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The purpose of this paper is to describe the standardization of cost accounting by diagnosis-related groups (DRG) and how specialized medical care has managed this change in Finland.

Qualitative research material was collected over six years to analyze the changes in the standardization process.

It was found that individual actors customize the process to meet their needs. Because the goal of standardization is comparison, the customization does not result in a homogenous national system.

This paper’s limitation is that it focusses on an investigation of the adoption and use of the DRG system in hospital districts. Extending the research from this area to also cover health centres and regional hospitals could provide a broader picture of the use of the system.

Even though the actors report that they are using the DRG, our research illustrates how the same system is used in different ways and for different purposes in different organizations that impacts the original goal of national cost comparability.

This paper’s contribution is to show how the construction of an accounting system takes shape when spreading through organizations and society, and how its homogeneous nature is managed.

This paper aims to discuss the implementation process for the new diagnosis-related groups (DRG) accounting system in the health-care sector, and the struggle to gain acceptance for the system. The emphasis is on the goals and the expected results of the system, and how the system finally becomes an actuality.

The paper illustrates the framing of an accounting system, that is, how the health organization constructs the goals and the purposes of the system during its implementation. The empirical data consist of interviews, newspaper articles and notes from participatory observations.

The goals and the purposes of the new system were not defined ex ante, but rather emerged as supporters of the system found a common language. This commonality enabled the linking of the interests of the hospital managers with the DRG system. At this point, the actual DRG-based systems for the product categorization and the full-cost pricing system became heterogeneous. Making the system visible through discussion entailed seeing the invisible. Seeing the invisible allowed the system to become a reality (national comparability). Visibility helped the DRG system to gain approval and become a stronger system.

This study is an illustration of a unique social process. The study’s applicability under other circumstances should be considered with caution.

The paper illustrates how the purpose of an accounting system emerges and is constructed through the interaction between various actors.

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.

We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.

Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.

Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.

In the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.

Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.

So far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

The adoption of DRG coding may be seen as a central feature of the mechanisms of the health reforms in New Zealand. This paper presents a story of the use of DRG coding by describing the experience of one major health provider. The conventional literature portrays casemix accounting and medical coding systems as rational techniques for the collection and provision of information for management and contracting decisions/negotiations. Presents a different perspective on the implications and effects of the adoption of DRG technology, in particular the part played by DRG coding technology as a part of a casemix system is explicated from an actor network theory perspective. Medical coding and the DRG methodology will be argued to represent “black boxes”. Such technological “knowledge objects” provide strong points in the networks which are so important to the processes of change in contemporary organisations.

This study aims to provide insights into management accounting changes (MACs) and potential roles of big data analytics (BDA) in accelerating the MACs in an Indonesian public hospital as a response towards the adoption of the diagnosis-related groups (DRG)-based payment system.

A mixed-method approach was used to collect and analyse data from a referral public hospital in Indonesia. First, a BDA simulation was carried out to reveal its usefulness in predicting and evaluating patient costs, and finally improving the cost recovery rate (CRR) of each DRG case. This part formulated and tested the mathematical models that predict patient cost, the CRR and determinants (length of stay/LOS, severity/SEV, patient age/AGE and gender/SEX). For this purpose, data of the top ten inpatient cases of 2018 were collected and analysed. Second, semi-structured interviews with senior staff and doctors were carried out to understand cost control strategies implemented in the hospital and the management and doctors’ perceptions regarding the application of tested mathematical models for cost control. Old institutional economics and new institutional sociology were used to gain insight about how and why management accounting practices changed in the hospital.

The findings show that the absence of detailed per-case/patient cost information has not only hindered further evolvement of MACs but also stimulate tensions between managerial and medical worlds in the studied Indonesian public hospital. The simulation of BDA in this study was not only discovering the determinants of case cost recovery but also enabling the prediction of CRR of patients immediately after admission. The application of BDA and casemix accounting in the hospital will potentially become catalysts of discussion and mutual learning between managerial and medical staff in controlling patient costs.

This paper provides a more comprehensive picture of the potential roles of BDA in cost control practices. The study assesses the feasibility of BDA application in the hospital and evaluates the potential roles and acceptance of BDA application by both management and doctors.

As an American participant in ‘Management and Financing of Hospital Services’, the DRG Convention held in London on llth‐13th December, 1986, I had looked forward to the presentations with a great deal of happy anticipation. That may seem a strange attitude unless one recognises that the life of a ‘DRG expert’ in the USA today is not necessarily a happy one. Like it or not, we are viewed as policemen. Much of the continuous, carping and often self‐serving criticism levelled against us can be described as woeful pleas from a band of corsairs; not very bloodthirsty ones mind you, but rapacious nonetheless.

This study aims to explore the complex, multi-level institutional dynamics of smart city reforms and projects and their potential sustainability pressures on the implementation of a management accounting system in an Egyptian state-owned enterprise (SOE), which has a politically sensitive institutional character.

This study adds to institutional management accounting research using a multi-level perspective of institutional dynamics in the smart city context. Data were collected from an interpretive case study of an Egyptian SOE that was under socio-political sustainability pressures to implement a smart electricity network project in New Minya city.

Smart city projects have formed social and political sustainability pressures, which introduced the enterprise resource planning (ERP) network as a new management accounting system. A new (complex and multi-level) management accounting system was invented to reinvent the sustainable city as an “accounting city” (which appeared rhetorically as a “smart city”). “Smart” being the visibility and measurability of the sustainability performance of the collective body, which calls the city and its connectivity to different institutional levels brought out in a city network project for the ERP-enabled electricity distribution.

This study examines a single case study from a single smart city and identifies the accounting community’s need for multiple and comparative case studies to further analyse the potential impact of smart city reforms and projects on the sustainable implementation of management accounting systems.

City policymakers and managers may benefit from the practical findings of this interpretive field-based case study in planning, implementing and monitoring smart city projects and objectives.

Individual and collective well-being may be enhanced through new management accounting forms of multi-level local governance and increased political, field and organisational sustainability.

This study provides important insights into the sustainability dynamics of management accounting in achieving smart city reforms. The achievement of sustainability management accounting systems has connected to multiple ERP roles at different institutional levels, which resulted in accommodating the socio-political objectives of smart city projects.

Concern over the rising cost of medical care has caused many countries to investigate and implement different methods of cost containment, particularly for hospital services. In the United States, Medicare replaced its ‘cost‐based’ reimbursement system, in which hospital payments were based on the actual costs incurred in treating patients, with a system that pays hospitals a fixed price per case. Under this new system, all hospital discharges are classified into 467 Diagnosis Related Groups (DRGs) or types of cases based on the patient's age, sex, principal diagnosis, additional diagnoses (comorbidities and complications), surgical procedures performed, and the discharge status. During the first three years of the programme, the payment rate for each DRG is a function of a DRG weight (reflecting relative resource consumption), the hospital's historic costs of treating patients in that DRG, and a federally established rate adjusted for urban/rural differences and census region. In the fourth year the price will be based only on the DRG weight and the federally established rate.

The purpose of this study is to conduct a comparative analysis of the Medicare patients discharged to a long-term (acute) care hospitals (LTCH), skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) following an acute inpatient hospitalization under Medicare-severity diagnosis-related group (MS-DRG) 207. The likelihood of discharge by provider type was also examined to determine criteria informing patient discharge to a LTCH, SNF or IRF for treatment.

Retrospective cohort study, based on secondary data analysis, utilizing Medicare Provider Analysis and Review (MedPAR) File data collected by Centers for Medicare & Medicaid Services for fiscal year 2011, October 1, 2010, through September 30, 2011.

Numerous analyses were conducted upon those patients discharged to a LTCH, SNF or IRF following an acute inpatient hospitalization under MS-DRG 207. Concerning those patients discharged to LTCHs, patients were not significantly older, did not have the highest length of stay and had comparable diagnoses and diagnosis counts to those discharged to SNFs or IRFs. However, costs were significantly higher among discharges to LTCHs. Multinomial logistic regression analyses also indicated numerous associations between certain variables and discharge location.

With the aging of the US population and increasing costs of rendering services, both the Medicare population and Medicare expenditures, already at their highest levels in the history of the program, are projected to rise going forward (The Boards of Trustees, 2012). As such, recent research has focused on Part A hospitals/facilities and the variations in costs submitted and payments received for treatment/services provided. This study aims to address whether patients discharged to LTCHs, which receive higher payment(s) as a result of serving a higher proportion of medically complex beneficiaries, are more medically complex than those discharged to SNFs/IRFs.

The purpose of this paper is to illustrate how the occupational identity of management accountants working in the public sector is influenced by a change in management accounting and control systems as well as the underlying management agenda.

From interviews with management accountants and their associates in five public hospitals, the paper illustrates how a change in new public management (NPM)‐related managerial agendas interacts with how the management accountants perceive their professional roles.

It is argued that the focus of the NPM agenda in Finnish public health care has shifted from a “down grid agenda”, emphasising private sector accounting and control methods, to a “down group agenda” that emphasises accountability, visibility and comparability. This change in agendas has materialised in the implementation of the diagnosis‐related groups (DRG) system, and the resultant abandoning of activity‐based costing (ABC) systems. Health care management accountants who rely on private sector ideals for constructing their occupational identity may resist the implementation of DRG if they interpret it as a shift in managerial discourse.

The paper links two different and sometimes contradictory agendas within the NPM framework with the occupational identity of management accountants. The observed reaction to the shifting agendas has implications for understanding why some accounting systems carry more appeal than others.