ࡱ> 5@ n%bjbj22 IXX9,nnnn8(Dl<h!&! !@BBBBBB$)R{f"Q!^!""fnn {^&^&^&"n@^&"@^& ^&~&BT ]>:#4F,0z~)#)nnnn)!!^& " "!!!ff$|%The Financial Management of Hospitals and Healthcare Organizations By Michael Nowicki  Chapter 13 Capital Budgeting David Herren July 15, 2007 Outline Capital costs make up a small percentage of total organization costs. They are in the range of six to ten percent for most hospitals. Under cost-based reimbursement from 1966 to 1983, capital costs for new equipment and plants exploded. It was not until the OBRA (Omnibus Budget Reconciliation Act) of 1990 moved capital costs to prospective payment over a ten-year implementation period. This along with the Tax Reform Act of 1986 that lowered the tax deductibility for charitable gifts and restricted the cost of acquiring capital through tax-exempt bond markets has made hospitals a much more risky area. The Tax Reform Act of 1986 lead to a dramatic decline in philanthropy dollars to not-for-profit hospitals. Capital Expenditures Purchases of land, buildings, and equipment for operations; are not for resale; and have a useful life of more than one year, a cost of $500 or more, and are subject to depreciation. Capital Expenditures fall into one of six categories: Land (purchasing and other costs associated with preparing it for use) Land improvements (sidewalks, parking lots) Buildings (construction and buying) Fixed equipment (permanently attached to the building. Example: plumbing system, furnace, air conditioners) Major movable equipment Major repairs that benefit future periods (extend the useful life of a building or piece of equipment) Capital Expenditure Budgets typically fall into two categories Replacement and New. Budgets for replacement capital expenditures include requests to replace existing buildings and equipment that are made for a number of reasons: For scheduled replacement at the end of the useful life or when fully depreciated For improved productivity For improved quality or because it is required by regulation Budgets for new capital expenditures include requests to add buildings and equipment for a number of reasons: Expanded services Improved safety conditions Reduced operating expenses Improved patient care The Capital Budgeting process is done in five steps: Identify and Prioritize Requests The budget committee has to identify and prioritize all capital requests from department managers. Project Cash Flows The department managers must project and the budget committee must confirm cash flows for each request. This is easy for replacement equipment because the numbers already exist. For new equipment, the department manager must obtain figures from either outsourcing volumes, projection volumes from medical record reviews or from neighboring facilities. Perform Financial Analysis This was rarely done when Medicare was reimbursing at cost but now is very important. The typical analyses are payback period analysis, net present value (NPV), and internal rate of return (IRR). Payback Period Analysis Easy to calculate but is the least sophisticated because it does not take into account the effects of time on money. Payback Period = Year before recovery period + unrecovered cost at beginning of year . cash flow during year Discounting allows the calculation of the effect of time on money Present Value = Future Value / ( 1 + i )n i = discount rate n = number of years the money is discounted. Net Present Value Incorporates the effect of time on money. Gives an answer in dollars instead of years. If NPV is positive then the expenditure is generating discounted cash flows in excess of the amount necessary to repay the original investment. NPV = cf0 + cf1 + cf2 + .. cfn . (1+k)1 (1+k)2 (1+k)n k = the capital expenditures discount rate cf = cash flow n = the number of years the money is discounted Internal Rate of Return The discount rate of a capital expenditure where the discounted cash flows equal the expenditures original investment, or the discount rate where the NPV is zero. Gives an answer in a percentage. Difficult to do without a calculator. = cf0 + cf1 + cf2 + .. cfn . (1+IRR)1 (1+IRR)2 (1+IRR)n Identify Nonfinancial Benefits The department manager requesting the capital expenditure identifies nonfinancial benefits for the request. (ex. Community need or medical staff politics). Evaluate Benefits and Make Decisions The budget committee must take in all the information and make decisions on which options to pursue. Financing Capital Expenditures Can be done in a number of ways including using cash generated from philanthropy, funded depreciation, operating surpluses and debt. Generally, an organization should use funded depreciation to finance replacement equipment while using philanthropy, operating surpluses, or debt to finance new equipment. Hospitals finance about 80 to 90 percent of their capital needs with debt. With recent restrictions on philanthropy and many healthcare organizations at debt capacity, future capital expenditures must be financed through operating surpluses. Lease vs. Purchase Decisions The decision to lease or purchase is made after the decision is made to acquire the equipment. There are two types of leases, operating leases and capital leases. Operating leases are for periods less that the equipments useful life and are common for copy machines, computers and cars. Capital leases are for he equipments approximate useful life and usually include provisions of the lessee to purchase the equipment at the end of the lease period. Lease decisions have several advantages over purchase decisions including more flexibility, more financing options, and more protection however, they do cost more. Evaluating Capital Budgeting Performance Several ratios are used to evaluate capital budgeting performance. Debt-to-Capitalization Ratio Long-term debt . (Long-term debt + net assets) Higher values imply a greater reliance on debt financing as a percentage and may imply a reduced ability to carry additional debt. Ingenix hospitals average was 27.4 while A hospitals were 33.8. Capital Expense Ratio (interest expense + depreciation expense) total expense x 100 Provides an indicator of operating leverage. High values imply a greater sensitivity to changes in volume. Ingenix hospitals average was 6.6 while A hospitals were 7.6. Average Age of Plant Accumulated depreciation Depreciation expense Provides an indicator in years of the healthcare organizations fixed assets. Higher values reflect an older plant and equipment. Ingenix hospitals average was 9.77 while A hospitals were 9.08. Terms & Definitions Capital Expenditures purchases of land, buildings and equipment for operations of more that $500 that last for more than a year and are subject to depreciation. OBRA Omnibus Budget Reconciliation Act moved capital costs to prospective payment over a ten year implementation period. Tax Reform Act of 1986 lowered the tax-deductibility for charitable gifts and restricted or increased the cost of acquiring capital through tax-exempt markets.       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X#a%n% "m%.! !,b$!o\qz(F 0e0e    ff A@ A5% 8c8c     ?1 d0u0@Ty2 NP'p<'pA)BCD|E||s " 0e@        @ABC DEEFGHIJK5%LMNOPQRSTUWYZ[ \]^_ `abN E5%  N E5%  N F   5%    !"?N@ABC DEFFGHIJK5%LMNOPQRSTUWYZ[ \]^_ `ab@ d(  hB  s *Dff>"ZB  s *Dff|ZB   s *Dff|l  HA ?echbkgndV#[n w&wT'T XD (DT_PictureBullets5o8oQ d*oo8*urn:schemas-microsoft-com:office:smarttagsdate 1520077DayMonthYear|E F J K eg5899;;<<>?ABDEdeoCE`e5899;;<<>?ABDEdeo333333v 2LU ! f ~ J ] etbC v' 6BKLsLM5899;;<<>?ABDEGQbdeokx wpp899;;<<>?ABDE^`deo Jessie Fox nTfihxnI|fb2ZN 61 t!┅S$r&nTh6\9?>sKBMK=GsURgp\:r.Ydb&hDCN 1 t!Ydb 1Z                   D;               1Z                          1Z                 1Z                                                                                                                           1Z                          1Z                                   A@KL3Ar%9N\S!RtS#9,2X<@=YAGCuAH$I LL*dTM U:dy]o`Zs@t\{}~"aY)>]y}MS^_\Z `7[$qZ`tLp z'8o/ fWP,8Y|~n&009EVabo@XXTXXnP@UnknownGz Times New Roman5Symbol3& z Arial5& zaTahoma?5 z Courier New;Wingdings"1h{} \5\5!88x4d++2QHP ?z*Chapter 1: Financial Management in Context Molly Freeman Jessie Fox                           Oh+'0=<L `l   +Chapter 1: Financial Management in ContextohapMolly Freemananoll-Healthcare Finance Summer 2007 Howard Fagind 1Normala Jessie Fox11sMicrosoft Word 10.0@d'@ J@Y>\G;VT$m*    ."Systemr0Xj -@"Tahoma-  2  % 2    2  1$ 2     2 5 %2 Z   2   $ '2  WChapter (%#%#2  W13%% 2 * W $W '@"Arial- 2 * 6'{@"Tahoma-n2 GBThe Financial Management of Hospitals and Healthcare OrganizationsNJF*EJGJ>F+fGJFJFpFJ,*I**ZI<J,F;*FJJ*ZFF-K=F0F*^0JFJ;F-IJ; 2 G J&2 By Michael NowickiNB*g>JFF*YHd>B 2 $  J@"Tahoma- 2  -@"Tahoma-2 #Chapter C@<?*;+2 #m13@@ 2 # @%2 Capital BudgetingC<?*<E@??;*@? 2 D ? 2  @2  David HerrenL<:?L;+,;@ 2 W A2 July e2@:2 15@@2 ), 2007@@@@ 2 e ?- 2 n - 2  -@"Tahoma-2 7Outline @5"51 2 7 6-2 eCapital costs make up a small percentage of total organization costs. They are in the range of six t2,.,&-%%F,),..,%G,.,&,.,.,--,-.-.%,-.'-%%0.-),,..,,..,-%) 2 o ten percent -,..,',.+2 Jfor most hospitals. -F-%.-%.,%2 J Under cost7..,'-% 2 J+-|2 JIKbased reimbursement from 1966 to 1983, capital costs for new equipment and .,%,.,F..%,F,.-F-.----.-.&,.,'-%%-.,>,...F,.-/.2 oplants exploded. It was not until the OBRA (Omnibus Budget Reconciliation Act) of 1990 moved capital costs to .,.%,).-.,.>,%.....,;142 ;F./.%1...,4,&-/&,-.3& -.-.-F.),.&,.,&-%%-.2  prospective payment ove.-%.,&),.-)F,..),2  [r a ten ,,. 2  O-2  mMyear implementation period. This along with the Tax Reform Act of 1986 that ),,F.,F,.,-./,-.1.%,...>..,0,)4,-F3&--.--.,2 x klowered the tax deductibility for charitable gifts and restricted the cost of acquiring capital through tax ->,,..,,).,..&.)-&.,,.,.%,..-%&,..,&.%--&../.&,.,.-./.,) 2 x u-2 x exempt ,),G.-_2 8bond markets has made hospitals a much more risky area. .-..F,),%.,%F,.,..%.,%,F.&.G-,%*)-,, 2 H  -P2 b .The Tax Reform Act of 1986 lead to a dramatic 351332=1 3%O9-#3 5556134"425$2O3",D2 A &decline in philanthropy dollars to not41,5154535#5$440432$,#363" 2 A -$2 A for!3$ 2 A d-$%2 A profit hospitals.n4%3 #53+4"2+ 2 A   6- 2  --)2 Capital Expenditures2,.,/).,...,%- @ ! - 2   2 -2 \ Purchases of land, buildings, and equipment for operations; are not for resale; and have a /.'.,%,%--.../...&,/.,...F,.--.,,-/&,,.--,%,,,...,),,=2 o !useful life of more than one yearo.%,.,.F-,.,.-.-),,e2 o v<, a cost of $500 or more, and are subject to depreciation. ,&-%..-.--F.,,..,,%..-&-.,.,&,-. 2 o  . 2  -[2 8 5Capital Expenditures fall into one of six categories:a2,.,/).,...,%,.--.,.%)&,,.-,% 2 8   .-2 X1.-@"Arial- 2  O-2 Land),..n2 B (purchasing and other costs associated with preparing it for use) ..&.,%..,..-.,&-%%,%%.&,,.>..,/,..-.%, 2   .'-2  X2.-- 2   O-%2  Land improvements),..F..),F,.%22   (sidewalks, parking lots) %.,?,)%.,)..-% 2  Y  .'-2 f X3.-- 2 f  O-2 f  Buildings1.../%#2 f 6 (construction a &..%/&-.-2 f w nd buying)./..).. 2 f  .'-2 X4.-- 2  O-"2 Fixed equipment+),.,...F-.2 OP (permanently attached to the building. 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