look at the file attached to answer this and answer also qustion on the files 1. What are the key elements of GVMC’s strategy? 2. Why does the existing capital budgeting system need to be changed? 3.
I don’t object to the priority given to medical equipment by the board of directors. At the same time, though, requests for administrative or support service capital frequently have significant cost-saving potential, and should not continue to be overlooked. There must be some way that these requests can be assessed on their merits without infringing on the hospital’s ability to provide the best possible patient care.The speaker was DeeAnne Willis, CEO of Green Valley Medical Center (GVMC). She was expressing concern that in her 12 years at the hospital, both administration and support services typically had taken a back seat in the capital budgeting process. This concern was of particular im- portance to Allen Klein, GVMC’s newly hired chief financial officer, who faced several decisions regarding the hospital’s capital budgeting process. His decisions needed to be made quickly since departmental directors were just weeks away from the October 15 deadline to submit both operating budgets and capital requests.Mr. Klein already had been approached by various senior managers in the hospital regarding their department requests for capital purchases. All had welcomed him with friendly greetings, fol- lowed immediately by informal presentations of their departments’ proposals for capital improve- ments. It did not take long for Mr. Klein to realize that he needed to understand better how the capital budgeting process worked, both formally and informally BACKGROUND GVMC was a 330-bed nonprofit teaching hospital affiliated with a large state university in a mid-size town located several hours from the state’s two urban centers. Established in the 1930s with a federal grant, Green Valley had grown with continuous support from state revenues. It also had issued municipal revenue bonds on several occasions to finance large expansions and improve- ments. Recent financial statements are contained in Exhibit 1.Green Valley served a regional patient base of over one million. It was the only regional hospi- tal, and one of only two in the state, with facilities in cardiology, oncology, and neurology. Green Valley’s specialty in these fields included teaching and research as well as clinical care. It prided it- self on its state-of-the-art technology and overall medical expertise. In fact, the hospital was widely regarded for the innovative work and research conducted by its medical community, particularly in the neurological and oncological sciences.The Current Capital Budgeting ProcessMr. Klein was delighted to find that the hospital’s available funds for capital purchases had grown at a rate of 10 to 15 percent per year during the past 5 years. How the money was distrib- uted, however, was not so clear. The process began in each service area, where individuals submitted requests to their department head for new and replacement equipment and machinery. Capital re- quests included items costing $1,000 or more. Anything under $1,000 was included as an operat- ing expense by the department. Once all new requests had been received by department heads, they were reviewed and ranked, and then ranked again incorporating all requests outstanding from the previous year. At that point, any requests not deemed necessary by the department were dropped from the list All additions to the list were documented on an Equipment Request Form which contained the name of the requester, the date, price, and a brief explanation of the request. Once the department head had a final list, he or she submitted it to the hospital’s fiscal affairs department where it was consolidated and prioritized along with the requests of all departments to form one master list. The master list was reviewed and approved by the Board of Trustees at their November meeting.At this point, it became clear to Mr. Klein why he had been pursued by so many department heads regarding their capital requests. Through his investigations, he learned that the general prac- tice of the board of trustees and of the previous CFO was to give high priority to medical equip- ment. In fact, several department chiefs and clinical program directors did not hesitate to confirm this unwritten policy. According to the Director of Cardiology:Let’s face it, it’s no mystery that medical departments win out in head to head competition. We’ve got tradi- tion, numbers, and the hospital’s mission on our side. Of course, administration is a necessary part of the whole organization, but physicians are the ones closest to the needs of the hospital and of the patients. We’re the ones who make decisions every single day.The Chief of Medicine noted that priority assessments also differed among departments:Naturally, some chiefs carry more weight than others, and they should. Ob/Gyn, for example is at a disad- vantage in the capital budgeting process compared to larger departments. If surgery, for example, fills 200 beds and Ob/Gyn only 20, then, all things equal, the Chief of Surgery is more likely to get what he wants.Historically, although capital requests tended to be presented subjectively, their financial conse- quences usually were taken into consideration as well. The financial data presented, however, tended to be unreliable and often unfounded. In an attempt to be fair, the CFO would try to ensure that each medical department received at least one high priority spot on the master list.Mr. Klein now understood why Ms. Willis had voiced such strong concern about the process. In a follow-up conversation with her, she elaborated: The argument of efficient services and financial contribution to the hospital is very important to the board of trustees. However, physicians also should be concerned that conditions in certain administrative service areas could deteriorate to the point that we’re unable to contain costs for the hospital, or that we’re unable to maintain quality. Everyone associated with the medical center is affected then.Mr. Klein realized he needed to measure all capital requests with a system that would be much more objective than what had been typical at Green Valley until now. Although he was not entirely familiar with capital budgeting systems used by hospitals, he was quite familiar with common prac- tices in the private sector, and was certain that the techniques were similar. Minimal research ac- quainted him with a technique used by some hospitals that consisted of a qualitative as well as a quantitative evaluation. He thought this technique would help to achieve a better balance of informa- tion for decision-making, and decided to use the current year to test its feasibility.The technique used a net present value approach to quantitative analysis, and a subjective, quali- tative analysis that considered a project’s impact on the hospital’s physicians, its community, and its employees. Exhibit 2 contains the formal scoring sheet that was used for the qualitative assess- ment. Exhibit 3 was used to combine the quantitative assessment with the qualitative one, and re- sulted in a ranking of all proposed investments according to the combined assessments.The Decision Making ProcessBy the October 15th deadline for departmental budgets, Mr. Klein had received a total of 130 capital requests ranging from $1,000 to $5.8 million. He felt that it was impractical to treat all capi- tal requests as homogeneous. Rather, he thought they should be divided into several broad group- ings to make it easier to compare projects of similar nature and costs. He developed four categories: Group I Essential items to maintain operations Group II Revenue producing or cost saving items Group III Optional items for improvement Group IV Miscellaneous items Within each major category, all requests would then be classified by cost groupings, not as a means of prioritization, however, but only to organize them for evaluation. After checking the 130 requests for complete information, he and his assistant sorted them into the four main categories, and into cost groupings within each.TWO REQUESTSTo evaluate the technique, Mr. Klein decided to use it to assess two very different capital re- quests. He chose the largest administrative support request and the most expensive request for medical equipment, assuming that there would be funds to support only one of the two. The cardi- ology, neurology and oncology programs had jointly requested a Positron Emission Tomography (PET) facility for a total investment of $5.8 million. The non medical request was for an entirely new in-house laundry facility costing approximately $1 million. The PET Proposal Positron Emission Tomography (PET) was an imaging technique that permitted examination of the chemistry of the brain and other organs. Unlike MRI and CT scanners which provided images and details about organs and tissues, PET could non-invasively measure biological and physiologi- cal activity. This application was most powerful in the areas of cardiology, oncology, and neurology/psychiatry. PET was used to detect diseases, to evaluate tissue viability, to measure tu- mors and the degree of malignancy, to pinpoint specific sources of neurological disorders, and to assist in the planning of various treatments.Financially, many observers believed that PET would save the healthcare system considerable resources by helping to avoid unnecessary procedures. The savings were to come from the technol- ogy that would replace other procedures and improve the medical community’s ability to diagnose and treat patients.The short- and long-term need for PET scans nationally had been determined by the American Hospital Association. In February, the AHA had predicted an annual need for 1.1 million scans in the short-term and 1.7 million scans in the long-term. Currently, there were only 64 PET centers in the U.S. and Canada, roughly half of which were in research centers.There were no PET centers within 600 miles of Green Valley. Yet,the AHA’s prediction, com- bined with a patient base of 1 million, translated into a regional demand for 2,750 scans per year: 300 epilepsy, 200 brain, and 2,250 cardiac. The hospital expected to provide a maximum of 2,300 scans, however: 1,600 scans for clinical use and 700 for research.The total capital investment included $1.4 million for the cyclotron, $2 million for each of two cameras (one for the head and one for the body), and $400,000 for facility renovations to accom- modate the equipment. The anticipated operating expenses (other than depreciation) were $1.7 mil- lion for each of the ten years of the depreciable life of the equipment.According to a study by the Institute for Clinical PET (a trade association), the scans would be reimbursable at an average rate of $1,700. Although the 700 scans each year for research purposes would be charged at $1700 each to research grants, Mr. Klein was concerned about reimbursement for the 1,600 clinical scans billed directly to patients and third party payers. The PET imaging proc- ess used several radiopharmaceutical drugs. The most important of these was a drug called FDG, which had to be produced on site or close by due to the drug’s short half-life. For this reason, the Food and Drug Administration had not yet approved FDG. While it was still under review, how- ever, the FDA permitted the hospitals to continue using it. Although some third party reimburse- ment was already available, several of the large national insurance companies were not covering some or all of the PET scans. Mr. Klein estimated that Green Valley would be reimbursed for roughly half of the 1,600 clinical scans as long as FDG had not been approved by the FDA.Green Valley’s medical staff thought the PET project not only would greatly contribute to the quality of the hospital’s clinical care and research, but, once FDG was approved, would be a big money maker for the hospital. The medical staff also was convinced that PET’s contribution to the medical needs of the hospital’s patient base, and to society as a whole, through teaching and re- search, far outweighed any potential losses in the short term. The Laundry Proposal Unlike some hospitals that subcontract laundry, Granite Valley provided all of its laundry serv- ices in-house, mainly because there were no available subcontractors locally. As the hospital grew, THE DISCOUNT RATE Mr. Klein evaluated each of the proposals using his proposed capital budgeting technique. Since the technique used net present value, Mr. Klein had to determine the appropriate discount rate to use. This presented the problem of deriving the hospital’s cost of capital and return on its assets. The hospital’s liabilities entailed several different rates of interest. Long-term debt included pay- ments on its municipal bonds averaging 6 percent and fixed mortgage payments at 8 percent.Equity capital, on the other hand, was divided between permanently restricted funds (where do- nors had stipulated that the principal could not be spent) and unrestricted funds (which could be used for any purpose). Mr. Klein believed that the appropriate discount rate should take all of the debt interest rates into account, but he was not sure what rate he should assign to the hospital’s net assets (or equity), or whether any rate should be used for equity at all. He had read that some hos- pitals used 10 percent for their equity, but he wondered if the discount rate should be adjusted to reflect the risk and uncertainty associated with each project. Finally, he learned that the hospital was earning a 10 percent average return on its certificates of deposit, and about 5 percent on its cash THE DECISION Mr.Klein was confident that his capital budgeting technique would be a vast improvement for the hospital. He was optimistic about the prospects of developing a system for that finally had a ra- tional, systematic approach to evaluating capital requests. By including the subjective analyses, he believed it would be possible to quantify some of the hospital’s returns that did not always translate into dollars. At the same time, however, he realized that someone would still lose out in the end.