SAEM Bootcamp COST ACCOUNTING SAEM Bootcamp COST ACCOUNTING Jim Bihun, MBA Vice Chair for Finance & Administration Vanderbilt Department of Emergency Medicine.

SAEM BootcampSAEM Bootcamp

COST ACCOUNTING COST ACCOUNTING

Jim Bihun, MBAJim Bihun, MBAVice Chair for Finance & Vice Chair for Finance & AdministrationAdministrationVanderbilt Department of Vanderbilt Department of Emergency MedicineEmergency Medicine

Disclosure of Disclosure of Commercial Commercial RelationshipsRelationships NoneNone No Off-Label DisclosuresNo Off-Label Disclosures

GoalsGoals

Overview of conceptsOverview of concepts Understanding of different Understanding of different

perspectivesperspectives Better management of your Better management of your

department and leadership in department and leadership in your organizationyour organization

ObjectivesObjectives

Understand Understand ““costscosts”” in light of in light of health care reformhealth care reform

Appreciate elements, system Appreciate elements, system needs, multiple perspectives on needs, multiple perspectives on cost accountingcost accounting

Prepare and understand financial Prepare and understand financial proposals, monthly reports, proposals, monthly reports, budgets, impact studiesbudgets, impact studies

Why is this Important?Why is this Important?

Understand what data is needed Understand what data is needed for best decision makingfor best decision making

DonDon’’t be mislead t be mislead Applied knowledge is needed to Applied knowledge is needed to

gain resourcesgain resources Speak fluently with the CFO and Speak fluently with the CFO and

your funding sources!your funding sources!

My BackgroundMy Background

MBA and Health Services BA from MBA and Health Services BA from the University of Michiganthe University of Michigan

14 years with Vanderbilt EM14 years with Vanderbilt EM 2 years in national practice 2 years in national practice

management consulting with HCAmanagement consulting with HCA 10 years in finance and operations 10 years in finance and operations

with Henry Ford Health Systemwith Henry Ford Health System

The Power of Data…The Power of Data…

““In God we In God we trust, all trust, all others must others must bring data.bring data.””

The Power of Data…The Power of Data…

““In God we In God we trust, all trust, all others must others must bring data.bring data.””

- W. Edwards - W. Edwards DemingDeming

Cost AccountingCost Accounting

The study of costs, including The study of costs, including methods for classifying, allocating, methods for classifying, allocating, and assembling costs to determine and assembling costs to determine ““productproduct”” costs costs

Purpose is to provide information to Purpose is to provide information to manage costs, set charges, analyze manage costs, set charges, analyze profitability, choose among profitability, choose among alternativesalternatives

Cost AccountingCost Accounting Includes the area of managerial Includes the area of managerial

accounting, and it overlaps with accounting, and it overlaps with financial accountingfinancial accounting

Information used for effective Information used for effective decision making, as well as decision making, as well as planning and control of operationsplanning and control of operations

Importance has grown with fixed Importance has grown with fixed reimbursementreimbursement

The Realm of The Realm of AccountingAccounting

Accounting

Financial

Accounting

Cost Accounting

Managerial Accounting

Financial AccountingFinancial Accounting

Purpose is to provide historic Purpose is to provide historic accounting information to accounting information to external usersexternal users

Prepared according to prescribed Prepared according to prescribed AICPA and GAAP formatsAICPA and GAAP formats

Managerial AccountingManagerial Accounting

Purpose is to provide accounting Purpose is to provide accounting information to internal users in information to internal users in order to support planning and order to support planning and control functionscontrol functions

Data is generally current or Data is generally current or prospective in natureprospective in nature

No prescribed format; varies No prescribed format; varies among organizationsamong organizations

Costing MethodsCosting Methods

Methods to Arrive at Methods to Arrive at the Cost of a the Cost of a Product/ServiceProduct/Service Classify costsClassify costs Allocate costsAllocate costs Assemble costsAssemble costs

Methods to Classify Methods to Classify CostsCosts By functionBy function By traceabilityBy traceability By behaviorBy behavior By relevance to decision makingBy relevance to decision making

Costs Classified by Costs Classified by FunctionFunction Operating costs are associated Operating costs are associated

with producing the with producing the product/serviceproduct/service

Non-operating costs are Non-operating costs are associated with supporting the associated with supporting the production of a product or serviceproduction of a product or service

Costs by TraceabilityCosts by Traceability

Direct costs can be traced directly to a Direct costs can be traced directly to a department, product, or servicedepartment, product, or service

Indirect costs (aka overhead) cannot Indirect costs (aka overhead) cannot be traced directly to a product/servicebe traced directly to a product/service

Full costs include directs + indirectsFull costs include directs + indirects Average cost = full cost / number of Average cost = full cost / number of

services producedservices produced

Costs by BehaviorCosts by Behavior

In relation to volume or over timeIn relation to volume or over time Variable costs change directly Variable costs change directly

and proportionately with changes and proportionately with changes in volumein volume

Fixed costs remain constant in Fixed costs remain constant in relation to volume changesrelation to volume changes

Costs by BehaviorCosts by Behavior

Semi-fixed costs are fixed in the Semi-fixed costs are fixed in the short term and can vary when a short term and can vary when a longer time horizon is consideredlonger time horizon is considered

Marginal costs are the changes in Marginal costs are the changes in costs related to incremental costs related to incremental changes in volumechanges in volume

Costs by Relevance to Costs by Relevance to Decision MakingDecision Making Sunk costs have already been Sunk costs have already been

incurred and will not be affected incurred and will not be affected by future decisionsby future decisions

Opportunity costs represent the Opportunity costs represent the opportunities foregone when opportunities foregone when rejecting an alternative choicerejecting an alternative choice

Methods of Allocating Methods of Allocating CostsCosts The process of allocating indirect The process of allocating indirect

costs, and some directs, to costs, and some directs, to departments which generate chargesdepartments which generate charges

Requires determination of revenue Requires determination of revenue and expense by cost centerand expense by cost center

Requires workload statistics that best Requires workload statistics that best reflect the departmentreflect the department’’s activitys activity

Cost Allocation Cost Allocation MethodsMethods Direct allocation from non-revenue Direct allocation from non-revenue

centers to revenue centers (driven by centers to revenue centers (driven by share of workload statistics)share of workload statistics)

In step-down apportionment, non-In step-down apportionment, non-revenue centers allocate to each revenue centers allocate to each other first, then to the revenue other first, then to the revenue centerscenters

In multiple apportionment, revenue In multiple apportionment, revenue centers can also reallocatecenters can also reallocate

Methods of Methods of Assembling CostsAssembling Costs Assemble costs by responsibility Assemble costs by responsibility

center to hold managers accountable center to hold managers accountable for their controllable costsfor their controllable costs

Full costing allocates directs and Full costing allocates directs and indirects to a product/service to indirects to a product/service to determine profitabilitydetermine profitability

Differential costing only looks at Differential costing only looks at incremental costs and revenues in incremental costs and revenues in making decisionsmaking decisions

Methods of Methods of Assembling Product Assembling Product CostsCosts Standard CostingStandard Costing Ratio of cost to charges (RCC)Ratio of cost to charges (RCC) Activity-based costing (ABC)Activity-based costing (ABC)

Standard CostingStandard Costing

Method of identifying expected Method of identifying expected benchmark costs for producing benchmark costs for producing your goods/servicesyour goods/services

Used in budgeting and for Used in budgeting and for comparison with actual resultscomparison with actual results

Ratio of Cost to Ratio of Cost to Charges (RCC)Charges (RCC) Calculated by dividing Calculated by dividing

departmental charges by departmental charges by departmental expenses and departmental expenses and applying that ratio to each producapplying that ratio to each productt ’’s charge to determine its costs charge to determine its cost

Flawed, as it assumes a consistent Flawed, as it assumes a consistent relationship among all products in relationship among all products in the groupthe group

Activity-Based Costing Activity-Based Costing (ABC)(ABC)

Uses cost drivers to assign direct Uses cost drivers to assign direct and indirect costs to productsand indirect costs to products

Ideal cost drivers are activities Ideal cost drivers are activities that pertain to each product in that pertain to each product in varying amountsvarying amounts

Drivers should have a high Drivers should have a high correlation to the consumption of correlation to the consumption of the overheadthe overhead

ABC for EDsABC for EDs

ABC focuses on the difference ABC focuses on the difference between volume-driven costs (eg, ED between volume-driven costs (eg, ED visits) and activity-driven costs (eg, visits) and activity-driven costs (eg, specific nursing duties and time)specific nursing duties and time)

Without ABC, overhead may be Without ABC, overhead may be overallocated to high-volume overallocated to high-volume productsproducts

ABC can be used to differentiate ABC can be used to differentiate patient cost by acuity levelpatient cost by acuity level

An Example of ABC in An Example of ABC in the EDthe ED Determine average ED nursing Determine average ED nursing

cost by patient group cost by patient group Use for comparison with Use for comparison with

contracted ratescontracted rates

ABC in the EDABC in the ED

Define patient groups (eg, ESI level)Define patient groups (eg, ESI level) Determine RN time (and salary) spent Determine RN time (and salary) spent

in direct and indirect patient care in direct and indirect patient care Build RN activity list and time needed Build RN activity list and time needed

for each taskfor each task Allocate RN activities by patient group Allocate RN activities by patient group

and determine total RN time by groupand determine total RN time by group Apply RN cost by patient groupApply RN cost by patient group

Visit Counts by Patient Visit Counts by Patient CategoryCategory

Patient CategoryPatient Category

ESI 1ESI 1

ESI 2ESI 2

ESI 3ESI 3

ESI 4ESI 4

ESI 5ESI 5

TOTALTOTAL

Annual CountsAnnual Counts

1,0001,000

10,00010,000

25,00025,000

12,00012,000

2,0002,000

50,00050,000

ABC Cost & Time ABC Cost & Time ElementsElements RN hours for 1.0 FTE = 2,080/yrRN hours for 1.0 FTE = 2,080/yr Salary & benefits cost of Salary & benefits cost of

$50,000/FTE$50,000/FTE Estimated that 75% of RN time is Estimated that 75% of RN time is

spent in direct care, 25% is spent in direct care, 25% is indirectindirect

For this example, total cost of 50 For this example, total cost of 50 FTEs is $3,000,000/yrFTEs is $3,000,000/yr

RN Activity List & RN Activity List & TimesTimes Take vitalsTake vitals 2 min 2 min

eacheach Give medicationGive medication 4 min 4 min Patient educationPatient education 10 min10 min ChartingCharting 5 min 5 min

# of RN Activities by # of RN Activities by PatientPatient

ESIESI VitalsVitals MedsMeds Pt EdPt EdChartChart

11 2424 2020 3.53.5 66

22 2020 1515 44 66

33 1616 1010 33 33

44 1010 33 22 22

55 6 6 00 11 11

Avg Hrs & Avg Avg Hrs & Avg Cost/PatientCost/Patient

ESIESI Avg Hrs/PtAvg Hrs/Pt Avg RN Cost/PtAvg RN Cost/Pt

11 4.294.29 $103.10$103.10

22 3.783.78 $ 90.81$ 90.81

33 2.602.60 $ 62.50$ 62.50

44 1.381.38 $ 33.12$ 33.12

55 0.600.60 $ 14.42$ 14.42TotalTotal 2.502.50 $ 60.00 $ 60.00 ($3m/50,000 pts)($3m/50,000 pts)

ABC in the ED ABC in the ED CommentsComments Look at patient time spent by each Look at patient time spent by each

job category (eg, RNs, paramedics, job category (eg, RNs, paramedics, techs)techs)

Cost is driven by number and type of Cost is driven by number and type of staff interventionsstaff interventions

Also include costs of non-chargeable Also include costs of non-chargeable supplies and non-productive staff supplies and non-productive staff costs when spreading costs across costs when spreading costs across patient groups patient groups

Contribution Margin Contribution Margin & Cost Volume Profit & Cost Volume Profit

AnalysisAnalysis

Contribution MarginContribution Margin

CM= Marginal revenue – marginal CM= Marginal revenue – marginal cost for an incremental volume of cost for an incremental volume of activityactivity

Break even (BE) point occurs where Break even (BE) point occurs where contribution margin/visit x activity contribution margin/visit x activity level = fixed costslevel = fixed costs

BE quantity = total fixed costs / BE quantity = total fixed costs / (revenue per unit – variable cost per (revenue per unit – variable cost per unit)unit)

Cost Volume Profit Cost Volume Profit (CVP) Examples(CVP) Examples

ED Daily Revenues and Expenses

-

20,000

40,000

60,000

80,000

100,000

120,000

0 33 66 99 132 164 197

Daily Visits

$ Amo

unt

Staffing (fixed) Cost

Other Direct (Variable) Costs

Total Direct Expenses

Revenue

$50 exp/vst

$534 rev/vst

89 Visits to BE

Daily CVP Graph NotesDaily CVP Graph Notes

Fixed Costs = $43,200 / dayFixed Costs = $43,200 / day Break even point occurs at 89 Break even point occurs at 89

visits/day visits/day (2,715/month)(2,715/month)

Contribution Margin (CM) = Contribution Margin (CM) = variable revenue – variable variable revenue – variable expense ($534 - $50 = $484)expense ($534 - $50 = $484)

BE of 89 = $43,200 fixed / $484 BE of 89 = $43,200 fixed / $484 CMCM

Add in Indirects for the Add in Indirects for the Month…Month…

Monthly CVP Graph Monthly CVP Graph NotesNotes Full costs = directs + indirectsFull costs = directs + indirects Break even point is pushed Break even point is pushed

further out to 3,500 visits; further out to 3,500 visits; 42,000/yr (vs 2,715/mo without 42,000/yr (vs 2,715/mo without indirects)indirects)

Indirects are typically applied on Indirects are typically applied on a monthly allocation basisa monthly allocation basis

And Now Consider And Now Consider Semi-Fixed Costs Over Semi-Fixed Costs Over the Yearthe Year

Annual CVP NotesAnnual CVP Notes

““FixedFixed”” costs can jump when costs can jump when volume warrants itvolume warrants it

Break even point moves further Break even point moves further to the right (eg, to 4750/mo; to the right (eg, to 4750/mo; 57,000/yr)57,000/yr)

Typically coincides with an Typically coincides with an increase in staffing levels (labor increase in staffing levels (labor costs) costs)

CVP ObservationsCVP Observations

Variable costs are linear with volumeVariable costs are linear with volume Fixed costs can be modified over an Fixed costs can be modified over an

extended time horizon or volume extended time horizon or volume rangerange

““Relevant RangeRelevant Range”” concept: the concept: the relationships between fixed and relationships between fixed and variable costs only hold true within a variable costs only hold true within a relevant range of activity or over a relevant range of activity or over a ““limitedlimited”” time period time period

CVP ObservationsCVP Observations

Different time horizons allow Different time horizons allow costs to be viewed and reported costs to be viewed and reported differentlydifferently

““ProfitProfit”” depends on allocation of depends on allocation of overheadoverhead

““ProfitProfit”” is not perfectly correlated is not perfectly correlated with volumewith volume

Capitated CVP Capitated CVP ExampleExample

Capitated CVP NotesCapitated CVP Notes

In a capitated environment, the In a capitated environment, the revenue line is typically horizontal revenue line is typically horizontal (based on $ pmpm amount x (based on $ pmpm amount x number of lives enrolled)number of lives enrolled)

““ProfitsProfits”” occur when costs are occur when costs are lowestlowest

Low cost may be seen as Low cost may be seen as skimping on careskimping on care

Costing for Decision Costing for Decision MakingMaking

Costing Scenarios for Costing Scenarios for Non- Routine DecisionsNon- Routine Decisions Adding a new service, or dropping Adding a new service, or dropping

an old servicean old service Expanding or cutting back a Expanding or cutting back a

programprogram Make vs. buy decisionsMake vs. buy decisions Establishing charges for services Establishing charges for services

to managed care companiesto managed care companies

Costing Methodology Costing Methodology for Non-Routine for Non-Routine DecisionsDecisions Identify alternativesIdentify alternatives Define relevant costsDefine relevant costs Consider nonfinancial issuesConsider nonfinancial issues

Applied Costing Applied Costing StudiesStudies ““The Financial Consequences of The Financial Consequences of

Lost Demand and Reducing Lost Demand and Reducing BoardingBoarding””, J. Pines, Annals of , J. Pines, Annals of Emergency Medicine, Vol xx, 2011Emergency Medicine, Vol xx, 2011

““The Cost of an ED Visit and Its The Cost of an ED Visit and Its Relationship to ED VolumeRelationship to ED Volume””, A. , A. Bamezai, G. Melnick, A. Nawathe, Bamezai, G. Melnick, A. Nawathe, AEM, May 2005 AEM, May 2005

New Business Pro New Business Pro FormaForma VA Staffing Proposal for 1.5 MD FTEsVA Staffing Proposal for 1.5 MD FTEs

Indiv Avg CostIndiv Avg Cost DeptDept’’s Marginal s Marginal CostCost

Revenue Revenue $414k$414k $414k$414k- Expense Expense $462k$462k $372k$372k

= Margin= Margin ($ 48k) $ 42k ($ 48k) $ 42kMarginal cost is based on a new MD starting salary Marginal cost is based on a new MD starting salary

(that(that’’s typically what the Dept will hire for backfill); s typically what the Dept will hire for backfill); Avg cost is based on who actually goes to the VAAvg cost is based on who actually goes to the VA

The Cost of Expanded The Cost of Expanded MD CoverageMD Coverage Determine the cost of starting a Determine the cost of starting a

physician-in-triage programphysician-in-triage program Staffed 24 hrs/wk (Mon & Tue, 12 Staffed 24 hrs/wk (Mon & Tue, 12

hrs daily)hrs daily) Identification of marginal costsIdentification of marginal costs Prepare revenue forecast Prepare revenue forecast

(marginal, not average)(marginal, not average)

Annual BudgetingAnnual Budgeting

Salary budgetSalary budget Non-salary budgetNon-salary budget Forecasting visits and collectionsForecasting visits and collections Rate and volume variance Rate and volume variance

analysisanalysis

Rate Volume Variance Rate Volume Variance Analysis ProblemAnalysis Problem WhatWhat’’s going on? s going on? WhereWhere’’s the problem?s the problem? What to do?What to do?

Example of Monthly Example of Monthly Rate & Volume Rate & Volume VariancesVariancesItemItem ActualActual BudgetBudget VarianceVariance

VisitsVisits 5,500 5,500 5,000 5,000 +10.0%+10.0%

RVUsRVUs 20,00020,000 18,00018,000 +11.1%+11.1%

CollectedCollected $ 750k$ 750k $ 700k$ 700k + + 7.1%7.1%

These are volume variances, with the These are volume variances, with the second two caused by rate variancessecond two caused by rate variances

Rate VariancesRate Variances

ItemItem ActualActual BudgetBudget VarianceVariance

RVU/VisitRVU/Visit 3.643.64 3.603.60 +1.1% +1.1%

Coll/RVUColl/RVU $37.50$37.50 $38.89$38.89 -3.6%-3.6%

Coll/VisitColl/Visit $136.36$136.36 $140.00$140.00 -2.6%-2.6%

Unfavorable Coll/RVU rate variance Unfavorable Coll/RVU rate variance may be due to changed payor mix, may be due to changed payor mix, delayed payments, or increased denialsdelayed payments, or increased denials

Management ControlsManagement Controls

Allow managers to monitor Allow managers to monitor performance and take performance and take appropriate corrective action appropriate corrective action when neededwhen needed

Benchmarking of Costs Benchmarking of Costs & Productivity& Productivity ED cost per visitED cost per visit Faculty salaries (by rank, longevity)Faculty salaries (by rank, longevity) Faculty RVU productivity (per year, Faculty RVU productivity (per year,

per hour, or per visit)per hour, or per visit) Physician visits (per hour or per year)Physician visits (per hour or per year) Physician clinical hours (per year, per Physician clinical hours (per year, per

week, or per day)week, or per day)

My Benchmarking My Benchmarking SourcesSources

SAEM Salary Survey (for total MD SAEM Salary Survey (for total MD compensation, annual clinical hours by compensation, annual clinical hours by job title, starting pay)job title, starting pay)

AAMC salary survey (by faculty rank, AAMC salary survey (by faculty rank, school type, geographic area)school type, geographic area)

AAAEM annual survey (for clinical hours, AAAEM annual survey (for clinical hours, visits, coding, payer mix, RVUs)visits, coding, payer mix, RVUs)

Others such as UHC (RVUs) and Others such as UHC (RVUs) and Academic MGMA (salaries, RVUs)Academic MGMA (salaries, RVUs)

Use Cost Data to Use Cost Data to Negotiate:Negotiate: Rates with payers, or your internal Rates with payers, or your internal

share of bundled paymentsshare of bundled payments Amount of hospital supportAmount of hospital support Faculty salary increases, staffing Faculty salary increases, staffing

ratiosratios Budgets, approval of new programsBudgets, approval of new programs Savings from initiativesSavings from initiatives

Costs on the National Costs on the National RadarRadar

Cost Accounting and Cost Accounting and Quality ManagementQuality Management Total Quality Management (TQM) Total Quality Management (TQM)

philosophy is that prevention is philosophy is that prevention is cheaper than curecheaper than cure

Focus on doing things right the Focus on doing things right the first time, avoiding reworkfirst time, avoiding rework

High quality is the key to low cost High quality is the key to low cost

Take Time for PlanningTake Time for Planning

Consider the costs of improving Consider the costs of improving qualityquality

Consider the potential savings Consider the potential savings resulting from quality improvementresulting from quality improvement

The organization must design a The organization must design a system to prevent failuressystem to prevent failures

Focus on those costs which directly Focus on those costs which directly affect the quality of patient care; affect the quality of patient care; ““value-added costsvalue-added costs””

Total Cost Total Cost ManagementManagement Cost accounting must change from Cost accounting must change from

being reactive to being proactivebeing reactive to being proactive Focus on sharing cost information Focus on sharing cost information

with all levels of employeeswith all levels of employees Focus on improving the quality in Focus on improving the quality in

the value-added areasthe value-added areas Selectively reduce non-value-added Selectively reduce non-value-added

costscosts

National Perspectives National Perspectives on Coston Cost PayersPayers EmployersEmployers IndividualsIndividuals ProvidersProviders Economists / government / Economists / government /

societysociety

Costs in Light of Costs in Light of Health Care ReformHealth Care Reform Cost reduction, shared savingsCost reduction, shared savings Cost shifting (pushing costs or payment Cost shifting (pushing costs or payment

expectations from one group to expectations from one group to another)another)

Cost per member per monthCost per member per month Cost sharingCost sharing

– Patient perspectivePatient perspective– Provider perspectiveProvider perspective– Insurance plan / employer perspectiveInsurance plan / employer perspective

Should We Be Worried?Should We Be Worried?

Cost ReformsCost Reforms

Bending the Bending the ““cost curvecost curve”” Value-based purchasingValue-based purchasing Case rates, bundled paymentsCase rates, bundled payments Sustainable growth rate (SGR) Sustainable growth rate (SGR)

reformreform ACOsACOs

Accountable Care Accountable Care Organizations (ACOs)Organizations (ACOs) Local health care organizations Local health care organizations

that can be held accountable for that can be held accountable for the quality and cost of care for a the quality and cost of care for a defined group of patientsdefined group of patients

Involves investment in systems of Involves investment in systems of care and provider integration, care and provider integration, taking financial risktaking financial risk

Cost Reduction Cost Reduction FallaciesFallacies From what baseline?From what baseline? Savings are NOT equal to average Savings are NOT equal to average

cost per case x number of cases cost per case x number of cases avoided, or number of days of avoided, or number of days of reduced LOS x avg cost per dayreduced LOS x avg cost per day

Typically, just a fraction of Typically, just a fraction of variable costsvariable costs

Questions for Questions for Designing Cost Designing Cost Information SystemsInformation Systems What information is neededWhat information is needed When is information neededWhen is information needed How much detail is neededHow much detail is needed Has a broad group been surveyed Has a broad group been surveyed

for their input?for their input? Widespread organizational access?Widespread organizational access? How complicated is it to use? How complicated is it to use?

Cost Accounting Cost Accounting System NeedsSystem Needs Ability to identify and track the Ability to identify and track the

cost of activitiescost of activities Method to link and allocate Method to link and allocate

activities and their costs to activities and their costs to ““products/servicesproducts/services”” produced produced

Methods to rationally allocate Methods to rationally allocate supporting resourcessupporting resources

““PeoplePeople”” System Needs System Needs

Need to audit and ensure the Need to audit and ensure the quality of your cost dataquality of your cost data

Focus on responsiveness to Focus on responsiveness to customerscustomers

Teamwork is essentialTeamwork is essential Health care needs us to take up Health care needs us to take up

the challenge and apply these the challenge and apply these conceptsconcepts

Cost Accounting Cost Accounting SummarySummary

What is cost accountingWhat is cost accounting How costing is doneHow costing is done Contribution Margin and Cost Volume Contribution Margin and Cost Volume

Profit conceptsProfit concepts Costing for business planning and Costing for business planning and

analysisanalysis Cost accounting & health care reformCost accounting & health care reform System needsSystem needs

Thank You!Thank You!

[email protected]

615-936-1323615-936-1323