Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? 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 Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? case study is a Harvard Business School (HBR) case study written by Aaron P. Coulon, James Biteman, Michael Wilson. The Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? (referred as “Hospital Instructor's” from here on) case study provides evaluation & decision scenario in field of Leadership & Managing People. It also touches upon business topics such as - Value proposition, Health, Risk 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 Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? Case Study

Bayou Side Hospital (BSH) is a critical access hospital in rural Louisiana that has offered labor and delivery services to its community since its beginning. However, the viability of this department and the hospital could be threatened by the changing healthcare reimbursement structure brought about by the Affordable Care Act. The decision to discontinue obstetric services would impact BSH's bottom line, but it may also complicate the hospital's relationship with its community and compromise its mission statement. The case will give insight into the complex ethical nature of hospital decision making and the way in which community reciprocity affects rural organizations. The instructor's manual offers a quantitative financial analysis and a qualitative discussion and review of literature on mission statements and community embeddedness. Further, the instructor's manual provides learning objectives, student preparation questions, and an outline for class discussion of the case.

Case Authors : Aaron P. Coulon, James Biteman, Michael Wilson

Topic : Leadership & Managing People

Related Areas : Health, Risk management

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Calculating Net Present Value (NPV) at 6% for Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10029895)	-10029895	-	-
Year 1	3457909	-6571986	3457909	0.9434	3262178
Year 2	3973732	-2598254	7431641	0.89	3536607
Year 3	3951458	1353204	11383099	0.8396	3317720
Year 4	3251468	4604672	14634567	0.7921	2575467
TOTAL			14634567		12691973

The Net Present Value at 6% discount rate is 2662078

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

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. Hospital Instructor's 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 Hospital Instructor's 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 Obstetrics in Rural, Critical Access Hospitals: Is it Feasible?

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 Leadership & Managing People 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 Hospital Instructor's 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 Hospital Instructor's 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	(10029895)	-10029895	-	-
Year 1	3457909	-6571986	3457909	0.8696	3006877
Year 2	3973732	-2598254	7431641	0.7561	3004712
Year 3	3951458	1353204	11383099	0.6575	2598148
Year 4	3251468	4604672	14634567	0.5718	1859037
TOTAL					10468775

The Net NPV after 4 years is 438880

(10468775 - 10029895 )

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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	(10029895)	-10029895	-	-
Year 1	3457909	-6571986	3457909	0.8333	2881591
Year 2	3973732	-2598254	7431641	0.6944	2759536
Year 3	3951458	1353204	11383099	0.5787	2286723
Year 4	3251468	4604672	14634567	0.4823	1568030
TOTAL					9495881

The Net NPV after 4 years is -534014

At 20% discount rate the NPV is negative (9495881 - 10029895 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Hospital Instructor's 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 Hospital Instructor's has a NPV value higher than Zero then finance managers at Hospital Instructor's 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 Hospital Instructor's, then the stock price of the Hospital Instructor's 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 Hospital Instructor's 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 –

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.

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 Obstetrics in Rural, Critical Access Hospitals: Is it Feasible?

References & Further Readings

Aaron P. Coulon, James Biteman, Michael Wilson (2018), "Obstetrics in Rural, Critical Access Hospitals: Is it Feasible? Harvard Business Review Case Study. Published by HBR Publications.