Year : 2010 | Volume
: 53 | Issue : 1 | Page : 68--74
Activity-based costing methodology as tool for costing in hematopathology laboratory
Sumeet Gujral1, Kanchan Dongre2, Sonal Bhindare3, PG Subramanian1, HKV Narayan3, Asim Mahajan3, Rekha Batura3, Chitra Hingnekar3, Meenu Chabbria1, CN Nair1,
1 Hematopathology Laboratory, Tata Memorial Hospital (TMH), Mumbai, India
2 Department of Pathology, Tata Memorial Hospital (TMH), Mumbai, India
3 Administrative Office, Tata Memorial Hospital (TMH), Mumbai, India
Department of Pathology, Tata Memorial Hospital, Mumbai
Background: Cost analysis in laboratories represents a necessary phase in their scientific progression. Aim: To calculate indirect cost and thus total cost per sample of various tests at Hematopathology laboratory (HPL) Settings and Design: Activity-based costing (ABC) method is used to calculate per cost test of the hematopathology laboratory. Material and Methods: Information is collected from registers, purchase orders, annual maintenance contracts (AMCs), payrolls, account books, hospital bills and registers along with informal interviews with hospital staff. Results: Cost per test decreases as total number of samples increases. Maximum annual expense at the HPL is on reagents and consumables followed by manpower. Cost per test is higher for specialized tests which interpret morphological or flow data and are done by a pathologist. Conclusions: Despite several limitations and assumptions, this was an attempt to understand how the resources are consumed in a large size government-run laboratory. The rate structure needs to be revised for most of the tests, mainly for complete blood counts (CBC), bone marrow examination, coagulation tests and Immunophenotyping. This costing exercise is laboratory specific and each laboratory needs to do its own costing. Such an exercise may help a laboratory redesign its costing structure or at least understand the economics involved in the laboratory management.
|How to cite this article:|
Gujral S, Dongre K, Bhindare S, Subramanian P G, Narayan H, Mahajan A, Batura R, Hingnekar C, Chabbria M, Nair C N. Activity-based costing methodology as tool for costing in hematopathology laboratory.Indian J Pathol Microbiol 2010;53:68-74
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Gujral S, Dongre K, Bhindare S, Subramanian P G, Narayan H, Mahajan A, Batura R, Hingnekar C, Chabbria M, Nair C N. Activity-based costing methodology as tool for costing in hematopathology laboratory. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Jun 5 ];53:68-74
Available from: http://www.ijpmonline.org/text.asp?2010/53/1/68/59187
Healthcare organizations use cost accounting to estimate the unit cost of services they provide. Such information helps establish a realistic budget; prices, identify inefficiencies and project the effect that changes in demand would have on resource requirement. The processes involved in the production of a laboratory test result include procurement of the sample, logistical services, administrative procedures, performance of testing procedure, professional consultation and oversight, rendering and administering an account and information technology and communication cost. 
Ours is a national comprehensive cancer centre for prevention, treatment, education and research in cancer. Every year nearly 43,000 new patients visit the clinics 1000 of whom visit the out patient department (OPD) daily for medical advice, comprehensive care or follow-up treatment. Every year nearly 6300 major operations are performed and 6000 patients treated with radiotherapy and chemotherapy. Laboratory investigations form an integral part of management of these patients.
The Hematopathology Laboratory (HPL) is accredited by the National Accreditation Board for testing and calibration laboratories (NABL). The policy of the laboratory is to provide reliable, accurate and timely diagnostic services to all our patients and referring clinicians. HPL performs both routine as well as specialized hematological tests. Most of these samples are from patients registered in the hospital. Referral samples are received only for immunophenotyping. The hospital allocates a substantial part of its annual capital and operating budget to the HPL. However, there is no method to determine the per annum cost of running the HPL.
All calculations have been done in Indian National Rupees (INR).
Indirect cost (fixed) is the common lab cost shared by all tests on the basis of number of samples processed for the tests. It is also known as handling charge per request.
Direct costs (variable) are expenses which are directly identifiable with a test. e.g., equipment, reagents, maintenance, spares etc
Consumables are supplies procured and consumed in one financial year.
Depreciation is defined as per annum cost of equipment. It is derived by dividing the cost of equipment by the average life span of the equipment. Average lifespan of a medical equipment as well as furniture is taken as seven years. This is the bench mark for capital equipment as our hospital policy.
Types of Costing Methods
There are two methods of evaluating cost of the laboratory tests; activity-based costing (ABC) and traditional cost accounting. In the ABC system, costs are traced by activities across departments or cost centers. , Traditional cost accounting methods do not accurately reflect the contribution of indirect costs to individual services. They pool all indirect costs and allocate them to the various services in proportion to service volume or direct costs. This approach tends to overestimate the unit cost of high volume services and underestimate the cost of low volume services. When indirect costs are large, often the case in healthcare, the cost of services may be seriously misrepresented. ABC solves this problem by estimating the cost of the work activities that consume resources and by linking these costs to the services that are provided. ,
Principles of Activity-based Costing
Step 1: Cost that can be directly allocated to each test separately is identified. These are considered direct costs for each test. The annual direct cost for each test is determined.
Step 2: Cost that cannot be identified with a particular test but are related to all the tests in the laboratory are pooled together as common lab costs (Indirect Costs).
Step 3: Indirect costs are allocated to each test in proportion to the number of samples processed for each test. Annual indirect costs are determined.
Step 4: Direct cost and proportionate share of indirect costs are added and divided by number of samples for that particular test. Per sample cost of each test is thus determined.
Direct, indirect and annual cost of each test is calculated. Cost unit is considered 'per sample cost of all the tests'. Per sample cost of a test is defined as a ratio of annual cost of the test to the number of samples processed in that particular year. We studied the cost per test to know the adequacy of the rate structure.
Aims and Objectives
To calculate indirect cost and thus the total cost per sample of various tests done in the HPL. Existing price list was compared with the calculated cost per sample.
Material and Methods
The staff includes two consultants (MD pathology), two senior residents (post MD pathology), six scientific officers (including two PhDs), two technical officers (M.Sc.), 13 scientific assistants/technicians (B.Sc.), and six labor staff. Work wise distribution of staff of the laboratory is - 21 technical staff and five phlebotomists. Fourteen technical staff were involved in performance of routine hematology including complete blood counts (CBCs), manual differential counts (MDC) and coagulation studies. Two technical staff were dedicated to flow cytometry (FCM), three worked in the molecular diagnostic laboratory and one technical staff took the responsibility of deputy quality manager (in addition to routine hematology duties). Information was collected from registers, purchase orders, AMCs, payrolls, account books, hospital bills, registers and other documents. These observations along with informal interviews with hospital staff formed the mode of research methodology followed.
The total number of samples received at HPL in the year 2005 was 227000 (a rounded off figure taken for further calculations) [Table 1]. Per sample indirect cost was calculated. This was added to the direct cost of the respective test to calculate the total cost of each test being done in the HPL. Calculations have been done in Indian (Rs). One United States Dollar is approximately equivalent to 48 Indian Rupees, 10 lakh is equivalent to one million and one crore is 10 million.
A. Indirect Cost (INR)
1. Land and building: The HPLs are located at four different places with a total area of 1186 sq ft. Monthly municipal rental value is approximately Rs. six per square feet; annual rent for land and building coming to Rs. 86,000.
2. Furniture and fixture : Total cost of furniture and fixture -
Rs. 4,29,400; annual depreciation value at Rs. 61,342.
3. Water: Cost of average annual water consumption for the whole annexe building is Rs. 12,80,000. Cost of water consumed for seventh floor is Rs. 72,000. Total floor area of seventh floor is 11,200 sq ft and the area occupied by HPL is approximately 600 square feet. Annual water consumption by the HPL is Rs. 3,900. Pls check: water consumption in rupees? Or is it cost of water consumption ?
4. Electricity (of common equipment): Annual cost of total expense on electricity is Rs. 5,44,000 [Table 2].
5. Depreciable value of common equipment: Total cost of common equipment is Rs. 30,22,104; annual depreciation value being Rs. 4,32,000.
6. Repair and Maintenance: AMC for instruments is Rs. 58,400 (including four microscopes, four printers and general repairs).
Annual cost of the remaining entities (in Rupees) include manpower (40,00,100), stationary (86,000), consumables (1,73,000), fire safety (1,000), glass ware (80,000), miscellaneous (21,500) and overheads (1,11,853).
Thus, total sum of the indirect cost (common laboratory cost) is Rs. 56,59,153. Since total number of samples received in the HPL is approximately 2,27,000 per year, common laboratory cost becomes Rs. 24.99. Thus per sample indirect cost (hidden cost) is Rs. 25.
B. Direct Cost and Per Sample Cost
It was calculated individually for all tests as follows:
1. Complete blood count (CBC):
Annual workload is 1,72,200 samples and includes use of 200 microtainers and 300 vacutainers per day. Different parameters were calculated including cost of equipment, cost of reagents, maintenance and spares, quality control material, consumables and electricity [Table 3].
Total direct cost of CBC is Rs..1,03,11,599 [Table 4]. Average number of CBC samples is approximately 1,72,200. As per sample indirect cost is Rs. 25, the annual indirect cost is Rs. 4305000. Total annual expenditure of doing CBC tests in the HPL is sum of direct and indirect cost (10311599 plus 4305000) is equal to Rs. 1,46,16,599. Per sample cost of doing CBC in HPL is Rs. 85.
2. Direct Cost of manual differential count (MDC):
Total Direct cost of MDC is Rs. 57,187. Total number of samples received in one year for MDC is 6, 900. Total indirect cost for MDC is Rs. 1,72,500 (6900 x 25). Thus total cost of the MDC is Direct cost (Rs. 57,187) plus Indirect Cost (Rs. 1,72,500) is equal to Rs. 2,29,687. Per sample cost of MDC will be 2,29,687/6900 is equal to Rs. 33. Per sample cost for the cases which require both CBC plus MDC, is 85 plus 33 is equal to Rs. 118.
3. Cost of Coagulation Tests [Table 5]:
Different types of tests done include prothrombin time (PT) (n is equal to 24104), activated partial thromboplastin time (APTT) (n is equal to 10752), Fibrinogen (n is equal to 12), fibrin degradation products (FPD) (n=90) and Thrombin time (TT) (n is equal to 50). FDP and TT were done manually. Per sample cost of PT and APTT is Rs. 94 and 91 respectively. Per sample cost of Fibrinogen, FDP and TT is Rs. 45,02,676 and 500 respectively.
4. Costing of Immunophenotyping (IPT) and CD34 Count
a). Direct cost of IPT and CD34 counts:
Monoclonal Antibodies: Cost of antibodies is Rs. 41,25,000 [Table 6].Equipment cost: Total cost of equipment [Table 7] is Rs.. 539731. Share of IPT and CD34 for the equipment cost is Rs. 4,77,313 and Rs. 62,418 respectively.Other costs [Table 8] involved in IPT and CD34 counts include cost of reagents, quality control, maintenance and spares, consumables and electricity. Total cost is calculated by multiplying total units consumed per hour of utilization in KW, total number of hours of utilization in a year, and rate applicable per hour in rupees. Share of IPT and CD34 for the total electricity cost is Rs. 1,26,256 and Rs. 16,510 respectively. Similarly, share of IPT and CD34 in the total cost of reagents is Rs. 1,38,964 and Rs. 18,172 respectively [Table 9]. Share of IPT and CD34 in the quality control is Rs. 88,435 and Rs. 11564 respectively. Cost of LASER is Rs. 2,50,000 with installed capacity of 5000 hours, estimated to run for 3.5 years, considering 1300 hours of usage in a year. Thus annual cost of laser is Rs. 65,000. Annual share of IPT and CD34 counts for 'spare and maintenance' is Rs. 1,34,687 and 17,612 respectively [Table 10]. Share of IPT and CD34 counts in the annual expenditure of consumables is Rs. 87,197 and Rs. 11,402 respectively.b). Indirect cost of IPT and CD34 counts:
Average number of samples received in a year for IPT is 1300 and per sample indirect cost is Rs. 124. The indirect cost of IPT is high as there are two cytometrists exclusively doing cytometry. Thus annual indirect cost for IPT is Rs. 1,61,000. Refer [Table 11] for summary of direct cost of IPT.
Per sample cost of IPT: Thus total annual expenditure on IPT is Rs. 5,35,7,025. Per sample cost of IPT for a case of hematolymphoid neoplasm is Rs. 4120. Similarly per sample cost of CD34 counts is Rs. 1700.
5. Costing of Cytochemistry Tests:
Cytochemical tests are performed in the HPL include myeloperoxidase (MPO, n is equal to 1700), non specific esterase (NSE, n is equal to 220), leucocyte alkaline phosphatase (LAP, n is equal to 700), tartarate resistance acid phosphatase (TRAP, n is equal to 12) and iron staining (n is equal to five). Total indirect and direct cost is 42500 and 12118 with a sum total of Rs. 54618. Thus per sample cost of MPO is Rs. 32 only. Similarly per sample cost of other cytochemical stains are LAP (Rs. 66), NSE (Rs. 38), TRAP (Rs. 225), and Iron staining (Rs. 58).
6. Costing of bone marrow (BM) aspirate examination [Table 12]:
Per sample cost of BM examination is Rs. 33 only. We routinely stain three BM slides for each case (two aspirates and one touch imprint slide). Thus cost of three slides per case is Rs. 49 [25 plus (8x3)].
7. Costing of other tests:
Similarly per sample cost of other tests is ESR (Rs. 51), reticulocyte count (Rs. 26) and body fluids examination (Rs. 38).
Costing based on working hours reveals that the cost of CBC and BM morphology per sample is Rs. 77 and 496 respectively, in comparison to Rs. 85 and 49 as seen above. Per sample cost of BM examination increases corresponding to the manpower cost (pathologists). Cost of the CBC tests is slightly less as it is being done by the technicians.
Of the total indirect cost of Rs. 56,5,9153, cost incurred by the hospital (which is not the part of the budgets allocated to the HPL) is approximately Rs. 48,66,653 (86%), while remaining 7,92,500 (14%) is from the HPL's budget. Total annual cost of the HPL was 23200849 [Table 1]. Annual operational cost incurred is Rs. 1,85,85,968 [Table 13]. Approximate annual expenditure is Rs. 1,85,85,968 plus 48,66,653 which is equal to Rs. 2.32 crore per year. However, annual budget for year 2005-06 for the HPL was Rs. 1.15 crore, which included operational budget (Rs. 1 crore) and capital budget (Rs. 15 lakh). The revenue earned by HPL in the year 2005 was approximately Rs. 1.32 crore. Though there appears to be gain of Rs. 17 lakh, actually there is an annual net loss of approximately Rs. 1 crore to the HPL.
Laboratories in government hospitals generally fend off financial scrutiny and accountability on the grounds of their complex nature and lack of compelling need. However, costing has now come under intense scrutiny because of budget reduction and possibilities for private/corporate sector competition. Costing provides robust data that accurately reflects how resources are consumed. There are occasional studies on ABC cost analysis of laboratory tests. , However, as literature suggests, there is a paucity of similar studies in India.
We made an attempt to do ABC of various tests done in a laboratory of a government hospital. Most of the expenditure in our cost analysis was on reagent purchase as also seen in the Thailand study.  HPL spends a mere 13% of its total expenses on the manpower, as reported in a Thailand study.  However, manpower constitutes approximately 40-60% of total laboratory expenses in the western world. ,, It may possibly be due to lower staff salary or lower number of staff which may in turn increase the turn around time. Various other factors include completeness of data, study method, place and duration, time of study, number of tests, technology used and changing rate of currencies. It is recommended that every laboratory should calculate their unit cost periodically.
Indirect cost (hidden cost) was Rs. 25 only as HPL is a large size laboratory. The direct costs are mainly borne by the HPL, while most of the indirect costs are by the hospital (86%). Common annual expenses of the HPL included reagents (60%) followed by manpower (13%). Expenditure incurred towards quality control procedures stood at three per cent (owing to large sample size). Cost of CBC test by our method was Rs. 85, however, per hour costing for CBC test was Rs. 77. Similarly per hour costing for bone marrow morphology was as high as Rs. 496, as pathologists spend most of their time in these specialized tests.
As a hospital mandate, 10% of our patients get free treatment and diagnostic services, another 50% are offered subsidized rates or a lower affordable price while remaining 40% are charged in the private category. The annual revenue loss to HPL is approximately Rs. 1 crore.
Extra testing is a common phenomenon and is assigned primarily to residents during training. Routine tests like MDC, PT, APTT are asked for at every routine surgery (minor as well as major). It leads to extra burden and expenditure on both the patient as well as on hospital infrastructure. Substantial amount of money may be saved in a laboratory by selective ordering of tests.  There is a wide variation in the cost of laboratory tests and their turnaround times.  Concept of faster turn around time is catching up in the Indian laboratories. Turnaround time is three days for bone marrow morphology and IPT and 24 hours for all remaining tests in the HPL. It highlights the use of automation, extra reagents, staggering duties and employing adequate staff.
Accreditation agencies make internal as well as external quality assurance programs (EQAP) mandatory thereby further increasing the cost of the laboratory testing. It outlines need of having national EQAP programs for various tests. Automation is in demand and most laboratories (private as well as government) opt for automated instruments. Though there are major advantages of the technology, it has lead to an increase in cost price of tests. Complete blood counts which used to cost a few rupees only now cost more than 100 Rupees per test.  In the recent past, charges of most of the tests have rocketed high owing to automation and the 'accreditation'. Thus, costing of laboratory test is an important issue to be dealt by the government-run laboratories. In the private sector, costing is defined by a few large size laboratories and rest majority of the laboratories follow these charges.
The total allocation for health sector in India in the present financial year budget 2008-2009 is Rs. 165,534 crore. This is an increase of 15 per cent over last year.  In the time of fast economic growth in India, the budgetary allocation to health sector is far from desirable proportion of two to three per cent of GDP and is constant at low rate of 0.9% of total GDP.  Although cost containment directed at misutilization and overutilization of existing services has conserved resources, to date, an effective cost control mechanism has yet to be identified and implemented in government-run laboratories in India.
Government-run clinical laboratories should enhance efficiency and reduce costs by forming alliances and networks; consolidating, integrating, or outsourcing to specialized laboratories (private, public or government funded). The laboratory business model in Indian laboratories suffers from fragmentation, redundancy, and excess capacity and is inadequate in the new reality of cost containment and competition. The advances in information technology and internet applications allow for efficient communication between collaborating laboratories.  Mumbai has four government medical colleges and we propose a single reference laboratory for specialized tests. All laboratories may outsource tests to such a reference laboratory with a higher level of expertise.  Larger test volume lowers both the unit cost as well as turnaround time. Cost and quality should improve, as efficiency is boosted. 
Limitations of the study:
The estimation of testing costs in the hospital environment is problematic. Even the identification of relevant costs is not easy. TMH has a tripartite mandate of service, training and research. Research and training costs are difficult to separate out and quantify. Laboratories attached to institute or hospitals like HPL have an academic excellence that sets them apart from the private sector.
This costing exercise was a short duration study (six months only). It was difficult to cost all the centers which indirectly help the HPL. Few of the support departments could not be included in the overheads calculation as required data was not available. There were no meters to measure the exact electricity and water consumption at the cost centers (different working stations of the HPL). Though depreciation is followed on all the equipment purchased, many of them (non analytical) have served beyond their useful life. Few instruments in the HPL have been procured from the research grants. Rates of reagents have been calculated without value added tax charges. A few spares for hematology cell counters are one time purchases like as vacuum accumulators, syringes, peristaltic tubing. Cost of hospital information system (laboratory information system), telephonic communication, and correspondence (national as well as international) was not included. Though the HPL has a molecular diagnostic laboratory, its costing was not included in this study. Budget for the molecular diagnostic tests comes from various research projects. Certain disciplines such as morphology and flow cytometry evaluation are signed by a pathologist, while remaining tests are handled by technologists. Many among the laboratory staff end up working beyond the defined 42 working hours a week to finish the day's work. Trainees, students and observers help regular staff in routine working. Local transport to attend meetings and the subsidized rates of meals and coffee to the staff are other indirect costs.
A new policy of the hospital is to acquire reagent rental instruments. Here the liabilities (insurance and maintenance etc.) are transferred to the instrument supplier. Consignment stock that includes reagents, consumables, control and calibrating material, are purchased by the HPL. Thus in present date, HPL incurs no direct cost prior to the performance of the test as most of the instruments are acquired on reagent rental. The laboratory continues to evolve and adds new feathers to its cap. It has acquired newer sophisticated instruments,, developed laboratory information system with unidirectional interfacing, bar coding of the vacutainers and pneumatic shoot for transport of samples.
There were a few assumptions made while doing the study. Rounded off values were considered for calculations. Values considered represent the value of stock as in the year 2005. Though refrigerators work for 24 hours, because of thermostat, actual consumption of electricity is for 15 hours. For CBC and MDC, lifespan of storage rack for micro tube is taken as two years. The cost of methanol, phosphate buffer, immersion oil and Wrights'' stain is shared by MDC, cytochemistry and BM tests. For coagulation tests, lifespan of magnetic stirrer is taken as five years and lifespan of rack tube floating foam is taken as two years. For IPT, life of a flow cell is considered as five years.
Though there were several limitations and assumptions, this was an attempt to understand consumption of resources in a large size government-run laboratory. Price is only a part of the per sample cost which also includes costs of quality and transaction. Cost per test decreases as the total number of samples increases. Number of samples analyzed is the most important cost setting factor. Our costing study concludes that the rate structure needs to be revised for most of the tests, mainly for CBC, BM examination, coagulation tests and IPT [Table 14]. Maximum annual expenses in the HPL are on reagents and consumables followed by manpower. Cost per test is higher for those specialized tests where the morphological or flow data interpretation is done by a pathologist.
This costing exercise is laboratory-specific and each laboratory needs its own costing, especially in the government setting. Such an exercise may help a laboratory re design its costing structure or at least understand the economics involved in the laboratory management. Charges for various laboratory tests have marginally increased in the last decade, as per the hospital policy. Charges for the poor and general category patients in the government hospitals are cheaper than ever before. Private category patients are charged as per the cost of the test.
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