Telemonitoring at Visiting Nurse Health System Net Present Value (NPV) / MBA Resources

Introduction to Net Present Value (NPV) - What is Net Present Value (NPV) ? How it impacts financial decisions regarding project management?

NPV solution for Telemonitoring at Visiting Nurse Health System case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Telemonitoring at Visiting Nurse Health System case study is a Harvard Business School (HBR) case study written by F. Warren McFarlan, Mark Keil, Mala Kaul. The Telemonitoring at Visiting Nurse Health System (referred as “Telemonitoring Vnhs” from here on) case study provides evaluation & decision scenario in field of Technology & Operations. It also touches upon business topics such as - Value proposition, Project management.

The net present value (NPV) of an investment proposal is the present value of the proposal’s net cash flows less the proposal’s initial cash outflow. If a project’s NPV is greater than or equal to zero, the project should be accepted.

NPV = Present Value of Future Cash Flows LESS Project’s Initial Investment

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Case Description of Telemonitoring at Visiting Nurse Health System Case Study

The Telemonitoring at Visiting Nurse Health System case presents one home healthcare organization's efforts to use telemonitoring to improve the quality of care provided to at-risk patients who were discharged from hospitals and needed home care. After two years of using the Health Buddy system for telemonitoring at-risk patients, Mark Oshnock, President of Visiting Nurse Health System (VNHS) must decide whether to invest in buying more Health Buddy units. While Oshnock believed that there were real benefits associated with telemonitoring, he was having difficulty quantifying those benefits and he was concerned about VNHS' ability to continue investing resources in telemonitoring given the realities of the health care reimbursement environment in which they operated. While several studies had demonstrated the benefits of telemonitoring, Oshnock felt that the long-term benefits accruing to the health system as a whole were not immediately quantifiable or visible to the hospitals and insurance companies. Without external support for the telemonitoring initiative from insurance companies, it would be difficult for VNHS to keep up the momentum and ramp up telemonitoring through additional purchases of Health Buddy units. From a purely financial standpoint, such an investment would be very difficult for VNHS to justify. The irony was that with the new regulatory pressures and increased focus on preventative healthcare, telemonitoring pointed to an effective tool in managing and reducing acute care hospitalizations. However, balancing these benefits against limited financial support from other key players in the health care system would be challenging.

Case Authors : F. Warren McFarlan, Mark Keil, Mala Kaul

Topic : Technology & Operations

Related Areas : Project management

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Calculating Net Present Value (NPV) at 6% for Telemonitoring at Visiting Nurse Health System Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10021752)	-10021752	-	-
Year 1	3455388	-6566364	3455388	0.9434	3259800
Year 2	3957730	-2608634	7413118	0.89	3522366
Year 3	3941498	1332864	11354616	0.8396	3309358
Year 4	3239223	4572087	14593839	0.7921	2565768
TOTAL			14593839		12657291

The Net Present Value at 6% discount rate is 2635539

In isolation the NPV number doesn't mean much but put in right context then it is one of the best method to evaluate project returns. In this article we will cover -

Different methods of capital budgeting

What is NPV & Formula of NPV,
How it is calculated,
How to use NPV number for project evaluation, and
Scenario Planning given risks and management priorities.

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Capital Budgeting Approaches

Methods of Capital Budgeting

There are four types of capital budgeting techniques that are widely used in the corporate world –

1. Payback Period
2. Profitability Index
3. Net Present Value
4. Internal Rate of Return

Apart from the Payback period method which is an additive method, rest of the methods are based on Discounted Cash Flow technique. Even though cash flow can be calculated based on the nature of the project, for the simplicity of the article we are assuming that all the expected cash flows are realized at the end of the year.

Discounted Cash Flow approaches provide a more objective basis for evaluating and selecting investment projects. They take into consideration both –

1. Magnitude of both incoming and outgoing cash flows – Projects can be capital intensive, time intensive, or both. Telemonitoring Vnhs shareholders have preference for diversified projects investment rather than prospective high income from a single capital intensive project.
2. Timing of the expected cash flows – stockholders of Telemonitoring Vnhs have higher preference for cash returns over 4-5 years rather than 10-15 years given the nature of the volatility in the industry.

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Formula and Steps to Calculate Net Present Value (NPV) of Telemonitoring at Visiting Nurse Health System

NPV = Net Cash In Flowt1 / (1+r)t1 + Net Cash In Flowt2 / (1+r)t2 + … Net Cash In Flowtn / (1+r)tn
Less Net Cash Out Flowt0 / (1+r)t0

Where t = time period, in this case year 1, year 2 and so on.
r = discount rate or return that could be earned using other safe proposition such as fixed deposit or treasury bond rate. Net Cash In Flow – What the firm will get each year.
Net Cash Out Flow – What the firm needs to invest initially in the project.

Step 1 – Understand the nature of the project and calculate cash flow for each year.
Step 2 – Discount those cash flow based on the discount rate.
Step 3 – Add all the discounted cash flow.
Step 4 – Selection of the project

Why Technology & Operations Managers need to know Financial Tools such as Net Present Value (NPV)?

In our daily workplace we often come across people and colleagues who are just focused on their core competency and targets they have to deliver. For example marketing managers at Telemonitoring Vnhs often design programs whose objective is to drive brand awareness and customer reach. But how that 30 point increase in brand awareness or 10 point increase in customer touch points will result into shareholders’ value is not specified.

To overcome such scenarios managers at Telemonitoring Vnhs needs to not only know the financial aspect of project management but also needs to have tools to integrate them into part of the project development and monitoring plan.

Calculating Net Present Value (NPV) at 15%

After working through various assumptions we reached a conclusion that risk is far higher than 6%. In a reasonably stable industry with weak competition - 15% discount rate can be a good benchmark.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 15 %	Discounted Cash Flows
Year 0	(10021752)	-10021752	-	-
Year 1	3455388	-6566364	3455388	0.8696	3004685
Year 2	3957730	-2608634	7413118	0.7561	2992612
Year 3	3941498	1332864	11354616	0.6575	2591599
Year 4	3239223	4572087	14593839	0.5718	1852036
TOTAL					10440933

The Net NPV after 4 years is 419181

(10440933 - 10021752 )

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Calculating Net Present Value (NPV) at 20%

If the risk component is high in the industry then we should go for a higher hurdle rate / discount rate of 20%.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 20 %	Discounted Cash Flows
Year 0	(10021752)	-10021752	-	-
Year 1	3455388	-6566364	3455388	0.8333	2879490
Year 2	3957730	-2608634	7413118	0.6944	2748424
Year 3	3941498	1332864	11354616	0.5787	2280959
Year 4	3239223	4572087	14593839	0.4823	1562125
TOTAL					9470998

The Net NPV after 4 years is -550754

At 20% discount rate the NPV is negative (9470998 - 10021752 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Telemonitoring Vnhs to discount cash flow at lower discount rates such as 15%.

Acceptance Criteria of a Project based on NPV

Simplest Approach – If the investment project of Telemonitoring Vnhs has a NPV value higher than Zero then finance managers at Telemonitoring Vnhs can ACCEPT the project, otherwise they can reject the project. This means that project will deliver higher returns over the period of time than any alternate investment strategy.

In theory if the required rate of return or discount rate is chosen correctly by finance managers at Telemonitoring Vnhs, then the stock price of the Telemonitoring Vnhs should change by same amount of the NPV. In real world we know that share price also reflects various other factors that can be related to both macro and micro environment.

In the same vein – accepting the project with zero NPV should result in stagnant share price. Finance managers use discount rates as a measure of risk components in the project execution process.

Sensitivity Analysis

Project selection is often a far more complex decision than just choosing it based on the NPV number. Finance managers at Telemonitoring Vnhs should conduct a sensitivity analysis to better understand not only the inherent risk of the projects but also how those risks can be either factored in or mitigated during the project execution. Sensitivity analysis helps in –

What are the uncertainties surrounding the project Initial Cash Outlay (ICO’s). ICO’s often have several different components such as land, machinery, building, and other equipment.

Understanding of risks involved in the project.

What can impact the cash flow of the project.

What are the key aspects of the projects that need to be monitored, refined, and retuned for continuous delivery of projected cash flows.

What will be a multi year spillover effect of various taxation regulations.

Some of the assumptions while using the Discounted Cash Flow Methods –

Projects are assumed to be Mutually Exclusive – This is seldom the came in modern day giant organizations where projects are often inter-related and rejecting a project solely based on NPV can result in sunk cost from a related project.

Independent projects have independent cash flows – As explained in the marketing project – though the project may look independent but in reality it is not as the brand awareness project can be closely associated with the spending on sales promotions and product specific advertising.

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Negotiation Strategy of Telemonitoring at Visiting Nurse Health System

References & Further Readings

F. Warren McFarlan, Mark Keil, Mala Kaul (2018), "Telemonitoring at Visiting Nurse Health System Harvard Business Review Case Study. Published by HBR Publications.