute (allocate) costs to various objects.

The main tasks of cost allocation include cost allocation:

By types of services provided (that is, determine what types of costs and in what volume are incurred for a particular service);

By sources of financing (the costs of providing the same types of services with different sources of financing may be different).

To do this, it is necessary to solve a number of intermediate problems:

1. Distribute costs for each item into fixed and overhead, direct and indirect, etc.;

2. Distribute costs among each department;

3. Develop criteria for allocation (redistribution) of costs in various cases;

4. Determine the order (stages) of cost distribution.

It should be noted that the problem of cost allocation is much broader than the problem of overhead cost allocation. Major costs also often require allocation. This applies to the following main situations:

Distribution of main costs by funding sources;

Distribution of that part of the main costs that cannot be distributed in a direct way (that is, that part of the main costs that does not coincide with direct costs) - utilities used in the process of providing medical care (electricity, water, etc.) and etc.;

Distribution of costs of treatment and diagnostic departments among the main clinical departments (if the cost of treatment and diagnostic services is included in the cost of services of clinical departments: bed-day, patient treated, completed case of outpatient care, etc.).

Thus, although more often one has to deal with the problem of allocating overhead costs, nevertheless, in essence, we are talking about choosing methods for allocating indirect costs. Therefore, in a number of cases, when talking about methods for distributing overhead costs, we will indicate indirect costs in parentheses, bearing in mind not the identity of these concepts, but the applicability of the approaches under consideration to the distribution of not only overhead costs, but also some types of basic costs, that is, about distribution methods indirect expenses. By the way, the Tax Code of the Russian Federation deals with methods of distributing indirect costs rather than overhead costs (the term “overhead costs” is not used at all in the Tax Code), which, in our opinion, is more correct.

In principle, there are two main options for cost distribution:

1. Article by article.

2. By department.

With itemized cost distribution, each item is distributed by department, by type of service, and by source of financing.

When distributing by division, the full costs of the divisions are first determined, and then the costs of divisions that do not directly provide final medical services are distributed among the main divisions that provide services (the so-called revenue centers). This method is also called the aggregate method. To do this, the total amount of all overhead costs is found, which is distributed between revenue centers (clinical and treatment and diagnostic departments that directly provide services to external consumers). The costs of these departments are then allocated to individual services.

The question naturally arises about which of these two methods to choose. As a rule, the most rational situation is when the costs for each item are first distributed among departments, and then the total costs of each of the auxiliary departments are distributed among the main clinical departments.

However, in practice it is often necessary to use much more complex schemes, combining not only different principles for the distribution of various cost items, but often the same cost items. For example, utilities between the main departments (clinic, hospital and diagnostic and treatment services), in the absence of meters, can be distributed in proportion to the area; inside the hospital between departments - according to the number of beds, and inside the clinic - according to the number of medical positions, volume of work, etc.

In addition, it is possible that some of the items are distributed between each of the departments (direct costs), then costs are redistributed (the costs of auxiliary departments are allocated to the main clinical departments), and the rest (indirect costs) are distributed only between the main clinical departments (departments).

The essence of cost distribution is that all costs must be attributed to a specific structural unit whose activities involve costs (the so-called cost center). Often these divisions (centers) are called differently: responsibility centers, or cost centers. Because funds are spent in all departments of a hospital, outpatient clinic, or other health care facility, each department is considered a cost center. In this case, cost centers are usually divided into two main groups:

Income centers (divisions) that sell services to third-party organizations and individuals. These are the so-called “earning units”. The term “earning” means in this case that the department is included in the list of services financed according to a certain criterion of the volume of work performed (number of patients treated, average per capita standard, etc.) and must receive (earn) funds, both for themselves and for the remaining departments of the institution (for economic services, etc.). However, if we are talking about budgetary estimated financing, then it does not matter whether these services should be paid for or not. Revenue centers usually include hospital clinical departments with beds (therapeutic, pediatric, surgical, etc.); services of outpatient doctors.

Auxiliary centers (divisions). Auxiliary centers are those units (cost centers) that support the implementation of medical work in the institution. These usually include the administration, the reception department, the catering department, the accounting department, the economic planning department, the economic service, the information service, etc.

Treatment and diagnostic (paraclinical) departments (radiology department, laboratory, etc.), depending on the accepted billing procedure in the compulsory medical insurance system or when providing paid services, can be both income centers (if their services are paid separately) and auxiliary (if the cost of their services is included on average in the cost of a bed-day, a completed case of inpatient or outpatient treatment).

Health care providers have some flexibility in determining the criteria used to determine which departments are satellite centers and which are revenue centers. One of the requirements that a revenue department must meet is the ability to fairly accurately determine the volume of services provided to patients in this department. For example, a transaction unit may also be considered a revenue center if the object of accounting (for example, for billing purposes) is a separate transaction. We can count the number and type of surgical operations performed, determine whether a particular patient has undergone surgery, and set a price based on this. The method used to pay for services provided by a hospital or other health care facility also affects the determination of income status.

Let's give another example. If a laundry, which is part of a medical institution, provides laundry services to other departments of this institution, then the laundry will be an auxiliary center. If the same laundry simultaneously provides laundry services to other medical institutions, then it will also be a profit center. That is, the laundry will have a dual status. On the one hand, laundry costs must be distributed among the main clinical departments (revenue centers). But, on the other hand, we cannot leave the laundry without expenses (that is, we cannot distribute all the laundry expenses to other departments) - otherwise we cannot determine the price of the laundry and bill for the services to another institution. What to do in this situation? In order to resolve such a conflict (which can occur with many other departments: diagnostic and treatment departments, catering unit, garage, etc.), it is necessary to distribute not all the costs of a given auxiliary department among the main clinical departments, but minus the costs related to the provision of services to third parties. We will return to this issue when considering the so-called step-by-step cost distribution method, which will be discussed later.

Distribution of costs among cost centers is carried out using special methods. Direct costs are allocated to each type of product and cost object in a precisely established amount, and indirect costs are distributed among cost centers and then among cost objects.

So how should costs be allocated? How should direct costs be allocated? How should overhead (indirect) costs be distributed? How should costs be distributed among individual items? How should the costs of auxiliary units be distributed among the main clinical units (revenue centers)?

Let's try to answer these questions.

First of all, we note that there is no clear regulatory framework that would determine in which case what the distribution method should be. The exception is the distribution of costs for tax purposes for payment of utilities, communication services, transportation costs for servicing administrative and managerial personnel in the presence of several sources of financing, as well as the distribution of costs of work in progress. In these cases, the Tax Code clearly describes the principle of cost allocation (we will look at these situations later). In other cases, it is necessary to use the logic of economic calculations. It is advisable to specify the procedure for the distribution of costs in the order on the accounting policy of a medical institution (although it should be borne in mind that this document is not mandatory for a budgetary institution).

When conducting an analysis for several types of services provided, one of the main issues is the method of allocating indirect costs by type of service, as well as choosing the basis for allocating costs. The allocation base is understood as any accounting value that characterizes the share of overhead (indirect) costs attributable to each type of service. Various indicators can serve as a base (the basis for allocating costs): the volume of services, labor costs, the amount of total costs, the number of employees, area, etc. The problem of choosing the optimal base option for distributing various types of expenses will be discussed later.

METHODOLOGICAL BASIS FOR COST DISTRIBUTION

In the context of tightening financial control over the activities of budgetary institutions, the question naturally arises about the legality of using certain methods of cost distribution. Although, as already noted, cost allocation methods must be reflected in the Accounting Policy of a medical institution, they must comply with (or at least not contradict) the requirements of regulations. Let's consider what the regulatory documents say about what relates to direct and indirect costs, overhead costs, what are the principles of cost distribution, etc.

First of all, let's see if there is any guidance on the basis(s) for allocating expenses. Here are excerpts from Order of the Ministry of Finance of the Russian Federation dated December 30, 1999 N 107n “On approval of instructions for accounting in budgetary institutions.” And although this order is no longer in force, it serves as a good illustration from the point of view of the issues we are considering. Unfortunately, the new instructions that replaced the above do not describe these issues so clearly. In paragraph 168 of the Instructions approved by this order, it was written:

“Subaccount 210 “Expenses for distribution” takes into account expenses that, at the time of their occurrence, cannot be attributed directly to a certain type of activity, a certain type of product or product in cases where there are several sources of financing or several types of products are produced. This account records also deferred expenses.

Expenses intended for distribution are recorded in the debit of subaccount 210 and the credit of the corresponding subaccounts during the month. At the end of the month, these expenses are distributed in the prescribed manner to individual types of activities according to funding sources.

Expenses, depending on specific conditions, are distributed in proportion to the occupied space by type of activity, number of contingents or sources of financing, etc.”

As you can see, this document (usually briefly referred to as Instruction No. 107n) provided for the possibility of choosing various options depending on the specific situation. In addition, the list of reasons for allocating costs is not closed (exhaustive); it can be expanded.

"Account 22 "Expenditures from extra-budgetary sources"

169. This account takes into account expenses planned according to estimates of income and expenses for business activities for the production of products, performance of work, provision of services, for the manufacture of experimental devices, procurement and processing of materials, as well as expenses planned according to estimates of earmarked funds and gratuitous receipts and funds generated from profits.

Planning of estimates of income and expenses, as well as its execution for these types of activities, are carried out according to the codes of the Economic Classification of Budget Expenditures of the Russian Federation.

Expenses from extra-budgetary sources are divided into direct and overhead (indirect) expenses.

Direct costs include expenses associated with the production of products, performance of work, provision of services that can be directly and directly included in the cost: materials, wages of production workers, researchers, etc., contributions to state extra-budgetary funds, electricity, expenses previous years, attributable to the cost of products of the reporting year, and other direct expenses.

Overhead (indirect) costs include: expenses associated with the organization and management of production, performance of work, provision of services related to the activities of the organization as a whole: maintenance of management staff and service personnel, including wages, contributions to state extra-budgetary funds, rental of premises , heating, lighting, water supply, maintenance and other indirect costs.

In those institutions where one type of product is produced, all costs are direct.

If there are several costing objects, overhead costs are preliminarily taken into account in subaccount 210 “Costs for distribution”.

The distribution of overhead costs for manufactured products, performed work and services is carried out monthly...

Overhead costs, depending on specific conditions, are distributed by institutions for individual types of products, items, works, services in proportion to the wages of production workers, researchers, etc. or materials consumed, or the totality of direct costs.

To determine the actual cost of manufactured products based on cost accounting data, a reporting calculation is compiled. In this case, the total amount of expenses under this subaccount minus expenses for work in progress at the end of the reporting period is distributed by type of finished product, after which the unit cost of each type of manufactured product is determined."

As we see, here too there are no strict restrictions on the choice of cost distribution methods.

Let us now turn to the Tax Code of the Russian Federation. In subparagraph 3 of Article 321.1., dedicated to the peculiarities of tax accounting in budgetary institutions, it is written:

“If the estimates of income and expenses of a budgetary institution provide for financing the costs of paying for utilities, communication services, transportation costs for servicing administrative and managerial personnel from two sources, then for tax purposes the acceptance of such expenses to reduce income received from business activities and funds targeted financing is carried out in proportion to the amount of funds received from business activities in the total amount of income (including funds of targeted financing). At the same time, the total amount of income for these purposes does not take into account non-operating income (income received in the form of bank interest on funds located on the property). settlement and deposit accounts received from the rental of property, exchange rate differences and other income)".

Article 319 of the Tax Code of the Russian Federation (Procedure for assessing the balances of work in progress, balances of finished products, shipped goods) defines the features of the distribution of costs for work in progress. Here are excerpts from this article.

"1. For the purposes of this chapter, work in progress (hereinafter referred to as WIP) means products (work, services) of partial readiness, that is, those that have not undergone all processing (manufacturing) operations provided for by the technological process. Work in progress includes work completed but not accepted by the customer and services. WIP also includes the balances of unfulfilled production orders and the balances of semi-finished products of own production. Materials and semi-finished products in production are classified as WIP, provided that they have already been processed.

The assessment of WIP balances at the end of the current month is carried out by the taxpayer on the basis of data from primary accounting documents on movement and balances. (in quantitative terms) raw materials and supplies, finished products by workshop (production and other production divisions of the taxpayer) and tax accounting data on the amount of direct expenses incurred in the current month.

The taxpayer independently determines the procedure for distributing direct expenses for work in progress and for products manufactured in the current month (work performed, services rendered), taking into account the correspondence of the expenses incurred for manufactured products (work performed, services rendered).

The specified procedure for the distribution of direct expenses (formation of the cost of work in progress) is established by the taxpayer in the accounting policy for tax purposes and is subject to application for at least two tax periods.

If it is impossible to attribute direct costs to a specific production process for the production of a given type of product (work, service), the taxpayer, in his accounting policy for tax purposes, independently determines the mechanism for distributing these costs using economically justified indicators."

These are a few cases where the regulatory document clearly describes the procedure for allocating certain types of expenses. In other cases, medical institutions themselves establish this procedure. At the same time, let us note one more important point. These provisions of the Tax Code relate to the procedure for distributing expenses only for tax purposes. Therefore, in other cases (for the purpose of economic analysis, pricing, etc.), it is possible to use other principles for allocating costs than those provided for by the Tax Code.

The Tax Code also contains instructions regarding which types of costs are considered direct and which are indirect. This is the subject of Article 318 of the Tax Code (Procedure for determining the amount of expenses for production and sales).

"1. If a taxpayer determines income and expenses on an accrual basis, production and sales expenses are determined taking into account the provisions of this article.

For the purposes of this chapter, production and sales expenses incurred during the reporting (tax) period are divided into:

1) straight;

2) indirect.

Direct costs may include, in particular:

Material costs determined in accordance with subparagraphs 1 and 4 of paragraph 1 of Article 254 of this Code;

Expenses for remuneration of personnel involved in the production of goods, performance of work, provision of services, as well as the amount of the unified social tax and expenses for compulsory pension insurance, used to finance the insurance and funded part of the labor pension, accrued on the specified amounts of labor expenses;

Amounts of accrued depreciation on fixed assets used in the production of goods, works, and services.

Indirect expenses include all other amounts of expenses, with the exception of non-operating expenses determined in accordance with Article 265 of this Code, incurred by the taxpayer during the reporting (tax) period.

The taxpayer independently determines in the accounting policy for tax purposes a list of direct expenses associated with the production of goods (performance of work, provision of services).

2. In this case, the amount of indirect costs for production and sales incurred in the reporting (tax) period is fully included in the expenses of the current reporting (tax) period, taking into account the requirements provided for by this Code. Non-operating expenses are included in the expenses of the current period in a similar manner.

Direct expenses relate to expenses of the current reporting (tax) period as products, works, and services are sold, in the cost of which they are taken into account in accordance with Article 319 of this Code.

Taxpayers providing services have the right to attribute the amount of direct expenses incurred in the reporting (tax) period in full to the reduction of income from production and sales of this reporting (tax) period without distribution to the balances of work in progress.

3. If in relation to certain types of expenses in accordance with this chapter there are restrictions on the amount of expenses accepted for tax purposes, then the basis for calculating the maximum amount of such expenses is determined on an accrual basis from the beginning of the tax period. At the same time, for the taxpayer’s expenses related to voluntary insurance (pension provision) of his employees, to determine the maximum amount of expenses, the duration of the agreement in the tax period is taken into account, starting from the date of entry into force of such an agreement.”

Here are excerpts from subparagraphs 1 and 4 of paragraph 1 of Article 254 of the Tax Code, to which reference was made in Article 318.

"Article 254. Material expenses

1. Material expenses, in particular, include the following expenses of the taxpayer:

1) for the acquisition of raw materials and (or) materials used in the production of goods (performance of work, provision of services) and (or) forming their basis or being a necessary component in the production of goods (performance of work, provision of services);

4) for the purchase of components undergoing installation and (or) semi-finished products undergoing additional processing from the taxpayer."

Doctor of Economics, Deputy

Chairman of the Committee

on healthcare

St. Petersburg

F.N.KADYROV

The association assists in providing services in the sale of timber: at competitive prices on an ongoing basis. Forest products of excellent quality.

5.1. Costs and their structure in healthcare

Numerous organizations represented in the field of medical services are divided into three groups: public, private non-profit and private for-profit. In countries with budgetary healthcare systems, public hospitals account for up to 80% of the total bed capacity. In countries with a compulsory health insurance system, this share is lower – about 50-60%. In countries where private health insurance predominates, private hospitals predominate. Each of the identified groups of organizations has many organizational and legal forms. The development of certain forms is determined in each country by historically established ideas about commercial medicine.

The functioning of various organizations in healthcare requires the expenditure of appropriate resources. These costs form production costs medical, medico-social, health services, determining to a large extent the volume of financing and prices for the corresponding services. Costs can be viewed from the perspective of either the individual producer or society as a whole. In some cases, both approaches give the same result, in others - different. This is because not all results are in monetary form; some of them are being implemented directly, bypassing the purchase and sale relationship, and have a direct impact on the well-being of society or individuals. Social and private costs coincide only in the absence of externalities.

All over the world, healthcare involves an increasing amount of resources used, which inevitably causes an increase in the costs of producing medical services. Appearance new technologies The medical and health process increases the dependence of healthcare on technological means: the traditional “doctor-patient” system is increasingly being replaced by the resource-intensive “doctor-technology-patient” system. Scientific discoveries and achievements of medical science give rise to mass demand for new, expensive, and until recently very rare medical services and related products (for example, transplant operations of artificial and living organs and tissues). Satisfying this demand requires attracting additional economic resources. Prospect of emergence and mass distribution new dangerous diseases necessitates the allocation of significant funds for large-scale scientific research and the development of adequate protection measures.

In healthcare, the dependence of average production costs on the volume of services provided is also described by a U-shaped curve. As the size of a medical organization increases, average costs decrease to a certain minimum and then begin to increase. At the same time, medical organizations are not homogeneous in terms of the composition of patients served, the complexity of the services provided, the cost of training specialists, the volume of scientific research, etc., therefore low average costs in themselves are not indicators of higher efficiency. In addition, the inability to transport and save medical services very often creates a situation where the long-term average cost curve reaches its minimum value at volumes much greater than the actual demand, i.e., the optimal production volume cannot always be realized.

The increasing complexity of the infrastructure related to the protection of public health leads to an increase in administrative costs, costs of maintaining various types of inspections, information blocks, statistical services, etc. Everything related to the coordination of the activities of various entities constitutes in total transactional cost growth factors.

The peculiarities of the operation of market mechanisms in healthcare lead to the fact that the costs of creating the possibility of providing medical care become socially necessary character. This manifests itself in the following four points:

1) the significant participation of government agencies in the formation of costs for protecting public health directly determines the public (not market) inclusion of these costs in the overall production process;

2) information asymmetry in relation to the consumer of medical services creates conditions for direct social inclusion of the benefits received in the total final consumption of society;

3) the dominant monopoly positions of medical service providers lead to the transformation of actual costs into socially necessary ones;

4) the presence of a significant number of intermediary entities gives the private interest of the consumer and producer of medical services elements of public economic interest.

In the case of budgetary financing of medical institutions, the calculation of expenses according to individual estimates is based on standard staffing levels, consumption rates for medicines and dressings, standards for the provision of household and soft equipment, etc. In other cases, when calculating costs, not standard, but actual expenses for the provision of therapeutic, preventive and other medical care.

There are three main methodological approach to determining costs in healthcare:

1) a method based on calculating the costs associated with the provision of each service (operations, procedures, manipulations, etc.). Based on this method, an invoice can be submitted to an individual patient, an insurance company; it is used in the formation of contract prices and private practice prices;

2) a method based on determining the costs required to treat the “average” patient in a given medical institution. This method makes it possible to determine the average standard, which is important when determining the financing standard.

3) calculation of costs depending on nosological forms of the disease (diagnostic-related groups, clinical and statistical groups). This method can be used in the public health insurance system.

Changes in costs are influenced by groups of factors. More rational use of funds, improved organization of the diagnostic and treatment process, reduction of treatment time, etc. – all this leads to cost reduction. On the other hand, their growth is caused by the intensification of healthcare, the introduction of new medical equipment, the use of expensive medicines and materials, etc.

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Koblova Galina Ivanovna. Organization and methodology of cost accounting in healthcare institutions: Dis. ...cand. econ. Sciences: 08.00.12: Saratov, 1999 205 p. RSL OD, 61:00-8/815-1

Introduction

CHAPTER 1 Economic features of the functioning of healthcare and their impact on the organization of accounting in modern conditions 10

1.1. The importance of accounting in the context of reforming the healthcare management system 10

1.2. Foreign experience in organizing and financing healthcare and its significance for domestic practice 30

1.3. Features of formation of costs for medical services in the conditions of development of market relations 44

CHAPTER 2 Organization of cost accounting for medical care in healthcare institutions 68

2.1. Organization of financial and management cost accounting 68

2.2. Improving the classification of cost accounting in healthcare institutions 93

2.3. Organization of cost accounting for medical services in healthcare institutions 108

CHAPTER 3 Main directions for improving methodological recommendations for calculating the cost of medical services 119

3.1. Features of methodological approaches to calculating the cost of medical services 119

3.2. Accounting and analytical support for the medical institution management system 145

Conclusion 15 6

List of used literature 164

Applications 181

Introduction to the work

The economic reforms carried out in the country are aimed at creating market relations in the national economy, which predetermines the need to create a medical care system that is adequate to the laws and principles of a market economy. A new approach to the organization of healthcare, the choice of forms and methods of its management, places increased demands on economic information, the main supplier of which is accounting. However, as the study showed, the traditional organization of accounting in medical institutions does not correspond to the new conditions of their activities in the health insurance system, because at its core it is a system for recording cash and actual expenses of budgetary funds of the health insurance fund (as an additional source of financing) in the context of items expenses of the budget classification and is focused not on identifying such economic indicators as the cost of medical care provided, the financial result and its use for its intended purpose, but on accounting for the use of cost estimates for the maintenance of medical institutions.

In connection with the transition to market relations, a fundamentally different organization of healthcare, which is based on the recognition of the commodity nature of medical services and the diversity of forms of ownership of medical institutions, problems of financing and pricing arise. which in turn is associated with the problem of maintaining an optimal balance of expenses and income, calculating the cost of medical services to provide quality medical care, etc.

Thus, the need for scientific research of the healthcare system is determined by the need for a rational solution to these problems and involves solving the problem of finding a more promising option for organizing cost accounting and calculating the cost of medical care.

services in medical institutions, corresponding to the conditions of market relations, which determined the choice of the topic of dissertation research.

State of knowledge of the issue.

The work of domestic scientists (Pupshikh T.F., Martynchik S.A., Khromchenko O.M., Boyarintseva N.A., Kadykov F.N., Popov G.A.) is devoted to solving theoretical problems of the system of management, planning and financing of healthcare. , Shipova.M., Shamshurin N.G., Svetlichnaya T.G., Zyyat-dinov K.Sh., Zakirova S.A., etc.).

Issues of accounting in non-production institutions are developed in detail in the works of Dedkov E.P., Goloshchapov V.A., Mastalyina N.A., Malov S.A. etc. However, the works of these authors relate to the conditions of administrative methods of healthcare management and the organization of traditional budget accounting and reporting.

The study of the theory and practice of medical institutions has led to the conclusion that insufficient attention is paid to the problems of improving accounting in the context of healthcare reform, in particular to the problems of accounting for the costs of providing medical care in medical institutions that provide paid services.

It should be noted that the proposed methodological recommendations (Denisov I.N., Obayan A.S., Shevsky V.I., Lunskaya L.L., Slageva E.V., Chelidze N.P.) on cost accounting and cost calculation medical services in the works of domestic economists are not widely used in practice due to the complex calculation mechanism that replicates production accounting.

Purpose and objectives of the study.

The purpose of this study is to improve the economic mechanism and increase the efficiency of health care.

opinions in the formation of costs for medical services, namely the development of theoretical provisions and practical recommendations for organizing the accounting of costs of medical care in accordance with the requirements for calculating the cost of medical services based on the study and practical understanding of current domestic practice, its compliance with the requirements of a market economy and international standards. To achieve this goal, the following tasks are defined in the work:

explore trends in the development of the healthcare management system, analyze the progress of its reorganization;

determine the role of accounting in the healthcare management system and justify the need to improve accounting for the costs of providing medical care in market conditions;

explore foreign experience in financial and information support of healthcare from the point of view of its possible application in the Russian Federation;

To study the settlement system of insurance organizations with medical treatment
preventive institutions and calculation of tariffs for medical
services and develop recommendations for its improvement;

comprehensively analyze the system of traditional budget accounting and determine the main directions for organizing cost accounting in medical institutions;

explore the composition of costs of health care facilities (medical and preventive institutions) and justify the classification of costs for the provision of medical services;

Analyze existing methods for calculating costs
medical services and give specific recommendations for their improvement
nu.

Object and subject of research.

The object of the study was selected medical institutions of different profiles, subordinate to the Ministry of Health of the Government of the Saratov Region, operating in the compulsory health insurance system: City Hospital No. 1 (Balakovo), Emergency Hospital (Engels), Polyclinic No. 14, City Clinical Hospital No. 1, City Clinical Hospital No. 2, City Clinical Hospital No. 3, City Anti-TB Dispensary.

The subject of the study was a set of theoretical and practical issues of organizing cost accounting in healthcare institutions. Current regulations, statistical information from the Ministry of Health of the Russian Federation and the Ministry of Health of the Government of Saratov and the Saratov region were used as information for the study.

Methodological basis and information base of the study.

The methodological basis is the works of Russian and foreign economists on general issues of economic theory, materials from government and departmental documents of Russia regulating the functioning of compulsory health insurance. Materials from periodicals, statistical collections, factual materials from surveyed medical institutions, developments of Russian research organizations, and international standards for accounting and reporting were used.

Scientific novelty.

The scientific novelty of the work lies in the formulation, theoretical justification and solution of a set of issues of improving the organization of cost accounting for the provision of medical care in the context of reforming the economic mechanism of healthcare:

a new grouping and classification of costs has been proposed according to the items of the budget classification of medical institutions in the provision of paid medical services in terms of their functions and the role of costs in providing quality medical care, in relation to the technical process, by the method of inclusion in the cost, by economic elements, by costing items ;

a methodology for accounting for the costs of providing paid medical services using the “direct costing” method in healthcare institutions was proposed;

a methodology for separating accounting and use of budget financing and compulsory health insurance funds and other extra-budgetary revenues to health care facilities has been proposed;

a scheme for organizing the provision of management personnel with accounting and analytical information on the formation of production costs, calculated within the limits of direct costs, has been developed;

a system of additional synthetic and analytical sub-accounts has been proposed to the Chart of Accounts for accounting the execution of cost estimates of institutions on the budget to account for the costs of providing paid medical services;

a system of registers has been proposed for grouping and consolidated accounting of costs for the provision of paid medical services, used to obtain accounting and analytical information for making effective management decisions;

a methodology has been developed for distributing the costs of auxiliary production and assessing their mutual services.

Practical significance.

The practical significance of the dissertation lies in the development of basic provisions and specific recommendations for organizing cost accounting for the provision of medical care to medical institutions in market conditions. Research into the results of the dissertation will contribute

creating effective information support for healthcare management.

Approbation of research results.

The main results of the study were reported and received approval at scientific sessions and conferences of the SGSEU in 1996 - 1998. and were published in collections on the topics: “Socio-economic problems of the development of society in the transition period to the market” (Saratov, 1996), “Improving accounting and analysis of economic activities in the transition to a market economy” (Saratov, 1998), “Reforming accounting analytical work at enterprises" (Saratov, 1998), "Improving the organization of accounting and analysis in a market economy (Saratov, 1999).

Publications.

The main provisions of the study are presented in 5 published works, with a total volume of 2.4 pp.

Work structure.

The dissertation consists of an introduction, three chapters, a conclusion, a list of used sources and literature, and applications.

The introduction substantiates the relevance of the topic and the need for scientific research into the healthcare system, characterizes the state of knowledge of the problems, sets the goal and objectives of the research, presents the object and subject of the research, as well as the scientific novelty of the work.

In the first chapter; “Economic features of the functioning of healthcare and their impact on the organization of accounting in modern conditions” critically analyzes the system of state (budgetary) healthcare, examines the main trends in the development and improvement of the healthcare management system, shows their influence on the organization of accounting, examines the main features of the formation

analysis of the costs of medical services as the final product of health care facilities, the features of the development of health care management systems in countries with developed economies are considered, and the role of improving accounting in the context of health care reform in general is determined.

In the second chapter: “Organization of cost accounting for the provision of medical care in health care institutions”, the current procedure for accounting for the costs of medical institutions is critically analyzed, the economic feasibility of introducing management cost accounting and calculating the cost of medical services is substantiated, a new, different from the traditional, grouping and classification of costs by expense items of the budget classification for the provision of paid medical services. A system of additional synthetic and analytical accounts has been proposed to the current Chart of Accounts for accounting for the execution of cost estimates for institutions and organizations on the budget.

The third chapter: “Methodological recommendations for calculating the cost of medical services” analyzes the features of methodological approaches to calculating the cost of medical services from the point of view of their application in practice, substantiates the need for a radical and constructive change in cost accounting and calculating the cost of medical services using the “direct costing” method ", the advantage of dividing and accounting for the costs of health care facilities into fixed and variable, the features of the distribution of general medical expenses into the main medical-technological departments and auxiliary activities are considered, the economic feasibility of introducing new registers for accounting costs of health care institutions is considered.

In conclusion, the main conclusions and proposals are formulated.

The importance of accounting in the context of reforming the healthcare management system

Economic reforms currently being implemented are aimed at creating a market economic mechanism. The emergence of market relations necessitates the formation of similar relations in healthcare. Taking into account the social significance of medical services and the impossibility of their subordination solely to commercial interests, it is necessary to form such an economic health care mechanism, when, on the one hand, high efficiency of medical services would be achieved, and on the other hand, the representation of their main range would be ensured, regardless of the state of personal income of consumers.

Since the late 60s, there has been a tendency in Russia to deteriorate all indicators characterizing the health of the population. In the 90s it intensified even more. This is directly related to changes in socio-economic living conditions, local wars, an increase in the number of refugees and internally displaced persons, and an increase in crime. True, in 1994-1995 in the dynamics of slowing down the process of deterioration: the rates of general and infant mortality and the incidence of certain controlled infections (diphtheria, scarlet fever, measles, whooping cough) have decreased. However, this does not provide grounds for concluding that the medical and demographic situation in the country has stabilized.

The deteriorating health status of the population is due not only to a complex of general socio-economic factors, but also to a number of negative trends in the healthcare system, such as:

1. An acute shortage of financial resources. After relative stabilization in health care financing associated with the introduction of compulsory health insurance (CHI) in 1995-1996, the situation worsened again. The emergence of a new source of financing in the form of contributions to compulsory medical insurance of the working population began to be blocked by a decrease in budgetary allocations, which is largely due to non-compliance with the law “On health insurance of citizens of the Russian Federation”.

2. Reduced level of controllability of the health care system. The complexity of the health care system has been largely lost. The efforts of different departments related to health protection were disjointed. The importance of strategic and current health care planning has noticeably decreased. The loss of the previous administrative levers for managing the network of medical and preventive institutions (hereinafter referred to as health care facilities) was not compensated for by methods of economic management. Both healthcare authorities and compulsory medical insurance bodies and structures are losing their leverage over healthcare institutions and the medical care system as a whole (see Fig. 1 and Fig. 2).

The diagram shows that the administrative subordination in force before the start of the health system reforms completely coincides with financial flows. Thus, centralized, unified financing also determined subordination. The basis of administrative management was the principle of economic dependence. In the new conditions of decentralization of funding sources, the main element of management in the healthcare system should be economics, which determines the effectiveness of medical care. Funds must be allocated for specific medical services, which, in turn, must have an objective price. In this case, the element of economic dependence on a simple administrative decision (“To give or not to give money”) takes the form of economic dependence of receiving adequate and timely payment (financing) on ​​timely and high-quality medical care, regardless of the source of funding

Organization of financial and management cost accounting

The fact of manifestation of accounting as a system for collecting, processing and transmitting economic information in the process of functioning of a business organization lies in determining the element-by-element structure of such a system. Of the totality of its constituent elements, the most characteristic is the system of accounting accounts linked using double entry. The following elements can be identified as other elements of the system: assessment of economic facts; documentation; calculation (estimate); inventory, balance; reporting.

In accordance with this, accounting includes a set of economic facts that can be counted or, in other words, accounting covers the facts of changes in the economic assets and resources of an enterprise, measured in numbers by price and quantity and reflected in special information carriers - accounting documents.

A set of accounting accounts is intended to summarize information about a set of economic facts related to a specific accounting object, which are economic assets, sources of their formation, economic processes that make up the content of the enterprise's activities.

The accounting system is created and functions primarily as the basis of the information system of a separate economic organization, which acts as an integral part of the public economy. In this sense, a specific version of the organization of accounting is revealed in the dialectics of the general, the individual and the special.

In other words, the complex element-by-element structure of the accounting system is revealed in a certain version of the organization of accounting and control through a reflection of the relative isolation, discreteness, limited space and time of the economic process of an individual enterprise, institution or organization with its inherent specific features that make up its qualitative and quantitative certainty and, in turn, through the reflection of the features of a particular variant of the organization of accounting and control, as an expression of its integrity in the sense of correlation, implementation in the information system of a certain enterprise of the general element-by-element structure of the accounting system.

The main content of changes in the economic mechanism of domestic healthcare was the inclusion of the health care system in the system of market commodity-money relations. This determines the recognition of the commercial nature of the product of a medical institution - a medical service that has its own value and price. Therefore, the urgent need to obtain information about the process of formation of the cost of medical services equally arises both for a private, commercial medical institution, and for an institution providing free medical care at the expense of charitable foundations, because With different payment systems for medical services performed and different sources of replenishment of spent funds, the common thing is the need to control the process of creating the final product.

The main feature of the organizational structure of most treatment and prevention institutions is the presence of a number of treatment and prevention units, each of which is designed to implement a specific medical program and, in general, they represent a closed technological cycle. These are treatment departments in hospitals, medical offices in outpatient clinics. At the same time, an important feature of the medical services sector is that the production and consumption of medical services coincide in space and time, i.e. if at some point in time there is no demand for medical services (the medical and preventive departments are not overloaded), the need for funds for the maintenance of a specific medical and preventive unit clearly remains in order to ensure its readiness to receive and use patients. In other words, it is necessary to develop an organization for accounting for the costs of providing medical care and the production of medical services in conjunction with the organization of accounting for the costs of maintaining the institution as a whole. The latter is nothing more than the organization of accounting for the use of cost estimates for the maintenance of a medical institution. This determines the features in the organization of accounting for the costs of medical care.

Features of methodological approaches to calculating the cost of medical services

The advantage of the proposed method is that it determines the cost of detailed dental services and, by grouping them in the required set, we can determine the cost of DRG. In addition, it becomes possible to include scientifically based costs in the price, and use them to determine the amount of funding for the clinic. Finally, payment on a completed case basis through DRG prices will encourage medical staff to complete treatment and improve work results by simultaneously increasing qualitative and quantitative indicators.

The advantage of this approach is a fairly accurate accounting of all costs for specific services, the creation of an information base for future calculations and an economic basis for the introduction of a new wage system, directly dependent on the quantity and quality of work performed.

However, it is necessary to note the following defects of this approach:

Not all simple services can be reduced to a set of detailed ones (you can take into account the time required to fill out a medical history, the number and costs of diagnostic tests, but it is impossible to determine how many times a doctor should approach a specific patient);

High information capacity and the lack of direct linkage with current accounting create difficulties in collecting source data;

This approach allows for the possibility of re-accounting the same expenses of a medical institution for various medical services (for example, taking a doctor’s labor costs when conducting a specific laboratory analysis to be equal to 5 minutes, the possibility of simultaneous performance of several tests is not taken into account);

The possibility of taking into account direct costs not related to the standard of medical service provision is not reflected, for example, in the case of a complication, concomitant disease, drug intolerance, the set and quantity of medicines changes, and there may also be a natural loss of resources (expiration date, etc.) .

The proportional methodology is based on the distribution of the costs of a medical institution among its divisions and the reduction of the calendar costs of the divisions to the calendar volume of activity (both standard and actual). Overhead costs are allocated either in proportion to the salaries of key personnel or the area of ​​departments.

The advantage of this approach is the relatively simple collection of source material, its compliance with the current forms of accounting for the expenses of a medical institution. Calculating the cost using this methodological approach is a good basis for analyzing financial and economic activities because Only by comparing the costs and volumes of activity of the unit as a whole can one judge the effectiveness of its work.

The disadvantage of this approach is that it is absolutely adequately applicable only to medical units providing homogeneous services (for example, treatment of patients in an inpatient department). The problem of distributing costs for departments providing various services is solved by introducing conventional units as a result of activity (in order to compare the labor intensity to the cost of various services) or by distributing costs in proportion to the working time of the doctor and nurse. For example, the services of a clinical diagnostic laboratory are extremely varied (more than 300 types of tests), but by bringing the department’s expenses to the working time budget, you can calculate the cost of each analysis. However, with this approach the accuracy suffers significantly, because labor costs are not always proportional to direct costs (research can be labor-intensive, but not resource-intensive and vice versa). In this case, an expert assessment is required in the introduction of additional conventional units (for direct costs).

Naumov, Alexander Nikolaevich

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Costs is a monetary value costs production factors necessary for the enterprise to carry out its production and sales activities.

Accounting costs represent the cost of resources expended in the production and sale of goods and services, and this fact is reflected in the documents.

Economic costs – These are opportunity costs that express the most efficient use of the enterprise's own resources:. accounting costs + implicit costs; or explicit costs + implicit costs. Explicit costs - the amount of expenses an enterprise costs to pay for consumed factors of production. Implicit costs include lost opportunity costs associated with the use of own funds. Long-term and short-term costs. Fixed and variable costs.Fixed (conditionally fixed) costs (FC) – this is the cost of resources that cannot be changed during their use in the short term Variable (conditionally variable) costs (VC) is the cost of variable resources that are necessary to produce a certain quantity (volume) of a product or service. Total (total or gross) costs (TC) – it is the sum of fixed and variable costs. Average costs (AC) – this is the total (total) costs per unit of production Average Variable Cost (AVC) – These are the variable costs per unit of production: Average Fixed Cost (AFC) – This is the fixed cost per unit of output. Marginal Cost (MC) – this is the change in total (total) costs when output changes Direct costs - These are costs that can be directly attributed to the cost of a product or service at the time they are incurred or accrued. Indirect costs – distributed by type of activity, structural divisions in proportion to revenue (income) from the sale of goods or services, i.e. they are conditionally included in the cost price. These costs include operating and management costs of the enterprise Elemental costs– consisting of one component (element), for example, depreciation of fixed assets; complex costs– consisting of a whole complex of homogeneous costs, for example, general production costs of an enterprise Production costs those. formed during the normal course of production and labor processes; Non-productive costs, which are caused by violations (shortcomings) of the organization and management of the production process at the enterprise. Current, future, upcoming costs- classification is made on the basis of the length of the period of time in which they are incurred or to which they relate.

7.Methodology for determining the cost of medical services

A medical service, like any product, has a cost. Cost (C) is the sum of two constituent elements: costs and required profit.

C = 3 x (1 + Pr), where

Z – costs of medical services

Pr – required amount of planned profit

The planned profit is set in the amount of funds necessary for the development of a medical institution, to finance social programs and other economically justified expenses in the amount established by the regulatory body. In this case, the profitability level should not exceed 25 percent.

Basic concepts and their definitions:

Medical service is a certain set of medical (therapeutic, preventive, diagnostic) measures carried out in relation to one patient, having an independent complete meaning.

1.Calculation of the cost of simple and complex medical services

The methodology for calculating prices is based on determining the average cost of one service in each given unit of a medical institution (inpatient departments, paraclinical units or outpatient clinics (doctor’s offices) units). The calculations are based on monetary expenses incurred both directly by the department itself, and indirect expenses to the extent that they ensure the provision of services in this department, i.e. expenses calculated on the basis of the received cost of the service fully ensure the functioning of the unit.

When calculating the cost of a simple service, it is necessary to use the technological standard established in a given institution (the time spent on this service, the quantitative and qualitative composition of medical workers performing this service, the types and quantities of medicines, drugs consumed, etc.).

The cost of services is calculated based on established standards and actual expenses of the institution.

C = (Zt+ Nz+ M + I + O+P + Sk) x (1 + Pr), where

Зт — expenses for remuneration of key personnel

NZ - accruals for wages of key personnel

M – material costs (medicines, etc. consumed in the process of providing medical services in full)

I – expenses for soft inventory

О – depreciation of equipment used directly in the diagnostic and treatment process

P – nutrition of patients

Sk - indirect costs

A complex service can be presented as a set of simple services that reflect the technological process of providing medical care that has developed in each specific institution.

Calculation of the cost of a complex medical service (Сс) is carried out by summing the cost of simple medical services according to the corresponding technological standard.

Сс = С1+С2+С3+С…, where

C1, C2, C... - the cost of simple medical services

8. Formation of a financial plan for a medical organization. Financial analysis of the activities of a budgetary healthcare institution

A financial plan is a document that reflects cash inflows and outflows.

Revenue part of a medical organization:

— entrance and membership fees are one-time or regularly made contributions to cover administrative and business expenses, the collection procedure of which is provided for in the Charter of a non-profit organization. Using these funds, public associations, consumer cooperatives, unions and associations are usually formed;

— voluntary contributions are funds voluntarily transferred by legal entities and individuals for the statutory activities of non-profit organizations. These contributions are collected from funds and autonomous non-profit organizations (Article 7 and Article 10 of the Federal Law “On Non-Profit Organizations” No. 7-FZ of January 12, 2006);

— income from business activities is the net profit received from commercial activities in accordance with current legislation and the charter of a non-profit organization.

Expenditure part:

— expenses reflected in the financial plan should be as close as possible to the statutory goals and objectives of the non-profit organization;

— the purpose and order of formation of articles should be clear to consumers of this information.

When drawing up a financial plan, the balance principle of financial planning must be observed, which assumes equality of income and expenses.

The formation of financial plans can be carried out in two ways:

1. a non-profit organization starts from the goals and objectives it faces when implementing a program or project, within the framework of which the costs necessary to successfully achieve its goals are calculated;

2. Based on the existing financial capabilities of the non-profit organization, the question is raised about using these funds to solve current problems or their possible allocation to long-term programs or projects.

Mechanism for drawing up a financial plan:

— the stage of forecasting possible sources of financial resources;

— after the stage of forecasting possible sources of financial resources, they proceed to the distribution of planned income to finance specific programs and areas of activity;

— the distribution stage is a sequence of procedures.

Financial analysis of health care facilities. It is customary to distinguish three main types (directions) of financial analysis:

1. Analysis of property (property, capital) of the organization;

2. Analysis of financial activities;

3. Analysis of financial condition (position).

Analysis of financial activity is intended to characterize the financial results and efficiency of a medical institution for a certain period of activity (month, quarter, year, etc.) regardless of the starting state. Financial condition is characterized by the availability of financial resources necessary for the normal functioning of the organization, their appropriate placement and effective use, financial relationships with other legal entities and individuals, solvency and financial stability. A universal document that reflects both the property of a medical institution and its financial condition and financial results is the balance sheet. However, unlike enterprises and commercial organizations providing medical services, traditional methods of balance sheet analysis for budgetary medical institutions are not always suitable. This is due to the following: Firstly, budgetary (state and municipal) medical institutions are not property owners and therefore cannot sell any of their fixed assets to improve their financial condition. Consequently, fixed assets - the largest balance sheet item - fall outside the sphere of real economic relations. Secondly, periodic revaluations of fixed assets have a great influence on balance sheet indicators. Meanwhile, an increase in the cost of fixed assets does not in any way improve the real financial situation of a budgetary medical institution. Thirdly, medical institutions usually maintain a single balance sheet for all sources of funds. In these conditions, balance sheet analysis is of little use - a separate analysis of the use of funds for the budget, compulsory health insurance, and business activities is needed. Two main groups of factors can be distinguished that influence both the results of financial activities and the financial condition of a medical institution: 1) External factors: - financing system (payment for medical services provided); — level of prices (tariffs) — for the provision of paid services and in the compulsory medical insurance system; — the value of per capita standards; — taxation system, etc. 2) Internal factors: - structure of the medical institution; — performance indicators of the institution and its departments; — incentive system (wage system), etc.

9.Analysis of the use of material resources and medicines in medical institutions

Saving material resources is of paramount importance for sectors of material production. At the same time, it does not lose its importance for budgetary institutions, where it is expressed in compliance with established standards for the consumption of certain types of materials when performing specific work. In this regard, in the process of analysis to assess the level of use of material assets, their actual consumption is compared with the standard one. The result is expressed in savings or overconsumption of certain types of material resources. It should be borne in mind that not all savings deserve a positive assessment. Of particular importance is not the economy in general, but by what means it is achieved. For example, savings in drug costs, if they are caused by a deterioration in the treatment of patients, should be considered as the most negative phenomenon. The savings resulting from more economical use of materials, fuel, tools, etc. deserve every encouragement. Therefore, it is precisely the possibility of obtaining such savings that should be identified in the process of analyzing the efficiency of using material resources.

In budgetary organizations, expense standards are currently not established for all groups of materials. The amount of their expenditure primarily depends on the provision of the institution with the appropriate types of assets, the need for them, as well as the possibility of obtaining savings.

But at the same time, for a number of groups of materials, planning standards have been approved and must be observed. Such materials include food, medicine, alcohol, dressings, fuel and fuels and lubricants, building materials, materials for prosthetics, as well as some types of household materials (washing powder, soap, etc.).

Depending on the type of material assets, standard consumption can be both in physical and value terms.

For most materials (alcohol, dressings, fuel and fuels and lubricants, construction and household materials), in the process of analyzing the effectiveness of their use, it is advisable to compare actual consumption with natural standards. It must be borne in mind that these norms should not be static. When calculating and approving them, emerging trends in the consumption of relevant materials and the possibility of reducing their consumption due to the use of new methods and operating technologies should be taken into account. To develop progressive standards, first of all, it is necessary to analyze the dynamics of actual specific consumption over a number of years, and then, based on identified trends and identified reasons for these changes, establish the optimal value of the standard, taking into account the possibility of obtaining cost savings without compromising the quality of services provided.

Medical service is a type of medical care provided

medical workers and public health institutions

A medical service begins to act as a specific product,

which has the following distinctive properties:

- intangibility (a patient who comes to see a doctor cannot

know the outcome of the visit in advance);

— inseparability from the source of the service (the patient who has signed up for

to a certain doctor, will receive the wrong service if he ends up due to

absence of this doctor to another);

— inconsistency of quality (the same medical service

doctors of different qualifications provide different services, and even the same

the doctor can help the patient in different ways depending on his

state).

A medical service can be detailed and simple.

By detailed medical service we mean basic,

indivisible service. For example, for a hospital with detailed services

type of bacteriological examination of the operating unit and

other. If some detailed services provided by individual

departments of the institution (for example, reception department,

bacteriological laboratory and others) will be separately

calculated, then the cost of maintaining these units

(the wages of their workers, the materials they consume

resources) must be included in the institution's overhead costs. At

When calculating the cost of a detailed service, you must use

the technological standard established in this institution

(time spent on this service, quantitative and

qualitative composition of medical workers producing this

service, types and quantities of consumed medications, drugs and

A simple service can be represented as a set

detailed services reflecting the prevailing situation in each specific

institution technological process of providing medical care

of this nosology.

A simple service is understood as a complete case of

a certain nosology: for hospitals - a treated patient, for

outpatient clinics - complete case

treatment, with the exception of dental clinics, where under

a simple service means a sanitized patient, for emergency services

assistance - departure and treatment. List of simple medical

services can be determined either by the institution itself or

a list approved by the administration (or authority) is used

health department in case of delegation of these rights to it)

of this territory in accordance with the regulations in force therein

medical and economic standards. When developing the list

medical services can take into account the age factor, as well as

factor of complexity in providing this type of service, due to

the presence of concomitant diseases, complications, etc.

To determine the established standard of provision of each type

simple medical service from the list reflecting it

technological process, or a large array is being processed

information from medical records or outpatient records,

or in the absence of these capabilities, the method is used

expert assessments.

Composition of costs included in the cost of medical services

The cost of medical services is a valuation

materials used in the process of providing (production) services,

fixed assets, fuel, energy, labor resources, as well as

other costs of its production.

economic elements and costing items.

Grouping costs by costing items reflects them

composition depending on the direction of expenses for providing

(production) services.

The costs attributable to the cost of the service, in accordance with

with the current accounting reporting system in budgetary

organizations include:

- labor costs accrued for all reasons (Art.

1 budget estimate);

— contributions to social insurance (Article 2 of the budget estimate);

— contributions for compulsory health insurance

employees (if a decision is made to include these costs in

cost of services for budgetary organizations);

— office and self-supporting expenses (Article 3 of the budget estimate);

- expenses for business trips and official travel (Article 4

budget estimate);

— food costs (Article 9 of the budget estimate);

— expenses for medicines (Article 10 of the budget estimate);

- the amount of depreciation charges for complete restoration

fixed assets (calculated based on book value

fixed assets and norms approved in accordance with the established procedure

wear), while for machinery, equipment and transport

funds, depreciation ceases after expiration

their standard service life, subject to complete transfer of all

cost of production costs;

— wear and tear of soft equipment and uniforms (calculated

based on the actual cost of soft equipment and uniforms

and their standard service life);

— major repairs of buildings and structures (Article 16 of the budget

cost estimates);

- other expenses, including training expenses, for production

student practice, research and acquisition

books for libraries, costs associated with the acquisition by the institution

licenses and certificates (Article 18 of the budget estimate).

The costs included in the cost price do not include:

— costs for the purchase of equipment (Article 17 of the budget

— costs for the purchase of soft equipment and uniforms

(Article 14 of the budget estimate);

— capital investments (Articles 13, 15 of the budget estimate);

— fines, penalties, penalties and other types of sanctions for violation

contractual relations.

Thus, we can say that the total cost of all

services provided is equal to the budget estimate minus Art. 12,

14 and increased by the amount of depreciation charges for fixed assets

funds and wear and tear of soft equipment.

Grouping costs by economic element reflects them

distribution by economic content regardless of form

use in the production (provision) of one or another type of service.

When determining the cost of any type of medical services

the following grouping of costs according to economic

elements:

— labor costs;

— payroll accruals;

— direct material costs;

- overhead costs.

Labor costs refer to the costs of paying

labor of medical workers performing services proportional to

the time spent on producing the service and the complexity of the service

(if it is taken into account in the tariff agreement).

Payroll includes expenses for

payment of contributions to state social insurance.

Direct material costs include the cost

consumed in the process of providing medical services in full

(medicines, dressings, disposable supplies,

food, etc.) or partially (depreciation of medical

equipment used in the provision of this medical

services, wear and tear of low-value and high-wear items)

material resources.

Overhead expenses for an institution include all types

expenses not directly related to the provision of medical

services (office and business expenses, depreciation

non-medical equipment, wages

administrative and management personnel, travel expenses

and others).

Cost of health care services: calculation and analysis; direction of decline

Calculation of the cost of services is prescribed in the "Instructions for calculating the cost of medical services (temporary), approved by the Ministry of Health N 01-23/4-10 and the Russian Academy of Medical Sciences N 01-02/41 dated November 10, 1999 and (hereinafter referred to as the Instructions for calculating the cost medical services),

Calculation of prices for medical services is based on actual costs and planned or standard costs of medical institutions and their structural divisions

Indicators used to calculate the price of a service

All types of expenses of the institution and individual structural divisions;

Medical personnel working time fund;

The number of patients treated in the institution as a whole and in specialized departments;

Planned and actual indicators on the number of patients treated:

By institution;

By department;

individual nosological forms of diseases

The cost of a service is the current costs of an enterprise expressed in monetary terms for the production and sale of a service.

There are: Technological, Shop cost, Production and Commercial (full) cost

Calculation of costs for medical services is carried out taking into account all expenses of the health care facility, its structural divisions in which the relevant services are performed, and the time spent on their implementation. Medical expenses products used for therapeutic and preventive purposes are taken into account when calculating the cost of patient management protocols and are not taken into account when calculating the costs of services.

Institutional expenses for calculation purposes are divided into:

1) for direct (technologically related to the implementation of services and consumed in the process of its implementation): 211- wages (of key personnel); 213 - accruals for wages; 340 — material costs (medicines, dressings, disposable medical supplies); 310 - the share of depreciation of soft equipment and medical equipment consumed in the process of providing the service;

2) overhead or indirect (necessary to ensure the activities of health care facilities and the provision of medical services, but not consumed directly in the process of performing the service): - labor costs for general institutional personnel; — accruals for wages; — business expenses (consumables and supplies, fuel and lubricants, payment for communication services, utilities, routine repairs of equipment and inventory, buildings and structures, rental of premises and other property; wear and tear of non-medical equipment and soft equipment; costs of licensing, accreditation , certification, personnel training, taxes; other operating expenses, organizational, commercial expenses, etc.

Calculation of costs for simple medical services:

The cost of a simple medical service (C) is calculated using the formula:

C = Sp + Sk = Zt + Nz + M + I + O + P,

where Sp - direct costs, Sk - indirect costs, Zt - labor costs, Nz - accruals for wages, M - costs for medicines, dressings, etc., I - wear and tear of soft equipment, O - wear and tear of equipment, P - other expenses.

Direct expenses. To determine the cost of remuneration for all key personnel, the basic salary and additional salary, i.e. the amount of compensation payments, are calculated separately. The calculations do not take into account: bonuses and financial assistance, payment of additionally provided (in excess of those provided for by law) leaves to employees

Calculation of labor costs for a specific medical service (Zt.us) is carried out separately for each category of personnel based on the average salary of employees in the department in accordance with the tariff lists and established standards for labor costs for the provision of these services.

where Zt.vr, Zt.sr - the wage fund of the corresponding category of personnel for the billing period;

Fr.vr, Fr.sr - working time fund for the corresponding category of personnel, calculated in conventional units of labor intensity for the billing period;

tр, tср - time of provision of medical services by the corresponding category of personnel in conventional units of labor intensity;

Labor intensity is measured by the time spent on providing a medical service. In order to simplify calculations, it is advisable to measure labor intensity in conventional units of labor intensity (CLU), taking a time equal to 10 minutes as 1 CTU.

Kisp.vr, Kisp.sr, is the standard coefficient for the use of working time of medical personnel directly for carrying out diagnostic and treatment work, research, and procedures.

In general, Kisp. determined by the formula:

where Fisp.v. — a fund for using time for the direct implementation of diagnostic and treatment work. Working time utilization rates are given in the Table in the temporary instructions.

F r.vr - the established working time fund for medical personnel in accordance with the instructions of the Ministry of Labor and Social Development of Russia for the corresponding billing period.

Total labor costs for a specific medical service:

Zt.us = Zt x (1 + Ku) x (1+Kd),

where Ku is the wage coefficient for general institutional personnel,

Kd is the coefficient of additional wages.

Payroll accruals (NZ) are established by the legislation of the Russian Federation as a percentage of the wage fund.

When calculating the costs of material resources (M) completely consumed in the process of providing the service, costs are taken into account in accordance with Art. “Medicines, dressings and other medical expenses” ECR - based on data on actual expenses for health care facilities as a whole and for its structural divisions.

In general, drug costs can be determined using the formula:

where M are material resources completely consumed in the process of providing the service

Svr., Sav. — the number of positions of doctors and nursing staff of the department, respectively;

Fr.vr, Fr.sr - the annual fund of working time of the corresponding category of personnel, calculated in conventional units of labor intensity (UCU);

tр, tср - time of provision of medical services (labor intensity) by the corresponding category of personnel, calculated in conventional units of labor intensity (CUT);

Kisp.vr, Kisp.sr, is the standard coefficient for using the working time of medical personnel positions directly for carrying out diagnostic and treatment work, research, and procedures;

The calculation of the share of wear of soft equipment (I) is carried out according to the standard of its wear in accordance with current standards, documents and prices for the calculation period. Calculation of the share of wear of honey. equipment is made by calculating the depreciation of equipment included in fixed assets. Depreciation is taken into account in proportion to the duration of the service. The annual amount of depreciation (Gi) of each type of equipment is calculated based on the book value of fixed assets (Bos): Gi = Bos * Ngi, where Hgi is the annual depreciation standard.

Indirect costs are transferred to the cost of the service:

Indirect expenses (IC) are the expenses of an institution for carrying out business activities, management, and provision of services that cannot be directly attributed to their cost.

The wages of general institutional personnel (Zu) are taken into account when calculating the costs of medical services through the coefficient of wages of general institutional personnel (Ku) to the basic salary of main personnel (Zt_osn):

Zu = Zt.osn x Ku

Accruals for wages of general institutional personnel are calculated similarly to accruals for wages of main personnel:

Other indirect costs in the cost of a medical service: indirect costs are included in proportion to the direct costs (Dc) attributable to the service.

To take into account indirect costs in the cost of a specific service, their coefficient (Kkr) is calculated:

Kcr = Sk/Sp,

Skus = Sp x Kkr,

where Skus is indirect costs taken into account in the cost of a specific medical service.

The cost of a specific medical service is calculated by summing the results for each type of cost:

Sus = Ztus + Nzus + Mus + Ius + Ous + Skus

Calculation of costs for complex and complex medical services: determined by summing up the costs of simple services in accordance with the nomenclature and frequency of simple medical services. services included in the complex and complex. In this case, the marginal components of costs, characterized by the amount of additional costs, must be taken into account. costs required to simultaneously perform one additional simple service according to the composition of a complex one. The costs of paying for services performed in other health care facilities (if it is not possible to perform them in this health care facility) must also be taken into account.

Directions for reduction: a comparison base is needed by year, the contribution of each parameter separately to the cost for each year is analyzed and it is found out where the greatest growth is recorded, more attention is paid to this parameter, reserves are sought in it

The property status of a healthcare facility can be characterized by the sum of working capital and fixed capital.

Working capital of a medical institution includes cash, securities owned by the medical institution, inventories of raw materials and accounts receivable.

The amount of fixed capital of a healthcare facility includes the active part of fixed assets, construction in progress, intangible assets and long-term investments. Long-term investments are financial investments diverted from the turnover of a healthcare facility. Intangible assets include those that characterize the amount of intellectual property of a medical institution.

The largest share of fixed capital consists of fixed assets.

Fixed assets

Fixed assets are means of labor that are involved in the process of creation, work, services, while maintaining their natural material form, and their value is transferred to the cost of the created service in parts as they wear out. This part comes in the form of interest payments as it wears out. TO fixed assets include buildings, structures and accompanying infrastructure (water supply, sewerage, ventilation, etc.), as well as medical equipment and equipment. The composition of fixed assets includes an active part, that is, what is constantly used in the treatment, diagnostic and rehabilitation process (devices, devices, parts of medical equipment), and a passive part (buildings, structures, etc.). The ratio of the active and passive parts of fixed assets is approximately one to four.

The valuation of fixed assets has three stages: initial, restoration, residual.

Initial(Op) = acquisition costs + delivery + storage. Restorative= Op taking into account revaluation.

In our country, constant revaluations of fixed assets began to be carried out in 1992 (previously they were carried out once every 5 years). In this case, the inflation coefficient is used. But at this rate of inflation today, the replacement cost does not provide a real assessment of the existing value of fixed assets, since the replacement cost of worn-out equipment is higher than the balance sheet value, but the quality of the equipment does not meet the requirements for operation.

Residual(Oo) = Op – Wear

A distinction is made between physical and moral wear and tear.

Physical wear and tear (IF) is the loss of technical and economic properties. There are two types of methods that determine physical wear: by service life and by technical condition.

By service life:

If = Tn * [Tf: (100-L)%], where Tf and Tn are the actual and standard service life, L is the liquidation value of the object as a percentage of the book value.

Moral depreciation (Im) - premature, before the end of the period of physical wear and tear, a lag of equipment in terms of its technical characteristics. There are two methods for valuing fixed assets:

1) a decrease in the value of fixed assets as a result of a reduction in labor costs for their restoration.

Im = Pb: [(1 - Mon)%], where Pb, Mon – production of basic and new fixed assets.

2) a decrease in the efficiency of fixed assets as a result of the introduction of new ones.

Im = Фв: [(1 – Фп)%] , where: Фв, Фп – replacement and initial cost of the means of labor.

The organization may also determine liquidation value which is the difference between two values: the cost of scrap from the liquidation of equipment or proceeds from its sale (if fixed assets are transferred to another enterprise for further operation) and the cost of dismantling this equipment.

Complete depreciation of fixed assets requires replacing existing ones with new ones, regardless of the type of wear.

Monetary expression of the degree of wear and tear fixed assets are determined by depreciation charges.

Under depreciation it is necessary to understand the actions associated with taking into account the wear and tear of property during their useful life and ensuring the transfer of part of their cost to the service or work performed.

Useful life- this is the period during which the operation of the facility must generate income for the institution or serve to achieve the goals of its activities.

The amount of depreciation, expressed as a percentage of the original (book) value is called annual depreciation rate. Unified depreciation standards for the complete restoration of fixed assets of the Russian national economy, incl. healthcare, are compiled into a directory in accordance with the assigned codes for the entire classification of fixed assets.

The depreciation rate (Na) is calculated based on the expected complete restoration (renovation) of fixed assets using the formula:

T*Sp

Where Cn is the initial cost of fixed assets;

Sl – liquidation value of fixed assets;

T - useful life of fixed assets, years.

The effective use of fixed assets of a medical institution depends on their rational use, which is influenced by many factors that ensure the operation of hospitals, clinics, rehabilitation centers, etc. These factors may be: the actual occupancy of the bed, the duration of hospitalization, the residual value of medical equipment, information support and computerization of the treatment and production process, the standard operating mode of the equipment, the workload of the buildings of the medical institution, the time and duration of current and major repairs of buildings and equipment, and others.

Analysis of the state and efficiency of use of fixed assets of a healthcare organization

Composition and structure of fixed assets.

— fixed production assets;

— fixed non-production assets;

- intangible assets. Fixed assets are tangible assets (implements of labor) that are repeatedly involved in the production process, do not change their natural material form and transfer their value to finished products in parts as they wear out. According to their functional purpose, the fixed assets of an enterprise are divided into production and non-production.

Production assets are directly or indirectly related to the production of products. Non-production funds serve to satisfy the cultural and everyday needs of workers.

Based on their use, fixed assets are divided into those in operation and those in reserve, reserve, conservation, etc.

Based on ownership, fixed assets are divided into owned and leased.

Fixed assets can be divided into active and passive. Active assets include those fixed assets that are directly involved in the production of products and have a direct direct impact on the volume of output. As a rule, active ones include machinery and equipment, vehicles and tools.

Analysis of fixed assets begins with an analysis of the availability, structure and movement of fixed assets in the enterprise. One of the main indicators when analyzing fixed assets is the average annual cost of fixed assets. This cost can be calculated as follows:

Fsr = Fper + (Fvv*Chm) / 12 – Fl * (12- M) / 12, (1) where Fs is the average annual cost of fixed assets; Fper is the initial (book) cost of the fixed asset; Fvv - cost of introduced OS; Chm – number of months of operation of the introduced OS; Fl - liquidation value; M is the number of months of operation of retired fixed assets. In addition, several other methods are used to calculate the cost of fixed assets. These methods include the chronological method of calculating the cost of fixed assets:

Фср = (½ *Ф1+Ф2+Ф3+….Фi-1+ ½ *Фi) / (n–1) (2)

where n is the number of periods (months, quarters, etc.) Fi is the cost of fixed assets in the i-th period; To simplify, most often, the following formula is used to calculate the cost of fixed assets (simple arithmetic average): Fsr = (Fnach + Fkon) / 2 where Fnach is the cost of fixed assets at the beginning of the year;

Fkon is the cost of fixed assets at the end of the year. This section of the analysis also examines the movement and technical condition of fixed production assets. For this, the following indicators are calculated:

Update factor: Cobn = Fpost. / Fkon.; (4)

Retirement coefficient: Kvyb = Fvyb./Fnach. ; (5)

Growth coefficient: Kpr. = Fpr./Fn., (6)

wear coefficient Kizn = I / Sp, where

I - the amount of accrued depreciation of the general fund at the time of calculation, starting from the day the funds were put into operation, thousand rubles;

Sp is the initial cost of OPF;

Fpost. – the cost of received fixed production assets,

Fkon. - cost of fixed assets at the end of the year,

Fvyb - the cost of retired fixed assets,

Fnach. - cost of fixed assets at the beginning of the year,

Fpr - the amount of increase in fixed assets. (Fpost. - Fvyb).

The next stage of the analysis is the analysis of the main indicators of the efficiency of use of fixed assets.

The main indicator of the use of fixed assets is the capital productivity indicator (an indicator of the efficiency of use of fixed assets), calculated as the ratio of the cost of manufactured products to the average annual cost of fixed assets:

Fotdacha = VP / Fsr. (7).

To increase capital productivity it is necessary:

— an increase in the share of fixed equipment and, as a consequence, a change in the structure of fixed assets;

— use of new equipment to replace outdated models;

— sale of equipment that is not used or rarely used in the process of work;

— increasing the number of shifts, eliminating downtime at the company, which will lead to an increase in the utilization rate of machine time;

— transition to the manufacture of products with a higher level of added value;

- general increase in production efficiency by increasing labor productivity, eliminating auxiliary fixed assets that are no longer needed

In addition, other indicators are calculated: capital intensity, the inverse indicator of capital productivity, characterizes the cost of production fixed assets per 1 ruble. products:

Femnost = Fsr. / VP (8),

In the process of analysis, the dynamics of the listed indicators, the implementation of the plan according to their level, comparison of indicators in the analyzed years in comparison with indicators in the base year are studied, inter-farm comparisons are carried out. For the purpose of a more in-depth analysis of the efficiency of using fixed assets, the capital productivity indicator is determined for all fixed assets. To calculate the influence of factors on the increase in capital productivity of equipment, the method of chain substitutions is used. In this analysis, instead of the values ​​of the base year, the values ​​of the analyzed year are gradually inserted into the formula and the influence of each of the factors is calculated: equipment structure, all-day downtime, shift ratio, intra-shift downtime, average hourly output. The next stage of the analysis is to determine the capital-labor ratio (analysis of the enterprise's provision of fixed assets). This indicator is defined as the ratio of the average annual cost of all fixed assets to the average number of employees at the enterprise:

Fvoor.=Fsr./P (9),

where P is the number of employees at the enterprise (includes all workers, engineers and administrative staff). This indicator shows the cost of fixed assets per employee.

To calculate the efficiency of using PF, the PF profitability indicators are calculated:

Overall profitability (P0, %)

P0 = 100 x Pb / (Sav.g + Co.s),

where Pb is the total (balance sheet) profit; Сср.г - average annual cost of fixed production assets; С.с - average annual cost of working capital.

Estimated profitability (Рр)

Рр = 100 (Pb - Pp)/ (Sav.g + So.s),

where Pp are various payments and taxes from the total profit.

The production profitability indicator, in addition to the efficiency of using the general fund, also shows the efficiency of using working capital.

Question

Identification and analysis of reserves and factors that determine the main directions for increasing the efficiency of healthcare organizations

— increasing the autonomy and independence of healthcare organizations:

continuation of the phased transfer of medical organizations into enterprises with the right of economic management, including the phased introduction of international financial reporting standards in healthcare organizations;

providing government healthcare organizations with greater independence in making management decisions;

rational division of functions and powers between healthcare entities;

development of an effective algorithm for interaction between healthcare and social security organizations;

ensuring continuity in the management of the patient at all stages (phasing of medical services);

— stimulating the development of the private sector:

systematic improvement of the relevant regulatory and methodological framework for the development of the private sector in healthcare;

elimination of unnecessary administrative barriers;

development and implementation of mechanisms for supporting and developing socially oriented corporate medical networks and organizations interested in providing guaranteed volume of free medical care (guaranteed volume of free medical care), implementing state programs for disease prevention and strengthening a healthy lifestyle of the population,

including taking measures to attract private health care providers to fulfill the state order;

phased implementation of the public-private partnership program

in healthcare, including measures for the transfer of fixed assets (buildings, equipment) to trust management and long-term lease to private medical organizations;

— improvement of personnel policy in healthcare organizations:

development of a concept for the development of human resources in health care, including planning for the development of human resources in the health care system and mechanisms for increasing the efficiency of its use;

expanding the practice of forming targeted orders from local executive bodies for the training of healthcare specialists;

provision and creation of a regulatory framework for attracting managers

with economic education in the management of healthcare organizations and training in their management in healthcare;

improving the remuneration system for medical workers;

increasing the social status and prestige of the profession of medical workers, including through mass information campaigns

in support and coverage of the professional activities of doctors;

development of republican and regional programs for the professional development of doctors, including the development of institutions of professional reputation and professional competition;

increasing the role and support of professional associations of medical workers (professional NGOs);

development and implementation of mechanisms for social protection of medical workers, including the preparation of a social package for them;

development and implementation of a system of preventive measures

for medical workers when there is a threat of the spread of quarantine and especially dangerous infections;

— development of informatization in healthcare:

further improvement and implementation of the UHIS (unified health information system);

implementation of clinical algorithms, protocols and other standards in the Unified Health Information System.

"Health care institutions: accounting and taxation", 2013, N 11

FFOMS officials in Letter dated July 23, 2013 N 5423/21-i (hereinafter referred to as Letter N 5423/21-i) presented methodological approaches to include in the tariff for payment of medical care costs necessary for the activities of a medical organization as a whole, but consumed in process of providing medical care. In this article we will consider the recommendations of the Federal Compulsory Medical Insurance Fund addressed to healthcare institutions of the constituent entities of the Russian Federation.

The organization of compulsory health insurance (CHI) on the territory of the Russian Federation is regulated by Federal Law dated November 29, 2010 N 326-FZ “On compulsory health insurance in the Russian Federation.” According to paragraph 7 of Art. 35 of this Law, the structure of the tariff for payment of medical care within the framework of the basic compulsory medical insurance program includes the costs of:

• for wages, accruals for wages, other payments;
• for the purchase of medicines, consumables, food, soft equipment, medical instruments, reagents and chemicals, and other supplies;
• to pay the cost of laboratory and instrumental studies conducted in other institutions (if the medical organization does not have a laboratory and diagnostic equipment);
• for catering (if there is no organized catering in the medical institution);
• to pay for communication services, transport, utilities, works and services for property maintenance, for rent for the use of property, for software and other services;
• for social security of employees of medical organizations established by the legislation of the Russian Federation;
• for the purchase of equipment worth up to 100 thousand rubles. for a unit.

Classification of costs for the provision of medical services

Classification of costs allows you to distribute all the listed costs provided for by the compulsory medical insurance tariff structure into three main groups:

1. for participation in the process of providing medical services, expenses are divided into basic and overhead;
2. according to the order of attribution to services (according to the method of attribution to the cost of a specific service), costs are divided into direct and indirect;
3. According to the degree of dependence on the volume of services provided (in relation to the volume of services provided, cost dynamics), expenses are divided into semi-fixed (constant) and semi-variable (variable).

Dividing expenses into basic and overhead. In accordance with clause 2.1.1 of Letter N 5423/21, the main expenses are those that are directly related to the provision of services (costs of paying wages, purchasing medicines, medical instruments, etc.).

It should be noted that according to this classification, costs for heating, electricity, water supply (that is, utilities) are also included in the main costs, since they are directly involved in the provision of medical care.

Institutional overhead costs include all types of expenses not directly related to the provision of medical services (clerical and business expenses, depreciation of non-medical equipment, salaries of administrative and management personnel, business travel expenses, etc.).

In other words, overhead costs are those types of costs that are necessary to ensure the activities of the institution, but are not consumed directly in the process of providing medical services.

Dividing costs into direct and indirect. With this classification of costs, a medical institution should take into account that direct costs are costs that can be directly (directly), without any auxiliary calculations, attributed to certain types of medical services provided. In other words, direct costs are associated with the provision of specific types of services.

Direct expenses include (clause 2.1.2 of Letter N 5423/21-i):

• salaries of key personnel;
• accruals for wages of key personnel;
• the cost of material resources completely consumed in the process of providing medical services (medicines, dressings, disposable supplies, food, etc.);
• the cost of partially consumed material resources (wear and tear of soft equipment, depreciation of medical equipment used in the provision of this medical service, wear and tear of low-value and fast-wearing items).

Indirect costs are expenses that cannot be directly attributed to specific types of services and are therefore distributed indirectly, usually in proportion to some indicators (established bases). Indirect costs are included in the cost of medical services through calculated coefficients. They are associated with the provision of all or several types of services. Therefore, indirect costs relate to the entire institution as a whole or its divisions in particular.

Indirect costs are, for example:

• remuneration of general institutional personnel;
• accruals for wages of general institutional (administrative and economic) personnel;
• utility and business expenses (costs of purchasing materials and items for current business purposes, office supplies, inventory and payment for services, including costs of current repairs, etc.);
• expenses for business trips and official travel;
• wear and tear of soft equipment in auxiliary departments;
• depreciation (wear and tear) of buildings, structures and other fixed assets not directly related to the provision of medical services;
• other costs.

As FFOMS officials noted in paragraph 2.1.2 of Letter No. 5423/21-i, the basis for the distribution of indirect costs may be the wages of key personnel, space, etc. Thus, part of the indirect costs is distributed in proportion to the salaries of the main personnel (for example, the salaries of administrative staff), while others (for example, utility costs) can be distributed in proportion to the area, etc.

In some cases, indirect costs can become direct if, for example, electricity meters are installed in each office.

It should be noted that the main costs can be both direct and indirect, and overhead costs, as a rule, are only indirect. For example, the costs of paying for electricity and water supply are among the main costs and at the same time are indirect costs, attributable to the cost of the service by the indirect method.

It is necessary to identify the features of the classification of costs of diagnostic and treatment services. Costs directly related to the implementation of research and the provision of medical care are considered major expenses. Most of these types of expenses are direct. However, if the cost of a bed-day, a completed case of treatment (inpatient or outpatient), etc. Since the costs of treatment and diagnostic services are included in an average amount, they will be distributed among the main clinical departments using auxiliary methods, that is, they will be classified as indirect costs.

As part of overhead and indirect costs, hospital-wide (general outpatient) and institutional costs can be distinguished.

Dividing expenses into semi-fixed (fixed) and semi-variable (variable). In clause 2.1.3 of Letter N 5423/21-i it is stated that, depending on the degree of dependence on the volume of services provided (in relation to the volume of services provided, cost dynamics), costs are divided into conditionally fixed (fixed) and conditionally variable (variable) .

Conditionally fixed (fixed) costs practically do not depend on the volume of services provided (costs of lighting, heating, etc.). The amount of fixed costs remains unchanged when the volume of services provided changes (time-based wages for workers, wages and charges for administrative and economic personnel, rental of premises, etc.).

Conditionally variable (variable) costs change in accordance with the volume of services provided (costs of purchasing medicines, consumables, food, etc.). In other words, the total amount of variable costs varies in proportion to the volume of services provided.

From the above it follows that utility costs are basic and it is not always advisable to include them in overhead costs. In a number of cases, utility costs are distributed in proportion not to the wage fund of the main personnel, but to the space occupied by the departments.

Distribution of expenses among various sources of financing, departments, types of services

In connection with the inclusion in the tariff for payment of medical care in the compulsory medical insurance system the costs of maintaining a medical organization, the question arises of how, within a single institution, to allocate a number of costs according to funding sources (from the budget, compulsory medical insurance funds, funds from the provision of paid services) . Separate accounting of costs distributed indirectly (utilities, travel expenses, etc.) by funding sources is often impossible. However, as FFOMS officials noted in paragraph 3.2 of Letter No. 5423/21-i, situations where, if there are several sources of financing, certain types of costs will be reimbursed exclusively from compulsory health insurance funds are unacceptable.

In addition, it is necessary to allocate costs associated with other types of activities (non-medical), for example, educational activities (which is typical for medical universities that have their own clinics and provide medical care, including within the framework of compulsory medical insurance).

A modern medical organization has a complex structure, provides a large number of different types of services, expends numerous resources, and receives funding from various sources. All this creates the problem of not only classifying costs, but also their ordering. For pricing purposes (including taking into account the availability of other sources of financing (except compulsory medical insurance)), there is a need to distribute (allocate) costs to various departments, sources of financing, types of services provided, etc.

The main tasks of cost distribution include their distribution:

• by type of services provided (that is, determining what types of costs and in what volume are incurred for a particular service);
• by sources of financing (the costs of providing the same types of services with different sources of financing may be different).

The algorithm for solving the cost distribution problem includes the following sequence of actions:

• distribute costs for each item into fixed and overhead, direct and indirect, etc.;
• distribute costs among each department;
• develop criteria for allocation (redistribution) of costs in various situations;
• determine the order (phase) of cost distribution.

There are two main options for distributing costs: by item and by department.

At item by item In the distribution of costs, each item is distributed among departments, types of services, and sources of financing.

When distributed by department first, the full costs are determined by department, and then the costs of departments that do not directly provide final medical services are distributed among the main departments that provide services (the so-called revenue centers). This method is also called the aggregate method. To do this, the total amount of all overhead costs is found, which is distributed between revenue centers (clinical and treatment and diagnostic departments that directly provide services to external consumers). The costs of these departments are then allocated to individual services.

Regarding the question of which of these two methods to choose, the following should be noted. As a rule, the most rational approach is when the costs for each item are first distributed among the departments, and then the total costs of each of the auxiliary departments are distributed among the main clinical departments.

The problem of allocating costs between various departments of a medical organization can be divided into two parts:

• distribution of indirect (overhead) costs (assignment of utility costs to one or another division, etc.);
• distribution between the main divisions of the institution that directly provide services, the costs of those divisions that only serve the main activities and do not directly provide services to consumers (administration, economic services, etc.).

In the first case, we are talking mainly about indirect methods of cost distribution, which are typical for overhead costs. Therefore, indirect and overhead costs will be used as synonyms (however, do not forget that these are different concepts). Indirect (overhead) costs are distributed in proportion to the selected base. There are several ways (methods) of allocating overhead costs to individual departments or types of services provided. These methods may concern the distribution of not only overheads, but also basic costs distributed indirectly. In other words, it would be more correct to call them methods of allocating indirect costs.

The cost allocation methodology consists of three main parts.

1. Calculation of direct costs in all cost centers.
2. Determining the basis for cost distribution.
3. Methodology for allocating expenses of auxiliary centers (divisions).

Cost distribution begins with the fact that all expenses of a medical organization are assigned to cost centers. Let's take a surgical department as an example. The direct costs of the surgical department include salaries of full-time employees with accruals. Direct costs also include the costs of purchasing supplies, drugs, food, soft equipment and other expenses that are under the direct control of the surgical department and are usually considered its costs. Under this approach, all costs directly borne by the department are considered direct costs, even if they are not directly related to the care of individual patients.

The next step is to allocate the costs of the support centers to the various revenue centers. It is necessary to select a base unit that would serve as the basis for allocating the expenses of each cost department to the revenue centers that use its services. The basic principle of distribution is the following: the majority of the costs of the auxiliary unit should be attributed to the income center that most often uses its services.

• distribution of total overhead costs in proportion to the share of overhead costs in the payroll of the main departments or the share of overhead costs in the total costs using the overhead cost ratio;
• distribution of total overhead costs is proportional to the wage fund (as a variation - proportional to the ratio of the wage funds of the main clinical departments);
• independent (independent, direct) distribution of certain types of overhead costs;
• step-by-step (step) method of cost distribution;
• simultaneous distribution of costs.

Overhead allocation methods

The method for distributing overhead costs between costing objects is selected by the medical institution in such a way as to optimize the degree of usefulness of accounting data for management purposes with an acceptable level of labor intensity of accounting procedures. Let us recall that the list of direct costs and the method of distribution of overhead (general) expenses are fixed in the accounting policy of the organization.

Let's consider some options for distributing overhead costs.

Distribution of expenses is proportional to the salaries of key personnel. The first indicator that we chose for consideration is the wages of workers directly involved in the provision of relevant services. The essence of this method is that the distribution of overhead (and general business) expenses (Rн) is carried out according to the profile of services provided in proportion to the wage fund of the main personnel according to the following formula:

Rj = (Rн / Ф) x Фj,

where Rj is overhead (general business) expenses for the corresponding service profile;

Rн - overhead (general business) expenses of the institution in the total amount;

F - general wage fund for key personnel;

Фj - wage fund for workers involved in the corresponding type of service (medical unit).

This calculation can be done by finding the overhead distribution coefficient using the following formula:

Rj = Rн x Kнр.

The overhead distribution coefficient is calculated using the formula:

Knr = (Фj / Ф).

Example 1. The dental clinic has two main structural divisions: surgical and therapeutic, which provide medical services within the framework of compulsory medical insurance. In November 2013, she made the following expenses (all figures are approximate).

The accounting policy of the institution establishes that in 2013, overhead and general business expenses are distributed in proportion to the wages of the main personnel of a particular department.

Expenses for paying wages to key personnel for November 2013 amounted to the following amounts.

Let's calculate the overhead distribution coefficient:

• for services A: 0.366 ((150,000 / 410,000) rub.);
• for services B: 0.634 ((260,000 / 410,000) rub.).

Overhead costs will be distributed as follows.

Distribution of overhead costs between funding sources. Before moving on to the second distribution method, according to which the institution takes the volume of revenue from services provided as the basis for distributing overhead (general business) expenses, we will provide some clarifications. As noted above, a medical institution can provide services both within the framework of compulsory medical insurance and as part of income-generating activities (and in some cases it may receive subsidies for the implementation of state (municipal) tasks), so the most correct decision would be to distribute invoices ( general business expenses, taking into account all sources of financial support for the activities of this institution. When considering this issue, one should proceed from the relationship between income and expenses, that is, whether overhead (general business) expenses are associated with the receipt of a particular income. Accordingly, to determine the amount of overhead (general business) expenses related to activities related to the provision of medical services at the expense of compulsory medical insurance funds, the following formula is used:

Rj = Rн x Compulsory Medical Insurance / (Compulsory Medical Insurance + D),

where compulsory medical insurance is the income received by a medical institution from a medical insurance organization;

D - income from income-generating activities.

Accordingly, to determine the amount of overhead (general) expenses related to income-generating activities, the formula is used:

Rj = Rн x D / (OMC + D).

Example 2. Let's use the conditions of example 1. The distribution of overhead costs between departments was as follows.

In accordance with the accounting policy of the dental clinic, overhead and general business expenses are distributed between types of activities in proportion to the amount of income from the corresponding source of financing.

In November 2013, the institution received compulsory medical insurance funds in the amount of 300,000 rubles. (including for services provided by the surgical department - 100,000 rubles) and income from the provision of paid services in the amount of 500,000 rubles. (including for services provided by the surgical department - 200,000 rubles).

The distribution coefficient of overhead costs for the surgical department between activities financed by compulsory medical insurance funds and activities financed by funds received from the provision of paid services is equal to 0.333 (100,000 / (100,000 + 200,000) rubles).

Overhead costs between these activities are allocated to the surgical division using this ratio.

Conclusion

In conclusion, a healthcare facility may choose other ways to allocate overhead costs. In particular, paragraph 134 of Instruction No. 157n<1>The following distribution methods are regulated:

• in proportion to direct labor costs, material costs, and other direct costs;
• in proportion to the volume of revenue from sales of products (works, services);
• in proportion to another indicator characterizing the results of the institution’s activities.

<1>Instructions for the application of the Unified Chart of Accounts for public authorities (state bodies), local governments, management bodies of state extra-budgetary funds, state academies of sciences, state (municipal) institutions, approved. By Order of the Ministry of Finance of Russia dated December 1, 2010 N 157n.

Any of the selected methods should optimize the degree of usefulness of accounting data for management purposes at an acceptable level of labor intensity of accounting procedures.

Magazine editor

"Health care institutions:

accounting and taxation"