Capital budgeting is an essential process for healthcare organizations. The challenge in quality and patient safety organizations is proving return on the

Capital budgeting is an essential process for healthcare organizations. The challenge in quality and patient safety organizations is proving return on the capital investment without revenue impacts.Select a capital investment that you would recommend making for a patient safety concern. In a 15 slide PowerPoint Presentation address the following requirements:

Describe the capital item in detail:
- Item description
- Rationale for selection
- Cost-benefit analysis
Complete a capital budget with projected financial benefit:
- Revenue or positive financial impact
- Capital equipment cost
- Personnel cost
- Supply cost
Review financial ratios
- Return on investment
- Net Present Value
- Cash Payback period
Make a recommendation to lease or finance the capital item. Please support your decision with financial data.

Your presentation should meet the following structural requirements:

Be 15 slides in length, not including the title or reference slides.
Be formatted according to Saudi Electronic University and APA writing guidelines.
Provide support for your statements with citations from a minimum of six scholarly articles. These citations should be listed in the Notes section of the slide in which they appear. Two of these sources may be from the class readings, textbook, or lectures, but four must be external.

Each slide must provide detailed speaker’s notes to support the slide content. These should be a minimum of 120 words long (per slide) and must be a part of the presentation.

CHAPTER 10 Capital Structure

In chapter 9, we noted that the weights used in the cost of capital estimate represent the optimal (target) mix of debt and equity financing. These weights are established by the capital structure decision, which requires managers to analyze a number of quantitative and qualitative factors to establish the business’s optimal capital structure.

The Capital Structure Decision

Capital consists of the funds used to finance a business’s assets.

Capital structure is the financing mix on the right side of the balance sheet. It is the proportion of debt (and hence equity) used by a business.

The capital structure decision involves identifying the optimal mix of debt and equity.

Impact of Capital Structure on Risk and Return

Consider a new for-profit walk-in clinic that needs $200,000 in assets to begin operations.

The business is expected to produce $150,000 in revenues and $100,000 in operating costs during the first year.

The clinic has only two capital structure alternatives:

No debt financing (all equity)

$100,000 of 10% debt (50/50 mix)

Projected Balance Sheets

	All Equity	Debt/Equity
Current assets	$100,000	$ 100,000
Fixed assets	100,000	100,000
Total assets	$200,000	$ 200,000

Bank loan (10% cost)	$ 0	$ 100,000
Total equity	200,000	100,000
Total claims	$ 200,000	$ 200,000

Projected Income Statements

	All Equity	Debt/Equity
Revenues	$ 150,000	$ 150,000
Operating costs	100,000	100,000
Operating income (EBIT)	$ 50,000	$ 50,000
Interest expense	0	10,000
Taxable income	$ 50,000	$ 40,000
Taxes (30%)	15,000	12,000
Net income	$ 35,000	$ 28,000

Based on net income, should we use debt financing?

Return on Equity (ROE)

	All Equity	Debt/Equity
Net income	$ 35,000	$ 28,000
Total equity	$200,000	$100,000
Return on equity	17.5%	28%

Based on ROE, should we use debt financing?

Conclusions

Although the use of debt financing lowers net income, it increases the return to equityholders.

Debt financing allows more of a business’s operating income to flow through to investors.

Because debt financing levers up (increases) return, its use is called financial leverage.

Business Risk Versus Financial Risk

A business has some overall level of risk.

In a stand-alone risk sense, it can be measured by the standard deviation of ROE.

In a market risk sense, it can be measured by the stock’s beta.

This overall (total) risk can be decomposed into business risk and financial risk.

Business risk is the uncertainty inherent in a business’s operating income (EBIT)—that is, how well can managers predict EBIT?

Business risk does not consider how the business is financed.

Business Risk

Probability

EBIT

E(EBIT)

Low business risk

High business risk

Factors That Influence Business Risk

Demand (volume) variability

Sales price variability

Input cost variability

Ability to respond to changing market conditions (operating flexibility)

Liability exposure uncertainty

Operating leverage (proportion of fixed versus variable costs)

• Demand (volume) variability. Nursing homes have stable demand.

• Sales price variability. Cosmetic surgery has highly volatile prices.

• Input cost variability. Pharmaceutical companies have highly uncertain input costs for R&D.

• Ability to respond to changing market conditions. Some hospitals are in a better position to raise their prices when input costs rise. Other hospitals are more adept at cutting costs if the need arises.

• Liability exposure uncertainty. Hospitals that perform a large number of high-risk surgeries face more liability risk than do hospitals with a limited surgery program.

• What is operating leverage? Operating leverage measures the proportion of fixed costs in a business’s cost structure. Hospitals have a high percentage of fixed costs which by definition do not decline when demand falls off.

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Financial Risk

Financial risk is the additional risk placed on owners (or noncreditor stakeholders in NFP businesses) when debt financing is used.

The greater the proportion of debt financing, the greater the financial risk.

Which of the following statements is most correct?

A firm’s business risk is determined solely by the financial characteristics of its industry.

A firm’s financial risk can be minimized by diversification.

A firm with low business risk is more likely to increase its use of financial leverage than a firm with high business risk, assuming all else equal.

Home health agencies typically have more operating leverage than hospitals.

An increase in operating leverage normally leads to a decrease in the standard deviation of its expected EBIT.

Self-Test

Capital Structure Theory

Capital structure theory attempts to define the relationship between the use of financial leverage and a business’s equity value.

The most widely accepted theory is the trade-off theory:

There are tax-related benefits to debt financing.

But there are also costs, primarily those associated with financial distress.

But first, we need to discuss MM.

Modigliani and Miller (MM)

MM published theoretical papers that changed the way people thought about financial leverage (and dividend policy).

They won Nobel prizes in economics because of their work.

MM’s papers were published in 1958 and 1963. Miller had a separate paper in 1977. The papers differed in their assumptions about taxes.

MM Assumptions

Firms can be grouped into homogeneous classes based on business risk.

Investors have identical expectations about firms’ future earnings.

There are no transactions costs, so securities can be bought and sold with no fees or commissions.

All debt is riskless, and both individuals and corporations can borrow unlimited amounts of money at the risk-free rate.

All cash flows are perpetuities. This implies perpetual debt is issued, firms have zero growth, and expected EBIT is constant over time.

There are no agency or financial distress costs.

MM Assumptions (cont.)

Proposition I:

VL = VU.

Proposition II:

R(ReL) = R(ReU) + [R(ReU) – R(Rd)](D/E).

MM Without Taxes (1958)

MM Without Taxes Graph

Cost of Capital (%)

Proportion of Debt

R(Re)

CCC

R(Rd)

The more debt the firm adds to its capital structure, the riskier the equity becomes and thus the higher its cost.

Although the cost of debt remains constant (by assumption), the cost of equity increases with leverage at a rate that is exactly sufficient to keep the CCC constant.

What is the optimal capital structure if this theory holds?

MM Without Taxes Conclusions

Value Versus Leverage Graph

Firm Value

VL = VU

Proportion of Debt

Under MM without taxes, the firm’s value is not affected by debt financing.

When corporate taxes are added, the MM propositions become:

Proposition I:

VL = VU + TD.

Proposition II:

R(ReL) = R(ReU) + [R(ReU) – R(Rd)](1 – T)(D/E).

MM with Corporate Taxes (1963)

Cost of Capital (%)

R(Re)

CCC

R(Rd)(1 – T)

MM with Corporate Taxes Graph

Proportion of Debt

MM with Corporate Taxes Conclusions

When corporate taxes are added, VL ≠ VU. VL increases as debt is added to the capital structure, and the greater the debt usage, the higher the value of the firm.

The cost of equity increases with leverage at a slower rate when corporate taxes are considered because of the (1 – T) term in Proposition II.

What is the optimal capital structure if this theory holds?

Under MM with corporate taxes, the firm’s value increases continuously as more and more debt is used.

Value Versus Leverage Graph

Proportion of Debt

Firm Value

Miller later (1977) modified the MM with corporate taxes model to incorporate individual (personal) taxes.

Miller’s Proposition I:

VL = VU + [1 – ]D.

Tc = corporate tax rate.

Td = personal tax rate on debt income.

Te = personal tax rate on stock income.

(1 – Tc)(1 – Te)

(1 – Td)

Assume Tc = 30%, Td = 35%, and Te = 20%.

VL = VU + [1 – ]D

= VU + (1 – 0.86)D

= VU + 0.14D.

Value rises with debt; each $100 increase in debt raises L’s value by $14.

(1 – 0.30)(1 – 0.20)

(1 – 0.35)

How does this gain compare to the gain in the MM model with corporate taxes?

If only corporate taxes, then

VL = VU + TcD = VU + 0.30D.

Here, $100 of debt raises value by $30. But with personal taxes added, firm value increases by only $14. Thus, personal taxes lower the gain from leverage, but the net effect depends on relative tax rates.

Impact of Personal Taxes

Corporate tax laws favor debt over equity financing because interest expense is tax deductible while dividends are not.

However, personal tax laws favor equity over debt because stocks provide tax deferral, a lower capital gains tax rate, and a lower dividend tax rate.

Impact of Personal Taxes (Cont.)

This increases the attractiveness of stock investments (lowers the cost of equity) and hence decreases the spread between debt and equity costs.

Thus, some of the advantage of debt financing is lost, and debt financing is less valuable to businesses.

What is the optimal capital structure if the Miller theory holds?

What does capital structure theory prescribe for corporate managers?

MM, No Taxes: Capital structure is irrelevant—no impact on firm value.

MM, Corporate Taxes: Value increases, so firms should use (almost) 100% debt financing.

Miller, Personal Taxes: Value increases, but less than under MM, so again firms should use (almost) 100% debt financing.

Do firms follow the recommendations of capital structure theory?

Firms don’t follow MM/Miller to 100% debt. Debt ratios average about 40%.

However, debt ratios did increase after MM. At the time, many thought debt ratios were too low, and MM led to changes in financial policies.

Financial Distress Costs

As firms use more and more debt financing, they face a higher probability of future financial distress, which brings with it lower sales, higher costs, lower earnings, and the greater potential of incurring bankruptcy costs. These effects, called financial distress costs, lower the values of stocks and bonds.

Agency Costs

As more and more debt is used, managerial actions become more restricted due to restrictive covenants and oversight by creditors. Furthermore, debtholders tend to increase monitoring activity as more debt is used, which raises the cost of debt. Such costs, called agency costs, also lower the values of stocks and bonds.

How do financial distress and agency costs change the MM and Miller models?

MM/Miller ignored these costs; hence their models show firm value increasing continuously with leverage.

Because financial distress and agency costs increase with leverage, such costs reduce the value of debt financing.

The major contribution of the Miller model is that it demonstrates that:

Personal taxes increase the value of corporate debt.

Personal taxes decrease the value of corporate debt.

Financial distress and agency costs reduce the value of corporate debt.

Equity costs increase with financial leverage.

Debt costs increase with financial leverage.

Self-Test

The trade-off theory includes financial distress and agency costs.

X represents either Tc in the MM model or the more complex Miller term.

Now, optimal financial leverage involves a trade-off between the tax benefits of debt and financial distress and agency costs.

VL = VU + XD – – .

PV of expected

fin. distress costs

PV of agency

costs

D/A

R(Re)

CCC

R(Rd)(1 – T)

What is the optimal capital structure?

Trade-Off Theory

Trade-Off Theory Implications

Both too little or too much debt is bad.

There is an optimal, or target, capital structure for every business that balances the costs and benefits of debt financing.

Unfortunately, capital structure theory cannot be used in practice to find a business’s optimal structure.

Trade-Off Theory Implications (cont.)

Firms should borrow more if they:

Have low business risk

Employ tangible assets (buildings and equipment)

Expect to pay taxes at a high rate

Firms should borrow less if they:

Have high business risk

Employ intangible assets (intellectual capital and goodwill)

Expect to pay taxes at a low rate

Asymmetric Information Theory

MM assumed that investors and managers have the same information.

But managers often have better information. Thus, they would:

Sell stock if stock is overvalued

Sell bonds if stock is undervalued

Investors understand this, so they view new stock sales as a negative signal.

What are the implications for managers?

Asymmetric Information Theory (cont.)

In general, mature firms follow a “pecking order” when financing:

First, use internal funds.

Next, draw on marketable securities.

Then, issue new debt.

Finally, and only as a last resort, issue new common stock.

This behavior is consistent with the asymmetric information theory.

Summary of Capital Structure Theory

Both too little or too much debt is bad.

There is an optimal (target) capital structure for every investor-owned business that balances the costs and benefits of debt financing.

Specific financing conditions are influenced by asymmetric information.

Unfortunately, capital structure theory cannot be used in practice to find a business’s optimal structure.

Not-For-Profit Businesses

The same general concepts of capital structure apply to not-for-profit businesses:

Benefit to debt financing—cost of debt is lower because it is tax exempt

Cost to debt financing—increased risk of financial distress

However, not-for-profit firms do not have the same financial flexibility as do investor-owned businesses.

Factors That Influence Capital Structure Decisions in Practice

Long-run viability

Managerial conservatism

Lender and rating agency attitudes

Reserve borrowing capacity

Industry averages

Control of investor-owned corporations

Asset structure

Growth rate

Profitability

Taxes

Implications of the Capital Structure Decision

The estimated optimal capital structure becomes the business’s target capital structure.

It is an important factor in financial decision making because:

It defines the weights that are used in the corporate cost of capital estimate.

It plays a role in future financing decisions.

Note that the target weights are market (as opposed to book) value weights for FP businesses.

Other things held constant, which of the following events is most likely to encourage a firm to increase the amount of debt in its capital st

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