PUBLIC HEALTH BRIEFS
REFERENCES 1. Portnoy, J., Brewer, J., and Harris, A. Rapid plasma reagin card test for syphilis and other treponematoses. Public Health Reports, 77:645-652, 1962. 2. Borchardt, K.A. A macroscopic latex screening test for syphilis. American Journal of Clinical Pathology, 44:241-243, 1965.
3. Wood, R., Lennette, E., Spaulding, E., and Truant, J. Tests for Syphilis, In Manual of Clinical Microbiology. Second edition, DC: American Society for Microbiology, Washington, 1974. 4. Hyland Laboratories, Syphla Chek Evaluation Protocol, # 050023.
Costs of Mental Health Services in a Colombian Hospital ROBERT L. ROBERTSON, PHD, RICARDO PAB6N, MS,
Introduction Cost data can be useful in health planning and administration. Nevertheless, relatively few detailed cost studies have been conducted at the level of specific institutions, especially in the field of mental health, as judged from the literature of several countries.1-5 This report briefly describes a research project in the state of Valle del Cauca, Colombia, and presents the most important findings of that project's intensive study of the costs of services for a year at the principal mental health facility in Valle, San Isidro Hospital. The psychiatric hospital of San Isidro is located on the outskirts of Cali, a city of approximately one million inhabitants that serves as the center of a catchment area containing several million persons. San Isidro functions as a regional hospital in the national scheme of health institutions and also as a specialized university hospital. It has the usual range of services and staff members for a sophisticated hospital, as well as some innovative training and care activities and provides educational experiences to medical students.6 Inpatients have a total of 200 beds available, divided during the study period among: 46 "pensionado" beds for privately paying persons who receive special treatment and billing; 114 general beds for miscellaneous public patients of comparatively short durations; and 40 "chronic" beds for longterm public patients. Ambulatory services are classified into two broad groups: individual consultations in the outpatient department ("consulta externa"), staffed by physicians and allied health personnel; and "hospital diurno," which provides a set of services by a variety of personnel in half-day blocks.
Methods Although more detailed explanations of our cost finding methodology can be found in other sources,7 8 some highAddress reprint requests to Dr. Robert L. Robertson, Department of Economics, Mount Holyoke College, South Hadley, MA 01075. Prof. Pab6n and Prof. Barona are affiliated with the Departamento de Administraci6n, Universidad del Valle, Cali, Colombia. Submitted to the Journal September 8, 1976, this paper was revised and accepted for publication March 16, 1977. 972
AND
BERNARDO BARONA, MS
lights of it are described here. It had many conventional accounting components shared with other cost systems9 such as a three-part division of cost (responsibility) centerscalled by us "administrative," "auxiliary," and "final" centers. There were, however, a number of distinctive features to our methods, such as: verification of data quality by special monitors; time study through work sampling to distribute professionals' costs among education and other such outputs and the various service programs; and adaptation of the "simultaneous equations" method (requiring a computer) for allocating certain overhead costs to final products. Probably the most important element was the computation of costs with and without the inclusion of allowances for full resource use, whether or not paid for by the hospital-for example, students' time contributed to the service program and all capital items (buildings and equipment) utilized.
Results The findings on total costs are presented in Table 1. Their two data columns illustrate the capability of our system to separate the full value of all resources, paid for or not, (called the "total" approach) from the costs which would be found in a more conventional approach covering only the resources paid for by the hospital (called "partial"). Comparison of the totals of the two columns shows that the limited or partial approach yielded only about three-quarters of the full costs found when the allowances of the total method, especially for personnel and capital, were included. Although the specific case of San Isidro cannot be considered an exact indication of values elsewhere, it suggests to administrators of health institutions the importance of avoiding possible understatements of costs. Table 2 contains the average costs of final health services at the hospital, computed by dividing total costs by service utilization figures. It reveals some differences between two types of outpatient care and among the three inpatient categories. We shall limit our comments here to the findings for outpatients, but comparisons of inpatients' costs are available to interested readers. During the study period the unit cost of consulta externa was much higher than that of AJPH October, 1977, Vol. 67, No. 10
PUBLIC HEALTH BRIEFS TABLE 1-San Isidro Hospital Total Costs of Final Cost Centers (August 1973-July 1974) (in Pesos-i Peso = 0.04 U. S. Dollar) Cost Center
"Partial" Approach
"Total" Approach
Outpatient Department (Consulta Externa) Hospital Diurno Hospitalization: Pensionado General Chronic Indirect Services: Education Research Services to Other Institutions
480,228 171,996
953,000 213,728
1,020,059 3,103,931 953,171
1,266,533 3,802,667 1,168,343
514,001
961,370 42,843
43,030
43,450
TOTAL
6,286,416
8,451,934
SOURCE: Computed (with rounding) from data collected at the hospital for each month of the study year.
hospital diurno. The difference was substantially greater for our total approach than for the partial one, because the consulta externa program used more heavily physician residents who contributed some of their time without full compensation. The two programs were very different, as the diurno program treated ambulatory patients in half-day blocks, longer than the typical contact of consulta externa. Although one would have expected diurno costs to be greater because more complicated cases were treated, efficiency apparently was promoted by greater reliance on paramedical personnel in direct program care and in supporting services of auxiliary departments, such as occupational therapy. Greater use of group therapy also helped to control expenses of diurno, with the result that it treated patients for a longer time per visit than consulta externa at lower average cost. These results and also the cost savings of diurno over inpatient care indicate the importance of further attempts to economize on the use of physicians and expensive facilities in treating mentally ill persons, reinforcing the lessons of other studies.5 7 The results here and at another Colombian hospital7 demonstrate that our cost finding methodology has proven
feasible for producing detailed data of high quality. They have been put to use by administrators at San Isidro for setting rates for self-pay patients (related at least in part to true costs) and calculating the value of fringe benefits, such as free meals for the staff, among other purposes. This cost system, or one like it, can be applied to other institutions, helping to meet a worldwide need to put scarce resources to their best uses.
Summary This paper describes the principal features of a methodology for health service cost finding which has been applied in the state of Valle del Cauca, Colombia. It presents selected results from an analysis of one year's costs at the San Isidro psychiatric hospital in Cali. Our data suggest certain ways to promote efficiency in the provision of ambulatory services and also indicate some differences in costs among inpatients. The methodology, which emphasizes full costing of services, is adaptable to other institutions beyond Colombia, as well as in it.
TABLE 2-San Isidro Hospital Average Costs of Services (August 1973-July 1974) (in Pesos) Service
Outpatient Department (Consulta Extema) Hospital Diurno Hospitalization-Days: Pensionado General Chronic HOSPITALIZATION-Discharges: Pensionado General Chronic
"Partial" Approach
"Total" Approach
41.65 34.35
82.66
157.76 76.69 71.67
195.88 93.95 87.85
4,000.23 1,807.76 43,325.95
4,966.78 2,214.72
43.31
53,106.50
SOURCE: Computed (with rounding) from data collected at the hospital for each month of the study year.
AJPH October, 1977, Vol. 67, No. 10
973
PUBLIC HEALTH BRIEFS
REFERENCES 1. May, P. R. A. Cost-efficiency of mental health delivery systems: I. A review of the literature on hospital care. Am. J. Public Health 60:2060-2067, 1970. 2. Roemer, M. I. Evaluation of Community Health Centres. World Health Organization, Public Health Papers, No. 48, Geneva, 1972. 3. Abel-Smith, B. Health priorities in developing countries: The economist's contribution. International Journal of Health Services 2:5-12, 1972. 4. Cobb, C. W. Community mental health services and the lower socio-economic classes: A summary of research literature on outpatient treatment. Am. J. Orthopsychiatry 42:404-414, 1972. 5. Smith, S. L. Lowering the cost of psychiatric care: An experimental brief-stay unit with the nurse as therapist. Canadian Psychiatric Association Journal 17:423-428, 1972. 6. Leon, C. A. Brighter Prospects. World Health: 28-33, October 1974.
7. Robertson, R. L., et al. Hospital cost accounting and analysis: The case of Candelaria. J. Community Health 3, no. 1. In Press. 8. Pab6n, R., et al. Manual de Metodos: Costos en Instituciones de Salud. Universidad del Valle, Cali, 1977. 9. Sorensen, J. E., et al. Cost-Finding and Rate-Setting for Community Mental Health Centers. Washington, DC: GPO, DHEW Publication No. (HSM) 72-9138, 1972.
ACKNOWLEDGMENTS The authors wish to acknowledge the assistance of many persons, including Drs. Rodrigo Guerrero, Dieter Koch-Weser, Carlos Climent, and Ray Neutra, and hospital officials. Helpful comments on earlier drafts were provided by Drs. Alfred Yankauer, Sidney Lee, and Robert Weiss, among others. In addition, we are grateful for the financial aid of The Rockefeller Foundation, which has supported this work in conjunction with Universidad del Valle and Harvard University. None of these parties is responsible for this paper.
Physician Distribution Analysis Based on Zip Code Areas Applied to Dermatologists MELVIN KRASNER, DAVID L. RAMSAY, MD, MED, Although spatial distribution of physicians in the United States has been a subject of investigation for decades,' recent years have witnessed an escalation of interest in this subject,2' 3 accompanied by a proliferation of programs designed to influence physicians' location.4 5 Little attention, however, has been paid to what constitutes an appropriate geographical unit for distributional analysis. The task of identifying a geographical unit that is both analytically meaningful and readily applicable for distribution analysis of physician specialists was undertaken as part of a broad study of dennatological care conducted by the American Academy of Dermatology. A variety of units have been defined by governmental agencies and other organizations for many purposes including health care planning; however, areas designed for the collection of census data, planning hospital facilities, or political purposes, are often inappropriate for studying the accessibility of physician care. In addition, a single unit is inadequate to deal with all types and levels of physicians' services, as each possesses a unique catchment area. Clearly the spatial distribution of primary care practitioners should be examined in relation to smaller population and geographic units than the distribution of physicians providing subspecialty care. Ideally, the geoFrom the American Academy of Dermatology Manpower Study, Department of Dermatology, New York University School of Medicine, New York, NY. Address reprint requests to Dr. David L. Ramsay, 560 First Avenue, New York, NY 10016. Submitted to the Journal December 28, 1976, this paper was revised and accepted for publication March 28, 1977.
AND PEYTON E.
WEARY, MD
graphic unit should be large enough to encompass the service area of the specialist, yet small enough to highlight important geographic barriers to care. The boundaries of the geographic unit should conform to local patterns of transportation and economic activity, and a wide variety of pertinent and accurate data for the area must be readily available.
Zipcode Areas and Physician Distribution A geographical unit that has received relatively little attention from health care analysts is the Zipcode Sectional Area. These areas, identified by the first three digits of the five-digit Zipcode number, were designated by the United States Postal Service for the management of mail distribution. They were established on the basis of local transportation patterns and thus, in most cases, approximate economic trading areas.6 It appears reasonable to assume that geographic patterns of health services utilization largely conform to those for goods and services in general, and this has been verified empirically in a recent study.7 Although Zipcode Areas do not cross state lines, areas in adjacent states can be readily consolidated to form an integrated economic trading area. Since the overwhelming majority of patients treated by many specialists are ambulant, a fairly large service area is appropriate. Thus, Zipcode Areas appear to be well suited for analyzing the physician distribution in the smaller specialties such as dermatology. Smaller areas seem suitable for studying primary care manpower, and larger areas are appropriate for highly specialized tertiary care. AJPH October, 1977, Vol. 67, No. 10
REFERENCES 1. Portnoy, J., Brewer, J., and Harris, A. Rapid plasma reagin card test for syphilis and other treponematoses. Public Health Reports, 77:645-652, 1962. 2. Borchardt, K.A. A macroscopic latex screening test for syphilis. American Journal of Clinical Pathology, 44:241-243, 1965.
3. Wood, R., Lennette, E., Spaulding, E., and Truant, J. Tests for Syphilis, In Manual of Clinical Microbiology. Second edition, DC: American Society for Microbiology, Washington, 1974. 4. Hyland Laboratories, Syphla Chek Evaluation Protocol, # 050023.
Costs of Mental Health Services in a Colombian Hospital ROBERT L. ROBERTSON, PHD, RICARDO PAB6N, MS,
Introduction Cost data can be useful in health planning and administration. Nevertheless, relatively few detailed cost studies have been conducted at the level of specific institutions, especially in the field of mental health, as judged from the literature of several countries.1-5 This report briefly describes a research project in the state of Valle del Cauca, Colombia, and presents the most important findings of that project's intensive study of the costs of services for a year at the principal mental health facility in Valle, San Isidro Hospital. The psychiatric hospital of San Isidro is located on the outskirts of Cali, a city of approximately one million inhabitants that serves as the center of a catchment area containing several million persons. San Isidro functions as a regional hospital in the national scheme of health institutions and also as a specialized university hospital. It has the usual range of services and staff members for a sophisticated hospital, as well as some innovative training and care activities and provides educational experiences to medical students.6 Inpatients have a total of 200 beds available, divided during the study period among: 46 "pensionado" beds for privately paying persons who receive special treatment and billing; 114 general beds for miscellaneous public patients of comparatively short durations; and 40 "chronic" beds for longterm public patients. Ambulatory services are classified into two broad groups: individual consultations in the outpatient department ("consulta externa"), staffed by physicians and allied health personnel; and "hospital diurno," which provides a set of services by a variety of personnel in half-day blocks.
Methods Although more detailed explanations of our cost finding methodology can be found in other sources,7 8 some highAddress reprint requests to Dr. Robert L. Robertson, Department of Economics, Mount Holyoke College, South Hadley, MA 01075. Prof. Pab6n and Prof. Barona are affiliated with the Departamento de Administraci6n, Universidad del Valle, Cali, Colombia. Submitted to the Journal September 8, 1976, this paper was revised and accepted for publication March 16, 1977. 972
AND
BERNARDO BARONA, MS
lights of it are described here. It had many conventional accounting components shared with other cost systems9 such as a three-part division of cost (responsibility) centerscalled by us "administrative," "auxiliary," and "final" centers. There were, however, a number of distinctive features to our methods, such as: verification of data quality by special monitors; time study through work sampling to distribute professionals' costs among education and other such outputs and the various service programs; and adaptation of the "simultaneous equations" method (requiring a computer) for allocating certain overhead costs to final products. Probably the most important element was the computation of costs with and without the inclusion of allowances for full resource use, whether or not paid for by the hospital-for example, students' time contributed to the service program and all capital items (buildings and equipment) utilized.
Results The findings on total costs are presented in Table 1. Their two data columns illustrate the capability of our system to separate the full value of all resources, paid for or not, (called the "total" approach) from the costs which would be found in a more conventional approach covering only the resources paid for by the hospital (called "partial"). Comparison of the totals of the two columns shows that the limited or partial approach yielded only about three-quarters of the full costs found when the allowances of the total method, especially for personnel and capital, were included. Although the specific case of San Isidro cannot be considered an exact indication of values elsewhere, it suggests to administrators of health institutions the importance of avoiding possible understatements of costs. Table 2 contains the average costs of final health services at the hospital, computed by dividing total costs by service utilization figures. It reveals some differences between two types of outpatient care and among the three inpatient categories. We shall limit our comments here to the findings for outpatients, but comparisons of inpatients' costs are available to interested readers. During the study period the unit cost of consulta externa was much higher than that of AJPH October, 1977, Vol. 67, No. 10
PUBLIC HEALTH BRIEFS TABLE 1-San Isidro Hospital Total Costs of Final Cost Centers (August 1973-July 1974) (in Pesos-i Peso = 0.04 U. S. Dollar) Cost Center
"Partial" Approach
"Total" Approach
Outpatient Department (Consulta Externa) Hospital Diurno Hospitalization: Pensionado General Chronic Indirect Services: Education Research Services to Other Institutions
480,228 171,996
953,000 213,728
1,020,059 3,103,931 953,171
1,266,533 3,802,667 1,168,343
514,001
961,370 42,843
43,030
43,450
TOTAL
6,286,416
8,451,934
SOURCE: Computed (with rounding) from data collected at the hospital for each month of the study year.
hospital diurno. The difference was substantially greater for our total approach than for the partial one, because the consulta externa program used more heavily physician residents who contributed some of their time without full compensation. The two programs were very different, as the diurno program treated ambulatory patients in half-day blocks, longer than the typical contact of consulta externa. Although one would have expected diurno costs to be greater because more complicated cases were treated, efficiency apparently was promoted by greater reliance on paramedical personnel in direct program care and in supporting services of auxiliary departments, such as occupational therapy. Greater use of group therapy also helped to control expenses of diurno, with the result that it treated patients for a longer time per visit than consulta externa at lower average cost. These results and also the cost savings of diurno over inpatient care indicate the importance of further attempts to economize on the use of physicians and expensive facilities in treating mentally ill persons, reinforcing the lessons of other studies.5 7 The results here and at another Colombian hospital7 demonstrate that our cost finding methodology has proven
feasible for producing detailed data of high quality. They have been put to use by administrators at San Isidro for setting rates for self-pay patients (related at least in part to true costs) and calculating the value of fringe benefits, such as free meals for the staff, among other purposes. This cost system, or one like it, can be applied to other institutions, helping to meet a worldwide need to put scarce resources to their best uses.
Summary This paper describes the principal features of a methodology for health service cost finding which has been applied in the state of Valle del Cauca, Colombia. It presents selected results from an analysis of one year's costs at the San Isidro psychiatric hospital in Cali. Our data suggest certain ways to promote efficiency in the provision of ambulatory services and also indicate some differences in costs among inpatients. The methodology, which emphasizes full costing of services, is adaptable to other institutions beyond Colombia, as well as in it.
TABLE 2-San Isidro Hospital Average Costs of Services (August 1973-July 1974) (in Pesos) Service
Outpatient Department (Consulta Extema) Hospital Diurno Hospitalization-Days: Pensionado General Chronic HOSPITALIZATION-Discharges: Pensionado General Chronic
"Partial" Approach
"Total" Approach
41.65 34.35
82.66
157.76 76.69 71.67
195.88 93.95 87.85
4,000.23 1,807.76 43,325.95
4,966.78 2,214.72
43.31
53,106.50
SOURCE: Computed (with rounding) from data collected at the hospital for each month of the study year.
AJPH October, 1977, Vol. 67, No. 10
973
PUBLIC HEALTH BRIEFS
REFERENCES 1. May, P. R. A. Cost-efficiency of mental health delivery systems: I. A review of the literature on hospital care. Am. J. Public Health 60:2060-2067, 1970. 2. Roemer, M. I. Evaluation of Community Health Centres. World Health Organization, Public Health Papers, No. 48, Geneva, 1972. 3. Abel-Smith, B. Health priorities in developing countries: The economist's contribution. International Journal of Health Services 2:5-12, 1972. 4. Cobb, C. W. Community mental health services and the lower socio-economic classes: A summary of research literature on outpatient treatment. Am. J. Orthopsychiatry 42:404-414, 1972. 5. Smith, S. L. Lowering the cost of psychiatric care: An experimental brief-stay unit with the nurse as therapist. Canadian Psychiatric Association Journal 17:423-428, 1972. 6. Leon, C. A. Brighter Prospects. World Health: 28-33, October 1974.
7. Robertson, R. L., et al. Hospital cost accounting and analysis: The case of Candelaria. J. Community Health 3, no. 1. In Press. 8. Pab6n, R., et al. Manual de Metodos: Costos en Instituciones de Salud. Universidad del Valle, Cali, 1977. 9. Sorensen, J. E., et al. Cost-Finding and Rate-Setting for Community Mental Health Centers. Washington, DC: GPO, DHEW Publication No. (HSM) 72-9138, 1972.
ACKNOWLEDGMENTS The authors wish to acknowledge the assistance of many persons, including Drs. Rodrigo Guerrero, Dieter Koch-Weser, Carlos Climent, and Ray Neutra, and hospital officials. Helpful comments on earlier drafts were provided by Drs. Alfred Yankauer, Sidney Lee, and Robert Weiss, among others. In addition, we are grateful for the financial aid of The Rockefeller Foundation, which has supported this work in conjunction with Universidad del Valle and Harvard University. None of these parties is responsible for this paper.
Physician Distribution Analysis Based on Zip Code Areas Applied to Dermatologists MELVIN KRASNER, DAVID L. RAMSAY, MD, MED, Although spatial distribution of physicians in the United States has been a subject of investigation for decades,' recent years have witnessed an escalation of interest in this subject,2' 3 accompanied by a proliferation of programs designed to influence physicians' location.4 5 Little attention, however, has been paid to what constitutes an appropriate geographical unit for distributional analysis. The task of identifying a geographical unit that is both analytically meaningful and readily applicable for distribution analysis of physician specialists was undertaken as part of a broad study of dennatological care conducted by the American Academy of Dermatology. A variety of units have been defined by governmental agencies and other organizations for many purposes including health care planning; however, areas designed for the collection of census data, planning hospital facilities, or political purposes, are often inappropriate for studying the accessibility of physician care. In addition, a single unit is inadequate to deal with all types and levels of physicians' services, as each possesses a unique catchment area. Clearly the spatial distribution of primary care practitioners should be examined in relation to smaller population and geographic units than the distribution of physicians providing subspecialty care. Ideally, the geoFrom the American Academy of Dermatology Manpower Study, Department of Dermatology, New York University School of Medicine, New York, NY. Address reprint requests to Dr. David L. Ramsay, 560 First Avenue, New York, NY 10016. Submitted to the Journal December 28, 1976, this paper was revised and accepted for publication March 28, 1977.
AND PEYTON E.
WEARY, MD
graphic unit should be large enough to encompass the service area of the specialist, yet small enough to highlight important geographic barriers to care. The boundaries of the geographic unit should conform to local patterns of transportation and economic activity, and a wide variety of pertinent and accurate data for the area must be readily available.
Zipcode Areas and Physician Distribution A geographical unit that has received relatively little attention from health care analysts is the Zipcode Sectional Area. These areas, identified by the first three digits of the five-digit Zipcode number, were designated by the United States Postal Service for the management of mail distribution. They were established on the basis of local transportation patterns and thus, in most cases, approximate economic trading areas.6 It appears reasonable to assume that geographic patterns of health services utilization largely conform to those for goods and services in general, and this has been verified empirically in a recent study.7 Although Zipcode Areas do not cross state lines, areas in adjacent states can be readily consolidated to form an integrated economic trading area. Since the overwhelming majority of patients treated by many specialists are ambulant, a fairly large service area is appropriate. Thus, Zipcode Areas appear to be well suited for analyzing the physician distribution in the smaller specialties such as dermatology. Smaller areas seem suitable for studying primary care manpower, and larger areas are appropriate for highly specialized tertiary care. AJPH October, 1977, Vol. 67, No. 10
