Financial Performance of Private Hospitals during the Covid-19
Pandemic
Yuyun Umniyatun
1
, Teuku Nebrisa Zagladin Jacoeb
2
, Mochamad Iqbal Nurmansyah
3
,
Sopyan
3
and Dinnisa Haura Zhafira Hidayat
4
1
Department of Public Health, Faculty of Health Sciences, University of Muhammadiyah Prof. Dr. Hamka, Jakarta,
Indonesia
2
SamMarie Basra Woman & Children Hospital, Jakarta, Indonesia
3
Department of Public Health, Syarif Hidayatullah State Islamic University Jakarta, Banten, Indonesia
4
Department of Medicines, Syarif Hidayatullah State Islamic University Jakarta, Banten Indonesia
Keywords: Covid-19, Financial Performance, Hospital, Ratio Analysis.
Abstract: The impact that occurred in hospitals during the COVID-19 pandemic was the increasing number of inpatients
with severe cases. This has caused an increase in length of stay, increased hospital costs due to increased costs
for labor, medicine, medical services provided, equipment, personal protective equipment, and other medical
and safety supplies, and a decrease in outpatient visits. Further, this has led to instability in the hospitals’
financial conditions. This study aims to analyze the financial performance of private hospitals during the
pandemic. The research design is descriptive and quantitative, using secondary data from hospital financial
statements for the years 2018-2020. The analysis was conducted by calculating the liquidity ratio, activity
ratio, profitability ratio, and cost recovery rate (CRR). Ratio analysis shows the following results: The
liquidity ratio with the cash ratio indicator decreased from 0.36 to 0.25, the quick ratio from 0.6 increased to
0.65, and the current ratio from 0.73 increased to 0.79. The activity ratio with the Total Asset Turn Over
(TATO) indicator decreased from 2.00 to 1.94, and Fixed Asset Turn Over (FATO) decreased from 2.7 to
2.76. In the profitability ratio with indicators, Return on Assets (ROA) decreased from 1.43% to 1.09%,
Return on Equity (ROE) decreased from 3.5% to 2.5%, and Total Margin (TM) decreased from 01.02% to
0.79%. The Cost Recovery Rate (CRR) decreased from 1.03 to 1.02. In conclusion, financial performance as
measured by the liquidity ratio, activity ratio, profitability ratio, and cost recovery ratio (CRR) of non-covid
private hospitals studied during the COVID-19 pandemic was lower than before Covid 19. This was due to a
decrease in the number of visits, which resulted in a lower income. To increase the net profit, hospitals need
to immediately open services that were closed during the pandemic by observing health protocols, controlling
costs, and increasing utilization of fixed assets.
1 INTRODUCTION
The COVID-19 pandemic that has occurred
throughout the world has significantly impacted
health systems in many countries, including health
services, for example, hospitals. Hospitals in the
health system play an essential role in providing long-
term health care to people in acute or complex
conditions (World Health Organization, 2022). The
impact that occurred in hospitals during the COVID-
19 pandemic was the increase in the number of
inpatients with severe cases due to suffering from the
disease, which caused an increase in the length of
hospitalization. A further effect is a rise in hospital
expenses brought on by higher prices for labor,
medication, medical services, personal protective
equipment, and other goods related to health and
safety. The decline in outpatient visits is the following
(KaufmanHall, 2021). These factors contribute to the
instability of the hospital's financial condition. The
American Hospital Association (AHA) conducted
four analyses of the pandemic-related financial
factors that affect hospitals, including the impact of
COVID-19 patient hospitalization on hospital costs,
the impact of COVID-19-related service
cancellations and abandonments on hospital income,
and additional costs for purchasing personal
protective equipment (PPE) and other additional
Umniyatun, Y., Jacoeb, T., Nurmansyah, M., Sopyan, . and Hidayat, D.
Financial Performance of Private Hospitals during the Covid-19 Pandemic.
DOI: 10.5220/0011662300003608
In Proceedings of the 4th International Conference on Social Determinants of Health (ICSDH 2022), pages 111-117
ISBN: 978-989-758-621-7; ISSN: 2975-8297
Copyright
c
2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)
111
worker support costs (American Hospital
Association, 2020b). An estimated total financial
impact of four months (March–June 2020) of $202.6
billion in losses for American hospitals and
healthcare systems, or an average of $50.7 billion per
month (American Hospital Association, 2020a).
According to Kaufman Hall, hospitals nationwide
would lose an estimated $54 billion in net profit this
year (KaufmanHall, 2021).
Hospitals in Indonesia are also experiencing a
financial impact as cash flow is disrupted. For
COVID-19 referral hospitals, the soaring number of
patients treated in hospitals has disrupted cash flow
because the down payment for hospital work (10-50
percent) is no longer sufficient for operational costs.
For non-COVID-19 referral hospitals, the pandemic
has caused a decrease in outpatient visits and non-
Covid-19 inpatients. This condition decreased the
occupancy rate so that hospital revenues fell between
30-50% (Hendrartini, 2020). Some routine services
carried out at the hospital were temporarily suspended
to prevent the spread of COVID-19. In addition, the
patient also refrains from going to the hospital for fear
of being infected. The study showed that outpatient
visits decreased by 55.63% during the pandemic,
which caused a decrease in income so that hospitals
had difficulty financing their operations (Giusman &
Nurwahyuni, 2021). Data shown by several hospitals
listed on the Indonesian stock exchange shows a
decrease in net profits in the 2nd quarter of 2020 and
even reached minus, although in the 3rd quarter it
began to increase in a positive direction (Manajemen
Rumah Sakit, 2021).
Based on the type of service, hospitals are divided
into general and special hospitals based on hospital
ownership in Indonesia. They are divided into
government-owned hospitals (Central and Regional)
and private hospitals (Ministry of Health of the
Republic of Indonesia, 2020). Not all private
hospitals in Indonesia serve COVID-19 patients, but
during the pandemic, these hospitals also experienced
a decrease in income. A study at a private hospital
recorded a decrease in the cost recovery rate (CRR)
in 2020 by 13.71% compared to 2019 (Setyorini,
2020). CRR describes the financial performance of a
business through the calculation of the comparison of
total revenue with total production costs. If the
pandemic continues and hospitals cannot increase
their income when operational costs increase, it could
cause hospital services to stop (Hidayah, 2020). The
incident involved the layoff of certain employees by
a private hospital in Bekasi, Indonesia, resulting in a
70% decline in revenue (Nugroho, 2020). Based on
data from Bloomberg quoted by the American
Hospital Association, it was reported that in the US,
more than 36 hospitals experienced bankruptcy
during the pandemic (American Hospital
Association, 2020a) and 11 hospitals were closed due
to financial difficulties experienced during the
pandemic (Ellison, 2021). The involvement of private
sector investment and the amount of money required
to build a hospital highly depend on the financial risks
and returns offered to investors (Bhat and Jain, 2006).
Private hospitals are the type of industry that requires
high investment and a long payback cycle, so their
development requires continuous investment of large
funds (Deloitte, 2017). Hospitals require large
amounts of capital for infrastructure development and
operational financing because they require a large
workforce both in terms of quantity and specifications
(labor intensive) and adequate medical equipment
and other supporting equipment in accordance with
the type of service provided (technology intensive).
However, the role of the private sector is very much
needed to assist the government in providing health
services. Due to its incapacity to fund the
development and upkeep of health services, the
government has adopted a strategy of privatizing the
sector to work with the private sector to promote
health care (Ayuningtyas, 2008).
Financial performance information is an
important factor for investors to find out the results of
their investments. External parties like banks or
creditors also need financial performance data that
can be used to determine if it would be feasible to
grant loans, for instance, by evaluating the hospital's
debt load, cash flow, and profit margin (Zelman et al.,
2003). Financial performance is the most common
criterion for evaluating hospitals and top management
(boards). Studies show a positive relationship
between a dynamic board structure and high financial
performance (Culica & Prezio, 2009). The literature
shows a relationship between the financial
performance of health care providers (financial
performance) and the quality of care they provide
(quality of care). Therefore, a systematic review was
conducted to examine whether there is a relationship
between financial performance and service quality in
hospitals (Barnes et al., 2018; Dubas-Jakóbczyk et
al., 2021). Another study looked at the relationship
between lean management and financial
performance; its results illustrate that lean
management has a direct and positive impact on
patient safety and an indirect impact on financial
performance (Dobrzykowski, McFadden &
Vonderembse, 2016). Numerous research on
hospitals' financial performance demonstrate that
financial success is a crucial metric for gauging the
ICSDH 2022 - The International Conference on Social Determinants of Health
112
effectiveness of other business activities. Analyzing
the hospital's financial statements can be done to
evaluate financial performance. The hospital's
financial report consists of a balance sheet,
operational report, asset change report, and cash flow
statement. The financial statements included
horizontal and vertical analysis, trend analysis, and
ratio analysis. Ratio analysis consists of an analysis
of liquidity ratios, profitability ratios, activity ratios,
and capital structure ratios (Zelman et al., 2003).
Horizontal and vertical analysis are the two most
commonly used techniques for analyzing financial
statements based on a percentage. The horizontal
analysis looks at the percentage change in a line item
from one year to the next. The vertical analysis allows
comparisons between the financial statements of
different organizations. Trend analysis compares
trends over a longer period of time by comparing each
year to the base year. Although horizontal and vertical
analysis is easy to calculate and commonly used, ratio
analysis is the preferred approach to gain an in-depth
understanding of financial statements. Numerous
questions can be answered through ratio analysis,
including the following: 1) the liquidity ratio will
show how well-positioned the organization is to meet
its short-term obligations; 2) the profitability ratio
will show how profitable the organization is; 3) the
activity ratio will show how effectively the
organization uses its assets to generate income; and
4) the capital structure ratio will show how the
organization finances its assets (Zelman et al., 2003).
Through financial statement analysis, this study
seeks to assess how privately owned hospitals fared
during the epidemic. The profitability ratio, cost
recovery rate, activity ratio, and liquidity ratio were
all examined. The findings of this study can be used
as a starting point for developing a strategy to address
the issues identified by providing information on
financial performance.
2 SUBJECT AND METHOD
The design of this research is descriptive quantitative.
This study uses secondary data, namely hospital
financial statements in 2018-2020. The variables
measured are financial performance through analysis
of liquidity ratios, activity ratios, profitability ratios,
and cost recovery ratios (CRR).
2.1 Liquidity Ratio
The liquidity ratio is a ratio that shows the company's
cash availability and ability to meet short-term
obligations and financial obligations that are past due.
The liquidity ratios used in this study are the current
ratio, the quick ratio, and the acid test ratio. The
current ratio measures current assets and current
liabilities. The formula is as follows (Zelman et al.,
2003; Niedar et al., 2022):
current assets
Current ratio = --------------------.... (1)
current liabilities........... .....
The quick ratio measures the company's liquidity
through a comparison of cash and cash equivalents
and receivables with current liabilities. The formula
is as follows (Zelman et al., 2003):
Cash + marketable securities +
net accounts receivable
Quick ratio = ----------------------------------- (2)
current liabilities......................
The acid test ratio is a measure of how much cash is
available to pay current liabilities. The formula used
is as follows (Zelman et al., 2003; Niedar et al.,
2022):
Cash + marketable securities
Acid test ratio = ----------------------------------- (3)
Current liabilities.............. ....
2.2 Activity Ratio
An activity ratio is a ratio that measures the efficiency
of hospital assets to generate income. This ratio will
answer the question of how much income is generated
for every dollar invested in assets. The indicators used
in this activity ratio are the total asset turnover ratio,
the fixed asset turnover ratio, and the number of days
in accounts receivable. The total asset turnover ratio
is used to measure the efficiency of all hospital assets
in generating revenue. The formula used is (Zelman
et al., 2003; Niedar et al., 2022):
Total Asset Total Operating Revenues
Turnover Ratio = ---------------------------- (4)
Total Asset...........................
A fixed asset turnover ratio is used to measure
how productive the hospital's fixed assets are used to
generate income. The formula is as follows (Zelman
et al., 2003; Niedar et al., 2022)
Total Fixed Asset Total Operating Revenues
Turnover Ratio = --------- -------- ------------.... (5)
Total Fixed Asset
Days in Patient Accounts Receivable is used to
measure effectiveness in managing accounts
receivable. The formula is as follows (Niedar et al.,
2022):
\
Days in Patient Accounts Receivable
Accounts Receivable = ------------------------- (6)
Revenue/365......
Financial Performance of Private Hospitals during the Covid-19 Pandemic
113
2.3 Profitability Ratio
The profitability ratio is the ratio used to measure the
hospital's ability to generate revenue. The
profitability ratios used in this study are Total Margin
(TM), ROA (Return on Assets), and Return on Equity
(ROE). Total margin, or total profit margin, is
measured by net income (total income) divided by
total revenue (total revenues). The formula used is as
follows (Zelman et al., 2003; Niedar et al., 2022):
Net income
Total Margin = -------------------- (7)
Total Revenue ......................
ROA measures the financial viability of the hospital
through the return obtained by the hospital for the use
of its assets. The formula used is as follows (Zelman
et al., 2003; Niedar et al., 2022):
Net income
Return on Assets = ------------------------ (8)
Total assets........
ROE is the main measure of financial performance
because it shows the level of business unit value. The
formula is as follows (Zelman et al., 2003; Niedar et
al., 2022):
Net income
Return on Equity = ---------------------- (9)
Total Equity....
2.4 Cost Recovery Rate (CRR)
Cost recovery, which may be estimated using the Cost
Recovery Rate (CRR), is the capacity of a health
service facility to pay its costs with the revenues
generated (Niedar et al., 2022). Through CRR,
hospitals can discuss and explain the connection
between the outcomes of a business's operations and
the resources utilized to provide a good output
(Arfiani, Fahlevi & Zuraida, 2020). The equation
reads as follows:
Total Revenue
Cost Recovery Rate (CRR) = -------------------- (10)
Total Cost....
3 RESULTS
3.1 Outpatient Visits
Outpatient visits rose by 11.8% in 2019, from 19,741
visits to 22,067 visits. However, hospitals saw a 5%
drop in outpatient visits in 2020 due to the pandemic
(table 1).
Table 1: The Number of Outpatient Visits Years 2018-2020.
Year Number of Visits Remark
2018 19741
2019 22067 +11,8%
2020 21061 -5%
3.2 Ratio Analysis
Based on the financial analysis of the 2018–2021
financial statements, the following results are
obtained:
3.2.1 Liquidity Ratio Analysis
Acis test ratio analysis in 2018 was 0.32, increased in
2019 to 0.36, and decreased by 3% in 2020 to 0.25.
Quick ratio analysis in 2018 was 0.52, increased in
2019 by 0.6, and increased by 8% in 2020 to 0.65. The
current ratio in 2018 was 0.66, increased in 2019 by
0.73, and 8% in 2020 to 0.79 (Table 2).
Table 2: Liquidity Ratio Analysis Years 2018-2020.
Indicators 2018 2019 2020 2019 to 2020
Acid Test Ratio 0,324 0,36 0,25 -3%
Quick Ratio 0,52 0,6 0,65 +8%
Current ratio 0,66 0,73 0,79 +8%
3.2.2 Activity Ratio Analysis
Analysis of Total Asset Turnover in 2018 was 1.84,
increased in 2019 by 2.00, and decreased by 3% in
2020 to 1.94. This analysis shows that for 2018, every
IDR 1 of the total assets owned by the company can
generate IDR 1.84 in sales. Furthermore, in 2019,
every Rp. 1 of the company's total assets generated
Rp. 1.94 in sales, and in 2020, every Rp. 1 of the
company's total assets is able to generate sales of Rp.
1.94. Fixed Asset Turn Over analysis in 2018 was
2.37, increased in 2019 by 2.7, and increased again by
2% in 2020 by 2.76. Days in Patient Account
Receivable in 2018 were 10.84 days, 10.12 days in
2019, and 11.76 days in 2020 (Table 3).
Table 3: Activity Ratio Analysis Years 2018-2020.
Indicator 2018 2019 2020
2019 to
2020
Total Asset Turn Over
1,84 2.00 1.94 -3%
Fixed Asset Turn Over
2,37 2.70 2.76 -2%
Days in Patient
A
ccount Receivable
10.84 10.12 11.76
ICSDH 2022 - The International Conference on Social Determinants of Health
114
3.2.3 Profitability Ratio Analysis
The Total Profit Margin in 2018 was 0.81%, increased
in 2019 to 1.02% and decreased by 8% in 2020 to
0.79%. Return on Assets (ROA) assesses the
company's ability to generate net income from assets
owned. Analysis of Return on Assets (ROA) in 2018
was 1%, increased in 2019 by 1.43% and decreased
by 24% in 2020 to 1.09. ROE assesses the company's
ability to generate net income from equity. Analysis
of Return on Equity (ROE) in 2018 was 2.7%,
increased by 3.5% in 2019 and decreased by 28% in
2020 to 2.5% (Table 4).
Table 4: Profitability Ratio Analysis Years 2018-2020.
Indicator 2018 2019 2020 2019 to 2020
Total Profit
Mar
g
in
0,81% 1,02% 0,79% -8%
Return on Assets 1,0% 1,43% 1,09% -24%
Return on Equity 2,7% 3,5% 2,5% -28%
3.2.4 Cost Recovery Rate (CRR)
Table 5: Cost Recovery Rate (CRR) Year 2019-2020.
Indicator 2018 2019 2020 2019 to 2020
CRR 1,02 1,03 1,02 -7%
The Cost Recovery Rate (CRR) is the company's
ability to finance hospital operations. The Cost
Recovery Rate (CRR) in 2018 was 102%, increased
in 2019 to 103%, and decreased by 7% in 2020 to
102% (Table 5). A CRR that is more than 100%
means that it has exceeded the target. Although in
2020 it decreased, the ratio is still above 100%.
4 DISCUSSIONS
The research hospital is located in East Jakarta City,
which has an area of 182.07 km2 or 28.39% of the
area of DKI Jakarta Province. East Jakarta is the city
with the most population in the province of DKI
Jakarta (28.76%) with a fairly high density (BPS,
2020). The number of COVID-19 cases found in this
city as of December 31, 2020 was 38,475 people,
which is the highest in DKI Jakarta Province (28.3%)
(Jakartasatu, 2022). The research hospital was a
private hospital for mothers and children of type C
and non-referrals for Covid-19. A class C special
hospital is a hospital that provides primary services in
one field or one particular type of disease based on
scientific discipline, age group, organ, type of
disease, or other specificity and has a minimum
number of 25 (twenty-five) beds (Ministry of Health
of the Republic of Indonesia, 2020). Therefore, there
are other services in the hospital studied, such as
internal medicine, dental, dermatology, and
venereology polyclinic. Due to the pandemic, several
services were closed, such as outpatient dental,
skincare, and beauty. As a result, fewer patients visit
the hospital, which results in lower revenue for the
hospital. There has been a significant decline in
visitors to numerous hospitals, particularly in the first
and second quarters of 2020, due to widespread social
restrictions and public worries about catching
COVID-19. According to data from California Health
Care Foundation (CHCF), hospital visits in California
fell by 7% in the fourth quarter of 2020 (Melnick &
Maerki, 2021). Research indicates that non-covid
private hospitals also saw a fall in visits, albeit the
amount of the decline was not specified (Setyorini,
2020).
The liquidity ratio measures the hospital's ability
to settle short-term obligations through its current
assets. In 2019, the hospital's liquidity ratio,
calculated from the quick ratio and current ratio,
increased from 2018 but was still below the hospital's
normal standard (current ratio > 2.18 and quick ratio
> 1.76) (Zelman et al., 2003). Meanwhile, the
standard acid test ratio is 0.35 (Zelman et al., 2003).
This standard can be achieved in 2019, but then
decreases in 2020. From these three measures, it can
be interpreted that hospitals still have difficulties
meeting their short-term obligations. A decline in
income, which resulted in less cash in hospitals and
more short-term liabilities, was the reason of the cash
ratio's decline in 2020.
The liquidity ratio, measured based on the quick
and current ratios, has increased. The quick ratio
measures the hospital's ability to pay its short-term
obligations through cash and receivables. This
indicates that cash is decreasing, but the amount of
receivables is increasing. The current ratio shows the
hospital's ability to pay short-term obligations from
cash, receivables, and inventories. This suggests that
inventory has increased or remained constant from
the previous year but that turnover or inventory sales
are slower due to a decline in customer traffic.
Hospitals with cash flow issues will pay off their
obligations over a longer period of time. Applying for
a short-term loan at the bank is the next step.
Hospitals may become more insolvent as a result of
current liabilities rising more quickly than current
assets (Niedar et al,. 2022). A study in a hospital with
a acid test ratio below 1.00 states that the hospital's
ability to cover its current liabilities using cash is still
Financial Performance of Private Hospitals during the Covid-19 Pandemic
115
weak. Therefore, hospital owners continue to invest
funds to cover their direct obligations (Jonny, 2016).
The activity ratio is a ratio that measures the
efficiency of the hospital's assets to generate income,
which is calculated from the assets owned by both
total assets and fixed assets and the length of days of
payment of receivables. From 2018 to 2020, the ratio
of hospital activity measured by total assets was
declared efficient because it was above the hospital
standard (TATO = 1.02) (Zelman et al., 2003).
However, there was a decline in 2020. However, if it
is measured using fixed assets to generate income, it
cannot be categorized as efficient because it is still
below the standard (FATO = 3.59) (Zelman et al.,
2003). Especially during the pandemic, the FATO
value decreased. The activity ratio, measured by the
days a receivable is returned, is very good because the
receivables are paid within 11–12 days. A study in
hospitals that experienced payment of receivables for
more than 90 days showed that hospital owners still
needed to invest funds (Jonny, 2016).
The profitability ratio is one of the measures of the
aggregate financial performance of a business
because it describes the net result of a large number
of managerial policies and decisions (Niedar et al.,
2022). The profitability ratios of the hospitals studied
from 2018 to 2020, which were assessed from the
Return on Assets (ROA) and Return on Equity
(ROE), were below the hospital's normal standards
(ROA = 0.03 and ROE = 0.06) (Zelman et al., 2003).
The concept of the return that a hospital can get on its
assets may be one of the keys to assessing its financial
viability. Managers can utilize ROA to determine
how productively resources are utilized. The more the
net income invested by a corporation in assets, or the
more productive the assets, the higher the ROA of
that company (Niedar et al., 2022). The low ROA of
the hospitals studied shows that the hospital's rate of
return from its assets has not been productive.
Especially during the pandemic, the decline in net
profit caused ROA to decrease by 24%.
Another ratio used to assess profitability is ROE.
ROE is the main determinant of a company's financial
viability. Companies that can grow equity with their
earnings will be able to finance future asset
acquisitions by the company. ROE is significant for
investors because investors can use it to see how well
managers use the capital provided by investors
(Niedar et al., 2022). The low ROE of the hospitals
studied shows that the net profit generated from
equity or owned capital has not been good, especially
when there has been a decline during the pandemic.
This decline was brought on by a decline in net profit
and an increase in owner equity, suggesting that the
owner may have provided additional funding during
the pandemic. Another indicator to measure the
profitability ratio is Total Margin (TM). TM
measures an organization's ability to control costs.
Assuming all other things are equal, a higher total
margin means lower costs relative to revenue (Niedar
et al., 2022). According to the findings of the hospital
calculations, the overall margin declined by 7.5%
during the pandemic as a result of a decline in total
income brought on by a drop in visits but an increase
in operating expenses.
The Cost Recovery Rate (CRR) measures the
company's ability to finance hospital operations. The
CRR of the hospitals studied from 2018 to 2020 was
in accordance with the hospital's normal standards,
namely > 1 (Zelman et al., 2003). Even though during
the pandemic, there was a decrease in CRR by 0.9%,
the CRR was still within the normal standard. The
decrease in CRR was due to a decrease in income.
When analyzed in terms of costs, the cost of business
decreased in line with the decrease in the number of
visits, but the cost of business increased.
5 CONCLUSIONS
Financial performance of non-covid private hospitals
evaluated during the COVID-19 pandemic was lower
than before the COVID-19 pandemic. The ratios that
experienced a decline were acid test ratio (-3%), total
assets turn over (-3%), fixed assets turn over (-2%),
return on assets (-24%), return on equity (-28%), and
cost recovery rate (-7%). This was due to a decrease
in the number of visits (-5%) and an increase in costs
such as the purchase of personal protective
equipment, which resulted in a decrease in income.
Hospitals must rapidly reopen services that were shut
down during the epidemic while paying attention to
health protocols, managing expenses, and
maximizing the use of fixed assets in order to
maximize net profit.
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