J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 10, Number 4, April 2018, pages 314-320

Using Time-Driven Activity-Based Costing as a Key Component of the Value Platform: A Pilot Analysis of Colonoscopy, Aortic Valve Replacement and Carpal Tunnel Release Procedures

Figure 1. The six components of Michael Porter’s value platform delivered at the American Society of Anesthesiologists Annual Meeting in 2016. TDABC is essential to creating integrated practice units, measuring costs and outcomes, moving into bundled payment care cycles and integrating delivery across facilities. TDABC: time-driven activity-based costing.

Figure 2. Referral process for patients requiring a gastroenterology procedure at Brigham and Women’s Hospital. After a request is made by the patient’s primary care provider, it is determined whether or not the patient’s medical history includes any of the following flag criteria: anticoagulation, pacemaker or defibrillator, cardiac disease, supplemental oxygen, obstructive sleep apnea, body mass index > 40, renal disease, insulin dependent diabetes mellitus, difficulty with sedation, airway issues, and chronic opioid use. Those patients not meeting flag criteria are eligible to bypass the pre-operative evaluation clinic and proceed to scheduling at the ambulatory facility. PCP: primary care provider; EMR: electronic medical record; RN: registered nurse; pts: patients; GI: gastrointestinal; MD: Medical Doctor.

**Table 1.** Cost per Case for SAVR and TAVR
Personnel	SAVR	TAVR
SAVR: surgical aortic valve replacement; TAVR: transcatheter aortic valve replacement. Capacity cost rate (CCR) = cost per clinical hour = ((s)/(w × y)) × t, where “s” is (salary + benefits), “w” is number of hours/week, “y” is number of weeks/year, and “t” is % clinical time.
Anesthesiology
Anesthesia attending	1	$171	270	$770	1	$171	180	$513
Anesthesia resident	1	$19	270	$83	1	$19	180	$56
Cardiology
Invasive attending	0	$197	0	$0	1	$197	120	$394
Invasive fellow	0	$20	0	$0	1	$20	120	$40
Non-invasive attending	0	$120	0	$0	1	$120	30	$60
Non-invasive fellow	0	$19	0	$0	1	$19	120	$37
Cardiothoracic surgery
Cardiothoracic physician assistant	1	$68	270	$305	0	$68	0	$0
Cardiothoracic surgeon	1	$190	210	$664	1	$190	120	$380
Miscellaneous
Manufacturer representative	0	$98	0	$0	1	$98	180	$293
Nurse catheter lab	0	$53	0	$0	5	$53	144	$632
Nurse OR	1	$47	270	$211	1	$47	180	$141
Operating room assistant	1	$19	90	$28	0	$19	0	$0
Perfusionist	1	$88	180	$263	1	$88	120	$175
Surgical technologist	1	$26	270	$117	1	$26	180	$78
Technical services provider	1	$32	60	$32	1	$32	60	$32
Supplies				$3,074				$3,419
Valve				$5,600				$32,000
Totals	9			$11,147	17			$38,250
Absolute cost difference								$27,103
Absolute % cost difference								70.9%

Table 1. Cost per Case for SAVR and TAVR

Personnel

SAVR

TAVR

No. of staff present

Capacity cost rate

Time (min)

Total cost

No. of staff present

Capacity cost rate

Time (min)

Total cost

SAVR: surgical aortic valve replacement; TAVR: transcatheter aortic valve replacement. Capacity cost rate (CCR) = cost per clinical hour = ((s)/(w × y)) × t, where “s” is (salary + benefits), “w” is number of hours/week, “y” is number of weeks/year, and “t” is % clinical time.

Anesthesiology

Anesthesia attending

$171

270

$770

$171

180

$513

Anesthesia resident

$19

270

$83

$19

180

$56

Cardiology

Invasive attending

$197

120

$394

Invasive fellow

$20

120

$40

Non-invasive attending

$120

$60

Non-invasive fellow

$19

120

$37

Cardiothoracic surgery

Cardiothoracic physician assistant

$68

270

$305

$68

Cardiothoracic surgeon

$190

210

$664

$190

120

$380

Miscellaneous

Manufacturer representative

$98

180

$293

Nurse catheter lab

$53

144

$632

Nurse OR

$47

270

$211

$47

180

$141

Operating room assistant

$19

$28

$19

Perfusionist

$88

180

$263

$88

120

$175

Surgical technologist

$26

270

$117

$26

180

$78

Technical services provider

$32

Supplies

$3,074

$3,419

Valve

$5,600

$32,000

Totals

$11,147

$38,250

Absolute cost difference

$27,103

Absolute % cost difference

70.9%

**Table 2.** Cost per Case for Carpal Tunnel Release (CTR) in the OR and the Procedure Room
Personnel	CTR - procedure room	CTR - OR
Capacity cost rate (CCR) = cost per clinical hour = ((s)/(w × y)) × t, where “s” is (salary + benefits), “w” is number of hours/week, “y” is number of weeks/year, and “t” is % clinical time.
Anesthesiology
Anesthesia attending	0	$171	0	$0	1	$171	26.2	$75
Certified registered nurse anesthetist	0	$93	0	$0	1	$93	52.5	$81
Surgery
Orthopedic surgeon	1	$186	48.1	$149	1	$186	52.5	$163
Miscellaneous
Circulator nurse	1	$47	48.1	$38	1	$47	52.5	$41
Patient care technician	0	$19	0.0	$0	1	$19	10.0	$3
Surgical technologist	1	$26	48.1	$21	1	$26	52.5	$23
Supplies				$178				$178
Totals	3			$386	6			$564
Absolute cost difference								$178
Absolute % cost difference								31.6%

Table 2. Cost per Case for Carpal Tunnel Release (CTR) in the OR and the Procedure Room

Personnel

CTR - procedure room

CTR - OR

No. of staff present

Capacity cost rate

Time (min)

Total cost

No. of staff present

Capacity cost rate

Time (min)

Total cost

Capacity cost rate (CCR) = cost per clinical hour = ((s)/(w × y)) × t, where “s” is (salary + benefits), “w” is number of hours/week, “y” is number of weeks/year, and “t” is % clinical time.

Anesthesiology

Anesthesia attending

$171

26.2

$75

Certified registered nurse anesthetist

$93

52.5

$81

Surgery

Orthopedic surgeon

$186

48.1

$149

$186

52.5

$163

Miscellaneous

Circulator nurse

$47

48.1

$38

$47

52.5

$41

Patient care technician

$19

0.0

$19

10.0

Surgical technologist

$26

48.1

$21

$26

52.5

$23

Supplies

$178

Totals

$386

$564

Absolute cost difference

$178

Absolute % cost difference

31.6%