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Analysis of Total Cost of Ownership (TCO) Applied to Processes of Biomedical


Technology Acquisition Competitive Intelligence
1

J. G. Barreneche1, A. M. Hernndez1, J. H. Garca1,

Grupo de Investigacin en Bioinstrumentacin e Ingeniera Clnica GIBIC


Programa de Bioingeniera, Universidad de Antioquia, Calle 67 N. 53-108, Oficina: 19-419, Medelln, Colombia.

Abstract The assessment of biomedical technology


framed in the Ministry of Social Protection Decree # 4725 of
2005 performed as part of the acquisition processes is of
great importance for health care institutions in Colombia..
Medical technology, being costly and complex, requires
detailed processes with rigorous methodologies that
guarantee an accurate assessment and transparent
acquisition process. The most important aspects to consider,
although not the only one is the economic assessment, which
has always had a great weight in the assessment processes,
even when not many variables are considered and financial
projections over time are not always carried out. This paper
aims to incorporate variables as the Total Cost of Ownership
(TCO), the technology life cycle, and the Net Present Value,
in the process of economic evaluation. Additionally, the
paper presents one of the most representative results
obtained in the acquisition processes carried out during the
last five years in different health care institutions in
Colombia, the assessment of a PET-CT using the proposed
methodology.
Keywords Health technology assessment, Total cost of
ownership, biomedical devices, biomedical technology, PETCT, Life cycle, clinical engineering, Net present value.

I.

INTRODUCTION

The health sector has every day a greater dependency


on technologies, particularly on biomedical equipment,
which belong to the medical devices class. This
equipment is regulated by strict international standards
that cover every phase of their life cycle. Fig. 1 shows the
phases in the life cycle of the biomedical technology.
Due to the high number of innovations of these kind of
technologies, which for developing or emerging countries
hit the market in a frequency superior than the capacity of
the health institutions to buy them. In addition to this, and
due to the high cost that represents the acquisition of
biomedical technology for a health care institution, it is
necessary to perform biomedical technology assessment
and acquisition processes.

MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE


978-1-4673-6968-8/15/$31.00 2015 IEEE

Fig. 1. Technology life cycle, adapted from [1].

The medical devices sector in Colombia bases its


economy in foreign technologies, with the United States
of America being one of the main suppliers. According to
the US Commerce Department, Colombia is the 22nd
country in their list of countries to which they export
technology. Just in 2011, the exports value rose to US 325
million. Additionally, after the signing of the Free Trade
Agreement between these two countries, about 96% of the
medical technology that comes to Colombia from US is
duty free. That explains why medical technology
assessment models are gaining greater importance every
day and are vital for the Colombian health sector.
The INVIMA (Instituto Nacional de Vigilancia de
Medicamentos y Alimentos), in Colombia makes the
function like the FDA in USA, medical devices classified
based on the duration of contact with the body,
invasiveness and local effect against systemic effects
among four classes:

Class I: low risk.

Class IIa: moderate risk.

Class IIb: high risk.

Class III: very high risk


The equipment analyzed in this assessment is
considered very high risk [25].

ISBN: 978-1-4673-6968-8
IEEE Catalog Number: CFP1518G-ART

2015 PAN AMERICAN HEALTH CARE EXCHANGES (PAHCE). CONFERENCE, WORKSHOPS, AND EXHIBITS. COOPERATION / LINKAGES.
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The process of technology assessment and acquisition


must be performed with clear, fair, and integral criteria.
The following components are part of the criteria: the
compliance with the technical features, the compliance
with the after-sales agreements or conditions, the analysis
and compliance with the economic conditions in the
whole life cycle of the technology, as well as the analysis
of economic and financial projections concerning the
technology to be acquired [23]. Those are some important
factors when performing an assessment of technology,
and different technology assessment and acquisition
models consider them. Generally, such models are
focused on the compliance with the technology standard
of the National Health Certification System in Colombia
and the valid applicable regulations [1-3].
This article presents the inclusion of a strict economic
analysis to the medical equipment acquisition model. In
addition, this article uses concepts of the analysis of the
Total Cost of Ownership (TCO) of the biomedical
technology before this be acquired by the health care
institution. To the same extent, it is based in the
calculation of the Net Present Value (NPV) of the
investment to be executed, so it is possible to visualize all
the possible costs related to the biomedical technology in
study during its projected life cycle. It also presents the
results of the application of this methodology in the
selection of a positron emission tomography (PET-CT)
for the Pablo Tobn Uribe Hospital in Medellin,
Colombia.
II.

METHODOLOGY

The Total Cost of Ownership (TCO) has been widely


used in the information technology industry and has been
successfully adapted to other fields [7]. Total Cost of
Ownership is defined as that variable that includes all the
possible costs of acquisition, use, maintenance, and
operation of a product before making the decision of
buying it [8]. One of the main difficulties for
incorporating this variable to the economic studies is that
it involves a great amount of work because the process is
not standardized [9].
In recent years, there have been made significant
efforts to develop a technology acquisition model [23]
[24] and with the incorporation of the previously
mentioned variables, it has been applied in tertiary
hospitals and clinics in Colombia during the last five
years, namely: Centro Mdico Imbanaco, Clnica
Comfenalco, Hospital la Maria, Clnica del Prado and
Pablo Tobn Uribe Hospital. With the study of economic
variables that allow the projection of the equipment cost
over time, there will be revealed for each medical device
the possible hidden costs that exist and, even, it will be
possible to compare the different companies of medical
MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE

equipment that participate in the invitation to quote the


technology.
The TCO is the cost involved in the operation of a
system (a biomedical equipment in this case) during its
lifetime within a company. Said estimate was used
initially in systems and information technology
equipment; however, it was adapted for the biomedical
equipment and was called Life Cycle Cost. Such
adaptation is based on the graph on Fig. 2, which shows
all the variables that affect the total cost of a biomedical
equipment.

Fig. 2. Aspects to consider in the estimation of the life cycle of a


biomedical equipment.

The items to consider vary in the execution of the


projects following the information delivered by the
suppliers. However, it is recommended to include the
following aspects, which should be delivered by each
proposer in a form:

Initial value: Acquisition value of the


biomedical equipment (it must be delivered with
and without VAT as there is the possibility for
some projects to not pay this tax for being located
in a free zone or that this value be returned for
being state institutions)

Import costs: For some health


institutions, it can represent a saving to carry out a
negotiation at international level directly with the
head office of the biomedical technology. This
negotiation is carried out by means of the use of
INCOTERMS
according
to
the
offered
INCOTERM, it is performed a projection of the
costs related to the import, transportation,
insurance,
shipment
cost,
technology
nationalization, currency exchange rate. Generally,
the negotiation is done in terms of EXW (Ex
Works), which means the purchase of the
technology at the manufacturer's factory.

Warranties: The range of the warranty


offered by the participant in the technology
ISBN: 978-1-4673-6968-8
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2015 PAN AMERICAN HEALTH CARE EXCHANGES (PAHCE). CONFERENCE, WORKSHOPS, AND EXHIBITS. COOPERATION / LINKAGES.
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acquisition project is revised, this with the goal of


not including in the estimate of the life cycle cost
the elements included during the offered years,
typically the maintenance and the metrological
assurance are exempted.

carried out under the following conditions that come


mostly from economic studies from Banco de la
Repblica de ColombiaBank of the Republic (see
Table 1).

Maintenance costs: The costs of preemptive and corrective maintenance, spare parts
and special components during the life cycle of the
technology are projected.

Metrological assurance cost: The costs


for the metrological assurance during the projected
life cycle are estimated, additionally, an analysis is
carried out in order to estimate the cost of the
agreements that exist compared to the purchase of
the patterns and the necessary staff for the
execution of the tests.

Consumable costs: The expenses of the


most important consumables of the evaluated
biomedical equipment are estimated, projecting an
operation similar or superior than that one that the
health care institutions has at that time.

Operation costs: It is estimated the


operation consumption of the basic services, such
as water, electricity, gas, among others.

Pre-installation cost: If there are costs


related to major adjustments and that allow a
comparison between offered models, they will be
estimated and added to the Life cycle cost.

Update costs: At the assessment and


acquisition stage, it is necessary to enquire about
the cost of software updates, interoperability,
connectivity not included initially but with the
possibility of being acquired in the future.

Final disposal cost: The cost of final


disposal of the technologies once their life cycle
has ended is projected.

Training cost: There is a projection of


the cost that must be covered if there are training
or practice sessions for the technology operation
and maintenance.
These parameters serve to perform the analysis at Net
Present Value (NPV) for simulations to 5, 7 and 10 years
of operation, following these stages:
A. Stage 1: Indexes definition
The economic evaluation process starts with the
definition of some standard variables for the technology
assessment, each project has its own variables and
assumptions; however, in most of the cases, the job is

MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE

Table 1. Necessary information for the economic analysis, taken


from Banco de la Repblica de Colombia [10].

The following items compose the general information


for the economic analysis of the proposals:

MER Market Exchange Rate, amount


of Colombian pesos (COP) per US dollar (USD)
. The MER is taken at a value greater than the
market average in the last 3 months, in order to
have a safety margin.

Euro to Dollar Rate amount of US


dollars (USD) per Euro; it is taken at a value
greater than the market average of the last 3
months.

Capital cost; the WACC (weighted


average cost of capital) is calculated for a project
in particular, which is the minimum return that the
company must receive in an evaluated operation. It
is used as the discount rate for the calculation of
the Net Present Value.

The CPI (Consumer Price Index)


measures the price variation of a basket of goods
and services representative of the consumption in
Colombian households; it is used as the base of the
increment operations in the project.
These indicators are used normally for projects to 10
years, for which these increases are estimated during that
period.
B. Stage 2: Acquisition of preliminary information:
In this stage, it is necessary to get estimates in
previously defined way that response the concerns related
to the life cycle. It should be noted that the model requires
ISBN: 978-1-4673-6968-8
IEEE Catalog Number: CFP1518G-ART

2015 PAN AMERICAN HEALTH CARE EXCHANGES (PAHCE). CONFERENCE, WORKSHOPS, AND EXHIBITS. COOPERATION / LINKAGES.
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this kind of information to be clear and accurate in order


to allow the model to be complete and comprehensive. In
order to avoid mismanagement, it is necessary to establish
beforehand dates for the proposal reception.
C. Stage 3: Information reception and
analysis
The information is received and processed checking if
the necessary fields and parameters for the economic
assessment of the technology are complete. In this stage,
it is necessary to give feedback to suppliers in order to be
able to request missing or incomplete information. In
order to avoid mismanagement, it is necessary to establish
beforehand dates for giving such feedback to each
participant. It is worth mentioning that suppliers in this
stage could not make changes to the proposals, they
would be able to change only the parameters the model
may need.
D.

It is necessary to define a period of time to consider


these costs, generally, for biomedical technology they are
projected in periods of 5, 7 or 10 years.
In the case of PET-CT, the model is executed
integrating more data from the life cycle into the TCO
equation in different stages including the following data:

Using the following expression [5] it is possible to


obtain the calculation of the Net Present Value of the
Total Cost of Ownership of the technology of each
commercial firm (1):
  
  

Maintenance Cost
Quality Control Cost
Consumable Cost XR tube
Generator Cost
Power Source Cost
Insurances

E. Stage 5: Results analysis and recommendations:

Stage 4: Indexes estimation

The information is standardized, so all the proposals in


analysis are comparable. It is not possible, for instance,
comparing the maintenance agreement of supplier A that
includes all spare parts in case of a failure to that one of
supplier B that only includes labor.

 

CO, the operation costs, CP, the pre-installation costs,


CA, the update Costs, CC, the training costs and VS, the
salvage value.

The results analysis should explain the components of


the life cycle and their individual contribution to the total
cycle of the technology evaluated and offered by each
commercial firm using the economic parameters of the
life cycle. This will generate total economic values that
summarize all the previously described variables, so the
model adds key information to the decision making
process in relation to the technology acquisition. The
equipment value including the variables of the economic
analysis can be included in the general technology
assessment model described in other studies [23],[24].

(1)
III.

RESULTS

Where:
VALUES refers to the costs that arise after the
warranty period and
Rate refers to the discount rate or, in this scenario, the
WACC taken from the health sector.
In relation to the TCO calculation, the equation (2) is
used for obtaining the Total Cost of Ownership of the
biomedical technology [6]:
             
    )
(2)
Where VI is the initial value,
CM, the maintenance costs, CMT, the metrological
assurance costs, CC, the consumable costs,

MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE

With the goal of illustrating the economic assessment


procedure, this study presents the results of the
assessment performed for the purchase of biomedical
equipment
called
PET-CT
(positron
emission
tomography) that combines computerized tomography
(CT) with the positron emission tomography (PET). This
device allows the imaging at molecular and physiological
level showing the presence of cancer cells in the patient's
body [26]. Although, generally, it is used after a
chemotherapy process with the aim of knowing whether
the treatment was effective or there are remnants of
malignant cells that can trigger the disease in the patient
once again, it has other applications at neurological and
cardiological level [4].. From a technical point of view,
the evaluated PET-CT has the capability to take 64 cuts.
The presented information corresponds to the
acquisition process of the Pablo Tobn Uribe Hospital in
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the city of Medellin-Colombia, in 2011, institution that


gave its consent for the information dissemination. The
technology assessment presented was part of the
renovation and expansion project of the radiology service
of said institution, the assessment was carried out with a
projection into 5 years because they wanted to assess the
project comparing the direct buy option of the technology
to a leasing option offered to 5 years. Regarding the PETCT, it had two technology options from two different
suppliers, each device satisfied the strict technical
requirements (hereunder, technologies A and B).
The assessment of the technical features of both
technologies took into account the following aspects,
among
others:
- Time delivery in days
- Time-Year warranty
- Number Of maintenance during the warranty
- Training Technique in hours
- Availability of technical support in the City
Additionally, the after-sale conditions were considered.
The technical analysis, which is not part of this
assessment, showed that device B doubles device A in
technological capabilities, which reflected in a lower
initial cost in device A compared to device B (see Fig. 2).
Proposal B differs from proposal A in USD$ 407.450,
taking into account only the initial investment. If a
decision were to be made with this economical
information, this decision would be inclined towards
device A, as both devices meet the basic technical
requirements.

possible leasing for the acquisition of the same device.


In the first assessment of economic variables, the
system receives the information of the maintenance costs
and the metrological assurance costs (for this kind of
technology, these should be taken as the system quality
control), the projection is initially done to 5 years. Fig. 4
shows the results of this iteration of the model integrating
more information.

Fig. 4. TCO with maintenance and metrology

We can see that the cost difference between both


brands after integrating these two variables was USD$
518.823, being lower the necessary investment form
brand A. This confirms the first hypothesis obtained in
the initial investment analysis. It is usual that technology
assessment processes at cost level conclude with the
information obtained until this point, which limits the
decision ability of those in charge of technology
acquisition in health care institutions.
Including in the analysis the costs of the consumable
accessories necessary for the device operation,
specifically the XR tube, the device generator, and power
source, as well as the insurance costs for the projected
life cycle to 5 years, we obtain the results shown in Fig.
5.

Fig. 3. Initial investment comparison. Clearly the initial investment


in equipment A is lower than B.

As previously mentioned, the model is projected to 5


years. This does not imply that once the 5 years period
has been reached the device will be disposed; this
temporal horizon obeys to the decision of comparing the
direct purchase of the PET-CT technology against a
MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE

It is proved that the difference in the TCO to 5 years


between brands A and B consists in USD$ 4.186, but in
this result, option B is less expensive than option A,
which is completely different to is the projected horizon
without all economic variables and in the comparison of
initial values. It can be concluded that, initially, the
USD$ 407.450 difference that favored the PET-CT brand
A in an analysis that only considered the initial
investment, turns into USD$ 4.186 difference that favors
option B after taking into account all the variables that
define the TCO to 5 years.
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System.
From a financial point of view, the fact of acquiring
technology with certainty of lower life cycling costs,
confirms the importance of performing a comprehensive
analysis that include technical, after-sale, safety-of-thepatient aspects, among others, vital at the moment of
taking a decision about an investment in biomedical
technology.

Fig. 5 TCO with consumables and insurance.

The obvious difference between the presented brands


is due, basically, to the equipment consumables analysis.
There is a consumable or special replacement in
particular, called XR tube, just this element has a cost of
USD$ 185.000 for brand A and USD$ 120.000 for brand
B, and the lifetimes are taken for this analysis according
to a projection of the equipment shoots based on the
Hospital use rates. This gives the information about
necessary replacements scheduled each year for device A
and every 3 years for device B.
Because of this important difference, it was possible to
obtain the results that proved that there were important
hidden costs in biomedical technology and that a health
services institution should consider these aspects in order
to choose a supplier that best adjust to their operation
conditions.

IV.

On the other hand, the economic analysis performed


with the technology life cycle model and the foundations
of the Total Cost of Ownership (TCO), allow the
institutions to have more information and, even, as seen
in the example, to change radically a decision previously
taken with less information. It is important to note that
the hidden costs should, likewise, be assumed by the
health care institution. This implies important increases
in the investment during the time of technology use.
ACKNOWLEDGMENT

This study was supported by the Universidad de


Antioquia through the grant Estrategia de Sostenibilidad
de GIBIC 2011-2012 (SOS11-2-01) The authors express
their gratitude to the Pablo Tobn Uribe Hospital
Engineering Department for gave them access to the
presented information.

CONCLUSIONS

The presented model finds its optimal operating point


when it is fed with the greatest possible amount of
variables. In order to do this, it is necessary to have
comprehensive quotation forms, constant meetings with
the suppliers so they can understand which information is
required, and time to run the models and present detailed
analysis about the model sensitivity to the included
variables.
The presented methodology has significant advantages
over the ability of making decisions in the long term and
not in the short term. In addition, it shows cost situations
that would remain hidden and gives the assessment a
transparency and clarity characteristic typical of
structured and developed processes. At the same time,
this methodology makes possible to meet several
technology standards of the National Health Certification
MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE

ISBN: 978-1-4673-6968-8
IEEE Catalog Number: CFP1518G-ART

2015 PAN AMERICAN HEALTH CARE EXCHANGES (PAHCE). CONFERENCE, WORKSHOPS, AND EXHIBITS. COOPERATION / LINKAGES.
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MARCH 23 28, 2015, VIA DEL MAR, SANTIAGO, CHILE

ISBN: 978-1-4673-6968-8
IEEE Catalog Number: CFP1518G-ART