대한진단검사의학회지제 26 권제 6 호 2006 Korean J Lab Med 2006;26:460-4 원저 기타진단검사의학 원내검사및원외검사결정을위한손익분기점분석경험 김윤희 보령아산병원진단검사의학과 Experience of a Break-Even Point Analy

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1 대한진단검사의학회지제 26 권제 6 호 2006 Korean J Lab Med 2006;26:460-4 원저 기타진단검사의학 원내검사및원외검사결정을위한손익분기점분석경험 김윤희 보령아산병원진단검사의학과 Experience of a Break-Even Point Analysis for Make-or-Buy Decision Yunhee Kim, M.D. Department of Laboratoty Medicine, BoRyeong Asan Hospital, Boryeong, Korea Background : Cost containment through continuous quality improvement of medical service is required in an age of a keen competition of the medical market. Laboratory managers should examine the matters on make-or-buy decision periodically. On this occasion, a break-even point analysis can be useful as an analyzing tool. In this study, cost accounting and break-even point (BEP) analysis were performed in case that the immunoassay items showing a recent increase in order volume were to be in-house made. Methods : Fixed and variable costs were calculated in case that alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), ferritin, free thyroxine (ft4), triiodothyronine (T3), thyroid-stimulating hormone (TSH), CA 125, CA 19-9, and hepatitis B envelope antibody (HBeAb) were to be tested with Abbott AxSYM instrument. Break-even volume was calculated as fixed cost per year divided by purchasing cost per test minus variable cost per test and BEP ratio as total purchasing costs at break-even volume divided by total purchasing costs at actual annual volume. Results : The average fixed cost per year of AFP, CEA, PSA, ferritin, ft4, T3, TSH, CA 125, CA 19-9, and HBeAb was \8,279,187 and average variable cost per test, \3,786. Average break-even volume was 1,599 and average BEP ratio was 852%. Average BEP ratio without including quality costs such as calibration and quality control was 74%. Conclusions : Because the quality assurance of clinical tests cannot be waived, outsourcing all of 10 items was more adequate than in-house make at the present volume in financial aspect. BEP analysis was useful as a financial tool for make-or-buy decision, the common matter which laboratory managers meet with. (Korean J Lab Med 2006;26:460-4) Key Words : Fixed cost, Variable cost, Break-even analysis, Make-or-buy decision 서 년대동안 2차례에걸쳐시행된의료기관추가공급정책으로국내의료시장역시다른경제분야와마찬가지로저성장시 접수 : 2006 년 8 월 15 일접수번호 : KJLM1980 수정본접수 : 2006 년 10 월 10 일게재승인일 : 2006 년 10 월 12 일교신저자 : 김윤희우 충남보령시죽정동 1 보령아산병원진단검사의학과전화 : , Fax: elimyh@naver.com 론 대에접어들며공급자간경쟁이심화되었다 [1]. 이러한저성장시대에의료기관이안정성과수익성을확보하기위해서는조직의체계와관리구조를혁신적으로변화시키고전략적차원에서원가를관리하는일이요구된다 [2]. 또한, 의료시장이소비자주도시장으로변화하면서, 소비자들의의료의질에대한요구가높아졌고, 의료의질적수준을강화하기위한여러정책들이시행되는환경에서, 의료기관이우위를확보하기위해서는원가관리뿐아니라질관리가필수적으로요구된다 [3-5]. 원가회계에는기업이나기관의재무상태를주로외부이해관계자에게보고할때사용하는전부원가계산과필요할때마다임시 460

2 원내검사및원외검사결정을위한손익분기점분석경험 461 적으로행해지는특수원가의일종으로, 주로단기이익계획을수립할때시행되는직접원가계산이있다. 전부원가계산 ( 전통적원가계산법 ) 은원가를제조비와영업비의총합으로집계하는데반해, 직접원가계산은원가를변동비와고정비의총합으로집계한다. 직접원가계산을시행하면, 1903년미국의 H. Hess에의해고안되어 1920년대이후경영계획을수립하는데널리이용되는손익분기점 (break-even point, BEP) 분석을시행할수있는장점이있다. BEP는매출액과원가가동일해이익이제로 (0) 가되는상태, 즉손익이나뉘어지는분기가되는채산점을가리킨다 [6, 7]. BEP 분석의검사실운영에서의유용성은새로수립한검사의가격을결정하거나, 외부수탁으로시행 (buy) 하던검사를검사실내부 (inhouse) 에서시행 (make) 하면서동일한수익을내기위한최소한의검사건수등을분석할수있는점이다 [8]. 본연구에서는검사실에서자주접하게되는원내또는원외검사 (make-or-buy) 결정의판단을위한경제성분석도구로서 BEP 분석의유용성을조사하고자하였는데, 최근본원검사실에서의뢰건수의증가추세를보인면역측정외부위탁검사들을검사실내부에서시행 (make) 할경우의직접원가와외부위탁시의구매비용과비교한 BEP 분석을시행하였다. 또한, BEP 분석시에는질관리를병행할경우와병행하지않을경우로나누어분석하였다. 대상및방법최근본원검사실에서의뢰건수의증가를보인위탁검사항목들중면역측정검사항목인 alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), ferritin, free thyroxine (ft4), triiodothyronine (T3), thyroid-stimulating hormone (TSH), CA 125, CA 19-9 및 hepatitis B envelope antibody (HBeAb) 의 10가지검사를 Abbott AxSYM (Abbott Laboratories Diagnostic Division, Chicago, IL) 장비및시약으로검사실내부에서자체시행할경우의직접원가계산을하였다. 고정비 (fixed cost) 는장비 (instrument) 비, 질관리비 [ 보정 (calibration) 비및정도관리 (external & internal quality control) 비 ] 및인건 (labor) 비의합으로, 변동비는시약 (reagent) 비및검사관련소모품 (test-related disposables) 비의합으로계산하였다 [9]. 고정비와변동비에간접비는포함시키지않았다. 장비비는대여 (rental) 하는경우로하여장비구입및유지비용이들지않는것으로하였고, 보정비는시약회사에서권장하는대로 2주에 1회시행할경우의비용으로하였고, 내부정도관리비또한시약회사에서권장하는대로 low, medium, high의 3가지정도관리물질에대하여각각 1일 2회시행하는경우의비용으로계산하였다. 외부정도관리비는면역측정검사항목에대한정도관리가입비및연 2회시행되는정도관리물질을각 1회씩측정하는경우의비용으로하였다. 보정비의건당소요비는건당보정물질비, 건 당시약비, 건당검사관련소모품비의합으로, 내부및외부정도관리비의건당소요비는건당정도관리물질비, 건당시약비및건당검사관련소모품비의합으로계산하였다. 인건비는본원정규직임상병리사들의평상임금의평균을기준으로하였을때의 0.5 FTE (full time equivalent) 를검사항목수인 10으로나누어계산하였다. 진단검사의학전문의의추가는없으므로인건비에전문의인건비는포함시키지않았다. 변동비에검체채취, 운반및접수등의분석전비용및결과전송등의분석후비용은외부위탁시와동일조건이기때문에포함시키지않았다. 또한, 손실이나검체희석및반복검사등의분석중질관리비용도포함시키지않았다. 이와같은방법으로구한고정비및변동비를가지고, 외부위탁시와비교하여 BEP 분석을시행하였다. 연간고정비손익분기건수 = ( 단위당외부위탁구매가 - 단위당변동비 ) ( 단위당외부위탁구매가 연간손익분기건수 ) 손익분기점비율 = ( 단위당외부위탁구매가 연간현재검사건수 ) 검사실내부에서시행할것인가외부위탁으로시행할것인가의판단은, 분야에따라다르기는하지만일반적인영업활동에서안정적경영을위한적절수준으로여겨지는손익분기점비율 80%[10] 를기준으로하여, 손익분기점비율이 80% 이상인경우원외검사가더적절하고, 80% 미만인경우원내검사가더적절한것으로하였다. 분석에사용된통계및그래프작성은 Microsoft Excel (Microsoft, Redmond, WA, USA) 을이용하였다. 1. Cost accounting 결 AFP, CEA, PSA, ferritin, ft4, T3, TSH, CA 125, CA 19-9 및 HBeAb의평균연고정비및단위당변동비의구성은 Table 1과같았고, 평균연고정비는 8,279,187원, 평균단위당변동비는 3,786 원이었다. Fig. 1과같이평균단위당변동비는검사건수에상관없이일정하고, 평균단위당고정비는검사건수가증가함에따라감소하였다. 2. Break-even point analysis AFP, CEA, PSA, ferritin, ft4, T3, TSH, CA 125, CA 19-9 및 HBeAb의연간손익분기건수는각각 1,064건, 1,197건, 1,496건, 1,548건, 1,156건, 1,271건, 1,042건, 2,272건, 2,115건및 3,310건, BEP 비율은각각 765%, 380%, 607%, 526%, 296%, 548%, 214%, 1,535%, 919% 및 2,724% 으로분석되었다 (Fig. 2). 과

3 462 김윤희 고정비에질관리비용을포함하지않은경우의연간손익분기검사건수는각각 138건, 113건, 122건, 198건, 151건, 162건, 124건, 154건, 146건및 231건, BEP 비율은각각 99%, 36%, 49%, 67%, 39%, 70%, 26%, 104%, 63% 및 190% 이었다. 고 검사를외부위탁으로시행할것인가검사실내부에서시행할것인가의문제는경제적측면뿐아니라환자의적절한치료를위해요구되는검사소요시간 (turnaround time), 외부위탁시의검사의질, 검사실내부의여유공간및전문인력의존재유무등의여러가지요소를고려해야한다. 검사실운영자는검사실내부에서시행하고있는검사들중적은의뢰건수를보이는검사들은 Table 1. Cost accounting 찰 Composition of fixed and variable costs Fixed costs per year Labor costs (Salaries) Instrument costs (Rental) Introduction Maintenance Depreciation Quality costs Calibration costs (Once per 2 wks) Quality control (QC) costs Internal QC (Twice per day) External QC (Twice per year) Variable costs per test Reagent cost Test-related disposables Line diluents Reaction vessel Matrix cell MUP dye Matrix cell wash solution 이검사들을외부로위탁하여시행하는경우의수익성과정기적 으로비교검토하여야하고, 공간, 장비및인력등에여유가있을 경우에는새로운검사를수립하거나외부위탁으로시행되던검사를검사실내부에서시행하는것에대해고려하여야한다 [2, 8, 11]. 이러한수익성분석을위하여손익분기분석 (break-even analysis) 이유용하게이용될수있다. 본연구에서는최근 2년간의뢰건수가증가하여외부위탁검사비용의증가를보인 10가지면역측정검사항목을검사실내부에서시행할경우의경제적측면의수익성과비교검토하기위해 BEP 분석을시행하였다. 분석결과 10가지검사항목모두에서질관리비용을고려할경우 BEP 비율이 80% 를상회하는결과를보여계속해서모든검사를외부위탁으로시행하는것이적절하였다. 현재건수에서의매출액에대한손익분기건수에서의매출액의비로계산되는 BEP 비율은일반적으로 80% 이하이어야불경기에서도안정적인경영을할수있는것으로알져져있다. 80% 이상의 BEP 비율을가 Cost per test (\) 13,000 11,000 9,000 7,000 5,000 3,000 fixed cost Test volume variable cost 1, ,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 Fig. 1. Fixed cost per test and variable test per test according to test volume change. Table 2. Break-even analysis results AFP CEA PSA Ferritin ft4 T3 TSH CA125 CA19-9 HBeAb Break-even volume 1,064 1,197 1,496 1,548 1,156 1,271 1,042 2,272 2,115 3,310 Break-even volume* BEP ratio 765% 380% 607% 526% 296% 548% 214% 1,535% 919% 2,724% BEP ratio* 99% 36% 49% 67% 39% 70% 26% 104% 63% 190% Contribution margin rate 69% 65% 59% 61% 68% 65% 69% 47% 49% 38% Possible number of calibration per year within profit* Possible number of QC per year within profit* *, In case that fixed costs were to be calculated without including quality costs such as QC or calibration. Break-even volume, fixed cost per year/(purchasing cost per test-variable cost per test); BEP ratio, total purchasing costs at break-even volume/total purchasing costs at actual annual volume); Contribution margin rate, (purchasing cost per test - variable cost per test)/purchasing cost per test. Abbreviations: AFP, alpha fetoprotein; CEA, carcinoembryonic antigen; PSA, prostate-specific antigen; ft4, free thyroxine; T3, triiodothyronine; TSH, thyroid-stimulating hormone; HBeAb, hepatitis B envelope antibody; BEP, break-even point.

4 원내검사및원외검사결정을위한손익분기점분석경험 ,000,000 Profit 12,000,000 25,000,000 20,000,000 Total purchasing costs 10,000,000 8,000,000 6,000,000 4,000,000 Contribution margin rate \ 15,000,000 10,000,000 Break-even point Break-even volume: 1559 Total costs \ 2,000, ,000,000-4,000,000 Break-even point \6,149,000 \18,447,000 \30,745,000 5,000,000-6,000,000-8,000, ,000 1,500 2,000 2,500 3,000 Test volume A -10,000,000 Loss Total purchasing costs B Fig. 2. Break-even chart (A) using total costs line and total purchasing costs line and (B) using contribution margin rate line. 질경우, 매출액이 10-20% 만감소하여도수익을내지못하게되기때문이다 [10]. 질관리비용을고려하지않을경우, CEA, PSA, ferritin, ft4, T3, TSH 및 CA 19-9의 7항목에서 80% 이하의 BEP 비율을보였으나, 이 7가지항목중 2주에 1회간격으로보정을시행하면서도수익 (profit) 을낼수있는항목은 CEA, ft4, TSH의 3항목뿐이었으며, 이 3항목에서수익 (profit) 을낼수있는범위내에서시행가능한내부정도관리의횟수는각각 4일에 1회, 3일에 1회및 2일에 1회이었다. 만일이 3가지항목의정밀도및정확도수준이높다면내부정도관리의시행간격을늘릴수있게되어, 질관리비용을포함하더라도 80% 이하의 BEP 비율이가능할것으로사료되었으나, 본연구에서는검사의정밀도및정확도등을포함하는총오차에대한연구는시행하지않았으므로, 시약회사에서권장하는내부정도관리시행횟수를적용하여계산한 BEP 비율을기준으로 10가지검사모두외부위탁으로시행하는것이적절한것으로판단하였다. 본연구에서원가계산시간접비 (indirect cost) 를고려하지않았는데 [12], 본원의경우재무제표를위해작성된전부원가계산이과별및장비별로세분되어있지않고, 병원전체에대해서만계산되어있어본과및새로이도입할장비에대한간접비배분이불가능하였다. 추후시간을기준으로하여간접비를배분하는전통적원가계산법이나활동을기준으로하는원가계산법 (activitybased counting, ABC) 등에의해간접비의배분이이루어지면좀더정확히직접원가계산을할수있을것으로기대되었다. 그러나, 본연구에서는모든검사항목에서손익분기검사건수가현재의실제연검사건수보다높았기때문에, 원가계산에간접비가포함되는것은충분조건이되므로, 원내또는원외검사결정에오류의영향은없었다. 또한본연구에서는통상적인 BEP 분석시사용되는매출비 (revenue) 대신, 외부위탁의경우와비교한 BEP 분석을위하여외부위탁공급가 (vendor s price=purchasing cost) 를이용하여 BEP를분석하였다. 매출비, 즉보험급여금액을이용할경우, 손익분기검사건수가감소하는결과를보이지만, 외부위탁시행시와의수익성비교분석은불가능하기때문이다. 심화된경쟁구도속에놓인의료기관이지속적품질개선을통한원가절감을목표로하는총체적질경영 (total quality management) 을성공적으로수행하기위하여재무제표작성에필수적인전부원가계산뿐아니라경영의사결정을위한직접원가계산및 BEP 분석을유용한도구로이용할수있다. 본연구결과진단검사의학전문의가검사실에서흔하게접하는문제중하나인원내또는원외검사결정을위한경제성분석도구로서직접원가계산을이용한 BEP 분석이유용함을알수있었다. 요약배경 : 심화된경쟁구도의료시장에서는의료서비스의지속적품질개선을통한원가절감이요구된다. 검사실에서는정기적으로원내또는원외검사 (make-or-buy) 결정을위한자료들을검토하는것이요구되는데, 이때유용한도구가손익분기점 (breakeven point, BEP) 분석이다. 본연구에서는최근본원검사실에서의뢰건수의증가추세를보인면역측정외부위탁검사들을검사실내부에서시행 (make) 할경우의원가계산을하여, BEP 분석을시행하였다. 대상및방법 : AFP, CEA, PSA, ferritin, ft4, T3, TSH, CA 125, CA 19-9 및 HBeAb 의 10가지검사를 Abbott Ax- SYM 장비로검사실내부에서자체시행할경우의고정비및변동비를계산하였다. 손익분기건수 (break-even volume) 는연간고정비를단위당외부위탁구매가와단위당변동비의차로나누어서, BEP 비율은손익분기건수에서의총구매가를현재의연검사건수에서의총구매가로나누어서구하였다.

5 464 김윤희 결과 : AFP, CEA, PSA, ferritin, ft4, T3, TSH, CA125, CA19-9 및 HBeAb의연고정비는평균 8,279,187원, 단위당변동비는평균 3,786원이었다. 손익분기건수는평균 1,599건, BEP 비율은평균 852% 이었다. 고정비에질관리비용을포함하지않은경우의 BEP 비율은평균 74% 이었다. 결론 : 임상검사의질보증은양보되어질수없는문제이므로, 현재의의뢰건수에서는재정적측면에서볼때, 10가지검사항목모두검사실내부에서시행하기보다는외부수탁으로시행하는것이보다적절하였다. 본연구로진단검사의학전문의가검사실에서흔하게접하는문제중하나인원내또는원외검사결정을위한경제성분석도구로서직접원가계산을이용한 BEP 분석이유용함을알수있었다. 참고문헌 1. Kim JQ, ed. Jo-en byungwon mandlgi. Seoul: Hangook-ehackwon, 2004:3-7 ( 김진규편. 좋은병원만들기- 의료의질향상사례. 서울 : 한국의학원, 2004:3-7.) 2. Weiss RL and Ash KO. Laboratory management. In: Burtis CA and Ashwood ER, eds. Tietz textbook of clinical chemistry. 3rd ed. Philadelphia: WB Saunders, 1999: Westgard JO and Klee GG. Quality management. In: Burtis CA and Ashwood ER, eds. Tietz textbook of clinical chemistry. 3rd ed. Philadelphia: WB Saunders, 1999: National Committee for Clinical Laboratory Standards. Application of a quality management system model for laboratory services; Approved Guideline Third Edition. NCCLS document GP 26-A3. Wayne, PA: NCCLS; National Committee for Clinical Laboratory Standards. Continuous Quality Improvement: Essential Management Approaches; Approved Guideline-Second Edition. NCCLS document GP 22-A2. Wayne, PA: NCCLS; Horngren CT. ed. Cost accounting. 10th ed. Seoul: Pearson education Korea, 2003: Higgins JM. ed. Quantitative methods for problem solving and planning. In Higgins JM, ed. The management challenge: an introduction to management. New York: Macmillan Publishing Company, 1991: Travers EM and Mcclatchey KD. Basic laboratory management. In: McClatchey KD ed. Clinical laboratory medicine. 2nd ed. Philadelphia: Lippincott Willams & Wilkins, 2002: Beard PL and Kerens EP eds. 1st ed. How to negotiate capitation for laboratory services. Wachington D.C.: AACC, American Association for Clinical Chemistry, Inc.,1996: Yang Namha ed. Sonikboongijumgwa hyungemhelm kyungyoung. 1st ed. Seoul: Sinrhonsa, 2000: ( 양남하편. 손익분기점과현금흐름경영. 1판. 서울 : 신론사, 2000: ) 11. National Committee for Clinical Laboratory Standards. Selecting and Evaluating a Referral Laboratory; Approved Guideline. NCCLS document GP 09-A. Wayne, PA: NCCLS; National Committee for Clinical Laboratory Standards. Basic Cost Accounting for Clinical Services; Approved Guideline. NCCLS document GP 11-A. Wayne, PA: NCCLS; 1998.

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untitled ORIGINAL ARTICLE http://dx.doi.org/1.15263/jlmqa.215.37.2.11 Evaluation of Analytical Performance of the Cobas 8 Analyzer Series Module e62 Kiwoong Ko, Min-Jung Kwon, Hee-Yeon Woo, and Hyosoon Park Department