The Effect of Corona Epidemic on Hospital Services and Revenues: A Case Study of Fars Province / Iran

Background: The economic impact of corona virus (COVID-19) disease on hospital performance in Iran is unknown. The aim of this study was to examine the effect of corona epidemic on hospital services and revenues: a case study of Fars province / Iran. Methods: The study was cross-sectional and descriptive. The information recorded in the hospital information system (HIS) of hospitals affiliated with Shiraz University of Medical Sciences, Iran from March to August 2019 and 2020 was used to identify the number of services provided. Revenues from services were derived from HIS and accrual accounting systems. Results: : The results showed that the total number of services provided from March to August 2019 and 2020 were 75,415,652 and 59,436,379, respectively, indicating that the total number of services in 2020 has decreased by 21% compared to 2019. The finding also indicated that the total revenue of services provided from March to August 2019 and 2020 is $ 166,929,626, and $ 146530916, respectively, indicating that the total revenue of services provided in 2020 decreased by 12% compared to 2019. Conclusions: : Corona epidemic could accelerate the redesign of the health care system to make it more efficient, active, sustainable and patient-centered. Some strategies to measure and control costs and revenues and improve clinical outcomes as well as changes in reimbursement systems that maintain the structure of the health system are vital to reaching this redesign and the desired results.

Hospital revenues are gained by activities like patient care, activities needed for patient care (tests, radiology services, and so on), and other revenues (gifts, grants, and so on).
Revenues from patient care make up the bulk of the hospital income and have two parts: the cost of daycare (nursing care, room, food, and so on) and specialized services (surgery, diagnostic tests, tests, and so on). The World Health Organization (WHO) has recently asked all the countries to focus their efforts on nancing health systems to respond to this epidemic [21,22] . Thus, it is essential to examine the economic consequences of this critical situation and its effects on health care organizations such as hospitals. The purpose of the study was to examine the effect of the corona epidemic on hospital revenue and services in Fars's province, Iran.

Method:
The study was cross-sectional and descriptive. The information recorded in the HIS systems of hospitals a liated with Shiraz University of Medical Sciences from March to August 2019 and 2020 was used to identify the number of services provided. Revenues from services were derived from HIS and accrual accounting systems.
Services and revenues were extracted at three levels of service, all hospitals and Shiraz, other cities, and Fars's province.
Moreover, the hospitals revenues were converted into dollars. According to the website of the Central Bank of Iran, each dollar was considered 42,000 Rials [23]. The dataset was compared with the aggregate information of Shiraz University of Medical Sciences collected in the center of the province and the opinions of managers and senior nancial experts of the University of Medical Sciences were taken in this regard after collecting the obtained data and to determine the accuracy of the information (validity and reliability). Excel software was used for data analysis.
Results: Table 1 is the number of services provided by hospitals a liated with Shiraz University of Medical Sciences, Iran from March to August 2019 and 2020.
Based on the results of this table, the total number of services provided from March to August 2019 and 2020 are 75,415,652 and 59,436,379, respectively, indicating that the total number of services in 2020 has decreased by 21% compared to 2019. The table ndings indicate that except for the three services -CT scan, radiotherapy, and dialysis that increased by 10%, 3%, and 0.7%, respectively -from March to August 2020 compared to March to August 2019, other services have decreased, with the largest decrease relating to rehabilitation services (49.5%). The highest frequency of services provided from March to August 2019 and 2020was related to medicine (31,922,072) and medical supplies (24,335,900), and the lowest to the operating room of the Cath lab (1,378 and 890, respectively). Table 2 is the revenue of services provided from March to August 2019 and 2020by hospitals a liated with Shiraz University of Medical Sciences.
Based on the table results, the total revenue of services provided from March to August 2019 and 2020is $ 166,929,626, and $ 146530916, respectively, indicating that the total revenue of services provided in 2020 decreased by 12% compared to 2019. Revenues for CT scan, anesthesia, dialysis, colic, radiotherapy, operating room and special beds also grew positively in 2020. The highest revenue of services from March to August 2019 and 2020 was related to regular bed ($ 27,847,144) and medicine ($ 22359052), respectively, and the lowest to the Cath lab operating room ($ 97,532 and $ 63435, respectively). Table 3 and Figure 1   It seems that because of the prevalence of corona disease, the number of hospital visits for elective services and nonurgent care and rehabilitation services has decreased, and considering that the common payment system in hospitals fee for service), with the reduction of the number of services provided, the hospital revenue has decreased too. Corona has resulted in an increase in the purchase of personal protective equipment and disinfectants, laboratory kits for corona, and consumables for a variety of graphs from patients with corona.

Sharifah et al.'s results In Malaysia indicated that only 19.5% of respondents in Klang Valley in Malaysia
have bene ted from health care services due to corona [24].
Glenn et al.'s results in the United States show that California's acute care hospitals earned an average of $ 8.7 billion in net income per month in 2018. The sharp reduction in inpatient and outpatient visits because of the corona has reduced their net income to $ 3.7 billion per month in the rst four months of the corona pandemic launch in June 2020 [25] .
The present study results indicated that the total revenue of services provided in 2020 decreased by 12% compared to 2019 with the largest decrease in revenue related to nuclear medicine (78%). Moreover, the revenues for CT scan, anesthesia, dialysis, colic, radiotherapy, operating room, and special beds grew positively in 2020. The total revenues of Shiraz hospitals and hospitals of Shiraz University of Medical Sciences in 2020 decreased by 13% and 7%, respectively, compared to 2019.
The reasons for declining hospital revenues can be the increased overpayment of staff, purchase of personal protective equipment and disinfectants, and cancellation of outpatient visits and elective surgeries at the hospital.
The study ndings are similar to those of Beck da Silva in Brazil. The results of Beck da Silva indicated that the monthly income of the hospital decreased by 10% from 2019 to 2020. Moreover, the hospitals in Brazil experienced declining hospitalization rates and incomes. The average bed employment rate in the intensive care unit decreased from 88-83% and from 85-73% in the hospital ward [26].
The results of the study by Colenda et al. indicated that Covid-19 disease might threaten the nancial infrastructure of academic medical centers as the costs of treating this contagious disease is high. Thus, these centers have incurred signi cant debts because of conducting medical procedures and providing the necessary facilities [6].

Conclusion:
Corona epidemic could accelerate the redesign of the health care system to make it more e cient, active, sustainable and patient-centered. Some strategies to measure and control costs and revenues and improve clinical outcomes as well as changes in reimbursement systems that maintain the structure of the health system are vital to reaching this redesign and the desired results. Moreover, because of the reduction in hospital revenues as a result of the corona pandemic, it seems that the nancial pressure on hospitals can be reduced by timely payment of hospital claims by insurance companies.  Tables   Due to technical limitations, table 1-3 is only available