Financial Performance of Private Hospitals during the Covid-19

Pandemic

Yuyun Umniyatun

, Teuku Nebrisa Zagladin Jacoeb

, Mochamad Iqbal Nurmansyah

Sopyan

and Dinnisa Haura Zhafira Hidayat

Department of Public Health, Faculty of Health Sciences, University of Muhammadiyah Prof. Dr. Hamka, Jakarta,

Indonesia

SamMarie Basra Woman & Children Hospital, Jakarta, Indonesia

Department of Public Health, Syarif Hidayatullah State Islamic University Jakarta, Banten, Indonesia

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

 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

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

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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