บทคัดย่อ
การศึกษาโครงสร้างพื้นฐานระบบข้อมูลทางการบัญชีสำหรับสถานพยาบาลในประเทศไทย สืบเนื่องจากสำนักงานประกันสุขภาพ กระทรวงสาธารณสุขมีความประสงค์จะใช้ข้อมูลต้นทุนของโรงพยาบาล เพื่อนำมาใช้ในการพิจารณาจ่ายเงินชดเชยค่าบริการทางการแพทย์กรณีค่าใช้จ่ายสูงโดยใช้เกณฑ์กลุ่มวินิจฉัยโรคร่วมให้กับหน่วยบริการและสำนักงานสาธารณสุขจังหวัดรวมทั้งกรุงเทพมหานคร แต่พบว่าโรงพยาบาลส่วนใหญ่มีโครงสร้างพื้นฐานระบบข้อมูลการให้บริการและข้อมูลต้นทุนค่าใช้จ่าย รวมถึงระบบการจัดเก็บข้อมูลที่ยังไม่สมบูรณ์และได้มาตรฐานดีพอ จึงยังไม่สามารถนำฐานข้อมูลกลุ่มวินิจฉัยโรคร่วมที่เกิดขึ้นมาใช้ในการประเมินต้นทุนโรงพยาบาลได้ ด้วยเหตุผลตามที่ได้กล่าวข้างต้น จึงนำไปสู่การทบทวนและประเมินผลในการนำกลุ่มวินิจฉัยโรคร่วมมาใช้เป็นเครื่องมือในการบริการทางการแพทย์ รวมถึงข้อมูลต้นทุนการให้บริการต่างๆ ซึ่งข้อมูลต้นทุนดังกล่าวจะสัมพันธ์โดยตรงกับโครงสร้างพื้นฐานระบบข้อมูลทางการบัญชีของโรงพยาบาล ในส่วนของการทบทวนโครงสร้างพื้นฐานระบบข้อมูลทางการบัญชีของโรงพยาบาล การดำเนินงานเริ่มจากการทบทวนเอกสารวิชาการ ศึกษาดูงานจากกลุ่มตัวอย่างทั้งโรงพยาบาลรัฐบาลและเอกชนซึ่งคัดเลือกโดยสำนักงานประกันสุขภาพ รวมถึงการรวบรวมข้อมูลเบื้องต้นเกี่ยวกับโครงสร้างระบบข้อมูลทางการบัญชีของโรงพยาบาลในประเทศไทย จากนั้นวิเคราะห์และประเมินผลเพื่อนำเสนอต่อผู้เชี่ยวชาญและผู้มีประสบการณ์ทั้งชาวไทยและชาวต่างประเทศ ตลอดจนผู้มีส่วนได้เสียเพื่อแลกเปลี่ยนความคิดเห็น รวบรวม และวิเคราะห์ข้อมูลข้อเสนอแนะแนวทางในการปรับปรุงโครงสร้างพื้นฐานระบบข้อมูลทางการบัญชีของสถานพยาบาลในประเทศไทย และนำข้อมูลดังกล่าวมาจัดทำเป็นเอกสารวิชาการเกี่ยวกับแนวทางการพัฒนาโครงสร้างพื้นฐานระบบข้อมูลทางการบัญชีของสถานพยาบาลในประเทศไทยฉบับนี้ เพื่อนำเสนอต่อสำนักงานประกันสุขภาพ
บทคัดย่อ
A Study on Basic Structure of Accounting Information System for Thai HospitalThe Office of Health Insurance, Ministry of Public Health needs hospital cost information for various Diagnostic Relate Groups (DRGs) to set standards (or guidelines) for the payment of compensation for the high medical costs borne by medical service units and hospitals under the authority of Provincial Health Office and the Bangkok Metropolitan Administration. However, DRGs information is not currently available for use in evaluating the medical costs of hospitals since the current basic structure of the hospitals’ information systems, their cost information and their data collection systems are not complete and up to standard. To improve this situation it was felt that a re-evaluation and re-designing of hospital accounting information systems might be required.To re-evaluate the basic structure of the hospital accounting information systems, academic papers were reviewed, public and private hospitals selected by the Office of Health Insurance visited, through which basic information about hospital accounting was gathered. After analysis and evaluation, the data gathered was submitted to local and foreign specialists, including stakeholders. There were then numerous discussions, and exchanges of ideas, and views, as a result of which a recommendation paper was drawn up on ways and means to upgrade the basic structure of Thai hospitals’ accounting information systems. The current basic structure of hospital accounting information systems and the recommendations for their development are below discussed in 5 areas.Accounting Principles and Accounting PolicyAccounting Principles There are 3 ways in which the accounting transactions of public hospitals are recorded. Cash basis accounting. (most public hospitals except the 92 hospitals under the Provincial Health Development Bureau – as pilot hospitals)Cash basis accounting, with preparation of some additional documents or activities apart from the transaction recorded on a cash basis. (as pilot hospitals except Saruburi hospital) Both a cash basis and an accrual basis. (pilot hospitals - only Saraburi hospital)Private hospitals record accounting transactions on an accrual basis, in compliance with Thai Accounting Standard. Accounting PolicyPublic hospitals have to comply with the regulations imposed by the Comptroller’s General Department of the Ministry of Finance. Private hospitals follow the policies and guidelines laid down by the Institute of Certified Accountants and Auditors of Thailand and must get approval from the Department of Commercial Registration, Ministry of Commerce. The differences in accounting principles and accounting policies mentioned above affect the correctness and reliability of the data used to prepare financial reports. Because most public hospitals record all information on a cash basis and do not accrued expenses, income, etc., their management and the relevant departments do not receive sufficient information on which to base management decisions. Moreover, the differences in accounting principles between public and private hospitals mean it is not possible to compare hospital costs.As part of the development of accounting principles and policies, both public and private hospitals should be applying the same accounting principles, especially with regard to the assumptions used for the recording of transactions. In fact, the Comptroller’s General Department has already changed the accounting policy for public hospitals from a cash basis to an accrual basis and this issue will therefore hopefully soon be resolved. Financial and Managerial Accounting SystemMost public hospitals recognize revenue and expenses when cash is received or paid. Although they keep a budgetary control register in order to monitor budget movement, they do not record the hospital transaction costs for management. The 92 pilot hospitals are already switching from a cash basis to an accrual basis so that the hospitals’ expense can be audited and evaluated efficiently. Also hospitals would be able to calculate the service cost for each patient using the Excel program launched by the International Health Policy Program. However, hospitals do not systematically collect data, which may result in incomplete and incorrect information.Private hospitals, however, record their financial and managerial accounting transactions systematically based on accounting standards, laid down by the Institute of Certified Accountants and Auditors of Thailand. However, cost information from each private hospital is different due to differences in management policies. An analysis of financial and managerial accounting, revealed differences in accounting policies between the public and private hospitals. With regard to budget information, the public hospitals do not focus on the analysis and evaluation of performance, but only on control of budget movement. Moreover, the data collected by public hospitals does not support the calculation of cost of services. Private hospitals meanwhile use traditional costs, which do not show the real service cost. The following improvements in the areas of financial and managerial accounting are recommended:Public hospitalsThe financial accounting system of public hospitals should basically follow the conceptual design report for hospitals under the Office of Permanent Secretary of Ministry of Public Health (shown as Appendix - F), adjusting some parts to comply with the Accounting Principles and Policies for State Agencies Vol. 1 prepared by the Comptroller General’s Department (shown as Appendix - E).Managerial accounting should consist of a budgeting system and a cost accounting system as follows:Budgeting systemThe Bureau of the Budget has changed the budget system in order to change the existing government management system to a performance-based budgeting system. The new system is much more concerned with outputs and outcomes.Cost Accounting system There are two different approaches for a cost accounting system: Traditional Costing and Activity-Based Costing (ABC). In Traditional Costing, overhead costs are assigned to cost pools (departments) before being assigned to products or services. However, in Activity-Based Costing costs are assigned to products based on the activities required by that product. As a result, the real cost of a product can be determined with much more fidelity than Traditional Cost. The specialists from 3M Health Information Systems recommended that to ascertain real service costs, it is appropriate to use Activity-based Costing (ABC). ABC should be introduced as pilot project in medical schools because they have complicated data. However, Saraburi hospital may be more suitable as a pilot hospital than medical schools because the complicated data of the latter may cause problems with the allocation of certain expenses.There are two suggested ways to implement Activity-based costing:Applying the ABC in a pilot hospital;Applying Traditional Costing for 3-5 years, and after that changing to ABC.Private hospitalsPrivate hospitals will upgrade only their managerial accounting systems, especially in the area of cost accounting. To select the most appropriate cost calculation method, costs and benefits should be compared and all hospitals are required to utilize the same method so that stakeholders can use the data generated in analysis and for comparison. In order to calculate the real costs of services and to better meet the stakeholders’ needs, it is recommended ABC be used by the hospitals. Information Technology SystemAlthough some of the public hospitals visited used computer systems in some parts of their accounting work, such as inventory, medical service and managerial systems, most did not use computer systems at all. Moreover only 2 or 3 public hospitals have the same type of system integration which links the medical service and accounting systems. In contrast, computer systems have already been introduced in many private hospitals, and some have full system integration between the medical service system and the accounting system.Private hospitals have invested more in information technology, such as accounting application software, than public hospitals have, providing management with more correct, complete and reliable information.Moreover, implementation of accounting information systems results in a change of the accountants’ role from bookkeeper to performing a review and analysis of accounting information. As a result, management has more up-to-date information to enable efficient running of the hospital operations.Due to the large amount of data involved, if hospitals do not use computers for data collection, this may impact on the correctness, the completeness of information and the convenience of its preparation for use by the management in making decisions and running the business.Guidelines for developing information technology system are as follows:Study the needs for financial information integration at each hospital in order to establish a Hospital Accounting Information Center.Study the accounting information systems, including the links between clinical and other aspects of patient care, in order to design computer systems and application software which produce complete and efficient managerial information systems. This process should start with a pilot hospital which is already following the new budget system. Human Resources Accounting staff at private hospitals generally have degrees in accounting, while most accounting staff at public hospitals do not. Staff’s lack of knowledge of accounting procedures and accounting principles, changes in accounting principles, and the use of computer systems to collect data can cause problems with the preparation of the financial statement.In addition, during the period of change from accounting on a cash basis to an accrual basis, it was found that accounting staff at pilot hospitals still lacked knowledge and understanding of the accrual basis principles. As a result, the Finance Department of the Principal Health Development Bureau was unable to prepare all financial statements for submission to the State Audit Office. Moreover, hospital management and the relevant authorities, such as the Principal Health Development Bureau, have still not be able to resolve the problems with recording accounting transactions on this basis. Training and education programs for both management and staff should be introduced so that the Finance Department is able to answer questions and solve problems for accounting staff, and hospitals are able to prepare their financial statements on an accrual basis for submission to the Finance Department and resubmission to the State Audit Office. Guidelines for developing Human resources are as follows:In the short term, management and accounting officers of public hospitals should be trained and educated to give them a solid grounding in basic accounting.In the long term, the Office of the Civil Service Commission (OCSC) should set new positions and job descriptions, and lay down guidelines for recruitment of staff. Also, OCSC should set procedures for dealing with current staff who lack proper qualifications. The OCSC should co-ordinate with the Rajabhat and Rajamankala Institutes to obtain accounting interns to serve apprenticeships because these two institutes have campuses in almost every province throughout Thailand. After the training is over, the accounting interns could take a post-training test and if they passed such test would be appointed accountants in hospitals. The minimum number of accountants for each hospital should be determined based on the number of transactions or significant events occurring. For example, in the conceptual design report, as shown in Appendix-F, the average number of accountants for each pilot hospital where computerized systems are introduced is stipulated to be not more than 12.MonitoringUnder the Law and Ministry of Finance regulations, public hospitals have to prepare monthly financial statements and submit them to the State Audit Office. Private hospitals, which are under the Bureau of Business Supervision of the Department of Commercial Registration at the Ministry of Commerce, have to prepare and submit financial reports yearly. Listed private hospitals also have to prepare and submit financial reports to the Stock Exchange of Thailand (SET).The Government should set up a Hospital Accounting Information Center under the National Health Insurance Committee (after announcing the National Health Insurance Act) in order to prepare an accounting system for Thai public hospitals.Providing hospitals with correct, complete and auditable accounting information systems will be an important factor in bringing about specific and transparent improvements in administration and development in the provision of medical services. However, accounting information systems cannot be used alone to set compensation payment for medical costs. This will require the use of, DRGs and medical coding as well.
