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17
IME – INTERDISZCIPLINÁRIS MAGYAR EGÉSZSÉGÜGY XIX. ÉVFOLYAM 1. SZÁM 2020. FEBRUÁR
MENEDZSMENT KONTROLLING
Aims: The main aim of the present study is to analyse
the economic and financial results of a pool of Romanian
public hospitals after the major salary increases of both
the medical and non-medical personnel of the past few
years through the methodology of controlling.
Methods and results: In order to perform the assess-
ment, a pool of public hospitals with implemented cont-
rolling systems has been selected, to be representative
for the Romanian health care system. Through utilizing
the data and information provided by their controlling
systems, we have analysed their results and draw com-
parisons to reach health policy level conclusions.
Results: With regard to the salaries and the subsidies
received as a result of the salary increase, it becomes
obvious that the volume of subsidies is comparable to
the revenue from services reimbursed by the payer.
Although there are dysfunctionalities in the system, on
average, the public hospitals manage to reach a surplus,
however, there are numerous hospitals in debt, accumu-
lating arrears. On a specialty level, there are some spe-
cialties that generate surplus on a regular basis, while
other surgical specialties, generate deficit.
Conclusions: The public hospitals in the Romanian
health care system are faced with systemic issues that
need to be dealt with on a decision-maker level. Nonethe -
less, it is the responsibility of the local management to
ensure the economic equilibrium of the institutions and
managerial decision-making can ensure the optimal
functioning of the public hospitals.
Célok: Jelen tanulmány fő célja a romániai állami kór-
házak egy csoportjának gazdasági és pénzügyi eredmé-
nyeinek elemzése az elmúlt évek jelentős bérnövekedé-
seit követően, felhasználva a kontrolling módszertanát.
Módszertan: Olyan állami kórházakat vontunk be az
elemzésbe, amelyek kontrolling rendszerrel rendelkez-
nek és amelyek megfelelő minőségű adatokat tudtak
szolgáltatni a jelen tanulmányhoz. A kontrolling rendsze-
rek által szolgáltatott adatok és információk felhasználá-
sával elemeztük az eredményeket és összehasonlításo-
kat készítettünk egészségpolitikai szintű következteté-
sek levonásához.
Eredmények: A bérnövekedés fedezeteként nyújtott
támogatások nagysága összehasonlítható a finanszírozó
által teljesítményfinanszírozással térített szolgáltatások-
ból származó bevételekkel. Bár a finanszírozási rend-
szerben számos működési zavar figyelhető meg, átlago-
san véve, az állami kórházaknak sikerül nyereségesen
működni, ugyanakkor számos kórház veszteséges és
adósságot halmoz fel. Vannak olyan szakmai területek,
amelyek rendszeresen nyereségesek, míg más, általában
sebészeti szakmák veszteségesen működnek.
Következtetések: A romániai egészségügyi ellátó-
rendszer állami kórházai rendszerszintű problémákkal
szembesülnek, amelyeket döntéshozói szinten kell ke -
zelni. Ennek ellenére, a kórházi vezetés felelőssége az
intézmények gazdasági egyensúlyának biztosítása és a
vezetői döntéshozatalnak kell biztosítania az állami kór-
házak optimális működését is.
INTRODUCTION
Controlling systems or management control systems
have been described and characterised starting as early as
the 1960s, saying that these systems offer a structure, resul-
ting in the control data and a process to use the data [1]. By
the 1970s management control systems have already been
implemented not only in profit-oriented organizations, but also
non-for-profit organizations, including public health care units.
In case of profit-oriented organizations these systems served
as an internal motivator to improve efficiency and quality. In
case of non-for-profit health care organizations profit cannot
be a motivator, thus these controlling systems would become
a source of motivation and efficiency [2].
In our days implementing controlling systems in public
health care units or hospitals is common practice in devel -
oped countries, including Norway [3] and Hungary [4] and
Romania is no exception, cost measurement being per -
formed on various levels, including institution level, depart-
ment level, and even disease level (for instance Alzheimer's
disease [5] or chronic heart failure [6]).
When it comes to the financing mechanism of public hos-
pitals in Romania, there is one specific aspect that cannot be
disregarded: starting with the second half of 2015 several
waves of salary increase occurred in the public system, in -
cluding publicly funded hospitals, which influenced the sala-
ries of both medical and non-medical staff. These steps have
been taken as a response to the current issues the Romanian
health care is facing, including the migration of medical per-
sonnel [7]. Even though these extra expenses (according to
the current financing mechanisms, such as the DRG –
Controlling in Romanian Hospitals:
revenues, costs and contribution after salary increase
László Lorenzovici1,2, Andrea Székely2, Bernadett Nyulas2, Alíz Bradács3, Lucia Daina3
1Faculty of Technical and Human Sciences, Sapientia University, Târgu Mureș, Romania
2Hospital Consulting, Târgu Mureș, Romania
3University of Oradea, Faculty of Medicine and Pharmacy, Oradea, Romania
18 IME – INTERDISZCIPLINÁRIS MAGYAR EGÉSZSÉGÜGY XIX. ÉVFOLYAM 1. SZÁM 2020. FEBRUÁR
MENEDZSMENT KONTROLLING
Diagnosis Related Groups – system) ought to be included in
the tariffs (base fee) of the services, such adaptation did not
take place. Instead, the National Health Insurance House
(NHIH) offers subsides to the health care units based on the
salaries the personnel had prior to the increase.
The aim of this study is to analyse the economic and
financial performance of a pool of hospitals with special
regards to the way the salary increase has influenced the
economic results of these institutions and how these relate
to the revenue from NHIH reimbursed services.
METHODOLOGY
For the analysis of each parameter/phenomenon a num-
ber of publicly financed hospitals have been selected of
various sizes (university, county, and town hospitals, includ -
ing single specialty hospitals) and from different geographical
regions, so that the selected cohort would be representative
for the Romanian public hospital system.
In order to calculate the studied parameters and indica-
tors, we used the data of the controlling system of these hos-
pitals (which relies heavily on the accounting data, payroll
data, databases of performed services reimbursed by the
NHIH, and service volumes of the internal structures of the
hospital), more specifically focusing on the total labour costs
per hospital, total costs, and revenues from health care ser-
vices reimbursed by the NHIH.
After collecting all the cost and revenue information of the
hospitals, the controlling system calculates the various levels
of contribution; contribution 1 refers to the revenue minus the
direct hospital costs (salaries, drugs and medication, medical
supplies, utility costs, repairs, spare parts etc.); contribution
2 is contribution 1 minus the indirect costs (costs associated
with the internal services of hospitals, such as diagnostics,
ICU, operating rooms etc); contribution 3 means contribution
2 minus the overhead costs (costs associated with manage-
ment, safety and security, taxes etc) [8-9]; these are reported
to the total income of the hospital, giving a proportion. This
calculation does not consider the depreciation, investment
expenses or income for investment purposes. Such calcula-
tions are performed at hospital and department/ward level
(although at department/ward level there is no contribution 3
calculated).
RESULTS
Salaries and subsidies
Based on data from 59 public hospitals, the average
share of salaries reported to the total costs of hospitals is of
70% (average weighted by the number of beds each hospital
has) (Figure 1). These have been calculated for each hospi-
tal, and if we consider the size/type of hospital, it is easily
noticeable that this share is smaller in case of the larger hos-
pitals (university hospitals) than in case of the smaller hospi-
tals, and the smaller the hospital is, the larger the share of
salaries becomes, mostly because of the economies of scale
and the higher level of medical technology used by university
hospitals.
A similar trend can be observed in case of the subsidies
as well. We have analysed the controlling data of 21 hospitals
again, of different sizes and from different geographic re -
gions. When compared to the total revenues from services
reimbursed by the NHIH, the average is of 87.9%. Since the
salaries represent a smaller share in case of the larger hos-
pitals, it is to be expected that the share of subsidies is smal-
ler in case of these hospitals. The smaller the hospitals are,
the higher the share of salaries of the total expenses and the
higher the share of subsidies. There are some institutions in
case of which the value of subsidies supersedes the revenue
generated from the services reimbursed by the NHIH, mean -
ing that their reimbursement needs to be doubled to be able
to sustain normal activity.
FINANCIAL RESULTS OF PUBLIC HOSPITALS
IN ROMANIA
In case of this study by the financial results of a hospital
we refer to the contribution 3. For the pool of 59 hospitals we
also calculated the financial results – in percentage of the
NHIH revenues – showing an average result of 1.1% (Figure
Figure 1
Share of salary costs reported to the total expenses of public hospitals in Romania
U-University hospital; USP-University single specialty hospital; SP-Single specialty hospital; C-County
hospital, T-Town hospital
19
IME – INTERDISZCIPLINÁRIS MAGYAR EGÉSZSÉGÜGY XIX. ÉVFOLYAM 1. SZÁM 2020. FEBRUÁR
MENEDZSMENT KONTROLLING
2). Again, this is an average weighted by the number of beds
each hospital has. The results range between -18.7% and
19.8%, showing that there is no consistency whatsoever and
the results do not seem to be influenced by the size of the hos-
pital. This is mainly because the results are highly influenced
a complex web of factors, including the results of the man -
agement’s decision-making process, the financing mechan -
isms (more specifically the mix of pathology that the hospital
treats and the reimbursement level), health policy, the differ -
entiated DRG base fee, the number of health care institutions
in a given area, demography, type of building (whether it is
a century-old building or a modern one) and many other
factors.
As we have mentioned before, contribution 3 takes into
account the overhead costs of the hospitals. The average
overhead costs of the 59 analysed hospitals is of 7.6%, mean -
ing that of the total costs 7.6% represent those associated
with operating the hospital. Because of the economies of
scale, it is to be expected for the larger hospital, with a more
complex activity, to have a smaller overhead costs that the
smaller hospitals (size expressed as the number of beds a
hospital has, which is directly correlated to its revenue gener -
ating potential, according to the current financing mechan -
isms).
As it has been mentioned before, the financial results of
hospitals are greatly influenced by the mix of pathology it
treats, which can be translated into the types of departments/
wards the hospital has in its structure. In our study we have
also considered the results of the individual departments and
wards and we have come to notice that there are some gener -
ally surplus generating specialties (Figure 3) and some deficit
generating specialties (Figure 4). These results are mostly
influenced by the financing mechanisms in place. As an
example, the HIV/AIDS department is a generally surplus
generating one (we would say profitable if it was not a public
hospital) mainly because the DRG system of Romania has
been adapted from the Australian system, without taking into
account the specific aspects of the local financing schemes,
leading to dysfunctionalities [10]. In this case, the DRG
system reimburses the costs of drugs and medication, which
are also included in the national health programs, thus almost
doubling the reimbursement of a single service. On the other
hand, many of the surgical specialties seem to be on deficit,
such as urology, mainly because the reimbursement offered
through the DRG system (and the subsidies) does not cover
the costs associated with the treatment of urology patients.
One of the most commonly found specialties in the hos-
pitals’ structures is general surgery. As we can see on Figure
4, this is a deficit generating specialty, and the same can be
seen on Figure 5 as well, which shows the results of individ -
ual hospitals. We can see that the results are not dependent
on the type of the hospitals (university, county, city) nor their
geographic location.
Table 1 shows the weighted average contribution 2 (%)
of some of the most common specialties in the Romanian
public hospitals, the minimum and maximum contribution 2
(%) and the standard deviation (SD). In case of some special -
Figure 3
Contribution 2 (%) of surplus generating specialties
Figure 2
Contribution 3 (%) of public hospitals in Romania (profitability with -
out depreciation)
U-University hospital; USP-University single specialty hospital; SP-
Single specialty hospital; C-County hospital, T-Town hospital
Figure 4
Contribution 2 (%) of deficit generating specialties
Figure 5
Contribution 2 (%) of general surgery specialty in Romanian hospi-
tals
U-University hospital; USP-University single specialty hospital; C-
County hospital, T-Town hospital
20 IME – INTERDISZCIPLINÁRIS MAGYAR EGÉSZSÉGÜGY XIX. ÉVFOLYAM 1. SZÁM 2020. FEBRUÁR
MENEDZSMENT KONTROLLING
ties, such as haematology, the SD is relatively small, while
other specialties, like obstetrics-gynaecology, show greater
variance in their results. This phenomenon at obstetrics-
gynaecology and other departments with high variance of
the contribution 2 can be explained not by the problem of the
hospital financing system, but the hospital’s unproper struc-
ture and management problems (which could also result from
the leadership style [11]).
EMERGENCY CARE UNIT
In case of the Romanian health care system, the Emer -
gency Care Unit is a special structure. It can only be found in
emergency hospitals and, although physically, it is a part of
the hospital, it’s financing is totally independent from the hos-
pital’s financing, furthermore, there is supposed to be a settle -
ment system between the hospital and the Emer gency
Care Unit, according to which, the hospital should be reim-
bursed for the expenses incurred with the patients of the
Emergency Care Unit that are reimbursed by the Ministry of
Health. The special aspect of the financing of this structure
is that not all expense categories are reimbursed, so the
department can seldom generate a surplus. As it can be seen
on Figure 6, the average contribution 2 of the department is
of -12%, but the results vary between -64% and 40%. The
various results are given by the effects of managerial deci-
sion-making and the deficient financing mechanism.
DISCUSSIONS
We have to note regarding the subsidies received by pub-
lic hospitals that these are meant to complete the service
reimbursement received from the NHIH. However, the same
services performed by private hospitals only receive the regu-
lar fees, without the subsidy, affecting the sector-neutrality of
the Romanian health care system.
Regarding the same subsidies, we have to note that these
are not connected to performance in any way. While in the rest
of the developed countries there is a shift towards pay-for-per-
formance schemes [14] (even though there are some concerns
regarding their effectiveness [15]), the current reimbursement
system does not motivate the hospital or the personnel
towards performance in any way [16]; the subsidies are only
linked to the salaries received before the salary increase and
is in no way linked to the performance of the personnel.
When it comes to the salaries of the medical staff, numer -
ous studies have been performed to present the experience
of developed countries [17]. These should be taken into ac -
count when making changes in the payment system to avoid
unforeseen effects, such as dissatisfied personnel even after
the increase of salaries. The question also arises whether or
not institution management should be able to adapt the sala-
ries according to their perceptions or should all this be done
on a national level [18].
The option of changing the salary system of the medical
personnel of public hospitals should always be available and
the change can be made at any point, however, aside from
the political effects, the policy-makers should also consider
the effect it will have on the motivation of the personnel [19]
(in some instances the personnel might be motivated to limit
the access to care for the patients if these do not result in
extra income for them).
In many cases we have mentioned that the smaller hos-
pitals have higher costs and higher overhead. This is all be -
cause they cannot achieve economies of scale and, on a
health policy level, it might be arguable whether or not these
small hospitals still manage to serve their purpose, or it would
be time to rethink their structure.
CONCLUSIONS
Regarding the salary increase of the medical and non-
medical personnel (while the salaries represent the largest
share among all expense types) of the public hospitals we
can conclude that this had a major influence in the traditional
ways of hospital financing; instead of being assimilated into
the reimbursement of services (DRG financing, chronic financ -
ing, one-day hospitalization, diagnostics etc.), it is offered as
a separate financing, without being connected to the service
volume in any way. Furthermore, in case of the smaller hos-
pitals, the volume of subsidies outweighs the volume of NHIH
service reimbursement.
The current financing mechanisms seem to favour some
of the medical specialties and “punish” others (mostly the sur-
Figure 6
Contribution 2 (%) of the Emergency Care Unit in Romanian hospi-
tals
U-University hospital; C-County hospital, T-Town hospital
Table 1
Results of the most common specialties of the public Romanian
hospitals (in percentage of NHIH revenues)
21
IME – INTERDISZCIPLINÁRIS MAGYAR EGÉSZSÉGÜGY XIX. ÉVFOLYAM 1. SZÁM 2020. FEBRUÁR
MENEDZSMENT KONTROLLING
gical specialties). The distorted economic result is the con-
sequence of a financing system that has been taken over
from a different health care system, but not adapted to the
local cost data, thus not financing the actual average costs,
unlike in other countries, such as Hungary [12]. Aside from
this, some of the services receive double reimbursement (in
the form of national health programs).
The fact that the average weighted contribution 3 (%) is
over zero shows that the hospitals are able to generate a
surplus, some of them having substantial savings. On the
other hand, there are also numerous hospitals in deficit,
having been in deficit for years, opening the need for arrears.
In some cases, the deficit is so large that the hospitals do not
have the financial capacity to acquire drugs and medication
for the patients in their care [13].
All in all, we can conclude that there are systemic issues
in the health care system, nonetheless, this does not absolve
the hospital management from adapting to the current reim-
bursement mechanisms and making decisions that ensure the
economic equilibrium of the hospital, in order for the institution
to be able to generate as much health gain as possible.
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22
MENEDZSMENT KONTROLLING
IME – INTERDISZCIPLINÁRIS MAGYAR EGÉSZSÉGÜGY XIX. ÉVFOLYAM 1. SZÁM 2020. FEBRUÁR
A SZERZŐK BEMUTATÁSA
Lorenzovici László 1999-ben Maros -
vásár helyen általános orvosi diplomát,
majd 2004-ben Kolozsváron közgaz-
dász képesítést szerzett, illetve Oxford -
ban folyatott posztgraduális képzést
egészség-gazdaságtan területen. M.Sc.
oklevelet egészségügyi menedzsment területén Buka rest -
ben szerzett 2006-ban. 2005 óta tanácsadóként dolgozik a
kórházfinanszírozás, kontrolling és gyógyszergazdaságtan
területén. 2016-tól a Marosvásárhelyi Sapientia Erdélyi
Magyar Tudomány Egyetem és 2019-től a Semmelweis
Egyetem Egészségügyi Menedzserképző Központ oktatója.
Székely Andrea 2012-ben szerzett
közgazdász diplomát Marosvásárhe -
l yen, 2016-ban egészségügyi me nedzs -
ment M.Sc. oklevelet Marosvásár he -
lyen, majd Budapesten folytatott mes-
terképzést egészségpolitika, tervezés és finanszírozás terü-
letén. 2012 óta tanácsadóként dolgozik a kórházfinanszíro-
zás és kontrolling területén. 2014-től egészségügyi közgaz-
dászként tevékenykedik, és a gyógyszergazdaságtan terü-
letén végez elemzéseket, tanulmányokat.
Nyulas Bernadett Andrea 2016-ban
szerzett közgazdász diplomát Kolozs -
váron, 2018-ban közgazdász mester-
képzést végzett ugyancsak Kolozsvá -
Bradács Aliz jogász, egészségügyi
menedzsment szakértő, 2018-tól PhD
képzést kezdett a Nagyváradi Egyetem
Daina Lucia Georgeta 1997-ben szer-
zett általános orvosi diplomát Nagy -
váradon, 2004-ben népegészségügy és
egészségügyi menedzsment szakor-
vosi képesítést Kolozsváron. 2005-ben
európai népészségügyi és egészség-
ügyi menedzsment mesterképzést és pedagógiai képzést
végzett Nagyváradon, 2006-ban szerezte doktori címét
Kolozsváron. 1997-től orvosként dolgozott, különböző sze-
repeket betöltve: általános orvos, népegészségügyi szakor-
vos, kórházmenedzser, orvosigazgató. 1999 óta a Nagy -
váradi Egyetem Orvosi és Gyógyszerészeti Kar oktatója.
ron, majd 2019-ben Marosvásárhelyen egészségügyi me-
nedzs ment M.Sc. oklevelet szerzett. 2017-től számviteli
szakértőként, 2018-tól pedig egészségügyi közgazdászként,
kontrollerként dolgozik.
Orvosi és Gyógyszerészeti Karán egészségügyi menedzs -
ment területén. 12 éve a Margittai Városi Kórház Főigaz -
gatója.
