Athletic Training and Sports Health Care

Systematic Review 

Is Activity-Based Costing a Gateway for Third-Party Reimbursement for Athletic Training Services in Massachusetts?

Elizabeth Suzanne Wolfe, CAGS, ATC; Dominique M. Ross, PhD, ATC



To evaluate the efficacy of activity-based costing in the United States health care system and whether it is a feasible method for third-party reimbursement for athletic training services in Massachusetts.


Articles were identified using PubMed, Gale Business Insights, Gale Nursing and Allied Health Collection, and Ovid Healthstar databases without date restrictions.


Three hundred forty articles were identified and 99 met the inclusion criteria. Five themes were identified: procedure cost (n = 14), finance (n = 35), patient outcomes/health care quality (n = 16), health care efficiency (n = 13), and policy/law (n = 19); 2 articles were uncategorized/miscellaneous.


Activity-based costing has not been explored with athletic training services, but has shown merit for other allied health professions in Massachusetts. Simulation modeling is warranted to project the cost benefits and value of athletic training services to justify third-party reimbursement using activity-based costing methods.

[Athletic Training & Sports Health Care. 2018;10(2):82–92.]



To evaluate the efficacy of activity-based costing in the United States health care system and whether it is a feasible method for third-party reimbursement for athletic training services in Massachusetts.


Articles were identified using PubMed, Gale Business Insights, Gale Nursing and Allied Health Collection, and Ovid Healthstar databases without date restrictions.


Three hundred forty articles were identified and 99 met the inclusion criteria. Five themes were identified: procedure cost (n = 14), finance (n = 35), patient outcomes/health care quality (n = 16), health care efficiency (n = 13), and policy/law (n = 19); 2 articles were uncategorized/miscellaneous.


Activity-based costing has not been explored with athletic training services, but has shown merit for other allied health professions in Massachusetts. Simulation modeling is warranted to project the cost benefits and value of athletic training services to justify third-party reimbursement using activity-based costing methods.

[Athletic Training & Sports Health Care. 2018;10(2):82–92.]

On March 23, 2010, President Barack Obama signed the Affordable Care Act (ACA) into law, which expanded the “Patient's Bill of Rights” and provided every American the opportunity to access health insurance.1 Since the implementation of the ACA, health care costs within Massachusetts have drastically risen due to increased use of and access to the health care system.2 Exorbitant costs in the Massachusetts health care system may be partially attributed to fee-for-service health care billing, in which each medical visit and procedure is billed separately.3,4 This “a la carte” style of health care limits cost savings, hinders billing efficiency, and adds financial stress to the health care payers.5

Massachusetts Medicare and Medicaid systems are taking preliminary action to reduce the amount of feefor-service billing by placing a new emphasis on value-based health care.3 On November 4, 2016, Massachusetts Governor Charlie Baker announced that the state would overhaul and reorganize its Medicaid program (MassHealth) to an accountable care model to place an emphasis on health care value.6,7 To reduce and disperse costs within all components of a patient's bill, payers to U.S. health insurance companies are currently exploring alternative payment options that are focused on a value-based design, thereby stressing cost sharing and varying levels of coverage.8,9 By definition, a value-based model is when providers use evidence-based, cost-effective practices to improve patient outcomes, quality of life, and satisfaction, which lowers health care use and costs overall.10 A value-based reimbursement model that shows great promise within the U.S. health care system is activity-based costing.11,12

Activity-based costing was first used in the manufacturing field by identifying the greatest contributors to the overhead cost (or drivers) and then negotiating a reduced cost rate and supplemental services needed for production.11,12 Activity-based costing is not new to the U.S. health care system and has emerged during the past decade as a viable method to offset the rising costs of the fee-for-service health care model and implementation of the ACA.13–16 Boston-based insurers are currently using activity-based costing for orthopedic procedures to bundle payments, improve patient care efficiency and outcomes, and lower prices and costs.12,17 The efficacy of activity-based costing for these procedures is pending; however, the proposal of a bundled payment by Witkowski et al.17 is notable and may be worth replicating with other payers, most importantly the Centers for Medicare and Medicaid Services.

Although athletic training is recognized by the American Medical Association, Health Resources Services Administration, and Department of Health and Human Services as an allied health care profession,18 few states participate in third-party reimbursement for athletic training services via private payers.19,20 Access and use of third-party reimbursement within U.S. allied health professions has been widely discussed since the 1970s with the premise of improving patient outcomes and health care efficiency.21–24 However, little progress has been made in gaining access and approval for third-party reimbursement to the allied health care professions (including athletic training) within the U.S. health care system.25–28 The purpose of this systematic review was twofold: to evaluate how activity-based costing became an effective reimbursement strategy within the United States and assess whether activity-based costing is a feasible pathway to third-party reimbursement for allied health professions, including athletic training services, within the state of Massachusetts in the near future.

Literature Review

Research articles were identified and retrieved using PubMed, Gale Business Insights: Essentials (peer reviewed articles only), Gale Nursing and Allied Health Collection, and Ovid Healthstar databases without date restrictions and regardless of level of evidence. The following terms were used to identify articles: “activity-based costing” and “healthcare,” “activity-based costing” and “third-party reimbursement,” “third-party reimbursement” and “healthcare,” “third-party reimbursement” and “athletic training,” and “activity-based costing” and “athletic training.”

Data Abstraction and Analysis

Article inclusion criteria were the inclusion of meaningful insight and support of activity-based costing in health care, prospective or retrospective data on activity-based costing and third-party reimbursement strategies for allied health professions, and sound theoretical support for activity-based costing in new or emerging areas of physical rehabilitation and allied health care services. Articles were excluded if the article title, abstract, and full-text were not applicable or translatable within good faith to activity-based costing, health care finance of athletic training or rehabilitation services, or third-party reimbursement for allied health professions. Duplicates and articles that were not relevant to the U.S. health care system were also excluded. Included articles were abstracted and placed into a spreadsheet where articles were examined, clustered, and categorized based on their relationship to activity-based costing, third-party reimbursement strategies, and athletic training and allied health professions. No statistical tests were performed or used for this review.


From the initial literature search, 340 articles were identified and 241 articles were excluded due to failure to meet the inclusion criteria; these also included 28 duplicates. Only 99 (29.1%) articles met the inclusion criteria for this review (Table 1 and Figure 1). Five themes were identified: procedure cost (n = 14), health care finance (n = 35), patient outcomes/health care quality (n = 16), health care efficiency (n = 13), and policy/law (n = 19). Two articles were deemed uncategorized/miscellaneous due to an abstract relationship to athletic training and third-party reimbursement. The article publication dates ranged from 1980 to 2016, allowing the authors to observe the evolution of third-party reimbursement and use of activity-based costing in health care. A wide range of health professions and types of articles were identified in this review (Table 2).

Article Search Summary

Table 1:

Article Search Summary

Article selection flow chart.

Figure 1.

Article selection flow chart.

Article Synthesis Summary

Table 2:

Article Synthesis Summary

Procedure Cost

A total of 14 articles addressed how activity-based costing can be used to identify the cost drivers of certain health care and surgical procedures. Once the cost drivers were identified, health care procedures and patient costs could be assessed.29 Strategies developed to use resources more sparingly, wisely, and efficiently were also assessed.30 Most articles were prospective cost analyses and case studies about specific health care procedures. A unique tool used within the studies was simulation modeling of health care costs for a specific procedure or practice type.31 We found that orthopedics was the most frequent health care profession to implement activity-based costing within clinical and billing practices. Specific procedures highlighted included total joint knee replacement,32 surgical procedure resource use for varying procedures,33 arthroplasty,14 and rotator cuff repairs.34 Additionally, costs of an orthopedic practice and procedure were greatly affected by payer type and were substantially increased by non-value– added activities (eg, administrative time, phone calls for patient care, and non-bedside care).35

Health Care Finance

Most articles found in this review (n = 35) pertained to the health care finance aspects of activity-based costing. Most of the health care finance articles were either literature or general review articles (n = 16) that were primarily focused on the health care payment systems within hospitals and community health centers. An overarching theme in the health care finance subgroup was that payment greatly depended on the value, need, and associated risk in regard to the type of patient care provided.28,36–38 Albertina and Bakewell36 stated that “value is understood as a function of expected return, the certainty of the return, and the return offered by similar investments in other hospital markets.” The ability to bill for third-party reimbursement will help determine the value of one's care,36 but without supporting evidence in the form of patient outcomes data to justify the quality of one's care, obtaining reimbursement for services rendered will be difficult.39

With the increased demand on various health care services after the implementation of the ACA, third-party reimbursement demands from a wide scope of allied health professions will continue to increase.40,41 The primary determinants of health care costs stem from current procedure technology,42 Internal Classification Disease codes,43 diagnostic related groups,44 and value-driven elements such as relative value units, resource-based relative value scales, and the cost–charge ratio.45–47 The cost of health care will continue to remain a top priority for the U.S. health care system in the years to come. Workman's Compensation has been identified as the most expensive realm of payment, alluding to the need for injury prevention services in the occupational setting.35 Athletic trainers are currently employed in industrial, military, and public safety settings to provide injury prevention and physical rehabilitation services that have helped to reduce Workman's Compensation claims across the United States.48 However, athletic trainers are currently not receiving direct reimbursements for their health care services rendered to injured employees.

The three most significant factors for successful activity-based costing implementation within the health care field are insurance/payer agreements and contracts,22,49–51 full cost-accounting for all aspects of a health care organization/practice/procedure,44,47,52,53 and improvement in the value (the highest quality of care at the lowest possible price) of care with activity-based costing practices through identifying the cost drivers.16,37,54–56

Patient Outcomes and Health Care Quality

A total of 16 articles focused on patient outcomes and health care quality in regard to third-party reimbursement and activity-based costing. Most of the articles were review articles (n = 7) that stemmed from hospital/surgical services or nursing settings. A primary theme within this subgroup was the importance of patient satisfaction and feedback on the value and quality of the health care that was received.57–61 Byrne et al.57 found that advanced nursing certifications not only increased the eligibility for third-party reimbursement, but also positively influenced patient outcomes and satisfaction. Similarly, Coddington and Sands59 found that nurse-managed clinics provided high quality health care with high patient satisfaction ratings, potentially providing a high value alternative to hospital and primary care clinics.

To receive reimbursement, health care providers must provide substantial documentation about their patient care and outcomes. The time commitment that is required to document appropriately adds strain to the work–life balance for health care professionals and also decreases the amount of time directly spent with a patient.62–64 This is important because health care provider work–life balance is one of the primary causes of burnout and work dissatisfaction, which imperils the triple aim of patient care.65 Additionally, health care providers must also be able to speak the “language of business”66 to make patient care, safety, and satisfaction a priority so that reimbursements can be maximized and health care businesses may be profitable. Using new technology to assist in streamlining health care documentation, patient encounters, and outcome measures can help to alleviate the time constraints that are required for reimbursement and simplify and validate the billing/coding processes to expedite payments.15,67 Patient feedback can identify weaknesses within the health care system. From emergency department visits,60 oncology care,68 and post-surgical care,69 the patient can be a driving voice to guide the activity-based costing process to increase patient outcomes, satisfaction, and health care efficiency.

Health Care Efficiency

The smallest subgroup of articles (n = 13) discussed how activity-based costing and third-party reimbursement can affect health care efficiency. Most of the articles were review articles from hospitals and health care organizations (n = 7). Health care efficiency was defined as the ability of an organization or hospital to accurately and efficiently account for its health care services and billing practices, thereby emphasizing the maximization of resources while minimizing waste.13,15 Activity-based costing has displayed promise in identifying the costly non-value–added activities (eg, patient care facilitation or paying office staff to obtain insurance authorizations and billing disputes),13 decreasing patient care delays while increasing care time,62,70 and optimizing the value of health care.71,72

Activity-based costing practices could also capitalize on the scope of practice among all health care professionals, including athletic trainers, which could play a vital role in maximizing health care efficiency.73 However, executive leaders and health care management must play an active role in the efficiency process to monitor and enforce changes in patient care.74,75 For example, adequate personnel support directly affects health care efficiency if the health care provider–patient ratio is too high, which leads to ineffective resource use.76 The contrary is also true; if the personnel support is too low, patient care will be inadequate and health care efficiency will suffer.76 Thus, health care managers must discern and be aware of factors affecting the efficiency and resource use of their health care business.

Health Care Policy and Law

Nineteen articles fell within the health care policy and law subgroup, and most were review articles (n = 12) and represented the nursing profession (n = 9). Health care policies and laws were noted as the drivers for obtaining and maintaining health care reimbursement in the United States. However, these policies can vary greatly from state to state. Thus, health care providers are responsible for knowing what their state regulations are for their credential/professional occupation.77 Allied health care professions have found that legislative efforts can be streamlined and are more effective with the assistance of a lobbyist and support from their organizational stakeholders.78–84

Allied health care practices are directly affected by policy and politics, and these regulations direct patient care practices to avoid health care provider shortages and emphasize best practices.80 As technology continues to grow and become intertwined with health care, the use of technology in allied health practice is a topic that warrants discussion and strategic implementation. Telemedicine could assist in addressing the health care practitioner shortages and consumer views on various health care professions across the country, but telemedicine services are currently not reimbursable in the United States.85 In Massachusetts, telemedicine services (ie, using video conferencing or other technologies to communicate with a health care provider) are currently being vetted for insurance coverage between state health insurance payers and legislators, but a final resolution on these services may not come to fruition for several years.86


Only 2 articles related to the profession of athletic training and third-party reimbursement, but neither article directly addressed or discussed activity-based costing as a means for third-party reimbursement. Manspeaker and Van Lunen87 stated that there is a need for third-party reimbursement education and teaching within athletic training education programs to enhance evidence-based practice instruction, but no additional information was provided on how to overcome this obstacle in athletic training education. Alternatively, Keeley et al.88 found that athletic trainers with high evidence-based practice implementation were forced to use evidence-based practices due to third-party reimbursement guidelines or mandates within their state. These 2 articles specified evidence-based practice as a driving factor for third-party reimbursement within the profession. However, due to the recent integration of evidence-based practice into athletic training practices and educational standards, the profession of athletic training needs time to adjust and implement evidence-based practice strategies into educational programs and health care facilities and practices nationwide.


Activity-Based Costing in the United States

Activity-based costing is being used in various health care professions and settings across the United States to identify the cost drivers of health care procedures, increase the efficiency of health care systems, and reduce waste in personnel efforts and supplies. The versatility of activity-based costing within the health care system allows for varying implementation among professions and settings while still serving as a tool to evaluate the efficiency and value of the care provided.11,46 The value of a health care procedure, visit, or patient encounter is the driver of third-party reimbursement.36,37,45 One of the primary outcomes from using the activity-based costing method in health care is cost containment by establishing full, accurate cost accounting measures for all expenses within a patient's care plan.46,47,51,89,90

Although activity-based costing is preferred by many to help their health care business practices,44,58 this costing method has positive and negative financial implications. The premise of activity-based costing is to cut costs and streamline patient care and billing processes. However, the financial ramifications of these savings may decrease the profitability and profit margins of health care providers and organizations.47,91 Thus, it is important for health care providers, professions, and organizations to know that the activity-based costing method may not be an effective means to make their business more profitable, but rather a systematic method to make their billing practices and resource use more economic.

Activity-based costing emphasizes high quality health care that can produce higher reimbursements and profit margins, but this cannot occur without strong management and leadership within the health care organization.74,92 Health care complications such as surgical infections, negative patient outcomes data, and non-value–added administrative delays in patient care can increase operating costs for the health care provider, which ultimately decreases profits.61,69 Health care executives and managers must be strategic and analytical decision makers to ensure that the health care process is not only efficient, but also resilient when under duress.74,75 Initial research has shown promise that athletic trainers can improve health care efficiency in a clinical/physician practice setting.93,94 However, the long-term effect of health care costs and patient outcomes with the addition of athletic trainers in the health care market is currently unknown.

Activity-Based Costing in Massachusetts

Activity-based costing has been an effective cost reduction and patient outcome improvement method for various orthopedic procedures within Massachusetts.12,17,55 Allied health professions such as occupational therapy, physician assistants, physical therapy, speech therapy, and nursing have been included on activity-based costing payment/bundled contracts within the state55; however, athletic trainers are typically not included due to the current status of the law, which creates barriers for reimbursement.

The main drivers of health care costs found in the collected literature were associated with surgical orthopedic procedures. Within Massachusetts, activity-based costing is becoming a popular billing method within orthopedic practices at several institutions.12,32,55 Time-based activity-based costing, or activity-based costing practices during a specific time period, has shown great promise to reduce costs of a surgical orthopedic procedure. However, most costs from the procedures stem from the shortest intervention within the entire care process: the surgery.54,95 In Massachusetts, postoperative rehabilitation is not the main cost driver of an orthopedic procedure, creating an obstacle to justify third-party reimbursement for allied health professionals despite the fact that postoperative care is the longest and most extensive phase within the activity-based costing model.12,54,55

Activity-Based Costing and Athletic Training

This review identified two articles that pertained to third-party reimbursement for athletic training in regard to evidence-based practices and education, but neither article addressed activity-based costing as a means for identifying the costs and potential reimbursements for athletic training services. A lack of literature on activity-based costing and third-party reimbursement practices for athletic training does not infer that reimbursement is not possible for athletic training, but rather that these reimbursement avenues have not yet been explored. The long-term benefits of activity-based costing after the implementation of the ACA are still unknown and the value and use of activity-based costing within various allied health professions for postoperative physical rehabilitation services and care are still developing.12

Nurses in Massachusetts have used activity-based costing billing practices to negotiate prices for long-term, inpatient rehabilitation services, but these agreements do not apply to outpatient or at-home services for postoperative services.44 Initial opposition to third-party reimbursement for allied health professions is well documented within the literature,24,77,96 and opposition to third-party and activity-based costing billing practices for athletic training services should be anticipated, especially for outpatient, long-term, community-based physical rehabilitation and other health care services. To that end, a scarcity of supporting literature to justify payment for athletic training services in the general population, outside of sports and recreation, is a potential hindrance for athletic trainers obtaining future third-party reimbursement. It is recommended that the National Athletic Trainers' Association and the Athletic Trainers of Massachusetts perform both local and national simulation models31 to quantify the costs, savings, and potential patient outcomes/health care quality that athletic trainers provide within various occupational and health care settings in Massachusetts and the United States.

Study Limitations

There are several limitations within this review. First, only four databases were used for the literature search. Additional searches within broad-based databases (ie, Google Scholar) or journals related to health care could yield additional information and articles that were not identified in this review. Second, no articles were found that directly addressed or were related to activity-based costing or third-party reimbursement within the profession of athletic training. Thus, the lack of specific and tangible information on activity-based costing and third-party reimbursement for athletic training makes conclusions and translation of activity-based costing from other allied health professions to the profession of athletic training potentially biased or speculative.

Finally, the number of articles that met the inclusion criteria was low (29.1% inclusion rate), which could also lead to biased interpretation of the literature. To that end, 42% (n = 42) of the articles found in this literature review were literature/general review articles and a small amount (n = 21, 21%) were prospective/original research articles that provided raw data on the topic, which also may lead to biased interpretation of the current research on activity-based costing and third-party reimbursement strategies. Additional prospective studies exploring the use of activity-based costing in emerging health care settings and for a wide variety of health care procedures are warranted to expand the body of knowledge on this topic so that potential bias may be reduced.


Activity-based costing originated within the manufacturing field to increase efficiency, minimize wasted resources, and identify the cost drivers of the manufacturing process. Value-based billing, or activity-based costing, is an emerging practice within the U.S. health care system and the state of Massachusetts as a means to control the rising costs of health care, increase the value of care, and provide an alternative to fee-for-service billing. Athletic trainers are credentialed and licensed to provide preoperative and postoperative care for patients, but they currently cannot bill for third-party reimbursement in the state of Massachusetts, which eliminates their services from an activity-based costing payment agreement. Through activity-based costing simulation modeling, athletic trainers may be able to justify their health care services and substantiate the value of their patient care to become a third-party reimbursable allied health profession in the state of Massachusetts.

Future Research

Simulation modeling has been used to identify potential and unidentified cost drivers within the emergency department and hospitals within the United States to simulate the potential costs, benefits, and outcomes from using activity-based costing in new areas of health care.31,52 It is recommended that athletic training organizations use this type of modeling to evaluate, validate, and justify their health care services to provide payers with quantifiable evidence as to why they should be included in activity-based costing payment agreements. Collecting and tracking health care resource use, patient care costs (via International Classification of Disease and Current Procedural Technology codes), and short- and long-term patient outcomes could establish the first health care practice benchmarks for the profession of athletic training.33

To provide the most accurate and unbiased assessment of activity-based costing for the profession of athletic training, future research and financial analyses need to be focused and isolated to athletic training services in all of the various practice settings in which athletic trainers are employed. It is recommended that the profession of athletic training consider creating a national databank that monitors, audits, tracks, and reports athletic training patient outcomes, procedures, and costs so that the quality, quantity, and value of athletic training services can be tracked and trended over time. Additionally, future activity-based costing–centered orthopedic procedures should identify athletic training as an allied health care and physical rehabilitation provider because many athletic trainers are currently providing these services in the secondary school and university settings. Supplementary research is warranted to compare the cost, patient outcomes, and effects of athletic trainers and physical therapists as physical rehabilitation providers for activity-based costing procedures. Evaluating the similarities and differences between the practices of athletic trainers and physical therapists may affect and open new cost-effective billing and reimbursement structures across Massachusetts and the United States.

Across the United States, payer type significantly affects the expenses of orthopedic procedures, particularly the non-value–added activity expenses.34,35 In addition to payer type, the length of hospital stay, time of a procedure, and severity of an orthopedic procedure are the main drivers for determining the overall cost.32,54 Future research focusing on prioritizing patient care efforts, decreasing the amount of time spent on non-value–added activities, and reducing health care administration costs within the athletic training setting is warranted.


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Article Search Summary

DatabaseArticles IdentifiedArticles Excluded (Including Duplicates)Articles Included
Gale Business Insights: Essentials341618
Gale Nursing and Allied Health Collection18113843
Ovid Healthstar523715

Article Synthesis Summary

Literature Review ThemeFocal Health Profession in Article (n)Type of Article (n)
Procedure costOrthopedics (5)Prospective analysis (6)
Hematology (2)Retrospective analysis (3)
Palliative care (1)Case study (3)
Nursing (1)Scholarly commentary (2)
Alternative Medicine (1)
Radiology (1)
Cardiology (1)
Emergency medicine (1)
Oncology (1)
FinanceHospitals/community health centers (16)Review article (16)
Nursing (4)Scholarly commentary (7)
Nutrition (4)Prospective analysis (6)
Primary care (3)Retrospective analysis (5)
Occupational therapy (2)Periodical summary (1)
Optometry (1)
Orthopedics (1)
Holistic medicine (1)
Diabetes care (1)
Health education (1)
Therapeutic recreation (1)
Patient outcomes/health care qualityHospital/surgical services (5)Review article (7)
Nursing (5)Prospective analysis/original research (4)
Physical therapy (2)Scholarly commentary/editorial (3)
Oncology (1)Retrospective analysis (2)
Emergency medicine (1)
Diabetes (1)
Primary care (1)
Health care efficiencyHospital/health care organizations (6)Review article (7)
Nursing/allied health (3)Prospective analysis/original research (3)
Emergency medicine (1)Retrospective analysis (2)
Ophthalmology (1)Scholarly interview (1)
Urology/obstetrician gynecology (1)
Radiology (1)
Health care policy/lawNursing (9)Review article (12)
Hospitals/health care organizations (3)Scholarly commentary (4)
Psychiatry/psychology (2)Original research/prospective study (2)
Diabetes (1)Public address (1)
Occupational therapy (1)
Nutrition (1)
Radiology (1)
Midwifery (1)
Uncategorized/miscellaneousAthletic training (2)Prospective analysis (2)

From Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts (ESW); and Lasell College, Newton, Massachusetts (DMR).

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank Brian FitzGerald, BSN, ATC, for his wisdom, energy, and support of this manuscript and his enduring legislative efforts for the athletic training profession.

Correspondence: Elizabeth Suzanne Wolfe, CAGS, ATC, 179 Longwood Avenue, Boston, MA 02115. E-mail:

Received: December 20, 2016
Accepted: June 15, 2017
Posted Online: October 6, 2017


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