Reading Rehabilitation Hospital: Implementing Patient-Focused Care 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 Reading Rehabilitation Hospital: Implementing Patient-Focused Care case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Reading Rehabilitation Hospital: Implementing Patient-Focused Care case study is a Harvard Business School (HBR) case study written by Jody Hoffer Gittell, Mason Brown. The Reading Rehabilitation Hospital: Implementing Patient-Focused Care (referred as “Care Patient” from here on) case study provides evaluation & decision scenario in field of Technology & Operations. It also touches upon business topics such as - Value proposition, Marketing.

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 Reading Rehabilitation Hospital: Implementing Patient-Focused Care Case Study

Reading Rehab Hospital has experimented with a popular new concept in health care--patient-focused care--intended to increase quality and reduce costs by organizing care delivery around particular diagnoses or "service lines," rather than around the functions or disciplines of the care providers. It is equivalent to product rather than process focus. Rehabilitation involves multiple disciplines which must share information about their evaluations of the patient, about planned treatments, and about patient progress. The decisions and actions of one care provider depend on those of another. This case illustrates the effects of a problem fundamental to service operations--variable demand and the limitations of organizing production by service lines under conditions of uncertain demand, due to the loss of pooling. Finally, its methods, for achieving the coordination benefits of service lines under conditions where the level or stability of demand is insufficient to justify the use of service lines.

Case Authors : Jody Hoffer Gittell, Mason Brown

Topic : Technology & Operations

Related Areas : Marketing

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Calculating Net Present Value (NPV) at 6% for Reading Rehabilitation Hospital: Implementing Patient-Focused Care Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10013655)	-10013655	-	-
Year 1	3451112	-6562543	3451112	0.9434	3255766
Year 2	3980139	-2582404	7431251	0.89	3542310
Year 3	3938932	1356528	11370183	0.8396	3307203
Year 4	3247257	4603785	14617440	0.7921	2572132
TOTAL			14617440		12677411

The Net Present Value at 6% discount rate is 2663756

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

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. Care Patient 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 Care Patient 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 Reading Rehabilitation Hospital: Implementing Patient-Focused Care

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 Care Patient 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 Care Patient 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	(10013655)	-10013655	-	-
Year 1	3451112	-6562543	3451112	0.8696	3000967
Year 2	3980139	-2582404	7431251	0.7561	3009557
Year 3	3938932	1356528	11370183	0.6575	2589912
Year 4	3247257	4603785	14617440	0.5718	1856630
TOTAL					10457065

The Net NPV after 4 years is 443410

(10457065 - 10013655 )

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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	(10013655)	-10013655	-	-
Year 1	3451112	-6562543	3451112	0.8333	2875927
Year 2	3980139	-2582404	7431251	0.6944	2763985
Year 3	3938932	1356528	11370183	0.5787	2279475
Year 4	3247257	4603785	14617440	0.4823	1566000
TOTAL					9485386

The Net NPV after 4 years is -528269

At 20% discount rate the NPV is negative (9485386 - 10013655 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Care Patient 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 Care Patient has a NPV value higher than Zero then finance managers at Care Patient 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 Care Patient, then the stock price of the Care Patient 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 Care Patient 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 will be a multi year spillover effect of various taxation regulations.

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 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.

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 Reading Rehabilitation Hospital: Implementing Patient-Focused Care

References & Further Readings

Jody Hoffer Gittell, Mason Brown (2018), "Reading Rehabilitation Hospital: Implementing Patient-Focused Care Harvard Business Review Case Study. Published by HBR Publications.