new transcript of full meeting - illinois.gov · 2017. 9. 27. · transcript of full meeting date:...

Transcript of Full MeetingDate: June 20, 2017

Case: State of Illinois Health Facilities and Services Review Board

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ILLINOIS DEPARTMENT OF PUBLIC HEALTH HEALTH FACILITIES AND SERVICES REVIEW BOARD

OPEN SESSION - MEETING

Bolingbrook, Illinois 60490 Tuesday, June 20, 2017 10:00 a.m.

BOARD MEMBERS PRESENT: KATHY OLSON, Chairwoman RICHARD SEWELL, Vice Chairman BRAD BURZYNSKI SENATOR DEANNA DEMUZIO JOEL K. JOHNSON JOHN MC GLASSON, SR. MARIANNE ETERNO MURPHY

Job No. 126145Pages: 1 - 303Reported by: Melanie L. Humphrey-Sonntag, CSR, RDR, CRR, FAPR

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EX OFFICIO MEMBERS PRESENT: BILL DART, IDPH ARVIND K. GOYAL, IHFS

ALSO PRESENT: JUAN MORADO, JR., General Counsel COURTNEY AVERY, Administrator MICHAEL CONSTANTINO, IDPH Staff GEORGE ROATE, IDPH Staff JESSE NUSS, Board Intern

Transcript of Full MeetingConducted on June 20, 2017 2

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C O N T E N T S PAGECALL TO ORDER 6ROLL CALL 6EXECUTIVE SESSION 7COMPLIANCE ISSUES/SETTLEMENT ARRANGEMENTS/ 7FINAL ORDERS Referrals to Legal Counsel 8 Final Orders 8APPROVAL OF AGENDA 9APPROVAL OF TRANSCRIPTS 10LONG-TERM CARE SUBCOMMITTEE EDUCATIONAL 10 SESSIONPUBLIC PARTICIPATION 43 Dialysis Care Center of McHenry 44 Crystal Lake Mercy Hospital 50, 55 Silver Cross 52ITEMS APPROVED BY THE CHAIRWOMAN 159ITEMS FOR STATE BOARD ACTIONPERMIT RENEWAL REQUESTS Presence Lakeshore Gastroenterology 160EXTENSION REQUESTS 164EXEMPTION REQUESTS 164



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C O N T E N T S C O N T I N U E D PAGEALTERATION REQUESTS 164DECLARATORY RULINGS/OTHER BUSINESS 164HEALTH CARE WORKER SELF-REFERRAL ACT 165STATUS REPORTS ON CONDITIONAL/CONTINGENT 167 PERMITSAPPLICATIONS SUBSEQUENT TO INITIAL REVIEW Mercy Health Hospital 168 Mercy Health Medical Office Building 226 Silver Oaks Hospital 231 Mercy Circle 260 Carle-Staley Road Medical Office 267 Building Dialysis Care Center of McHenry 271APPLICATIONS SUBSEQUENT TO INTENT TO DENY 295OTHER BUSINESS 295RULES DEVELOPMENT 295OLD BUSINESS HFSRB Handbook Update 296 Legislative Update 301



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C O N T E N T S C O N T I N U E D PAGENEW BUSINESS Financial Report 297 IDPH/HFSRB Intergovernmental Agreement 297 Executive Meeting Transcripts 298 2018 Meeting Dates and Locations 299 Corrections to Profile Information 300ADJOURNMENT 302



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P R O C E E D I N G S (Member Goyal was not present.) CHAIRWOMAN OLSON: I'd like to call themeeting to order. May I have a roll call, please. MR. ROATE: Thank you, Madam Chair. Mr. Sewell. VICE CHAIRMAN SEWELL: Here. MR. ROATE: Ms. Murphy. MEMBER MURPHY: Here. MR. ROATE: Mr. McGlasson. CHAIRWOMAN OLSON: He's here -- oh, herehe is. MR. ROATE: Mr. Johnson. MEMBER JOHNSON: Here. MR. ROATE: Mr. Ingram's absent. Senator Demuzio. MEMBER DEMUZIO: Here. MR. ROATE: Senator Burzynski. MEMBER BURZYNSKI: Here. MR. ROATE: Madam Chair. CHAIRWOMAN OLSON: Here. MR. ROATE: That's eight in attendance. CHAIRWOMAN OLSON: Thank you.



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The first order of business is executivesession. May I have a motion to go into closedsession pursuant to Sections 2(c)(1), 2(c)(5),2(c)(11), and 2(c)(21) of the Open Meetings Act. May I have a motion. MEMBER JOHNSON: So moved. CHAIRWOMAN OLSON: And a second. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: All those in favor? (Ayes heard.) CHAIRWOMAN OLSON: We're now in executivesession for approximately 20 minutes. Oh, I'm sorry. Let the record reflect thereare seven in attendance. So I'll need everybody to clear the room.We are going to be in executive session for about20 minutes. (At 10:01 a.m. the Board adjourned intoexecutive session. Member Goyal joined theproceedings, and open session proceedings resumedat 10:34 a.m. as follows:) CHAIRWOMAN OLSON: The next order ofbusiness is compliance issues, settlement



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arrangements, and final orders. Juan, are there motions to come out of execsession? MR. MORADO: Yes. Madam Chair, we're going to be seeking areferral of the Clark-Lindsey Village matter tolegal counsel. CHAIRWOMAN OLSON: May I have a motion torefer Clark-Lindsey Village to legal counsel. VICE CHAIRMAN SEWELL: So moved. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The motion passes. Anything else? MR. MORADO: Yes. We have a -- we'reseeking a motion today for a final order on theClark-Lindsey Village matter. CHAIRWOMAN OLSON: Do this one more time. May I have a motion to approve a final orderon the Clark-Lindsay Village matter. MEMBER DEMUZIO: Motion. CHAIRWOMAN OLSON: Second?



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MEMBER JOHNSON: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The motion passes. Thefinal order is approved. MR. MORADO: And, finally, we're seeking afinal order on the Neighbors Rehabilitation Center,Project 14-008, also known as HFSRB 16-12. CHAIRWOMAN OLSON: May I have a motion toapprove this project. MR. MORADO: Final order. CHAIRWOMAN OLSON: Final order. I'm sorry. MEMBER DEMUZIO: Motion. CHAIRWOMAN OLSON: Second? VICE CHAIRMAN SEWELL: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The motion passes. Thefinal order is approved. MR. MORADO: Thank you. CHAIRWOMAN OLSON: Thank you, Juan. The next order of business is approval of



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the agenda. May I have a motion to approve the agenda. MEMBER DEMUZIO: Motion. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: Motion. Second? MEMBER MC GLASSON: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The agenda's approved. May I have a motion to approve the meetingtranscripts of the May 2nd, 2017, meeting? MEMBER DEMUZIO: Motion. CHAIRWOMAN OLSON: And a second, please. MEMBER JOHNSON: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Motion passes. The next order of business is Long-Term CareFacility Advisory Subcommittee educational session. Juan, do you want to introduce this, please? MR. MORADO: Yes. So recently I've begun working with the



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Long-Term Care Advisory Subcommittee. And some of you may recall -- I believe itwas two meetings ago -- we came before this Board togive our annual report and recommendations on apossible buy/sell program. Since that time we've had some opportunitiesto reconvene and thought that it would be best if,moving forward, what we did for the Board wasprovide them with some additional education on anumber of issues that are affecting the long-termcare industry, and, you know, some of these issuesare going to be very specific to long-term care,some that will be more general towards the healthcare services in Illinois. And what we have today is a presentation onthe Medicaid -- not just the Medicaid applicationprocess but Medicaid reimbursement -- and how that'sbeen affecting the long-term care industry. So we have a number of members from theLong-Term Care Advisory Subcommittee with us today.I'll give them an opportunity to introducethemselves. CHAIRWOMAN OLSON: Please speak directlyinto your microphones for the court reporter. There



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are two mics. MR. MORADO: And before you begin,Mr. Chairman, I'm going to go ahead and pass aroundsome documents which we're going to be referring toduring our presentation. CHAIRMAN WAXMAN: Good morning. My name isMike Waxman, and I am the chairman of thesubcommittee. MR. LAVENDA: My name is Steve Lavenda. MR. FOLEY: Yes. My name is Charles Foley,F-o-l-e-y. MR. GAFFNER: I'm Alan Gaffner, a member ofthe Alden network of long-term care as my employer.I represent the member facilities of the Health CareCouncil of Illinois on the Long-Term CareSubcommittee. CHAIRMAN WAXMAN: First of all, we'd like tothank the members to allow us to come in and spendsome time with you and provide some education. I think this committee's been functioningfor a number of years, dealing with some veryserious issues in terms of long-term care, and theopportunity to share with the Board is welcome, andthe opportunity to provide some information that you



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may not be aware of is also appreciated, and that'skind of what we're going to be doing over the nextfew months. But today, just to kind of highlight wherewe are, the marketplace in Illinois, like moststates, is undergoing a lot of change and a lot ofdifferentiation among types of options for oursenior citizens. And I think we have to remember that, eventhough we may be representing facilities orrepresenting organizations, that our purpose is tomake sure that our seniors and others that needlong-term care are able to get the types of care atappropriate levels with a payer source that is ableto make it all happen. And so that's part of whatour issues are. If you look at the marketplace and talkabout long-term care, there are very -- there aresegments to the long-term care market. It's simplynot one size fits all. And, you know, there is the originallong-term care skilled building; the ICF building,which is intermediate care, licensed by PublicHealth; and sheltered care. And there is a



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tremendous growth that is outside that jurisdictionof buildings that are referred to as assistedliving, independent living, memory care, and, youknow, now you have the dichotomy of who is governingwhich segment of that world. What's unique about it is that the assistedliving, independent sheltered care, or independentmemory care is basically a private-pay environment.You know, there aren't any third-party pay programsthat will cover someone moving in. The reasonthey're growing in popularity is because they'rebrand-new, they look beautiful, and people who aremaking decisions about where their loved ones shouldgo -- or the loved ones themselves -- are looking atbrick and mortar and the gyms and the cafeterias andsometimes forgetting about the level of care that isneeded to protect that resident. And so you have situations that are kind ofiffy, in some of our opinions, where people are inthe wrong place at the wrong time, so something isgoing to have to be done about that. The other thing is that, when I drive frommy residence in the northern part of the state to --from Lake County into DuPage County, I see seven



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brand-new buildings that are either recently openedor to be opened rather shortly, which is all welland good except that you've got two issues that haveto be dealt with: A, how are you going to staffthem, knowing that long-term care, the traditionallong-term care, is always fighting for staff? You know, when somebody says, "I can makeX dollars at a quick food place or X dollars at along-term care. Where am I going to go?" Andlong-term care has a great deal of extra work withelderly, and the work is much different thanstanding in front of a cash register and saying,"Would you like coffee with your hot dog?" versus"I have to change a diaper." So it's hard sometimesto get staff. Currently in the industry -- and nowyou have the influx of all these brand-newbuildings. So let's say they can staff them. Now,where are the residents coming from, given that it'sa private-pay environment, given that nursing homesacross the state are averaging about 78 percentoccupancy? So where are they going to pullresidents from? So it's an issue that needs to belooked at.



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And to be quite honest, our committee hassent several hours, several meetings, several monthslooking at that. As some of you know, part ofgetting a CON approved to build a new nursing homeor remodel one is that we have to deal with thequestion of whether or not Illinois is overbedded.And based upon the bed need formula, the answersometimes is yes. What I'd like to put on the table, just foryou to be aware of, is that the bed need formulaconsists of two pieces: One is the formula itself,the actual mathematical calculations, and the secondis the numbers that go into that. Now, we spoke last time about this problem,and I'll do it briefly again. What nursing homestend to report are licensed beds, and that's whatgoes into the formula; however, most nursing homestoday are not operating at the licensed bed level. So, for an example, I may own a home thathas a license for 150 beds, but, for a variety ofreasons, I may have converted some of those roomsinto offices, into gyms, into activity rooms, orI simply have taken the beds out because I don'thave the demand for them, so I'm operating with



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125 beds. So now our formula is counting 150 bedswhen, in fact, there's only 125 beds available. Sois that bed formula really that useful? The other question becomes the bed formuladoes not really take into account what I think ismost important, which is the demand, what ourconsumers want from our long-term care facilities. If they're looking for a cardiac rehab unitor a dialysis unit, for example, in a long-term carebuilding and they're sitting in an area where thereare four or five nursing homes, none of which havethose kinds of options available, then are we reallyoverbedded? So I think we have to continue to look atwhat the needs are and the variations of ways ofproviding services, another issue that needs to beaddressed somewhere. The application talks about a 90 percentoccupancy. The question becomes, in this worldtoday where we're living in, 76, 78 percentoccupancy, is the 90 percent rule really validanymore? So, again, something that needs to be



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discussed, something that our committee is workingon. We have taken research -- on all thesequestions, by the way, we have had other states'information brought to us so that we can comparewhat's going on in our surrounding states withwhat's going on in Illinois. So, you know, we'renot trying to make decisions in a vacuum. We have membership, I think, that'sextremely diverse, and I think it's an incrediblegroup of individuals, especially from where westarted to where we are today. It's become a muchmore cohesive group, a much more active group, and agroup that really wants to represent the long-termcare industry however it's defined. So, again, it represents for-profit,not-for-profit, religious-based organizations. Itrepresents providers, advocates, and some othertypes of people who are involved in selectinglong-term care sites, long-term care buildings forothers. So that, I think, is important. I talked about staffing issues. Buy/sell -- we've spent several longmeetings talking about buy/sell, and, again, toremind you, what we're talking about is a couple of



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variations in the buy/sell transfer agreement. For example, in its simplest form, if I mayuse the gentleman to the right of me, hisorganization, Alden. Alden, they have a building inthe southern part of the state that has 50 beds theyaren't using. They may have a building in thenorthern part of the state where they have a demandfor 50 beds. So can they be allowed to simplytransfer the beds and the license from Point A toPoint B? Second, there may be a sole proprietor inthe southern part of the state that has 25 beds thatthey're not using. Can that sole proprietortransfer the beds to another sole proprietor in thenorthern part of the state, beds and license? Or we may have a group of homes downsizingand somebody in another area that wants to eitherstart a building or increase their beds. And canthose beds be bought and sold? It raises a tremendous amount of questionsabout, you know, what is a bed worth. And rememberthat, for most nursing home ownerships, that bed andthe license attached to it is part of theirfinancing arrangement, so their lender has based



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their lending limit on the value of that licensedbed. If that bed doesn't exist, now what happens tothe loan at the building that moved it away? Andwhat can we do, as a committee, to make sure thatany money that is gained from the movement of bedsis put to good use? Good use. Into the homeowner's pocket?That's not a good use. Used to improve theconditions of the buildings that they're moving thebeds to? Good use. How do we make that happen? What mechanismsdo we have that can ensure that, if there's movementof money from Home A to Home B, that Home A uses themoney that they've received to improve theconditions, improve the clinical care, improve theoperations of the building? Versus how do we ensure that the people whoare receiving the beds are worthy of being anoperator that we would want to refer somebody weknow to that building? Questions that we have manydiscussions about and, again, not agreed-to answers. I've talked about the effect on theassisted-living facilities. I want to make it clearbecause I've been accused of being an enemy of



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assisted living. I am not. I'm simply saying thatthere are some assisted-living buildings thatI think are amazing and are well put together andprovide the services that they're supposed to. I'm only questioning whether we have theright tools in place to ensure that, when familiesmake decisions about where Mom should be, are theydoing it with the best information possible. Theintentions are all well. No question about that. When you look at the brick and mortar andthe cafeterias and what looks like exercise rooms,I mean, it's hard to say that's the wrong placecompared to a skilled building that's 30 years oldif that skilled building has 24-hour nursing care,in some cases where those nurses have the ability totake care of higher acuity. Remember that hospitals are dischargingfaster. I'm sure that's not new information to you.They're discharging faster and discharging sicker.So where should those people end up to maintaintheir health, their quality of life, and theirability to continue to survive? Because I thinkeveryone believes that the goal of anyone going intoa long-term care facility is to go back home. So



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how do we make that happen? So those are the kinds of things that we arelooking at and dealing with. There's some otherthings that we'll bring to you, but those are thekind of things that, as you afford us theopportunity to share information with you, we willdevelop those subjects into broader and moredetailed information. As Juan said, today we want to talk aboutMedicaid. Medicaid is the State-funded program --well, it's Federal funded and the State enacted --that reimburses nursing home residents. The twothird-party payers that are important to a nursinghome are Medicare and Medicaid. Medicaid is a program to help those thatcan't financially afford to pay out of pocket or,for whatever reasons, do not qualify for Medicare Abenefits. Medicare A benefits pays for room andboard, Medicare B pays for ancillary services, andMedicare D is the pharmacy piece of it -- and,again, I'm probably repeating things that youalready know, but it just feels like I should. So Medicaid then picks up the room and boardcharges for nursing home residents in the state of



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Illinois, and we'd like to share some informationabout the program, how it's evolved over the years,and where we view it currently. And we'll startwith Steve. MR. LAVENDA: Thank you. Again, my nameis Steve Lavenda. I am a partner at the accountingfirm of Marcum, LLP. I've been involved in the nursing homereimbursement area for a little over 35 years, 33 ofthose years here in Illinois, so I'm very familiarwith how the Medicaid system reimburses nursinghomes here in Illinois. But -- is it coming through? So what Juan passed out to you was a chartI put together kind of giving a history of Medicaidreimbursement starting with July 1, 1993, becausethat was -- what I'll call -- the last normal yearwhen it came to cost reimbursement. Shortly after that fiscal year began, inJanuary of 1994, the State put a freeze on theMedicaid reimbursement, and, from that pointforward, there have been two rebasings of thesupport and capital rates -- and I'll go into themakeup of the Medicaid rate in just a little bit.



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But just -- a rebasing was done just twice in almost25 years, once using the 1999 or 2000 cost reportsfor July 1, 2001, and then again on January 1st of2008, using either the 2003 or 2004 cost reports. So -- and since then and even prior to that,all there was was either inflationary increases or,as this charts points out, there were actuallydecreases in addition. So, yes, there have been some rebasings, butconsidering that the last one was based on the 2004cost report, which is 13 years ago, that's --there's a lot of years in the middle in whichoperating costs, which some -- most of which can'tbe controlled -- have increased, and the amount thatthe homes get reimbursed is a lot less than whatthey're actually paying out. As I mentioned, the Medicaid rate's made upof, basically, three different components. And,again, I've broken them down for you on page 2,nursing, support, and capital. The nursingcomponent is based not on cost but based on anassessment tool called minimum data set, also knownas MDS, and those rates do change every quarter,based on the assessments which are filed for the



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quarter before. And although, when that system was put inplace, the homes did see some increase in thenursing component of the rate, it's also more of ayo-yo. I mean, one quarter could go up, nextquarter could go down. It all depends on patientmix. It depends on the -- the staffing, how peoplefill out the MDSs. So there's not a lot ofconsistency. In addition to nursing, the supportcomponent, which is the only truly cost-reimbursedportion of the rate, which is for your overhead,such as dietary, housekeeping, laundry, linen,maintenance, some administrative costs -- again,those are things that you have to pay that may notrelate to direct care but certainly things that youneed to run the nursing home. And that, again,hasn't been updated since the 2004 and 2003 costreport. Finally, you have the capital component,which goes based on a very complicated, convolutedformula, which, depending on when your building waseither bought or leased, can help determine therate. And there have been some increases in the



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base part of the capital rate, depending on if anursing home owner or nursing home group decides toput a certain amount of capital improvements in thebuilding, and then they can qualify every June 30thfor a capital rate increase I know our office endsup filing about 30 to 40 of these every year forvarious amounts of increases. However, one thing that Mr. Waxman touchedon is the building of new buildings, modernizedbuildings. The cost to build a new building issomewhere approaching $200,000 a bed, depending onthe area of the state you're in. The actual amountin the capital formula -- which hasn't been updatedsince 2001 -- the actual cost per bed that theyallow is closer to $50,000. So, again, there's nota lot of incentive to build new facilities in thestate and to modernize to better serve theresidents. Finally, in the capital portion or the ratethere's also a component for real estate taxes, andthe real estate taxes you get reimbursed based onyour actual bill except that component has beenfrozen since July 1, 2001, which -- what was used tocalculate that was the 1998 bill, paid for in 1999,



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so that is a lot of intervening years in which thetaxes have gone up for which -- and the homes arenot receiving any reimbursement for. I know a lot of providers we work with doprotest the bills, and they are able to somewhatkeep them in line, but then there are others thathave gone up 2-, 300, 400 percent over this timeperiod. And what that does, you know, in all thesedifferent things with the freezes and the percentagedecreases and the lack of incentive to invest inyour building, you know, it just further widens thegap between the actual gap a nursing home receivesin reimbursement from Medicaid and what they'reactually spending. And the last time I looked at the 2015 costreport database and did a comparison, where theactual costs for a nursing home -- the differencebetween what the costs were and what thereimbursement rate was was almost $66 a day, onaverage. So some of that may be made up withMedicaid revenue, some with private pay. But forthe homes where it's a fixed or a large Medicaidpopulation, that puts a very big hardship on the



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operator. So I will turn it over to Alan. MR. GAFFNER: Thank you, Madam Chair andmembers of the Planning Board, for your invitationto start this education process today following ourtime with you in January. As a representative of aprovider, I'm encouraged and appreciate yourinterest in the future of long-term care within thestate. The Alden network of long-term care hasapproximately 40 facilities that span from the northshore area of Chicago to Rockford on the west andspan the continuum of care from independent toassisted living, supportive living, freestandingmemory care, rehabilitation care, and then skilledlong-term care. My assignment today is to frame and put inperspective the impact of the Medicaid reimbursementrate within the state. Steve has identified thefacts associated with that rate history; mine is totry to bring it into 2016 terms and its impact uponoperation that ultimately directly impacts qualityof care to residents. The Illinois Medicaid long-term care



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reimbursement rate is the 49th lowest in the nation.I have, again, verified this information since beingwith you in January by using the American HealthCare Association and the research that they do asthe country's premier association that representslong-term care providers at the Federal level. Steve shared with you the rate isapproximately $66 per day below the costs ofproviding daily care. For one Medicaid resident ina long-term care facility, the shortfall is $24,090annually. The average Medicaid utilization in anIllinois long-term care facility is 75 percent. If we use a 100-bed facility, that wouldallow our math to be very simple. With the Medicaidutilization of 75 percent, the yearly loss is$1.8 million for the cost of providing care to theMedicaid residents in that building. It isimpossible to recover this loss through charges toprivate-pay residents. And there was a saying for many years that,"Well, you could make it up on the private-paycommunity." It's no longer possible, if it ever was. First, I would disagree with that. Twofactors today make that totally impossible. First,



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even private-pay residents entering a facility enterthe Medicaid program more quickly than ever before.They've simply outlived their resources. Secondly, with the increasing costs that areassociated with providing care, it's impossible topull that into the private-pay rate. Medicaid-pending applications have become avery significant problem within the state. They'veadded to the already fragile financial viability oflong-term care providers. A Medicaid-pending application is theprocess of taking someone who is applying forMedicaid coverage -- they may enter the nursing homewith no Medicaid coverage or, while receiving carein the facility, they've exhausted their personalfunds and now must apply for Medicaid long-term carebenefits. The application process is intended toappropriately determine if personal assets aredepleted with no inappropriate transfers of assetsto family members or others. The number of Medicaid-pending applicationsfor individuals seeking coverage has reached anepidemic proportion. There has been a markedslowdown in the ability, on behalf of the State, to



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process those applications and make a determinationof either Medicaid eligibility or no Medicaideligibility. The number of applications awaitingdetermination has increased significantly over thepast five years, and it's very common for a periodof 18 months or more to expire before Medicaideligibility is determined. Often a resident may pass away before adetermination is made. State statute requires that,in essence, that application start over again withthe assistance of an advocate or a representative,and so you basically move to the back of the line. During the time that the long-term careresident is awaiting determination, the facilitydoes not receive Medicaid or private-payreimbursement for the care provided. The cost ofcare exists each day while no payment is received.If Medicaid eligibility is approved, payment will bemade retroactively; however, if Medicaid eligibilityis denied, no payment from the State will be madefor the care rendered. At the present time it is estimated that thetotal costs associated with Medicaid-pending



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long-term care applications is between $200 millionand $300 million statewide. It is unlikely theState has the financial capability of making thesepayments without borrowing the funds. I'd like to share with you three veryreal-world financial ramifications that exist as aresult of Illinois' Medicaid long-term carereimbursement rate, the combination of that49th lowest reimbursement rate in the nation andslow Medicaid payments. Illinois has historically been anywhere fromsometimes 3 months, 9 months -- I remember a time inthe facility where I was employed, 18 months --behind in making payments. They've placed theIllinois long-term care providers in greaterfinancial peril than ever before. Here's the first example I would share: Achain of approximately 10 long-term care facilitieslocated from Chicago to downstate is now inreceivership. There has been little interestexpressed by potential buyers of the properties. Ifthe facilities close, residents will be forced tofind another provider that may not be in proximityto their community or family members.



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A second financial ramification: Vendorswho supply long-term care facilities wait months forpayment as a result of cash flow shortages. Example No. 2: MEDLINE, one of the nation'slargest suppliers to long-term care facilities, iscurrently on payment terms of 180 days or six monthswith a multifacility long-term care provider inIllinois. This payment delay has ramifications forthe supplier as well as the provider, as both areincurring increased costs as a result of theinterest to carry the debt. A third ramification: Lending institutionsare now requiring more financial data and securitythan ever before to provide operating capital orfunding for renovations or new construction. Thisis applicable whether it's a single owner or whetherit's a multifacility organization. An example that I received two weeks agowhile we were in Washington, DC, meeting withmembers of Congress regarding the ongoing Federalreform of health care, I was in the Congressman'soffice, and the single facility owner in the ruralarea of Northern Illinois shared that he recentlywas required by his banker to mortgage his personal



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home as collateral for operation of his long-termcare facility. He's been an owner-operator for decades, notan owner new to the profession, has a longtimehistory behind him. But he shared with us, as wewere just now amazed at this new requirement, thathe has mortgaged his own home as collateral to keephis long-term care facility in operation. The inability of long-term care providers tomeet fixed costs, increasing costs of labor, andproperty taxes, as Steve identified, has createdthis financial, very perilous situation because therevenue flow for 75 percent of the business is nolonger adequate. And I share with you that across theMedicaid provider community that there is the desireto offer a higher wage level. In fact, in myconversation with providers from the southern partof the state to the northern part of the state, theyall are facing staffing challenges because they arelosing or unable to hire staff that now identify,when they are interviewed or upon leaving, that theyare receiving higher wages at retailers such asWalmart or Target or at convenience stores than they



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are receiving within the long-term care setting, notbecause there is an effort to say "We're not goingto pay you more" but the inability, from a businessmodeling perspective, to pay more and make itsustainable. And this was, again, a common theme that wasshared two weeks ago from providers across thecountry, and the fear of what may be occurring withthe Medicaid program as it makes its way throughCongress has an exponential impact on Illinoisbecause of the Illinois financial situation. I'llleave you with these outlooks that give both a Stateand a national perspective. Here's a positive: Most acute settings area lower cost provider than hospitals. They are85 percent lest expensive. The rehabilitation workthat's offered in long-term care facilities,compared to what would be offered in an acute caresetting, same type of rehabilitation, same type ofcare, is 85 percent less expensive. That's apositive. The Federal government has proposed -- andin the Federal reform of health care that was passedby the House of Representatives, there are



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unprecedented cuts to the Medicaid program.Concerns about block grants, concerns aboutper capita caps, these reductions have direct impacton Illinois. Currently the average operating margin forlong-term care providers nationwide is 0 to2 percent. As I share that with others in the worldof commerce or business or manufacturing, they'reamazed. Their response is, "Why would you even wantto enter that business if you knew your likelymargin would be 0, breakeven, or something as smallas 2 percent?" Regulations and requirements add annually tothe cost of providing care. Increased operatingcosts further reduce the margins, pushing them intoa negative position. At a time the baby boomers are aging rapidlyand life expectancy is increasing, many believe thata shortage of long-term beds is approaching. I was at the Del Webb community in Huntleylast week receiving a legislative update. Thatcommunity has 7,000 residents. An investment brokerin the community and another retailer were tellingme that they're seeing that community's residents



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now leaving because they need care in othersettings. They've been in that independentcommunity long enough that now they're having toseek other care levels. I believe that's the start of that tidalwave that we're going to see wash over us: Thoseresiding in those assisted-living facilities orcommunities are no longer able to remain independentor appropriately receive the intensity of homehealth care required could be without long-termcare. Decreasing Medicaid rehabilitation ratesfrom the Federal government that provided a limitedsubsidy for low Illinois Medicaid long-term carerates have been reduced. For organizations that owntheir own pharmacy, therapies, and home healthdivisions -- that many times were started as anecessity to subsidize the long-term care rate --have now seen these payments decrease. We've really seen the lifeboat, which wasthe Medicare program for Illinois long-term care --it has now hit an iceberg and is sinking, as well.No one is paying reasonably and appropriately forthe cost of providing care.



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Knowledgeable professionals in Illinoisbelieve that in 2017 there could be record numbersof long-term facility closures or sales as a resultof the Medicaid funding crisis in Illinois. At arecent conference in Chicago, this observation waspresented by several national experts. Old Medicaid-heavy facilities are of littleinterest to most institutional capital sources.Non-CON states offer the challenge, as well. Repealof the Federal Affordable Care Act adds to theuncertainty and risk. These factors, as theircommon denominator, have at their center an impactand outcome on availability and quality of long-termcare in Illinois. Thank you. MR. MORADO: Thank you, Alan. So another sheet you have in front of you isthe Medicaid application process that kind of breaksdown, over a page and a half, what actually happenswhen someone is seeking Medicare certification -- orMedicaid certification. Excuse me. There's a number of different steps inthere. We talked a little bit about some of thedelays and the effects of those delays, so we wanted



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to make sure you had this information. Generally speaking, you may be askingyourself -- some of the things mentioned, some ofthe issues mentioned this Board doesn't have directjurisdiction over, and that is absolutely true. But part of the reason we wanted to makethis presentation to you today is, as you well know,we have applications that come before this Board foreither new long-term care facilities ormodernizations of facilities, and a lot of differentstatements are made by these folks. And I get thesense that the Board itself may not have all theinformation that they would like to have beforethey -- before they're hearing the presentation. So this education session, in particular,was to give you some more background on Medicaid, toallow some of the members of this committee to tellyou about the issues that are facing them so that,when either they or other folks from the long-termindustry come before this Board with an application,you'll have a better sense of what the landscape is,and perhaps it's more information for you to askbetter questions and to engage with the Applicants. But I really want to thank the members for



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taking their time to put this together. I wanted togive the Board an opportunity to ask some questions. And if you have anything at all, we have theBoard members here. CHAIRMAN WAXMAN: Juan, if I may, I'd kindof like to follow up on your last comment. We certainly know that you do not have theability to fix all the problems that we havepresented. But we did want to share with you whatwe're seeing, being closer to the issues on aday-to-day basis and hope that we can work togetherwith your power and your knowledge and yourconnections to figure out how we can make somechanges to the environment because the last thing wewant to see happen is what Alan spoke about,facilities closing. I mean, there is nothing -- you know,there -- I've heard story after story ofopportunities for people to want to move or be movedout of a nursing home and go into a community livingcenter, and the people don't want to because this istheir home that they've known for the last 10 or15 years. This is where they're comfortable at. So we don't want to get into that situation



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where we have mass movement of people out of nursinghomes into other areas, be it another nursing homesomeplace away, so it's important that we try tofind some solutions to allow the owners andoperators to at least maintain some profitability,something slightly above breakeven, so that they cancontinue to provide the services. And I'd like to, again, just take asecond -- you know, from an old accountingperspective -- that without a profit -- and, again,not-for-profit organizations must have a profit tocontinue business. If you don't want to call itprofit, excess revenue over expenses. It works thesame way. But without that bottom line in a positivesituation, you can't improve clinical services, youcan't hire better staff, you can't hire the staffthat you need, you can't make the improvement to theheating and air-conditioning system and the dietaryprograms. So these operators do need some relief inwhat they're looking at. So, again, our purpose was to provideinformation, as Juan said, and to see if there aresome ways that we can all work together so that we



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can take our messages to appropriate people that canmake changes, and we certainly are available to dothat, and we look forward to future meetings withyou to broaden the topics and get into some moredetail. And we are here to answer any questions thatyou may have. CHAIRWOMAN OLSON: I think you've certainlygiven us a lot to think about and to continue onwith the conversation. Thank you so much for all your efforts andwork that went into the presentation today. I am going to move the meeting along becausewe have over 50 people for public participation, sowe're going to have to move. But we certainly willlook forward to further conversations and thank youfor all your efforts. We also are working on a Board liaison tomake sure that we have somebody in attendance atyour meetings so we'll be able to keep in bettercontact. So thank you very much. We appreciate it. CHAIRMAN WAXMAN: Thank you. MR. GAFFNER: Thank you.



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CHAIRWOMAN OLSON: The next item of businessis public participation. Juan's going to read thenames today. We have over 50 people here for publicparticipation, so when your two minutes are up,you're going to hear, in George's loudest voice,that your two minutes are up. I will ask that youfinish your sentence and stop. We have too manypeople to allow people to go on. Also, we're going to call everybody's nameonce -- or twice. If you miss your name, if youmiss your call, we're going to have to move on. So two minutes. And when you're done at thetable, please make your exit rapidly so we can getthe next group up. The court reporter would appreciate youspeaking into the microphone loudly, and pleasespell your name. And if you have written comments,if you'll leave them with Michael Constantino, we'llmake sure the court reporter gets those, as well. Do you have anything to add, Juan? MR. MORADO: No. That's all. Yes, please just make sure, if you have anycomments, that you give them over and spell your



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name clearly for the court reporter, both first andlast name. The first project we're going to be havingcomments on is Dialysis Care Center of McHenry.That's Project No. 16-058. And I have the following four names:Dr. Mohammad Zahid, James Dilts, Dr. Karol Rosner,and Dr. Michael Braun. If you could step on up to the front so youcan give your comments, you don't have to go in thatorder. But please sign in, spell your name for thecourt reporter. CHAIRWOMAN OLSON: Okay. We're going tocall those names one more time, and then we're goingto move on. MR. MORADO: Dr. Mohammad Zahid, JamesDilts, Dr. Karol Rosner, and Dr. Michael Braun. CHAIRWOMAN OLSON: Be seated at the fronttable when your name is called. MR. MORADO: Please make sure you sign in.Thank you. DR. BRAUN: My comments were for thehospital, not the dialysis center. MR. MORADO: That's okay.



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CHAIRWOMAN OLSON: Just make sure youclarify that when you start speaking. If everybody can do that, if you tell whatproject you're speaking on and if you're for oragainst the project, that would be really helpful. And the first person can go ahead and start. DR. ZAHID: Hi. Good morning. I'm Dr. Mohammad Zahid. I'm a board-certified nephrologist at ARA, American RenalAssociates, McHenry Dialysis Center, and I am hereto oppose the establishment of yet another dialysisfacility in McHenry. The Dialysis Care Center of McHenry, whichis Item H-06 on your agenda, is proposed to belocated one minute away from McHenry DialysisCenter. I would like to address two points:Number one, Planning Area 8 has a calculated needfor two stations. That's misleading, I believe. Planning Area 8 runs from Lake County toKane County. The driving time from being inLake County to Sugar Grove in Kane County is1 1/2 hours. As demonstrated, the need in the planning



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area does not mean that there is a need in theMcHenry area. Our facility, one minute away fromthe proposed site, is operating at 37.5 percentutilization. Another facility two minutes away fromus is working at 42.9 percent of capacity. Patientaccess in the McHenry area is not an issue, andthere is no need for an additional dialysis facilityin the McHenry area. Second, the application of another dialysiscenter in the last year has no track record ofsuccessfully opening or operating a dialysis center.As identified, innovation costs are only a smallfraction of your standard and have identifiedequipment costs far below your standard. Last, I mention that ARA facilities areoperating at 30.2 percent of their capacity. Eachof the nephrologists in the building and intend toadmit patients have admitting privileges at ourcenters. 6 of our 37 patients are admitted by oneof the four nephrologists, indicating a desire touse the proposed facility, again, only one minuteaway. And lastly, I -- as I promised during ourlast CON application --



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MR. ROATE: Two minutes. DR. ZAHID: -- our -- 25 percent patientsdialyze already. That's the reason for low capacityuse. CHAIRWOMAN OLSON: Thank you, Doctor. Next. MR. DILTS: My name is James Dilts, and I'ma divisional vice president for American Renal. CHAIRWOMAN OLSON: Can you pull the miccloser, please? Thank you. MR. DILTS: My last name, Dilts, D, as in"David," -i-l-t-s. ARA operates over 200 dialysis facilitiesnationwide, including three in Illinois. I'm hereto oppose the establishment of another dialysisfacility in McHenry. McHenry already has two dialysis facilities,including ours, which is a one-minute drive awayfrom the proposed new center which is Item H-06 ontoday's agenda. Members of the Board, I cannotimagine any reason to approve another dialysisfacility in McHenry. We operate with a medical -- with an open



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medical staff, which means that any areanephrologist can both refer patients to our facilityand follow their patients as acutely and asaccurately as they wish. We have been open forfive years, and our occupancy rate is currently37.5 percent. If there's ever been a case ofunnecessary duplication of services, I believe thisis it. Thank you for your attention. CHAIRWOMAN OLSON: Thank you. Next, Doctor. DR. ROSNER: My name is Karol, K-a-r-o-l;Rosner, R-o-s-n-e-r. I am a board-certifiednephrologist in McHenry, also raised in McHenry. I'm also here to oppose the building of anew dialysis unit, a third unit for our small town. There is certainly, in my opinion, no needfor additional stations. Overcapacity in a veryspecific field like nephrology or dialysis willcertainly raise a potential for hurting patients,diluting the health care providers, and increasingthe stressors on all of those involved. As of March 31st, just less thanthree months ago, the unit that I have the majority



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of my patients in runs at 40 -- just under43 percent capacity, and, as was just mentioned,ARA runs at 37 1/2 capacity. There are ampleadditional stations available in the current --where McHenry is at present. There have been a total of 20 new end stagerenal disease starts, new dialysis starts, for ourgroup in the past five years. Again, that, to me,does not justify creating and building a newdialysis facility in our small town. Contrary to one of the letters that supportsthe unit, written by Dr. F. Bangash datedDecember 26th of 2016, a quote, "extreme growth ofESRD patients." Unfortunately, he has yet to starteven one patient in our unit. Again, his census inour unit is zero. That, to me, does not support hisletter of support. Additionally, another letter of support thatwas written by Dr. F. Mohammadi supporting theunit -- she no longer practices in the area. And,to me, for somebody to walk away from a -- what isan extreme number of ESRD patients is someone whodoes not justify, again, a new unit being built. Thank you.



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CHAIRWOMAN OLSON: Thank you, Doctor. Next. DR. BRAUN: Okay. Good morning. My name is Dr. Michael Braun. Thank you forallowing me to express my opinion about Mercy'sproposed microhospital in Crystal Lake. I'm a board-certified emergency physicianand practice at Advocate Good Shepherd Hospital aswell as the Good Shepherd urgent care inCrystal Lake. I'm here to oppose the project, asthere is an abundance of emergency care services andimmediate care services available in theCrystal Lake community. One of the reasons Mercy states they'reproposing this hospital is the citizens ofCrystal Lake deserve access to emergency services.I think they're right. But the residents alreadyhave great access to four emergency departmentswithin 20 minutes of the proposed sites. Twoimmediate cares, which are open 365 days a year, arealso within five minutes. I'm concerned that theadditional emergency department will just dilute thevolume from the existing hospitals and immediatecares.



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It also seems that Mercy's hospital willonly take low-acuity patients. If a patient istransferred via ambulance and is having a stroke ora heart attack, Mercy will stabilize the patient andtransfer them to another facility, which will wastetime. I'm worried that a hospital such as thiswill create confusion for the EMS providers. Wedon't want them to have to make decisions aboutwhich hospital is best for the patient in front ofthem. We want them to take the patient to thenearest hospital, knowing that the hospital willtake great care of their patient and won't need tobe transferred to another facility. This hospital will not be a trauma hospital.It will have limited stroke capabilities, limitedcapabilities to take care of heart patients. Thisdoesn't describe the access that Crystal Lakeresidents deserve. I urge you to vote no on this project.Thank you. CHAIRWOMAN OLSON: Thank you, Doctor. Next four, please, Juan. MR. MORADO: Next four, we have the



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Honorable James Glasgow, the Honorable Tim Baldermann,Karen Lambert, and Kevin Fitch. Again, it's the Honorable James Glasgow, theHonorable Tim Baldermann, Karen Lambert, and KevinFitch. If you could please sign in, state and spellyour name for the court reporter. Thank you. CHAIRWOMAN OLSON: We're missing two people.Are they coming to the table? They're not coming? UNIDENTIFIED MALE: Mayor Baldermann willnot be coming. CHAIRWOMAN OLSON: That's one. Where's theother one? (No response.) CHAIRWOMAN OLSON: Last call. Okay. Twomore. MR. MORADO: Okay. Cheryl Vanderlaan andIlene Steiner. We can start with the folks that are here tospeak on behalf of the Silver Cross project, andthen we can move into the next project. Thank you. MR. GLASGOW: Good morning. My name isJim Glasgow. I'm the State's attorney here in



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Will County. I'm in my sixth term. I've had the pleasure of working withSilver Cross Hospital going back to 1995, when weopened our Children's Advocacy Center. They wereone of the first critical partners that allowed usto get the center open and so that we could treatour sexually abused children and effectivelyprosecute the predators who abused them. An officersaid back then it was a godsend, that that facilitywas a godsend. Well, this new hospital that US HealthVestintends to build here in Will County is anothergodsend. You all know that, when Tinley Park wasclosed, I testified at all those hearings, created anightmare on the street for us. Our jail is now amental hospital. I've got five specialty courts --mental health, domestic violence, veterans court,drug court, Redeploy Illinois -- that all depend onthese kinds of beds. If you've seen the numbers for Will County,700,000 people, we're an economically viablecommunity. We've got CenterPoint. Things arebooming, unlike in other parts of the state. But as far as mental illness, we're in the



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dregs. The number of beds per hundred thousand iswoefully inadequate, as you have all seen from thestatistics you've been given. This is critical tolaw enforcement. My job is to make sure that peoplearen't disobeying the law because they have a mentalillness that, if it's controlled through our courtsystem and through our treatment, they can live alaw abiding life. And when you look at the remedial costs andfailure to fund treatment dollars like this, they'reastronomical. You manage this individual, they --the productive life, law abiding, and truthful. Andotherwise they don't. So I would -- this isn't justa need. This is a moral imperative. And I've got something framed in my office.It's a quote by John Kennedy, his statement to thechairman of the people forming the Peace Corps, andhe's paraphrasing Dante's Inferno: "The hottestplace is in hell, reserved for those who, in a timeof moral crisis, maintain a neutrality." We have a moral crisis in Will County rightnow, and neutrality is not acceptable, and I hopethat you can see these numbers and look at thistremendous project. It's all -- all funded --



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MR. ROATE: Two minutes. MR. GLASGOW: -- no State dollars needed. Please vote yes. Thank you. CHAIRWOMAN OLSON: Thank you. Next. Is there another Silver Cross? No? That's it for Silver Cross? MR. GLASGOW: Yes. CHAIRWOMAN OLSON: Okay. Thank you. MR. MORADO: We can start with the nextproject. MS. LAMBERT: Okay. Thank you. Good morning, Chairman Olson and members ofthe Board. I'm Karen Lambert, president of AdvocateGood Shepherd Hospital, and I appreciate theopportunity to be here today to share my concernsregarding the Crystal Lake Mercy Hospital project. Our hospital has served the residents ofCrystal Lake and its surrounding areas since weopened our doors over -- almost 40 years ago. Weare about 6 miles from the proposed hospital. The Mercy project before you is one thatcould set a major health care policy precedent.Approval of this project would essentially set a



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precedent to establish new small hospitals in metroareas with existing hospitals and excess beds. A primary purpose of the Planning Act is tofoster systematic planning for health carefacilities. One way for the Board to fulfill itspurpose is to have predictable policies consistentlyapplied. Board rules provide a benchmark. I believe if you -- if you believe themicrohospitals in metropolitan areas are appropriateand a new direction for health care policy, we'dsuggest maybe changing -- an amendment to yourrules. As the staff's Board report shows, thisreport fails many of your review criteria. Moreimportantly, the project provides no benefits thatjustify disregarding the Board's rules. This typeof expensive project goes counter to health carecost reform, where we seek to serve patients outsideof the hospitals and outside of emergency rooms. Other speakers will come forward today toshow you that, one, the project shifts hospitalresources from Harvard, which is much more remotegeographically and more challenged demographically;many of the patients projected to use the hospital



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or emergency department actually live closer tofull-service existing hospitals than the proposedhospital; the project is far too large andexpensive; patients can obtain far more advancedemergency services at existing close-by hospitals,including two Level I trauma centers -- MR. ROATE: Two minutes. MS. LAMBERT: -- within minutes of CrystalLake and less expensive -- CHAIRWOMAN OLSON: Two minutes. MS. LAMBERT: -- care at nearby immediatecares. CHAIRWOMAN OLSON: Please conclude. MS. LAMBERT: I ask -- thank you -- that youfollow the rules and deny the project. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MS. STEINER: Good morning, Ms. -- CHAIRWOMAN OLSON: Just pull it closer. MS. STEINER: Good morning, Ms. Olson,members of the Board. My name is Ilene Steiner. I'm the planningmanager at Advocate. Thanks for the opportunity to



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share one of the reasons I think you should deny theMercy Crystal Lake project. As you may be aware, most of the hospitalsacross the country are facing declining revenue.That's declining resources to take care of ourpatients. Declines are being driven by lowerpayment rates by both private and public payers andby skyrocketing bad debt because our patients can'tafford to pay their co-pays and deductibles. Here in Illinois, the budget impasse hasdelayed State payments for Medicaid and Stateemployment group insurance. Of local interest, there was a recentCrain's article explaining that Advocate itself isreducing its budget by $200 million in order to getahead of this financial problem. Another recentCrain's article reported the financial deficit thatCentegra's facing. In addition to these financial challenges,only one of the eight area hospitals within the45-minute drive of the proposed site operates at theBoard's target med/surg occupancy. The 18 surgerycenters near the proposed site are operating at halfthe Board's target occupancy.



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I share these facts because the Mercy -- thenew Mercy Hospital will further adversely affectthese area facilities already facing decliningrevenues and low occupancy. The proposed service area for Mercy includesall of the communities in the Good Shepherd primaryservice area and most of the communities in theAdvocate Sherman service area. The Mercy physiciansare on staff at the area facilities, and theirpatients use the area hospitals. So, yes, the Mercy Hospital will reducevolumes at facilities with already low occupanciesand declining revenues and declining resources totake care of our patients. This is one of the reasons I ask you to denythis project. MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Thank you. Next. MS. VANDERLAAN: Good morning. I'm CherylVanderlaan and I'm a physician strategy manager atAdvocate Health Care. I'm here to address Mercy's claim of aphysician shortage in Crystal Lake and their concern



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about the continuum of care and why a new hospitalwould solve these purported problems. The Health Resources Services Administration,also known as HRSA, is a branch of the Department ofHealth and Human Services and an importantorganization that identifies geographies across thecountry that are underserved. According to HRSA, in 2016 there were522 areas in the state of Illinois that weredesignated as health professional shortage areas and176 medically underserved areas in the state.Crystal Lake was not one of these areas. We do not need another hospital to attractmore physicians to the area. Physicians alreadyhave a choice of four hospitals within 20 minuteswhere they can send their patients and be seen. Next, Mercy claims that it needs a hospitalto provide continuity of care for patients. Asmedical staff members, Mercy physicians can alreadyaccess the full continuum of care for theirpatients. There are many Mercy-employed physicianswho practice at an Advocate facility and are part ofAdvocate's PHO and ACOs. In fact, two Mercyphysicians hold prominent leadership positions at



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Advocate Good Shepherd in Barrington. Just because there are Mercy physicians thatadmit to an Advocate facility does not mean thatthey lack the continuum of care when it comes toproviding good patient care. Any physician on staffcan follow their patients via Advocate's electronicmedical record, reading images and writing ordersfor the patient without having to leave their officeand even can do this in the comfort of their ownhome. This ability to remain in touch with thepatient is what continuum of care is all about. Thefull continuum of care at Advocate ranges fromhealth management centers for chronic diseasepatients to open-heart surgery, which is not plannedfor in the Mercy microhospital. In conclusion, there's no need for an influxof new physicians to Crystal Lake, and the continuumof care, indeed, exists between Advocate and Mercy. I urge you to vote no on this project.Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. FITCH: Good morning, ladies and



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gentlemen of the Board. I'm Kevin Fitch, vicepresident of finance for Advocate Sherman Hospital,speaking in opposition to the Mercy HospitalCrystal Lake. You'll hear considerable testimony thismorning -- and we thank you for your time --testimony in opposition, very detailed, specificarguments. I'm going to recap some of the keyarguments that I think are important. First off, the project does not meetsix important Board criteria. This is a much highernumber of negative findings than typically seen inprojects this Board approves. Second, the project shifts resources fromthe financially challenged and isolated community ofHarvard to the more affluent Crystal Lake community,which is already well served by five hospitals. Third, a new hospital is not needed inCrystal Lake. The area is well served with fivehospitals, multiple immediate care centers, and anambulatory surgery center. There are five existingarea hospitals that already provide the servicesthat Mercy says are needed in geriatrics and chronicdisease management.



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All five existing area hospitals also servethe medically indigent and provide higher levels ofcharity care than that provided at Mercy of Harvard,and all provide transportation services to enhanceaccess. Fourth, Mercy's claim that an emergencydepartment is needed in Crystal Lake is unfounded.Most emergency patients will live closer tofull-service hospitals than this location. Andbecause the services of a microhospital are verylimited, most life-threatening and critical patientswill be transferred, which will delay care. And theless acute patients could be better cared for atlower-level immediate care centers at a lower cost. Next, Mercy's claim of a physician shortageis unfounded, and Mercy's physicians do not need anew hospital for a continuum of care. They'realready members of Advocate's physician-hospitalorganization and have access to coordinated systemof care contracts. Finally, by affording Mercy an acute carehospital license for what is primarily an outpatientfacility, Mercy would be paid at higher ratescosting the government --



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MR. ROATE: Two minutes. MR. FITCH: -- more money. Please vote no. CHAIRWOMAN OLSON: Thank you. Next, Juan. MR. MORADO: Next we have Trent Gordon,Colette Fraterrigo, Michael Ploszek, and Joe Ourth. Again, that's Joe Ourth, Michael Ploszek,Colette Fraterrigo, and Trent Gordon. CHAIRWOMAN OLSON: Somebody can go ahead andstart. MR. PLOSZEK: Good morning, everybody. Myname is Mike Ploszek. I'm the vice president ofphysician strategy and operations at Advocate GoodShepherd Hospital. Good Shepherd Hospital in Barrington islocated 6 miles from the proposed Mercy site and,more importantly, it is a 12-minute drive from theproposed site. I work closely with our physicians, and wehave a number of Mercy physicians on our staff atGood Shepherd. Not only are they on our staff, butthey are also in leadership positions at thehospital, including our accountable care



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organization, our physician-hospital organization.We highly value our Mercy physicians. They are oneof many independent groups that work at thehospital, and we certainly do not oppose thephysician office building that has been proposed onthat site. However, I do very deeply oppose thehospital that is proposed for this site, and I wantto address two of the reasons that Mercy has broughtforward relative to building the hospital. And thetwo reasons are reasons that, quite frankly, youdon't need a hospital. They can start right now. First off, they want to establish a clinicto take care of patients with chronic health needs,such as diabetes and congestive heart failure. AtGood Shepherd we're proud of our health managementclinic, which does exactly this. We care forchronic disease patients with those symptoms andothers. The purpose of this center is to keeppatients out of the hospital and out of theemergency room. Mercy could establish a clinic like thistoday in one of their existing outpatient centerswithout a hospital.



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Next, Mercy states that they want to bringgeriatric services to Crystal Lake, but they don'tstate why a hospital is necessary to providegeriatric services. We agree that it's importantfor patients to remain independent and healthy andout of the hospital. MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Please conclude. MR. PLOSZEK: Six million is a big amountwhen health care reimbursement is going down. CHAIRWOMAN OLSON: Thank you. MR. PLOSZEK: Thank you. MS. FRATERRIGO: Members of the Board, I'mColette Fraterrigo. I am the VP of finance at GoodShepherd Hospital. The Mercy Hospital project will increasecosts to patients, the community, Medicare,Medicaid, and I ask the Board to reject thisapplication. The project has an exceedingly high cost.The majority of the hospital space is designated fornonclinical functions such as administration,storage, support services, and not patient care.This large allocation for nonclinical space is



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highly unusual and not an economical plan. Hospitals are expensive settings to care foroutpatients. Most of the health care industry islowering costs by moving services from the expensivehospital setting to the lower-cost sites of care,such as surgicenters, immediate care centers, andfreestanding imaging centers. Advocate Sherman recently received a CONpermit to build a surgicenter with a chargestructure that is one-third less than a hospital forthe same set of procedures. This is a directsavings to the patient and the payer. Advocate and major systems are offeringlow-cost options to the costly emergency department,such as immediate care centers, walk-in clinics, andextended physician hours. Mercy's plan to build anew hospital to serve primarily outpatients is indirect contrast to the industry moving outpatientservices to lower cost settings. You have heard of the term "hospital-basedbilling." The Centers for Medicare & MedicaidServices pays outpatient services at a higher ratewhen performed in a hospital rather than outside ahospital because it recognizes that hospital-based



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care is more expensive. As an example, the payment for frequentoutpatient imaging tests is 50 percent higher in ahospital than the same tests in a nonhospitalsetting. Similarly, emergency care and surgery arepaid at a higher rate in a hospital than in othersettings. By providing outpatient services in ahospital, Mercy would significantly raise rates foroutpatient services. MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Please conclude. MS. FRATERRIGO: This, in turn, increasesthe cost to the patient, payer, and community. Forthose reasons, I ask the Board to deny this project. CHAIRWOMAN OLSON: Thank you. Next. MR. OURTH: Good morning. I'm Joe Ourth,legal counsel for Advocate. Today you're being asked to approve anexpensive new hospital that deviates far from yourrules. There's no need. Numerous hospitals arenearby, and the proposed hospital is nowhere nearthe hundred-bed minimum that your rules require.



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Now, who could justify approving a project thatdeviates this far from that? Mercy has said -- sometimes says, "Well,this is an innovative project," other times hassaid, "Oh, this is a common project. There's lotsof small hospitals." Well, it can't be both, but neither justifyapproval of this project. If innovative, the Boardshould change the rules to adopt a rule that allowshospitals of less than a hundred beds. Alternatively, if it's something that'scommon and there are a number of other smallhospitals to use as a model, this doesn't work,either. At staff's request Mercy provided the Boardwith a list of small hospitals, 48 of them who arelicensed for less than 25. Of those, on theaverage, there's only an average occupancy of24 percent. Not a single small hospital meetstarget occupancy. Are small hospitals universally bad? No, ifthey're in the right place. My home county inwestern Illinois has two stoplights and one 15-bedhospital. And they're glad they have it, but on an



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average day, there's only three patients there thewhole time. Now, when you see a small hospital, most ofthose, everything that's 25 and under is acritical-access hospital. A critical-accesshospital is one that gets favorable reimbursementfrom the Federal government. Now, to qualify as acritical-access hospital, there's a requirement forthat. You have to be 35 miles away from the nearesthospital. The hospital that's being proposed today,6 miles is the closest one. Now, if you want to change this policy --and this is a significant policy change -- then whatyou ought to do is adopt your rules. You -- MR. ROATE: Two minutes. MR. OURTH: The Board frequently does that.And this would set a bad precedent, and we would askthat you vote no. CHAIRWOMAN OLSON: Thank you. Next. MR. GORDON: Good morning, Chairwoman Olsonand members of the Board. My name is Trent Gordon.I'm the vice president of business development at



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Advocate. I'm here to oppose the Mercy Hospital. Part of my job at Advocate is actually tolook at numbers and then to make sense of thosenumbers in a larger context. Having read Mercy'sapplication for a new hospital, some things justdon't add up. The application states that one ofthe purposes of this project is to provide care forthe indigent population. A study of demographics, however, showedthat the community of Crystal Lake is actually apretty affluent community in an affluent county. Itis certainly much more affluent than Harvard, yetMercy is proposing to shift services from lower-income Harvard to higher-income Crystal Lake. This proposed new hospital will serve alower percentage of Medicaid patients requiringinpatient services and does not offer the obstetricand pediatric services often needed by Medicaidpatients. I am concerned that Mercy will be leavingonly five med/surg and ICU beds in financiallychallenged Harvard. Five beds is hardly a hospital.Mercy Harvard reported a peak census of 11 patientsto the State, so where would the other 6 patients



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go, then? Mercy's history at Harvard further undercutsits claim that this project is to serve the indigentpopulation. We pulled some COMPdata numbers andfound that Centegra has more charity/Medicaidadmissions from the city of Harvard than MercyHarvard does. In fact, it's a lot more. In 2016Centegra saw 260 Medicaid self-pay admissions fromHarvard while Mercy saw only 29. I certainly believe that Mercy will see someMedicaid and self-pay patients in Crystal Lake.Don't get me wrong. However, what they were tellingyou in their application that they will see andtheir experience of running a small hospital inIllinois are actually two very different things. Finally, as Mr. Ourth pointed out, approvingthis project will result in the two smallesthospitals in the entire state of Illinois, the twosmallest hospitals. The Board should consider ifit's clinically appropriate to have a five-bedhospital -- MR. ROATE: Two minutes. MR. GORDON: -- in the state -- CHAIRWOMAN OLSON: Please conclude.



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MR. GORDON: -- and the precedence this maycreate. Thank you for your time. CHAIRWOMAN OLSON: Thank you. Next. MR. MORADO: Jeni Hallatt, Sue Schrieber,Ann Bunnell, and Ted Ducker -- Tim Aurand. CHAIRWOMAN OLSON: Somebody can pleasebegin. MS. HALLATT: Sure. I'm Jeni Hallatt, J-e-n-i H-a-l-l-a-t-t,vice president with Mercy Health. We are requesting permission to redistribute13 underutilized beds from Mercy Harvard Hospital toa responsibly sized small hospital we're proposingin Crystal Lake. We are not adding beds to theplanning area but redistributing beds and doing whatother health care providers are doing across thecountry in reconsidering facility design in order tomeet today's technology, moving to outpatient careand decreasing reimbursement. I'd first like to take a moment to clarifythe cost breakdown of our project. Clinicalconstruction costs for our 13 inpatient beds is a



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total of $3.6 million. For the ED it's2.25 million. For the surgical department,6 million. And the diagnostic and treatment areas,6.4 million. There's $17.2 million for all the supportservices in the facility. That's facilities,dietary, medical records, cafeteria, pharmacy,et cetera. And the remaining 44 million is for allthe land prep, the architectural fees, theequipment, and a project of this size has multiplemillions of dollars in contingencies. These costs are very much in line withprojects this Board has approved, and I noticedthere were recent approvals for a $4.6 millionfitness center for Kishwaukee and a $35.6 millionsurgical center with only four operating rooms. Themost telling aspect is that the CON staff hasindicated our costs for this project meet the Statestandards. I also want to mention that therepresentatives at Advocate had spoken of their --the Medicaid that they serve. And that's great butthey didn't share the numbers. Good -- excuse me. Advocate Good Shepherd



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served 4.6 percent of Medicaid -- of their Medicaidpopulation -- MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Please conclude. MS. HALLATT: -- Mercy Harvard Hospitalserved 27 percent Medicaid. CHAIRWOMAN OLSON: Thank you. Next. MS. SCHRIEBER: My name is Sue Schrieber,and I am the vice president of planning at MercyHealth. Planning Area A-10 has one of the highestoutmigration percentages in Illinois. More than55 percent of inpatients who live in McHenry Countyare treated at hospitals outside the county. Incomparison, counties with multiple hospitals, suchas Peoria and Sangamon County run about 5 percentoutmigration. The services Mercy Health proposes atCrystal Lake are designed to fill the gaps asdocumented in the 2017 McHenry County communitystudy. Mercy Health did not participate in thisstudy, but we have read the study and know theresults.



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We do participate in health needsassessments for all the communities we serveincluding Harvard. We listen to the voices of thecommunity and our patients and design programmingthat is in response to service gaps and communityneeds. We know that cancer is the leading cause ofdeath in McHenry County. Easy access to diagnosticservices such as colonoscopy is key to earlydetection. The study also identified mental health as apriority. Mercy Health has a long-standingcommitment to providing mental health services inthe communities we serve, and we will assess andwork to meet the needs of individuals living inCrystal Lake. Finally, in the county health communitystudy and focus groups, community leaders notedcertain overarching issues, including a lack ofcontinuity of care for chronic conditions, limitedaccess to physicians for Medicaid patients,availability and accessibility of publictransportation. The new Mercy facility is designed to fill



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service gaps and meet community needs. Ouropponents would have you believe there areabsolutely no service gaps in McHenry County.Clearly, gaps exist. We urge you to support this innovativeproject and do the right thing for the citizens ofCrystal Lake. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MS. BUNNELL: Hi. I'm Ann Bunnell, seniormanager for the Mercy Health behavioral healthservices. I'm speaking in support of Mercy Health'sproject. Mercy Health has a long-standing commitmentto providing behavioral health services in thecommunities we serve. We currently offercomprehensive behavioral health programs inJanesville and Rockford. These services include acontinuum of hospital-based inpatient mental healthand detox services, day treatment services forchildren, adolescents, and adults, as well asaddiction adult day treatment services. Additionally, we offer outpatient mental



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health and addictions services in many of ourcommunities with over 50 treating counselors,therapists, nurse-practitioners, and psychiatrists.We have continued to expand our services as needsdictate. The McHenry County Healthy Community Studyidentified mental health as a priority. At ourCrystal Lake facility, we're looking forward toestablishing outpatient behavioral health servicesat our medical office site. Once the clinic isoperating, we will take our guidance from McHenryCounty's outstanding board of health that helpsguide 27 agencies in the county already. Given our long-standing track record inproviding mental health services, we look forward tomeeting the needs of Crystal Lake residents and willwork to that end. CHAIRWOMAN OLSON: Thank you. DR. AURAND: Good morning. I'm Tim Aurand,the James E. Thompson professor of marketing atNorthern Illinois University. The study I'll report on was conducted byfaculty and students at Purdue University. It's acommunity survey done to assess residents living in



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the Crystal Lake region regarding their views on theneed for emergency department services inCrystal Lake. Specifically those residents in theprimary service area were the main focus, whichincludes the communities of Crystal Lake, Cary,Algonquin, Lake in the Hills, and Fox River Grove. Three survey methods were used with a totalof 396 respondents. Survey size and time was -- onthe data -- were appropriate for each report. Over 93 percent of people in the primaryserve area believe it is very important to have anemergency department close to their home. When welooked at age in consideration, results showed that,as age increases, their definition of "close" becamevery evident. Those respondents aged 55 years orolder reported the need for an emergency department2 1/2 miles closer than younger respondents,indicating current -- indicating current emergencydepartment service were too far away by miles aswell as by drive time minutes. They were acutelyaware of the need to access care quickly. For residents who indicated they haddifficulty accessing emergency services, therespondents were asked to explain what location they



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were trying to reach. Problem locations too faraway included Sherman Hospital, NIMC McHenry,Centegra, Lutheran Geneva, Good Shepherd,St. Alexius, and Advocate Christ. With regard to difficulty in reaching anemergency department, comments such as "Due toSaturday traffic on Randall Road; it was a longdrive even though it was in the middle of thenight." That was a 65-year-old female trying toreach Good Shepherd. Also, 52.2 percent reported increaseddifficulty in reaching the nearest emergencydepartment in rush hour traffic. The need foremergency department services in our community rosesignificantly and geographically. 65.4 percent of respondents fromCrystal Lake indicated there was a significant needfor emergency department services -- MR. ROATE: Two minutes. DR. AURAND: -- in Crystal Lake. CHAIRWOMAN OLSON: Please conclude. DR. AURAND: Okay. This was a direct response to the statement:"I feel there is a need for the emergency department



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in Crystal Lake." CHAIRWOMAN OLSON: Thank you. MR. MORADO: Next up we have Michael Eesley,Aaron Shepley, Hadley Streng, and David Tomlinson. Please, if you have written comments, canyou make sure you get them to Mr. Constantino whenyou're done speaking? Thank you. CHAIRWOMAN OLSON: Please go ahead. MR. TOMLINSON: Okay. Good afternoon. Myname is David Tomlinson, and I'm speaking inopposition to Project 17-002. I serve as the chief financial officer atCentegra Health System, and this project willnegatively affect area hospitals, including CentegraHealth System's existing hospitals in Huntley,McHenry, and Woodstock. Mercy itself acknowledgedthis in its application. Just 10 months ago we opened CentegraHospital-Huntley, which, according to the Staterules, still has two full fiscal years to meettarget occupancy standards. If another facility isconstructed less than 9 miles away, the volumeprojections and analysis that went into the creation



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of Centegra Hospital-Huntley would be in vain. Ourability to serve patients would clearly becompromised. In its application Mercy states that ahundred percent of the hospital's volumes would bemade up by diverting patients from each of thefive surrounding acute hospitals, an average of156 patients per hospital. This is only shiftingvolume from existing hospitals to their proposedfacility, which does not create value; rather,duplication. In addition, Mercy projects 17,000 emergencydepartment visits in the first year of operations atthis new facility. Using these numbers, this meansevery hospital in the planning area would lose about3400 emergency department visits to Mercy. This isa significant loss in volume and would result inabout a 15 percent loss in volume at Centegra HealthSystem. Mercy's project does not add value, costsavings, or enhanced services for the patients ofour community. It simply shifts volumes away fromthe five existing hospitals with no added benefitsto the patients.



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Thank you. Please vote no. CHAIRWOMAN OLSON: Thank you. Next. MR. EESLEY: Good afternoon. I'm MikeEesley, CEO of Centegra Health System. ChairwomanOlson and members of the Board, thank you forallowing us this opportunity. We service -- our hospitals service McHenry,Kane, and Lake Counties in Illinois. It is mostimportant that we keep our focus on the needs of ourpatients and their families. Patients are wantinghigh-quality local care. Our region already hasfive nearby hospitals that provide this service. Our community is already experiencingchanges as a result of major shifts in the healthcare industry. The Affordable Care Act made morepeople eligible for government-sponsored healthplans that they cannot afford. Patients are suffering from a burden ofhigh-deductible health insurance and we're alsoseeing the same kind of outcomes within our healthsystems. We are receiving lower reimbursements,more than ever, for the leading care that weprovide.



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In 2010 this Board projected a bed need inMcHenry County for medical/surgical, obstetrics, andintensive care beds. At the time the medical/surgical need was 83, and that was when we wereproposing to build Centegra Hospital-Huntley. Just a year later the State revised theregion's medical/surgical bed need to be evengreater, to be 138 beds, and Centegra HuntleyHospital was approved by this Board. Since that time our community's projectedgrowth has flattened. The State again revised thebed need to reflect that trend. Like every otherresponsible health care system in the state, we mustreevaluate where and how we provide services to ourpatients. We must become more efficient so that wecan continue to care for our community. As we have more than 100 years of service,Centegra Health System will continue to adjustservices to address the needs of the patients weserve. Our community does not need anotherhospital. Please deny this project. MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Thank you.



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Next. MS. STRENG: Good afternoon. My name is Hadley Streng, and I'm seniorvice president of strategy and development forCentegra Health System. I am here in opposition toMercy Health's project, 17-002. Mercy Health is proposing to establish amicrohospital; however, the proposed project doesnot meet the commonly recognized characteristics ofa microhospital. The Advisory Board Company is one of themost respected health care consulting firms anddescribes the design and purpose of microhospitalsas follows: Beds, typically 8 to 10. MercyHealth's proposal is 13. Cost, usually rangesbetween $7 million and $30 million. Mercy Healthrevised theirs to be just under $80 million, over$6 million a bed. Size, typically 15,000 to 50,000 squarefeet. Mercy Health's proposal is 111,000 squarefeet. The average general hospital across thecountry is only 75,000 square feet. Purpose, to fill in service gaps in areaslacking inpatient facilities. There are five



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hospitals within 12 1/2 miles of their proposedsite. There's not a lack of service. Mercy Health's proposed microhospital is notmicro in size, not micro in cost, and not micro inpurpose. This project does not meet the ReviewBoard's criteria and should be denied. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. SHEPLEY: My name is Aaron Shepley, andI'm here today as the general counsel for CentegraHealth System. My family moved to Crystal Lake 45 yearsago, and for the last 18 years I've also served asthe mayor of Crystal Lake. I'm opposed to Mercy Health System'sproposed project in Crystal Lake. In the simplestterms, this proposal is nothing more than a ploydesigned to allow Mercy to do what Illinois Courtsand this Board have rejected at least four times. Mercy packages this project as a 13-bedmicrohospital, a, quote, "new" type of hospital thathas received little support in the United States,has never been approved or constructed in Illinois,



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and, in fact, is not even permitted under thePlanning Act. A review of the size and scope of thisproject reveals that it bears a striking resemblanceto Mercy's failed projects of the past. In 2004Mercy presented a proposal for a 70-bed facilitywith 160,000 square feet and a cost of $81 million.In 2011 the proposal was 162,000 square feet andcost $115 million. In both proposals well over halfthe space was reserved for clinical activities. Today Mercy is proposing a 111,000-square-foot, 13-bed hospital at a cost of $79 million withwell under half the space reserved for clinicalactivities. Significantly, Mercy filed a separateapplication for a 40,000-square-foot MOB that is notmerely interdependent with the hospital; it will bethe top two floors of the hospital and will share anopen two-story atrium. The most likely explanation for the separateapplications is that, had Mercy combined theapplications as required by planning standards, thetotal size of the project would be 151,000 squarefeet, nearly identical to the rejected 70-bed



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proposals. If approved, Mercy would arguably have theability to systematically add beds and incrementallyconvert nonclinical space to clinical without anyfurther approval from this Board. This ploy should be rejected and Mercy'sapplication denied. CHAIRWOMAN OLSON: Thank you. Next, four more. MR. MORADO: James Adamson, Dan Lawler,Matthew Wilson [sic], and John Cook. CHAIRWOMAN OLSON: Please, somebody, goahead and start. MR. COOK: I'd be happy to start. My nameis John Cook. I'm chief financial officer ofMercy Health. I would like to comment on thefinancial viability of Mercy Health's proposedhospital in Crystal Lake. Mercy Health has a long history of achievingthe highest quality at an affordable cost. This isdue to our integrated care model as confirmed byattainment of the Malcolm Baldrige Award, whichMr. Bea will talk about in his presentation. Each of our hospitals and clinics are



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expected to meet national benchmarks for quality andcost. Over the last 10 years, operating income asa percent of revenue has averaged over 3 percentannually for Mercy Health. Mercy Health hasrealized revenue growth and positive operatingincome every fiscal year. When Mercy Health acquired the nearlybankrupt Harvard Hospital, we invested over$26 million in the facility, turned around theoperation, and brought high-quality health care tothe residents of Harvard. The Harvard Hospital has averaged a5.5 percent operating margin even though 27 percentof its enrollees -- or patients are enrolled inMedicare. Mercy Health has the fiscal disciplineneeded to make strategic decisions that generate areasonable return on investment. This is due togreat planning and execution of its strategic plans. As with all of our projects, including ourmerger with Rockford Health System and the RockfordCON applications approves by this Board, MercyHealth engages in stringent financial modeling as toconstruction and operating costs.



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Our proposed Crystal Lake projects have beenvetted and will achieve profitability withinthree years from opening and an 8 percent return oninvestment. While other systems have announced massivecost-cutting initiatives or are merging with largeregional hospital systems, Mercy Health has beenquietly reducing costs and improving qualitymetrics. To be financially sustainable, healthsystems need to deliver high quality and low cost,and that's exactly what the Crystal Lake project isdesigned to do. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. WATSON: Good afternoon. My name is Matthew Watson, and I'm theregional director of operations for OrthoIllinois,an independent group of 33 physicians, and we serveCrystal Lake, McHenry County, and the Rockford metroarea. I'd like to give you my opinion about theproposed Mercy Crystal Lake hospital. Neither our physicians nor our staff areemployed by a health system, so I think that we



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bring a unique perspective for this debate. As aprivate orthopedic group, we believe that there areplenty of services in the Crystal Lake area when itcomes to physician access to patients, emergencyservices for patients, and hospital beds forpatients. We don't think it would be a benefit for ourpatients nor our physicians if another hospital wereto open in McHenry County. The only group thatwould benefit from the hospital would be Mercy.Should they open up a medical office building andhospital, they would be able to charge higher ratesfor their outpatient ancillary services, such asMRIs and X-rays, than if they opened such servicesin a clinic. For example, my group, we own an MRI andX-ray, but because we're not in a hospital setting,we only charge provider-based rates. The hospitalscan charge hospital-based rates, which are muchhigher and -- at least the base rates -- and thismeans much higher payments to Mercy from governmentpayers, private payers, and from patients. While this is a small hospital, it will meanbig bills for patients. That's not what we want for



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the patients in our community there. Finally, health care resources are scarcethese days for health systems, hospitals, andphysicians. As you may be aware from a recentCrain's article, Centegra's losing $40 million afteropening their new hospital in Huntley. This shouldbe a cautionary tale and should aid you in makingyour decision. As I read the application, I saw thatMercy's volume to fill these hospital beds woulddirectly come from other systems, includingCentegra. In conclusion, I know that you'll hear fromseveral health care systems today. Please also hearwhat private independent physicians are saying.We're saying "Please, no" to Mercy's hospitalproject. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. ADAMSON: This is a statement inopposition to the Mercy Crystal Lake project,17-002. My name is Jim Adamson. I'm the directorof risk and regulatory matters for Centegra Health



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System. There's ample competition among health careproviders in the McHenry County planning area. Weknow this because whenever Centegra has tried to addor expand services, there has been opposition byat least five different hospitals and health systemsto it. They only do that because they areaggressively competing for patients in McHenryCounty; however, all this competition in theplanning area does not create the typical freemarket benefits. Mercy Health's vice president Jennifer Hallrecently said at a Review Board public hearing justa few weeks ago, "This is not a free marketsituation in which placing a Walgreens next to a CVSis better for the consumer." Indeed, the economicsof health care are different. Opening a hospitalnext to an existing one does not, in fact, make itbetter for the patients. Large consumers such as Medicare andMedicaid dictate their own prices, frequently belowthe cost of the services being provided.Additionally, various governmental requirements forfree or discounted care, such as EMTALA, further



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stress providers. These realities are not part ofthe regular free market. In recognition of the unusual economics ofhealth care delivery, the Illinois legislature hastasked the Review Board with assuring the properallocation of services so as not to createunnecessary duplication of services andmaldistribution of services. The primary danger of unnecessaryduplication and maldistribution is that it reducesutilization at existing facilities and reducesmargins that are already razor thin, therebydestabilizing the entire health delivery system. This Board has no obligation to protectCentegra's market share or Advocate's market share;however, the Board does have an obligation under thePlanning Act to establish an orderly andcomprehensive health care delivery system thatguarantees the availability of quality health careto the general public. The Planning Act is designed to promote theorderly and economical development of health carefacilities in the state of Illinois that avoidsunnecessary duplication of such facilities.



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Mercy Crystal Lake Project 17-002 is anunnecessary duplication of -- MR. ROATE: Two minutes. MR. ADAMSON: -- facilities. It willundermine the -- CHAIRWOMAN OLSON: Please conclude. MR. ADAMSON: -- comprehensive health caredelivery system. CHAIRWOMAN OLSON: Thank you. Next. MR. LAWLER: My name is Dan Lawler. I'm apartner with the law firm of Barnes & Thornburg andhere to oppose the Mercy Crystal Lake Hospital. Mercy describes its microhospital as a newmodel of health care delivery. I agree with thatand the State has an interest in promoting newmodels of health care. That is why we have theAlternative Health Care Delivery Act. Under that act a new model of care is firstresearched by the State Board of Health, recommendedto the Governor and the General Assembly by theDepartment of Public Health, and enacted into law.Only then are these new models in care subject toreview by this Board under criteria specifically



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adopted for that particular model. That was theprocess for birthing centers, residential rehabcenters, and other new models of care that thisBoard has been empowered by the General Assembly toreview. Were this Board to proceed on its ownwithout the State Board of Health and Public Healthand the Governor and the General Assembly and absentcriteria for microhospitals, it would still have tofind substantial compliance with criteria that areavailable. What is substantial compliance with a rulethat requires 100 medical/surgical beds? Is it 90?80 beds? 70? The Board has discretion but at somepoint there can be an abuse of discretion. Where isthat point? The Circuit Court of Illinois has held thatapproval of a 56-bed unit when a rule requires100 is an abuse of discretion. I litigated thatcase. If 56 beds is not substantial compliance andtransgresses the bounds of proper discretion, whatdoes that say about 11 med/surg beds when the rulerequires 100? Thank you.



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CHAIRWOMAN OLSON: Thank you. Next four. MR. MORADO: John Hanley, Matthew Sanders,Dr. John Dorsey, and Pat Cranley. CHAIRWOMAN OLSON: Please go ahead. MR. SANDERS: Hi. My name is -- THE COURT REPORTER: Wait. I can't hearyou. CHAIRWOMAN OLSON: Pull the mic toward you. THE COURT REPORTER: Would you start overagain. I didn't hear your name. Sorry. MS. AVERY: You still need to bring it veryclose. CHAIRWOMAN OLSON: Use your outside voice. MR. SANDERS: Okay. My name is MatthewSanders, and I am a licensed architect with AECOM, anational health care design firm representing MercyHealth. I have worked on health care projects formore than 25 years. There have been references made tomicrohospitals built elsewhere throughout thecountry. The cited examples are stripped-downmicrohospitals built by developers. One facility isnot even a hospital; it's a stripped-down ER. These



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are inaccurate projects to compare, considering thedifferences in program and location. These facilities are leased. They are notowned like Mercy Health would be owned. Componentsof the cost are not being accurately captured. Thetrue cost of construction is obscured. There are significant program differences,as well. Surgery, in many cases, is not included.Imaging services are limited. Outside food servicesare used versus a full cafeteria service model.Support services like central sterile are outsourcedand not provided on campus. These facilities operate like an outpatientclinic. Their nursing units are designed similar toobservation units with double-occupancy patientrooms, which would not be competitive in thismarket. These facilities would not even meet theIDPH standards. In terms of costs and sites, you shouldconsider more appropriate comparisons to the MercyHealth facility project. Kirby Hospital inMonticello, approved for $34 million in 2009 withone-third less square footage equates to, today'sdollars, about $68.3 million.



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The proposed abandoned expansion ofCentegra-Woodstock Hospital was proposed in 2008 andapproved for $52 million. It would be $77 millionin today's dollars, almost the same cost as thisproposed project. Lurie Children's outpatient facility inNorthbrook was recently approved by this committeefor $35 million. It is only 36,000 square feet,one-third the size of Crystal Lake. It is over athousand dollars per square foot. So, in summary, the Mercy Health CrystalLake proposed project is appropriately programmed,and the cost is in alignment with the current marketand meets the State standards. Similar projects -- MR. ROATE: Two minutes. MR. SANDERS: -- as Crystal Lake's have beenapproved by the State in the past. Thank you. CHAIRWOMAN OLSON: Please conclude --thank you. Next. DR. DORSEY: Good morning. I'm Dr. JohnDorsey, D-o-r-s-e-y, vice president of physician



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services and CMO at Mercy Health. I am here not only to express my support forthe Mercy Health project but also to explain ourvision of care delivery at this facility. Thecombination of an emergency department, ambulatoryfacility, and 13 inpatient beds affords our patientsconvenience, flexibility, and efficiency. Consider this facility as a first line ofmedical defense for the 50,000 people ofCrystal Lake. We believe in delivering the rightcare at the right location at the right price, andthis project achieves these goals. We envision in our ambulatory facility thatpatients will be able to easily access more than oneprovider on the same day, as these providers willall be under the same roof. This minimizes returnvisits, delays in diagnosis and treatment, and thisconcept of coordinated care is especially importantfor the elderly, ill, and the economicallychallenged citizens of Crystal Lake. When a patient presents to the ED, they willbe triaged. If their clinical needs fall in theimmediate care category, we will have primary careproviders with extended hours available to treat



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them. If the triaged patient needs ED care, thiswill be delivered by board-certified ED docs withthe goal of 15-minute wait times in an efficientmanner. And this also, in our layout, will allowprivacy for those individuals presenting with suchthings as acute mental health needs, potentialvictims of physical or sexual violence. Once evaluated and stabilized, patients maybe discharged home, they may be transferred to oneof the comprehensive hospitals already existing inthe area, or kept overnight for observation in oneof our 13 inpatient beds. Sometimes theseextra hours in a bed are necessary to further treatand evaluate the patients and, again, particularlyimportant for the elderly and vulnerable. These13 beds will provide safe and efficient care -- MR. ROATE: Two minutes. DR. DORSEY: -- for those needing a longerperiod of observation -- CHAIRWOMAN OLSON: Please conclude. DR. DORSEY: -- than can be done in anemergency department. Thank you.



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CHAIRWOMAN OLSON: Thank you, Doctor. Next. MR. HANLEY: Hi. I am John Hanley, head ofhealth care investment banking at Ziegler, a healthcare specialty investment bank celebrating 115 yearsof operation in Illinois. I work with health systems in states withand without the certificate of need process. Inmany situations I find those who oppose projectsselfishly look to protect their market share whileignoring the optimum model of care to best servepatients. I support Mercy Health's 13-bed hospital andmedical clinic for several reasons. First, healthcare is local; it is not the relative size of anorganization, measured by gross or net patientrevenue, but its size relative to its market. Thebuilding of a campus which includes a small hospitalwill accomplish these goals for Mercy Health, whichhas, for decades, provided the Crystal Lake marketwith quality health care. Failing to implement appropriate size andscale often results in financial pressures to anentity, as we have seen at many facilities across



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the country, in the state of Illinois, and evenlocally with Centegra and their significant lossesover the last two years. Second, management matters. I've seen thestrength of Mercy Health's senior management team,led by Javon Bea, tackle challenges head-on. Thelatest examples include the uniting of two systems,Mercy Alliance and Rockford Health System in theiraffiliation and the tremendous financial turnaroundof Rockford Health. Mercy Health enjoys a strongrating by Moody's Investors Service and Fitch. And as to the opposition comments that thisproject cannot be financially viable, they're simplynot true. Ziegler has analyzed 44 hospitals in thestate of Illinois that are 25 beds and under and8 that are 50 beds and under. 50 percent of thosehospitals have positive operating margins. My conclusion is that small hospitals can beand are viable. It all comes down to the managementof these smaller hospitals and the ability toappropriately provide care to the patient populationthey serve in the right setting. MR. ROATE: Two minutes. MR. HANLEY: Mercy management --



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CHAIRWOMAN OLSON: Please conclude. MR. HANLEY: -- has proven to beexceptionally strong in these categories. And I -- CHAIRWOMAN OLSON: Thank you. MR. HANLEY: -- recommend the Board approvethe project. CHAIRWOMAN OLSON: Thank you. Next. MR. CRANLEY: Madam Chair, members of theBoard, my name is Patrick, P-a-t-r-i-c-k; Cranley,C-r-a-n-l-e-y. I am senior vice present and chiefoperating officer of Mercy Care Health Plans. Mercy Health is both vertically andhorizontally integrated as a health system. MercyHealth has operated its own health plan since 1996. While "population health management" hasbecome kind of a buzzword these days, Mercy Healthhas long-term experience managing the cost andhealth of our patient population. Mercy Health's approach to population healthand our integrated care models ensure thecost-effective use of premium dollars. This resultsin extremely low and competitive premium prices foremployers and employees and permits the deployment



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of greater resources in caring for patients. In Wisconsin MercyCare offers a variety ofplans, including individual and family plans, seniorsupplement plans, a Medicaid MCO, and commercial HMOand PPO plans. Last year MercyCare made national news asthe only company in Wisconsin to lower our rates onthe Wisconsin Health Insurance Exchange, whichprovides affordable care under the ACA to low- andmiddle-income families. Last year MercyCare also began offering ourHMO products in the Illinois counties of Boone andWinnebago. We hope to bring our health insuranceofferings to McHenry County, as well. Unfortunately,that will not be possible without the ability toalso fully implement our integrated care model. In order to manage the full spectrum of careand provide care coordination, Mercy Health'spatients must have access to the full spectrum ofhealth care services, including hospital care.Today, a single hospital system, Centegra, controls95 percent of all the beds in McHenry County. Based on my 20 years in managed care, mostof it devoted to negotiating with hospital systems,



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I can assure you that that's a recipe for increasingprices and decreased choices for consumers. MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Please conclude. MR. CRANLEY: Where there is no competitionin a market for health care services, payers -- CHAIRWOMAN OLSON: Please conclude. MR. CRANLEY: -- have no choice but to meetthe demands of the providers. CHAIRWOMAN OLSON: Thank you. MR. CRANLEY: Thank you. MR. MORADO: Next up we have Ladd Udy,Michael Hill, Mark Kownick, and Jen Hall. That's Ladd Udy, Michael Hill, Mark Kownick,and Jen Hall. CHAIRWOMAN OLSON: Please go ahead. MR. UDY: Good morning. My name is Ladd Udy,L-a-d-d U-d-y. I'm the director of populationhealth for Mercy Health, and I'm here to share withyou just two data points that demonstrate whyI support the Mercy Health project. One of the strongest levers in thepopulation health movement away from paying forvolume but paying for value instead in health care



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is called accountable care. You've heard that termtoday. This is a new way of contracting in whichMedicare and other insurers measure us on qualityand on the total cost of health care. It so happens that Mercy Health, Centegra,and Advocate are all part of the same accountablecare program, Medicare Shared Savings Program, sothis is the best apples-to-apples comparison ofoverall value delivery we have. I'll review the results with you from 2015,which is the most recent year we have data for.Here's how the quality scores came in, from high tolow on a 100-point scale: Mercy Health at 97.97,Advocate at 94.19, and Centegra added up to 89.82. On the flip side, here's what Medicare spentper patient per year in 2015, again from high tolow: Advocate at $10,909 per patient, Centegra at$10,438, and Mercy Health at $8,773 per patient. So of the three main competitors in McHenryCounty, Mercy Health had the highest quality and byfar the lowest spend. And what that means is that,if all Medicare patients assigned to any of the ACOsin McHenry County would have received their care atthe Mercy Health cost rate, it would have saved



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Medicare over $67 million just in 2015. And on a larger scale, let's say all ofAdvocate's assigned Medicare patients across theirfootprint had received their care at the MercyHealth cost rate. That would have saved Medicareover $320 million in one year alone. And those arethe savings for Medicare only, so the potential fortotal savings are enormous with all patients withinthe Mercy Health model. But we're missing one piece in McHenryCounty in order to deliver that full spectrum ofcare so our patients have to go to our competitorsfor those services, where it ends up costing more. The residents of Crystal Lake deservebetter, and they clearly want a better option. Theobjective data show that Mercy Health is that betteroption for delivering value. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. HILL: Good afternoon. Good afternoon. I'm Michael Hill. I'm thepublic health administrator for McHenry County. CHAIRWOMAN OLSON: I need you to speak right



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into the microphone, please. MR. HILL: I'm having allergy problemstoday. Is that better? CHAIRWOMAN OLSON: Yes. MR. HILL: I'm Michael Hill. I'm the publichealth administrator for McHenry County, Illinois.I'm here to express my strong support of the twoMercy Health certificate of need requests seekingapproval to build a multispecialty clinic and 13-bedhospital in Crystal Lake, Illinois. Our health department is charged with usingevidence-based research to address priority healthconcerns in our community. Our needs assessmentshave confirmed that more than 65 percent ofMcHenry County residents seek care outside ofMcHenry County. This is an unfortunately highpercentage. It is also a significant and unfair burdenon disadvantaged populations, including theindigent, elderly, and those with limited access toreliable transportation, populations that aretraditionally underserved and forgotten. Mercy Health's proposed projects would bringvital new resources to the Crystal Lake community



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that would improve the level of access to care tothis group in particular. Mercy Health has alreadydemonstrated its commitment to serving theunderserved in the markets where they currentlyprovide health care. This measured proposal is notseeking to increase the licensed beds but, rather,to redistribute beds to where they are most needed.Allowing them to further their mission inCrystal Lake is both critical and responsible. Mercy Health's proposed projects will alsoprovide for the first-ever emergency department inCrystal Lake. Again, from a public healthperspective, at-risk populations in Crystal Lakehave suffered from lack of adequate emergency careprovided locally. This contributes to poor healthand skyrocketing health care costs. The Crystal Lake area is a growing communityof 60,000-plus. It is large enough to need andsupport an emergency department and a smallhospital. The proposal directly addresses thehealth needs and priorities identified in the 2017Healthy Community Study. We would all benefitsignificantly. How can you say no to increasedefficiency, reduced cost, and better care for our



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most vulnerable populations? For these reasons I respectfully requestthat the Illinois Health Facilities and ServicesBoard approve Mercy Health's certificate of needproposals. CHAIRWOMAN OLSON: Thank you. Next. MR. KOWNICK: Madam Chair, Board members, myname is Mark Kownick. I'm the mayor of the Villageof Cary. On behalf of the Village, I am here toexpress our support for Mercy's proposed hospitaland medical office building at the intersection ofRoute 31 and Three Oaks Road in Crystal Lake. Theproposed project would be located approximatelyone-half mile west of Cary's corporate boundary andwould provide our residents with an importantresource that would easily be accessible. This is especially attractive for tworeasons, the first being expanding access to vitalhealth care services close to home increasesconvenience and encourages residents to seek care ona proactive basis, when it's least expensive. Secondly, adding an option for emergency



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care close to home is a great benefit for everyresident in our area and, for some in particular, itwould be a significant improvement to the quality oflife. Our goals as a Village include supportingthe development of services that benefit our growingsenior population. That population, in particular,has long needed and desired a local emergencydepartment. This fills an existing gap in a long --and is long overdue. We also appreciate how the proposal isstructured in such a thoughtful manner, deliveringservices where and when without overdelivering. Itis an appropriate use of resources. I understand the emergency department willbe classified as comprehensive, the highestclassification conferred by Illinois. This meansthat it will be able to cover approximately97 percent of all emergency needs, which arecurrently not being met locally. This is asignificant and positive change with the power toimprove the lives for all Cary residents. Additionally, the new hospital is proposedalong two major roadways in the most densely



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populated part of the McHenry County, with ThreeOaks Road providing direct and convenient accessfrom Cary and other communities along US Route 14 tothe east. This means that the large majority ofMcHenry County residents would have increased accessto quality care, a benefit for all of us. The Village is highly supportive of thisproposed project and the benefits it would have forthe entire region. The Village recommends approvalof Mercy Health Care's application. CHAIRWOMAN OLSON: Thank you. Next. MS. HALL: Good morning. My name isJennifer Hall. I'm the vice president of governmentrelations and community advocacy for Mercy Health. While I appreciate that our opponents arepaying attention to what I say in the press, I'djust like to put the quote that they just made forme into context when I stated I was talking aboutthis is not a free market situation and it's notlike putting a Walgreens and CVS next to each other. That has nothing to do with Crystal Lake.It was in regards to highly specialized services ina Level III NICU.



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Our opponents would have you believe thatthe residents in McHenry County are different, areaffluent, and that they own or have access to a car,which is often not the case. There is a significantworking class who struggles to afford medical careand a growing charity population. In fact, Crain's Chicago Business reportedthat Centegra lost at least 30 million so farthis year, and I quote, "Centegra executives blamedthe bleeding partly on being stiffed by patients whowon't pay or can't afford the medical bills, not onthe health system not being able to fill its newhospital." According to the McHenry Healthy CommunityStudy which our opponents developed, McHenry Countyhas a total population of 49,938 Medicaid enrollees,representing 16 percent of the County's totalpopulation. This population is growing, evidencedby the 6.2 percent increase since 2006. The Healthy Community Study identifiedaccess to health care for Medicaid recipients as amajor problem in McHenry. Community leadersidentified physicians in the area limiting thenumber of Medicaid patients they will accept as one



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of the most troublesome issues. 14.7 percent ofthose responding stated that they did not receivemedical care because they could not find a providerwho accepted Medicaid. Mercy Health's Crystal Lake hospital willhelp alleviate this pressing issue. Mercy Health isdedicated to serving charity populations. MercyHealth's Harvard's Medicaid population is 27 percentof the patients served. MR. ROATE: Two minutes. CHAIRWOMAN OLSON: Please conclude. MS. HALL: This exceeds Centegra-Woodstockat 3.9, Centegra-McHenry at 3.6, and Advocate GoodShepherd at 6.4. CHAIRWOMAN OLSON: Thank you. MS. HALL: Thank you. MR. MORADO: Next up we have Dr. JosephFojtik, Dr. Emily Shen, Dr. Doug Henning, andMariann Vieweg. Dr. Joseph Fojtik, Dr. Emily Shen, Dr. DougHenning, and Mariann Vieweg. CHAIRWOMAN OLSON: Who are we missing? MR. MORADO: One more, Tom Jensen. CHAIRWOMAN OLSON: Somebody can please



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begin. DR. FOJTIK: I'll go. My name is JosephFojtik, F-o-j-t-i-k. Good afternoon. I'm a generalinternist and I have been in practice for 28 yearsin the state of Illinois, 20 of them with MercyHealth. I'm here in strong support of Mercy Health'ssmall hospital and clinic proposals. There is anongoing and necessary transformation in the healthcare delivery system that we are now going throughas a country, both regionally and nationally. Part of this transformation will require theso-called improvement of the triple aim, where wetry to improve the overall experience of thepatient, decreasing costs, and try to improve theentire health of patient populations. This will, in the next step, necessarily tryto improve the coordinations of care betweenclinicians and also try to improve how wecommunicate to each other with our clinical data.The truth is, when patients are in a single systemand they have the same electronic medical recordsystem between the clinicians and the hospitals, thestandard transformation occurs much more readily and



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much more safely. So, for example, recently one of my patientswas admitted to a local hospital. The patient hadsignificant shortness of breath, and thepulmonologist thought the patient had an activeheart condition. He ordered the patient anechocardiogram, an ultrasound of the heart. The patient saw me three weeks later, stillvery short of breath, and she had not heard thereport of that echo. That echo was done at thehospital, whose computer system does not communicatewith the pulmonologist. We later found out the patient hadsignificant congestive heart failure, and weimmediately admitted the patient, where she wasstabilized. But I'd just point out that, indeed,the patient's clinical data was not readilytransferred from the hospital to the clinician. So, in summary, I'd like to point out that,when physicians have access to data under the samecomputer system, that it's much more readilytransferred to the clinician and, preferably, thepatient gets results quicker. MR. ROATE: Two minutes.



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DR. FOJTIK: Thank you for your time. CHAIRWOMAN OLSON: Thank you, Doctor. Next. Please go ahead. DR. SHEN: Good morning. My name isDr. Emily Shen. I'm in here to support MercyCrystal Lake Hospital. I'm a family practice clinician with myclinic being in Crystal Lake. I have been withMercy for over eight years serving the Crystal Lakecommunity. I work with patients of all ages fromnewborn to the elderly, and a large percentage of mypatients are either Medicaid or Medicare insurance.Many of these patients find it difficult to travelfrom one facility to the other. Having access to service such as labs,X-rays, and other physician specialties in the samebuilding greatly improves the access to care and, ofcourse, quality of care. I know our proposedhospital and clinic would help other Mercyphysicians, as well. Patients should be granted access to thecloser ER and hospital. This can further offerimmediate emergency care to my patients instead of



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making them travel a long distance to receive suchimportant care. I'll give you an example. I currently havea patient with a below-knee amputation, and he isthe caregiver of his wife, who is wheelchair-boundand has a serious medical condition. Having to travel from other -- from oneplace to the other, not only he has trouble withtaking care of himself, but taking care of his wifeis becoming increasingly difficult. A hospital integrated with my practice withthe same electronic medical records improves myability to care for my patients during theirinpatient stay as well as the timely review ofrecords after discharge. Too often I don't have immediate access tothe patient's medical records from otherhospitalizations from outside hospitals. Thesedefinitely lead to delay of the treatment andincrease the chances of errors. It has been my honor to serve the communityover the last eight years. I have seen a growingcommunity in Crystal Lake. I know a new clinic andhospital is needed in this area to serve not only my



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patients -- MR. ROATE: Two minutes. DR. SHEN: -- but the growing community. CHAIRWOMAN OLSON: Please conclude. DR. SHEN: Please approve the Mercy HealthCare. CHAIRWOMAN OLSON: Thank you. Next. DR. HENNING: Hi. My name is DouglasHenning. I'm a board-certified pediatrician atMercy Health Crystal Lake East. I've been practicing in the Crystal Lakearea for 20 years. I'm here to support MercyHealth's small Crystal Lake hospital and clinicapplications. As a primary care physician, I knowhow important it is to have coordinated care for mypatients. Mercy Health's small hospital and clinicproposals provide community care, access toemergency care, continuity of care, and reducedcosts. This is what our patients want. For example, I order any testing for mycurrent patients, they need to travel to otherlocations throughout the county to have thiscompleted, sometimes multiple locations, depending



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on the type of testing I've ordered, whether it befor lab tests, X-rays, or to see a specialist. Fora parent with small children, this is often veryinconvenient, leading to difficulties in gettingcare. I recently saw a 14-year-old boy for a verylarge lymph node that had not changed afterantibiotics. I referred him to my ear, nose, andthroat colleague in my own office. As the node was very large and close to anerve, my colleague wanted an ultrasound prior todoing the needed bypass. The ultrasound had to bescheduled to be done at Mercy Health's main clinicin Woodstock, a 20-minute drive away under the bestof traffic conditions. 3 miles but 20 minutes. My point here is, if you're located in amultispecialty clinic and small hospital, the entireprocess could have been done the same day that wouldinclude, if necessary, an outpatient surgicalprocedure. This would have saved this young man and hisparents days of worry as to whether or not he has anoveractive node versus lymphoma. This family wouldhave also, of course, saved money by decreasing



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travel costs, time away from work to take care ofhis specialty follow-up visits. In summary, I strongly believe both theclinic and hospital projects are critical in orderfor us to better serve Crystal Lake now and wellinto the future. I believe our small hospital andclinic projects will provide our patients enhancedcare and convenience, increased efficiencies, andthe potential to expand for additional access. Notapproving the hospital and clinic application deniesa hospital -- MR. ROATE: Two minutes. DR. HENNING: If you want to truly serve thecommunity -- CHAIRWOMAN OLSON: Please conclude. DR. HENNING: -- I strongly urge you toapprove this project. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. JENSEN: Can you hear me? Okay. Hi. My name is Tom Jensen. I'm from MercyHealth. That's J-e-n-s-e-n. McHenry County has a public transportation



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problem which acts as a major barrier to countyresidents receiving health care. In a 2017 HealthyCommunity Study, lack of public transportation wasidentified as one of the three major barriers toreceiving health care in the county. Mercy Health's Crystal Lake Hospital and ERwould provide community residents who lack access totransportation to increased access in health careservices. The greatest population density is inCrystal Lake and the surrounding communities. Rightnow there is no hospital and no emergency departmentin Crystal Lake. In the Healthy Community Study, over40 percent of those responding rated the publictransportation system in McHenry County as poor. Here are some comments: "McHenry County issorely lacking in public transportation." "Publictransportation in McHenry County is nonexistent." In the study that Dr. Aurand spoke of, therewere many comments from residents which highlightthe problems. A 63-year-old female responded "Thecurrent emergency departments are on extremeopposite ends of Crystal Lake and require takingheavily traveled corridors."



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A 37-year-old female responded, "Consideringthe size of our community, an all-encompassing ER,not immediate care, seems necessary. Route 14 isfar too congested on reliable travel times, and ithinders the travel between Crystal Lake andBarrington." There is a public transportation system inMcHenry called MCRide, which is part of the poorlyrated system mentioned above. However, MCRide doesnot operate on Sundays, MCRide does not operate onevenings after 7:00 p.m., and there is a cost, plusresidents must book, at minimum, two hours inadvance with no guarantee of accommodation. Right here, this ninja turkey slicing dadneeded ER care at 7:30 a.m. -- at or 7:30 p.m. -- onThanksgiving -- MR. ROATE: Two minutes. MR. JENSEN: -- and we all know how injuriesand illnesses seem to be a part of Murphy's Lawduring evenings and weekends. CHAIRWOMAN OLSON: Please conclude, NinjaCarving Dad. MR. JENSEN: Yes. (Laughter.)



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CHAIRWOMAN OLSON: Do you still have yourfingers? MR. JENSEN: I still do. I'm in good shape. Thank you very much. CHAIRWOMAN OLSON: Thank you. MR. MORADO: Okay. Next up we haveBen Slack, Bette Schoenholtz, Kelly Howard, CaseyHaefs, and Dr. Jay MacNeal. That's Dr. Jay MacNeal, Casey Haefs,Kelly Howard, Bette Schoenholtz, and Ben Slack. CHAIRWOMAN OLSON: Please, somebody can goahead. MS. SCHOENHOLTZ: My name is BetteSchoenholtz. CHAIRWOMAN OLSON: Pull the microphone wayclose. MS. SCHOENHOLTZ: My name is BetteSchoenholtz, S-c-h-o-e-n-h-o-l-t-z. I am thedirector of Senior Services Associates, andI support the Mercy Health certificate of needproposals to build a hospital and multispecialtyclinic in Crystal Lake. Senior Services is an organization thatserves older adults and persons with disabilities.



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Last year we served over 11,000 needy and frailseniors in the county. Our staff performsprescreens for the Choices for Care program in allhospitals in McHenry County, and we provide avolunteer transportation program. We see on a daily basis how our Crystal Lakearea clients struggle with getting appropriatehealth care, due in large part to the lack ofreliable transportation. These older adults areunable to access transportation for several reasons.Some can no longer drive safely. Others can nolonger afford to maintain a car and pay forinsurance. Sometimes the person is temporarilyunable to drive due to surgery or illness. Whatever the reason, losing the ability todrive becomes a barrier to receiving vital healthcare services that they need. And when you throwdistance into the equation, getting appropriateservice becomes even more difficult. So as our clients age, they requireever-increasing levels of care. They are frequentvisitors to the emergency room, and for years theyhave expressed a desire for an ED option that iscloser to home.



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Having an emergency room and multispecialtyclinic closer to where they live would be ablessing. It would also improve coordination ofcare, which would not only benefit the clients whocurrently see doctors in the multiple Mercy Healthlocations. First, patients would have the benefits of amultispecialty clinic with diagnostic capabilitiesand access to -- MR. ROATE: Two minutes. MS. SCHOENHOLTZ: On behalf of SeniorServices, I fully support this project, and I urgeyou to approve -- CHAIRWOMAN OLSON: Thank you. MS. SCHOENHOLTZ: -- Mercy Health Care'sapplication. CHAIRWOMAN OLSON: Thank you. Next. Please, someone, go. MS. HAEFS: Hi. My name is Casey Haefs.I have been a resident of Cary, Illinois, forthree years. Prior to that, I lived in Crystal Lakefor 10 years. I still spend most of my time inCrystal Lake since I have a 12-year-old son who's



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very active in multiple sports. I'm here today to show my support for bothMercy Health projects. I know, firsthand, MercyHealth's projects would be a great benefit to bothme and my son. As a mother working full-time andraising a teenager, it becomes challenging to evenmake appointments with our hectic schedules. There are no options for emergency serviceswhere I live. With my son playing several contactsports in Crystal Lake, that really concerns me.Not everything can be seen in an immediate care.Sure, I might use those services for a sore threat,but what about when my son breaks his ankle in afootball game, suffers a head injury in a lacrossegame, or wakes up in the middle of the night withsevere abdominal pain from appendicitis? I need toget him to an emergency room fast. I believe we should have another option forhealth care. Just recently I, personally, had tovisit Advocate Good Shepherd for severe stomachissues. Not only did they not have my medicalrecords, but also, when I made my follow-up visitwith my primary care physician at Mercy Health, itmade it very difficult.



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She didn't have my information; she didn'tknow what testing was done. I was the one tellinghere what they did at the hospital. Mercy Hospitaland clinic projects will keep my care all under onemedical record, making it easy for my doctors tokeep track of my care. For the sake of my health, as well as myfamily's, I urge you to approve Mercy Health'shospital and medical center. Thank you. CHAIRWOMAN OLSON: Thank you. MS. HOWARD: Hello. My name is Kelly Howard,K-e-l-l-y H-o-w-a-r-d. I've been a member of theCrystal Lake community for 16 years. I'm veryexcited about Mercy Health's proposal to build ahospital and medical center in Crystal Lake. Earlier this year my son called me in anemergency. He told me he hurt his ankle, it wasextremely swollen and bruised. He was in a lot ofpain, and I knew he needed medical attention rightaway. Instantly I felt panicked; he isn't with me;I can't get him anywhere. If we had an emergencydepartment in Crystal Lake, I would have sent him



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there and he would have received medical attentionwithin minutes. When this injury happened, thenearest emergency room was a 20-minute drive toWoodstock or nearly 30 minutes to Elgin. Also last year, my daughter sustained aninjury requiring surgery. Her surgeon operates inHarvard. If there was a hospital in Crystal Lake,I would have not have had to drive the 80-minuteroundtrip for her to have her surgery. As expected, she was very groggy afterreceiving anesthesia. The long car ride home causedsome motion sickness that we had to contend with.Additionally, the farther distance home delayed herelevating her foot, which she was ordered to do byher surgeon. For me, having local access would bringpeace of mind, knowing I can quickly see providersin an emergent situation. Having local emergencyservices is a must. Please approve Mercy Health's hospital andclinic in Crystal Lake. Thank you. CHAIRWOMAN OLSON: Thank you. MR. SLACK: Good afternoon. My name is



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Ben Slack, B-e-n. Last name is Slack, S, as in"Sam," -l-a-c-k. I'm the executive director for theEpilepsy Foundation of North/Central Illinois, Iowa& Nebraska. We provide epilepsy services for individualswith epilepsy in McHenry County, and we operate anoffice in Crystal Lake. I want to speakspecifically today in support of the Mercy Healthproposed projects. Some of the biggest struggles that we facein the epilepsy community is -- one is lack oftransportation. Most of our clients can't drive,and public transportation in McHenry County isextremely poor, so travel is always a difficulty forindividuals with epilepsy. And, secondly, the -- one of the majorproblems that we're facing right now is a lack ofepilepsy subspecialists. There is no epilepsysubspecialist in McHenry County, and there is noepilepsy center in McHenry County, meaning that ourindividuals have to travel. A third problem that we're seeing a lot ofin McHenry County is that there is no overlappingcoverage between Medicaid providers, meaning that



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individuals either have to choose between theiremergency room coverage or their specialistcoverage, so individuals -- like the epilepsycenters in Chicago don't take the same Medicaidproviders as the emergency room departments inMcHenry County, so that means the individuals arehaving to choose between those two levels ofcoverage. So for that, I'm hopeful that more optionsin McHenry County will be very beneficial to theindividuals with epilepsy in McHenry County. So thank you. CHAIRWOMAN OLSON: Thank you. DR. MAC NEAL: My name is Dr. Jay MacNeal.I'm the EMS medical director for Mercy Health. I'm responsible for EMS services in the15-county service area. I'm board certified in bothemergency medicine and the subspecialty of EMS.I have over 27 years of experience in the emergencymedical field and am very familiar with EMSproviders from first responders through criticalcare paramedics. I develop treatment and transportprotocols as well as direct on-scene medicaldirection in the worst of situations.



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I understand the opposition is toutingconfusion among residents and EMS regarding thelevel of care that we plan to offer at our proposedemergency department. I'm here to tell you thereshould be no confusion and, in fact, our competitorsare the ones causing this confusion. Cities both large and small across thecountry have emergency departments that offervarious levels of care based on the needs and sizeof the community they serve, and there's noconfusion as to where or what level of care theyprovide or where to go in an emergency. We are proposing a comprehensive emergencydepartment for the Crystal Lake community, whichwill provide adequate care for the vast majority ofED cases. Immediate access is vital for those patientswho are suffering a stroke or heart attack.Unfortunately, despite aggressive public campaignsnationwide, 33 percent of stroke patients and50 percent of heart attack patients do not call anambulance. Seconds count and providing immediateaccess to an emergency department for citizens in acity the size of Crystal Lake will save lives.



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Quick interventions to stabilize the patient and, ifneeded, transfer the patient to another hospitalwill provide better outcomes. For the patients that call 911, paramedicsand other prehospital professionals are proficientlytrained to triage patients on the scene. There areextensive protocols in place for EMS professionalsto follow, ensuring that patients are transported tothe nearest appropriate hospital. I also find it ironic that the oppositionfeels there will be confusion, as these protocolscurrently guiding EMS in McHenry County are guidedby their EMS medical direction in accordance withIDPH regulations and regional policies. Ourcompetitors should know firsthand that their EMSprofessionals will not be confused about where totake critically ill patients. Every day patients who come to our smallhospitals with these types of conditions receiveexpedient care by our emergency medicine-trainedphysicians and staff. MR. ROATE: Two minutes. DR. MAC NEAL: Critical, time-sensitiveintervention that leads to lives being saved --



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CHAIRWOMAN OLSON: Please conclude. DR. MAC NEAL: I strongly urge you toconsider supporting this. Thank you. CHAIRWOMAN OLSON: Thank you. MR. CONSTANTINO: Madam Chair -- (An off-the-record discussion was held.) CHAIRWOMAN OLSON: It is one o'clock.I believe what we're going to do is break for a45-minute lunch. We do have 13 more for public participation,so we're going to break for -- we will reconvene at1:45 promptly. (A recess was taken from 12:59 p.m. to1:52 p.m.) CHAIRWOMAN OLSON: We'll continue withpublic participation. The next five. MS. AVERY: Okay. The next five we have areDr. Glenn Milos, Theresa Hollinger, Hayden Creque,and Paul Van Den Heuvel -- Van Den Heuvel -- andDave Syverson -- Senator Syverson. I'm sorry. CHAIRWOMAN OLSON: Once again, two-minutetime limit, and please state your name for the court



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reporter. Please go ahead. DR. MILOS: Good afternoon. My name isDr. Glenn Milos, and I'm the regional medicaldirector of emergency services for the emergencydepartments at Mercy Health. I oversee all aspects of emergency care forour hospitals in Janesville, Wisconsin; Lake Geneva,Wisconsin; and Harvard, Illinois. I am an emergencymedicine physician, and we save lives on a dailybasis. I'm here to talk to you today about why theresidents of Crystal Lake need and deserve ahospital with a dedicated emergency department. It was not long ago when emergencydepartments were staffed with any kind of physicianavailable to work. They were staffed with surgeons,primary care physicians, and psychiatrists. Butwhat does a psychiatrist know about treating yourheart attack or stroke? Since that time emergency medicine hasevolved as a specialty that provides a wide range ofconditions that require special skills delivered ina very time-sensitive manner. Today, emergencydepartments are staffed with board-certified, highly



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skilled specialists who can handle any emergencyproblem you might have. The challenge now, however, is how long willit take you to get to the emergency department tostart receiving care. Will you get there in time? When you are having a heart attack, everyminute spent getting to the hospital is anotherminute that your heart is deprived of oxygen. Foreach minute you spend getting there when you arehaving a stroke, approximately 1.9 million neuronsdie per minute. If you asked me how many minutes I'd bewilling to spare in an emergency, I'd say, "Well,none." And I imagine you would say the same. Inmedicine we like to say "Time is muscle. Time isbrain. Time is life." The residents of Crystal Lake deserve tohave the highest quality emergency care, and theydeserve to have it available right within theircommunity. Mercy Health wants and needs to bringthis care to the Crystal Lake community. I assure you that your favorable vote todaywill result in many lives being saved tomorrow andwill enable the residents of Crystal Lake to receive



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timely, evidence-based, compassionate medicalcare -- MR. ROATE: Two minutes. DR. MILOS: -- close to home. CHAIRWOMAN OLSON: Please conclude. DR. MILOS: I have a passion for makinglives better. This is who I am, and this is who weare at Mercy Health. CHAIRWOMAN OLSON: Thank you. DR. MILOS: Thank you. CHAIRWOMAN OLSON: Next. MS. HOLLINGER: I'm Theresa Hollinger,director of nursing at Mercy Health Hospital andMedical Center in Harvard. I have been a nurse for over 24 years, andI've worked in a wide variety of environments, fromvery small critical-access hospitals to largeLevel I trauma centers. Each type of hospital hasits advantages for patients. Working in a small hospital provides a greatopportunity to really get to know my patients in amore meaningful and personal way. We have a uniquemethod of providing care based on hospitaloperational efficiencies.



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At a small hospital many of our supervisory,ICU, and medical nurses are cross-trained inmultiple environments to facilitate agility whenpatient needs are higher in one area over another. This flexibility, including leadership,fosters teamwork and collaboration regardless ofprimary unit. The high level of competence andfamiliarity in various work environments enables usto provide specialized, patient-specific careanywhere it's needed. Because we are a large, Illinois, verticallyintegrated medical system, we provide the same highlevel of services to every Mercy Health patientregardless of the size or the location of thefacility. At Harvard the majority of our nursingpartners are bachelors prepared with a very highpercentage of our nursing partners as master-prepared nurses, all practicing at the bedside. It's important to think about the needs ofthe community we're seeking to reach. A communityof over 50,000 souls, Crystal Lake has the right toaccessible emergency care. Without an emergencydepartment, Crystal Lake is in a position of risk as



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patients have to navigate traffic in a state ofpanic seeking treatment. To illustrate this need, I have recentlyheard from one of the 9500 residents of Harvard, whofelt that, if Harvard's ER was not there, her sonwould not have survived to reach a farther facility.The individual had begun to have an allergicreaction at home and decided to drive thefew minutes from his home. By the time he arrived,his throat was closing and he could not speak toexplain what was happening. His airway had quicklybecome blocked and he was having great difficultybreathing. The clinical expertise of our nurse and -- MR. ROATE: Two minutes. MS. HOLLINGER: -- quick assessment by oneof our board-certified -- CHAIRWOMAN OLSON: Please conclude. MS. HOLLINGER: -- emergency departmentphysicians resulted in the patient being immediatelytreated. CHAIRWOMAN OLSON: Thank you. MS. HOLLINGER: Please support. CHAIRWOMAN OLSON: Thank you.



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Next. MR. CREQUE: Good afternoon. My name is Hayden, H-a-y-d-e-n, Creque,C-r-e-q-u-e. I serve as assistant general counselfor Mercy Health. And, Ms. Avery, I will always answer to"Mr. Crackoo" [phonetic]. (Laughter.) MR. CREQUE: I'm a bit new to this process,and I've got to be honest with you. I'm a bitsurprised at the amount of resources expendedopposing a 13-bed hospital. Our opponents clearlywant to do one thing and one thing only, eliminatecompetition. They want to continue to have applied anoutdated health care model that does not reflect thereality of a new health care economy, which isdeemphasizing hospitalization and focusing ondelivering the right care at the right time in theright setting. To be clear, hospital beds are still needed.They're just not needed in increments of a hundred.Indeed, arguably, the opponents have conceded thispoint in recent Crain's articles. Advocate has said



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its existing cost structure is not sustainable. Asa result, they have begun a course correction. In advance of its merger with Northwestern,Centegra's troubles have also been well publicized.Crain's reported that it's likely as a result ofconstructing hospitals ill-suited to today's healthcare environment. Advocate has 431 licensed beds, Centegra413 in the McHenry County area. They'reexaggerating the impact of our proposal. At the endof the day, we're talking about a census that's lessthan 2 percent in terms of impact. Mercy Health understands and we're deeplycommitted to size and locate facilities tosuccessfully deliver necessary services close towhere parents live -- sorry; that would be"patients" -- but parents, too. We also understand the financial,geographical, and social hurdles traditionallyunderserved patient population have to traverse.Our application to serve the Crystal Lake areareflects that understanding. We have 5,501 signedpetitions in support. We ask that you give thoughtful



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consideration -- MR. ROATE: Two minutes. MR. CREQUE: Well, thank you. Two minutes.Thank you. (Laughter.) CHAIRWOMAN OLSON: Thank you. MR. VAN DEN HEUVEL: Hello. I am PaulVan Den Heuvel, Mercy Health's vice president andgeneral counsel. My last name is spelled V-a-ncapital D-e-n capital H-e-u-v-e-l, and, apparently,only difficult last names can work at Mercy. (Laughter.) MR. VAN DEN HEUVEL: I ask that you pleaseconsider the following as you deliberate today:Advocate, with 3,500 total licensed beds, andCentegra, with a 413-bed super monopoly, want you tobelieve that Mercy Health's 13-bed hospital is athreat to their empires and the entire Illinoisregulatory structure. That is simply absurd. Let's review the reality: Mercy Health'sinnovative yet modest proposal follows the form ofour innovative Rockford hospital applications whichthis Board unanimously approved in November of 2015. Specifically, our hospital application



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respects State standards, meeting all keyrequirements, including cost. It's odd to hear costcited as an issue, given the State's report clearlyconveys that Mercy Health meets cost standards. Wewill present more on this issue during the hearing,but just months ago you rightly approved a$35 million surgical center and a $46 million healthand fitness center. Two, for those few standards that we do notmeet, there is strong rationale for not doing so.For instance, as to the 100-bed standard, we haveproposed a proper-sized facility to delivernecessary services to the Crystal Lake area. Third, our application simply seeks toredistribute 13 of Mercy Health's existing licensedbeds within the same planning area. It will notresult in any increase in the bed inventory whilemaintaining our commitment to Harvard. We seek to apply a more patient-centered useof these beds to the Crystal Lake area population.This includes comprehensive emergency services,which 65 percent of the area's residents and otherpublic officials have expressed are needed. I urge you to reject the protectionist



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tactics of our competition and approve MercyHealth's modest yet innovative 13-bed hospitalapplication. MR. ROATE: Two minutes. MR. VAN DEN HEUVEL: Thank you. CHAIRWOMAN OLSON: Thank you. SENATOR SYVERSON: Thank you. My name isSenator Dave Syverson. I'm also a member on theboard of Mercy Health, and I'm here in support ofthese two projects. The projects that are before you today areboth innovative and are consistent with the goals ofthe Health Facilities Planning Act. It's because ofthat I believe they should be approved. Now, it's not surprising that competitorsare here to oppose this project. I can understandthat. They don't want competition in their markets,but that's not good for consumers. I'm still tryingto wrap my head around why two of the largest,wealthiest health systems in the state are concernedabout a 13-bed hospital, especially going into acommunity where they have not wanted to be in thepast. These two systems generate billions of



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dollars of revenue annually. This little13-bed facility, which is not a microhospital,wouldn't even be a rounding error on their balancesheet. However, the impact this will have on thefamilies that live in Crystal Lake and do not havethese services, that find getting transportation toanother community -- as stated, 20 minutes away --to be difficult, to them this project will be aworld of difference. This is why you have localleaders from senior citizen programs, healthdepartments, epilepsy association, and others heresupporting this project. This request is consistent with the purposeof the CON act, in that it addresses the unmet needsof the families of Crystal Lake, a community, by theway, that has more Medicaid residents than Harvard. On a side note, Mercy -- while others talkedabout serving Medicaid, Mercy, I believe, is thelargest Medicaid provider outside of Chicago. Thisinnovative solution solves the problem for thepeople in Crystal Lake without adding one new bed inthe county. It's just shifting beds to wherethey're needed most, to a community where nearly



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50,000 people live without -- MR. ROATE: Two minutes. SENATOR SYVERSON: -- important local healthcare services that we're all used to. CHAIRWOMAN OLSON: Please conclude. SENATOR SYVERSON: Thank you for your time. CHAIRWOMAN OLSON: Thank you. Next. MR. MORADO: First off, we have TraceyKlein, Dirk Enger, John Hanley, and Matthew Watson. Again, that's Tracey Klein, Dirk Enger,John Hanley, and Matthew Watson. UNIDENTIFIED FEMALE: John Hanley alreadywent. UNIDENTIFIED MALE: Matthew Watson alreadyspoke, as well. UNIDENTIFIED FEMALE: There are others. MS. KLEIN: Good afternoon. I'm TracyKlein, like Calvin but no relation. And I'm --I represent Mercy Health. As lawyers, we have an ethical duty ofhonesty toward the tribunal. I was a bitdisheartened to see and hear some of the commentaryby attorneys for the opposition today. I have been



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trying to kind of keep track of all themisstatements, and there have been several. First, our opponents' attorneys focus on theper-bed cost of the project as if it's a legalstandard that the Board is required to adhere to.No such review criterion is found in the PlanningBoard's governing regulations. The only reviewcriterion relating to cost in the regulations is thecost per square foot, 1120-Appendix A, and Mercyhappens to meet that standard. Second, the opponents' attorneys referencethe hundred-bed minimum standard as if it's aprecondition for Board approval. As you all know,the 100-bed minimum medical/surgical unit standarditself is not an absolute requirement. Rather, it'sone of many standards that the Board may consider inreviewing an application. Obviously, your legal standard issubstantial compliance but with the balance of allfacts and circumstances in the criteria in the regand, also, the purposes of the Act. Third, there was the unsupported statementmade by Attorney Shepley that this project is notpermitted under the Planning Act, period. I don't



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know why we'd be here. Fourth, we heard that this sets up a newprecedent and that it requires new standards by thisBoard. It's an innovative project. No questionabout it. But to suggest, as care migrates to theoutpatient setting, that your regulations don'tallow you to consider a broad range of projects is,frankly, not correct. You can see it in your ownwork, including the fitness center for 46 million inprior meetings. MR. ROATE: Two minutes. MS. KLEIN: Fifth, this is not analternative -- CHAIRWOMAN OLSON: Please conclude. MS. KLEIN: -- model. In closing -- CHAIRWOMAN OLSON: I need you to conclude. MS. KLEIN: I urge your support. CHAIRWOMAN OLSON: Thank you. MR. ENGER: Thank you, Board members. Myname is Dirk Enger. First name is spelled D-i-r-k;last name, E-n-g-e-r. I am president ofIronworkers, Local 393, in Aurora, Illinois. Ourlocal covers five counties in northern Illinois, all



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large, including McHenry County. I'm here today not on behalf of jobs foryou. I am here on behalf of my members, numerousmembers, which live within that area in which thisproject would be built if you granted it. What itgives is my members access to good quality,affordable health care. I have many members rangingfrom many ages that would benefit from this project. Also, to let you know that our local hasbuilt, with the people that are here in opposition,every single facility that has been mentioned onrecord here today. They all started out small; theyall grew. How they grew and how they manage theirmoney is their own perspective. But I also would just like to add in thatI also am a former County Board member for DuPageCounty, which DuPage County, as you know, is thesecond largest in the state. We also are the onlyone -- one of the two counties that has a nursinghome. I am very proud to have sat as vice chairmanon the human services committee and developed it. So today I ask you to take -- judge yourjudgment based upon the stats. And what I've heardhere today I'd just like to close with. It's about



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quality of life, that you have to give yourresponsibility to the residents of Illinois andespecially McHenry County. I hope you base it uponthat but also realize this is not, as it's known inthe development committee -- which I sat on, also --a NIMBY project, "not my backyard." And that's whatI am very disappointed in, seeing the other peoplethat have given testimony here today based upon thedollar. Health care should never be based upon thedollar. That's why our country's in trouble like itis now. People can't afford health care. We shouldbe providing health care to those that need it.Many here took an oath. I took an oath to representmy members, and that's why I'm here today, askingyou to strongly support this project. Thank you. CHAIRWOMAN OLSON: Thank you. MR. MORADO: We do have four more, MadamChair, Pam Cumpata, Ronald Eck, Mary Maule, andCharles Wheeler. MS. CUMPATA: Okay. Hello. My name is Pam Cumpata, and I serveas the president of the McHenry County Economic



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Development Corporation. Our mission is to promote and enhance theeconomic health of McHenry County through theretention, expansion, and attraction of commerce andindustry. We do all this to be a con- -- to have anopportunity -- or optimal quality of life for ourcitizens. On May 9th the McHenry County EconomicDevelopment Corporation board of directors approveda resolution to support the economic impactgenerated by the Mercy Crystal Lake microhospitaland medical office, which has been sent to theIllinois Health Facilities and Services ReviewBoard. This project will generate jobs, income, andcapital investment for the region, which alignsdirectly with our corporate mission. In addition tothe jobs, income, and capital investment, theeconomic activity associated with this project willalso facilitate infrastructure improvements at thearea of Route 23 and Three Oaks Road inCrystal Lake. McHenry County Board Chairman Jack Frankswas unable to attend today, but he has authorized me



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to convey that he is personally supporting thisproject, "creating" -- to quote him -- "creatinghundreds of jobs, both during construction and inthe long term, plus all of the economic spin-off andgrowth that will occur to support this new projectand population is good for our region. It willattract business and place Crystal Lake on par withother cities of similar size, almost all of whichhave a local hospital." Thank you. CHAIRWOMAN OLSON: Thank you. MR. ECK: My name is Ron Eck. It's R-o-nE-c-k. I'm the business representative forCarpenters, Local 2087. The McHenry County Building TradesAssociation were planning to have many speakers heretoday; however, out of respect for the Board's time,I'll speak to you on behalf of all of our trades. We'd like to express our full and unwaveringsupport of Mercy Health's proposed projects. Theseprojects are good for our local economy. Localcontractors and businesses will have an opportunityto participate in the construction process, and theproject will also provide long-term jobs to area



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residents when the construction is completed, all ofwhich will feed into Crystal Lake's positiveeconomic momentum. When Mercy completes this project,Crystal Lake will be far more attractive to newbusinesses, enhancing workforce attraction andretention. We need this type of continued growth ifwe're going to be an economical viable city. Weneed to think about the future and continue to pushforward, supporting innovative projects andembracing change. It's the only way to remainviable in our area. On behalf of the McHenry County buildingtrades, we fully support Mercy's applications toconstruct the proposed hospital and medical centerin Crystal Lake, and I also encourage this Board toapprove this project. I thank you for your time and consideration.Ron Eck, Carpenters, Local 2087. Thank you. CHAIRWOMAN OLSON: Thank you. MR. WHEELER: Thank you, members of thecommittee. I appreciate the opportunity of



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addressing you today on this precedential issue ofus building a hospital here in -- MS. AVERY: Sir, you've going to have tomove it closer so the court reporter can hear you. MR. WHEELER: Thanks for telling me.I appreciate it. My name is Chuck wheeler, and I'm a CountyBoard member as well as chairman of the communityhealth and public services committee. I have abackground in health care and health care economics. McHenry County needs this project. Centegracurrently has a monopoly in McHenry County, in thatit owns and operates 95 percent of the licensedbeds, totaling 413 hospital beds. Mercy Health's Crystal Lake small facilitywill provide patient choice. Centegra's motivationin opposing these projects is clear: They want toeliminate competition. In recent years residents of McHenry havebegun seeking care outside of McHenry County, andI and our family are one of those that do that.According to the IDHP [sic] and the IHFSRBstatistics, McHenry County hospitals had acollective 45,503 medical/surgical patient days in



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2013. Compare this to the 52,154 medical/surgicalpatient days recorded for McHenry County residentsoutside of the county. More McHenry Countyresidents received care outside McHenry County, farfrom home, than within the county. We believe the reason for this exodus ismultifaceted and it includes patient perceptions ofquality -- MR. ROATE: Two minutes. MR. WHEELER: -- cost, and a lack ofaccessible facilities. CHAIRWOMAN OLSON: Please conclude. MR. WHEELER: Thank you very much forallowing me to address you. CHAIRWOMAN OLSON: Thank you. MS. MAULE: My name is Mary Margaret Maule.M-a-r-y M-a-r-g-a-r-e-t; it's one word. Last name,M-a-u-l-e. I'm the president of the Crystal LakeChamber of Commerce, and I'm here today to expressthe chamber's support for the Mercy Health'scertificate of need request to build amultispecialty medical center and hospital inCrystal Lake. Mercy Health is an active member of



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my chamber and an ongoing contributor. Our mission at the chamber of commerce is tocreate value and opportunity for our members withthe belief that a positive business climate is anintegral part of a strong and healthy community.The Mercy Health projects will bolster the economy.The project will create permanent, high-paying jobswith Mercy Health in the Crystal Lake facility. The economic boost that this project offersmakes our region far more attractive to new businessand business retention. We must continue toinnovate and support positive development to growour community. For these reasons, the chamber of commerceboard of directors would like to offer its supportfor the Mercy Health certificate of need proposalsto build a hospital and clinic in Crystal Lake. Webelieve in this project. It will create jobs; itwill bring commerce to our area and to your members.It's a significant spillover economic effect thatwill lift us all and improves access to criticalhealth care services. We strongly urge you to support and approvethese proposals for the benefit of Mercy Health.



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Thank you. CHAIRWOMAN OLSON: Thank you. That concludes the public participationportion? MR. MORADO: Yes. - - -



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CHAIRWOMAN OLSON: Next, we have itemsapproved by the Chairwoman. George. MR. ROATE: Thank you, Madam Chair. The following items were approved byChairwoman Olson in absence of the full Board:E-018-17, Fresenius Medical Care, Lake Bluff, changeof ownership; E-019-17, SwedishAmerican Hospital,Rockford, to establish a 10-bed NICU, neonatalintensive care unit; E-021-17, St. Anthony HealthCenter, Alton, to discontinue pediatrics service;E-022-17, OSF St. Clare Hospital, Alton, todiscontinue inpatient physical rehab and long-termcare services; E-023-17, DMG Center for PainManagement, Naperville, change of ownership;E-024-17, DMG Surgical Center, Lombard, change ofownership; Permit Renewal 16-020, Dialysis CareCenter of Oak Lawn, an eight-month permit renewal;Permit Renewal 16-022, Dialysis Care Center, OlympiaFields, an eight-month permit renewal. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you, George. - - -



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CHAIRWOMAN OLSON: Next, we have items forState Board action. First, we have permit renewalrequests, Project 15-005, Presence LakeshoreGastroenterology, Des Plaines, for a six-monthrenewal. May I have a motion to approve this permitrenewal. MEMBER BURZYNSKI: So moved. MEMBER JOHNSON: Second. CHAIRWOMAN OLSON: Second. Mr. Constantino, your report. MR. CONSTANTINO: Thank you, Madam Chairwoman. The Applicants are proposing a six-monthpermit renewal for Project No. 15-005, which was theestablishment of a limited specialty ASTC inDes Plaines, Illinois. This is the second permit renewal requestfor this project. The project cost is a fraction of$3.1 million. Thank you, Madam Chairwoman. CHAIRWOMAN OLSON: And there was no -- MR. CONSTANTINO: No findings, no opposition. CHAIRWOMAN OLSON: Okay. Do you have comments -- I'm sorry. We need



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to swear you in first. Be sworn in. THE COURT REPORTER: Would you raise yourright hands, please. (Two witnesses sworn.) THE COURT REPORTER: Thank you. MR. STERN: Good morning -- good afternoon.My name is Les Stern. I'm the chief operatingofficer for Presence Medical Group. With me is ourcertificate of need counsel Clare Ranalli. We're here before you to request a permitrenewal. The surgery center is basically complete.We've gone through the design and life safety codesurvey with the Illinois Department of PublicHealth. We are about to conduct our clinicalsurvey. When the clinical survey is complete, weanticipate beginning to see patients in August orSeptember, based on the timing of the survey. Weanticipate no issues with the opening of the centerand having our first patient at that time. With that said, we thank you and will answerany questions. CHAIRWOMAN OLSON: Thank you. Questions from Board members?



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(No response.) CHAIRWOMAN OLSON: Seeing none, I'd ask fora roll call vote. MR. ROATE: Thank you, Madam Chair. Motion made by Senator Burzynski; secondedby Mr. Johnson. Senator Burzynski. MEMBER BURZYNSKI: Aye. MR. ROATE: Senator Demuzio. MEMBER DEMUZIO: Aye. MR. ROATE: Mr. Johnson. MEMBER JOHNSON: Yes, based on the Stateagency report. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on the Stateagency report. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on the Stateagency report. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: Yes. There were no



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findings. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, for reasons stated. MR. ROATE: Thank you. There are 7 votes in the affirmative. CHAIRWOMAN OLSON: The motion passes. Thank you. MR. STERN: Thank you. - - -



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CHAIRWOMAN OLSON: There are no extensionrequests, no exemption requests, no alterationrequests, no declaratory rulings. - - -



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CHAIRWOMAN OLSON: Under Health Care WorkerSelf-Referral Act we do have business. Juan, I'll let you take that one. MR. MORADO: Yes. You'll notice in yourpackets we have a State Board staff report for aHealth Care Worker Self-Referral Act opinion. It's from a Ms. Modglin, who is a speechpathologist, and she's a practitioner of the healingarts. And she would like to have a determinationmade on her work being done for McLean County UnitDistrict No. 5. So what you're doing today is you're votingto deem this request complete, which will give Boardstaff the opportunity to write up her opinion andthen present it to her. In order to deem a HealthCare Worker Self-Referral Act request as complete,it needs seven affirmative votes. So what you have before you is a breakdownof the request that was submitted and all theinformation that was submitted. Board staffbelieves that everything that's needed to be turnedin has been turned in and so they -- today we'reseeking an affirmation of seven votes. CHAIRWOMAN OLSON: May I have a motion to



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approve this request. VICE CHAIRMAN SEWELL: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: I'll ask for a roll callvote, please, George. MR. ROATE: Thank you, Madam Chair. Motion made by Mr. Sewell; seconded bySenator Burzynski. Senator Burzynski. MEMBER BURZYNSKI: I vote yes based on thecompleteness of the request. MR. ROATE: Thank you. Senator Demuzio. MEMBER DEMUZIO: Yes, based upon -- THE COURT REPORTER: I'm sorry. I couldn'tunderstand you. MEMBER DEMUZIO: Yes, based upon the findinghere. THE COURT REPORTER: Thank you. MR. ROATE: Thank you. Mr. Johnson. MEMBER JOHNSON: Yes, based on the reportand comments from counsel.



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MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on counsel'srecommendation. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, for reasons stated. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: Yes, for reasonsstated. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, reasons stated. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: Motion passes. We have nothing under status reports onconditional/contingent permits. - - -



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CHAIRWOMAN OLSON: We will now move toapplications subsequent to initial review. I will call to the table Project H-01,17-002, Mercy Health Hospital. Please come to thetable. While they're doing that, I would ask for amotion to approve Project 17-002, Mercy HealthHospital, to establish a 13-bed hospital inCrystal Lake. MEMBER JOHNSON: So moved. MEMBER DEMUZIO: Second. CHAIRWOMAN OLSON: I have a motion and asecond. The Applicants will be sworn in, please. THE COURT REPORTER: Would you raise yourright hands, please. (Eight witnesses sworn.) THE COURT REPORTER: Thank you. CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, MadamChairwoman. The Applicants are proposing theestablishment of a 13-bed hospital in Crystal Lake,



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Illinois, at a cost of approximately $79.5 million.The expected completion date is November 30th, 2020. There was a public hearing held on thisproject, and the State Board staff has received anumber of support and opposition letters regardingthis project. There were State findings -- StateBoard and staff findings, as noted on page 5. Thank you, Madam Chairwoman. CHAIRWOMAN OLSON: Thank you, Mike. And I'm sure you have comments for theBoard. MR. BEA: Thank you. Should I begin? CHAIRWOMAN OLSON: You can, please. MR. BEA: Thank you, Chairman -- MadamChairman. Good afternoon, Board members, staff, andrepresentatives of the Department of Public Health.I'm Javon Bae, CEO of Mercy Health, based inRockford, Illinois, the Applicant in connection withour Crystal Lake hospital and clinic applications. I'd like to introduce members of our -- whoare up at the table -- of our project team. We have Ralph Weber, who is a CON consultantwith us. And we have Tracey Klein, who introduced



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herself earlier with Reinhart; Jeni Hallatt, vicepresident in the Crystal Lake area with MercyHealth. Dr. Jason Bredenkamp, the medical directorof our emergency services at Mercy Health; JohnCook, the health systems CFO; Paul Van Den Heuvel isthe general counsel; and Dr. John Dorsey, who is ourchief medical officer; and Matt Sanders, who is --I guess Dr. Dorsey is not here -- or is he? I can'tsee back there. Dr. Dorsey is here. Okay. CHAIRWOMAN OLSON: Do you want him to besworn in? MR. BEA: Yeah. That would be good, I guess,if you don't mind. CHAIRWOMAN OLSON: Can we swear Dr. Dorseyin, please? THE COURT REPORTER: Would you raise yourright hand, please. (One witness sworn.) THE COURT REPORTER: Thank you. CHAIRWOMAN OLSON: Thank you. MR. BEA: Thank you. I'd like to begin by just sharing the fact



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that the Federal government, as you all know, isworking on a new health plan nationwide. The onething we've been able to ascertain so far is thatthey're definitely moving from a volume-based systemto a value-based system. And I think it was reported earlier byMr. Ladd Udy, who is our director of populationhealth, that we can look at the ACO reportingrequirements to the Federal government for our ACOmembers, and so we can -- it's an apples-to-applescomparison with Advocate and Centegra, and I thinkMr. Udy alluded to the fact that we are, as asystem, approximately 20 percent lower in our costsand just under 10 percent higher in quality. And, frankly, that comes from looking athealth care differently. Instead of having thisfragmented pluralistic system where patients have togo to this location to see a primary care physicianand then be sent to a specialist who doesn't havethe clinical information or the test results fromthe primary care and then go to an ambulatory carecenter or to a hospital who doesn't have the resultsand the tests are repeated -- that's what allcontributes to the high cost of care, and that's



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what contributes to the fact that there's clinicalgap in care. And so, clearly, what the accountable careorganization is under the Affordable Care Act andthe way, actually, President Obama designed theAffordable Care Act is to bring about anintegration, vertical integration of care wherehealth care providers will manage all types oflevels of care from the time the patient enters theoffice until the time the patient may have to bedischarged from other -- some other alternativesetting, and that requires one medical record. And, frankly, we have based our model -- andwe've done this for three decades -- on theMayo Clinic model in the sense that Mayo discoveredover a hundred years ago that, if you integrate theinpatient and the outpatient care, the doctors andhospitals are contiguous to each other, and there'sone medical record, that you're going to get thisbetter quality of care and at a lower cost. And so,frankly, that's what Mercy's done to be able toachieve the results over and over. And, you know, our competitors or ouropponents have talked about we're trying to escape



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Harvard. That's not the case at all. Harvard is avery successful small hospital for us, just like thesmall hospital that we have in Lake Geneva,Wisconsin. Here, you have a hospital that had 18 beds,was ready to close, has 27 percent Medicaid,high indigent population in Harvard, less than10,000 people. And we invested $26 million in it,put in new ORs, new emergency room; we did a six-bednew unit. And Harvard today is just, to me, astellar organization because it generates a5 1/2 percent return on a 27 percent Medicaid mix,which is about a million to $2 million a year in netincome. Now, our average census -- back when wetried to do a CON in 2003, 14 years ago, when wesought 70 beds, we were using those 18 beds. Today,our average daily census is 4 patients at Harvard,but inpatient care only represents 30 percent of ourtotal revenue there. 70 percent is outpatientrevenue. We have a vascular surgeon there. We haveorthopedic surgeons. All of our services are goingto stay at Harvard. All of our doctors are going to



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stay there, the emergency room, the surgery suites.They're all going to stay there. We just don't needto have 13 beds that are mothballed, that we don'tuse. And so the whole vision is to be able to dowhat we did for Harvard, in a city of less than10,000, for Crystal Lake. It's a city of 50,000,five times larger, because -- and primarily whatI think, if you talk to the residents of Harvard, isbeing able to have that access to emergency care, sothat's what I'd like to talk with you about today. And the proposed hospital is going to allowus to be able to do this because, when you have anemergency room, you've got to have some short-staybeds to be able to stabilize a patient overnight.Any of you -- you certainly look healthy enough. Ifyou came in for your gallbladder removed, you willprobably be able to be sent home in four tosix hours. But if you bring your 89-year-oldgrandmother, with her metabolism that she has, it'sfragile, she may need to be stabilized overnight.So the same simple outpatient procedure is differentbased upon the other physical attributes of the



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patient. That's the reason why, when we have thisemergency room, we're going to be able to treat97 percent of all cases, which I'll allude to in aminute. So the idea is just to be able to bring thisvery needed service to a city of 50,000 people thathas really been needed for a long time and whythere's been all of this community, agencies --thedirector of the public health department. He was uphere earlier saying that 65 percent of people leaveMcHenry County for health care. And I think he saidthe average for the other counties in the state isless than 10 percent, so it shows there's somethingwrong going on in McHenry County. So our CON today, our request today, isreally very similar to what we brought to you inNovember 2015, and you kindly and unanimouslyapproved being able to take underutilized beds atRockford Memorial Hospital, 194 beds out of the400 beds, and move them to a location where they'reneeded, which is now going to allow us to be able togo back, by offloading those beds when the newfacility's done, and do a total retrofit at afacility on the west side of Rockford that has been



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stagnant with facilities that are 60 years old. AndI just want to just give you a little footnote ofhow that's going since you approved that. We were here before you and reported thatRockford Memorial had something close to -- it was$48.7 million in losses in the previous five years,an average of $10 million a loss. In our first yearof operating it, we had a $22 million net incomefrom operations. And so we can talk a lot about howthat's all happened, but I think that's thedifference of what management does. And I want to make another footnote, too,since we had opponents up here talking about a$40 million lost of Centegra. Their $40 millionloss is not due to the fact that they've builtHuntley. The facility component of the health caredollar represents 7 percent. 7 percent. 93 percenthas the ongoing operation. But they reported to their bond brokers thatthey haven't been managing the revenue cycle,billing properly, collecting properly, so they'vehad tens of millions of dollars of write-off.That's called management. And not doing this facility, not giving the



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50,000 people of Crystal Lake who don't have anemergency room -- not giving that isn't going tosolve Centegra's problem. That's easily solvedanother way. So what we are proposing is to bring a smallhospital to Crystal Lake -- and mainly an emergencyroom -- to try to address the over 7,500 patients wehave that are on Medicaid and charity and havetremendous barriers to care. There's a study done by the doctor fromPurdue who said the biggest barrier in Crystal Laketo the Medicaid and the charity and the elderly togetting care is not getting care when they get tothe place; it's the transportation. It's being ableto get to one of the emergency rooms in these othercities. That's their biggest barrier to care, andthat's why we've heard people from the communitycome up. And so what we propose is to do a 13-bedhospital and taking our unutilized beds -- thedifference between what our average daily census isin Harvard -- we're going to leave an extra bedthere -- and move 13 beds to Crystal Lake, wherethere's five times the population, have two



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operating rooms, just like we have in Harvard, twoprocedure rooms, a comprehensive 24/7 emergencyroom, comprehensive radiology and imaging, a fullpathology lab, in-house pharmacy services, and asleep study center. In our long-standing patients in CrystalLake -- we have 30,000 patients in Crystal Lake now.Our doctors have over 43,000 patient visits. Wehave over 20 physicians, multispecialty physicians,and we want to be able to consolidate those20 physicians into one location. That's themultispecialty clinic. So that with the emergency room, even thoughI have board-certified emergency trauma physiciansfor the emergency room 24/7, if a patient needs acardiologist, an orthopedic surgeon, an ENTspecialist, they'll be on-site in the clinic or beon call for the emergency room. It's going to be a very successful hospital,just like we've experienced in Harvard and LakeGeneva, Wisconsin. I want to connect one other dot, too. Whenwe built that hospital in Lake Geneva, Wisconsin, itwas in 2009, at the time that Centegra was doing



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Huntley. And we built a 25-bed beautiful hospitalin Lake Geneva for $43 million. And yet -- you wouldn't know this. In 2009where were we at? The crash. The material costs,the construction cost was a fraction of what it istoday. That's why we built a 25-bed, unbelievablehospital -- you should see it sometime -- in Lake --between Lake Geneva and Delavan -- for 43 million.And yet the fitness center at Kishwaukee is going tocost 46 million today that was just recentlyapproved. It's just the difference in theconstruction costs and material costs. But I go back to the fact the cost of thefacility is the issue. That's only 7 percent of thepatient care dollar, for the depreciation andinterest over time. It's the -- how you operate it.It's eliminating the duplication of testing. It'sbeing able to streamline and manage the patients'care. That's where the real cost comes in and thecost savings or the cost-effectiveness. Again, Mercy has been, for a long time, apioneer in vertically integrated and integratedhealth care. We've had -- and we've been, actually,an accountable care organization for decades. We've



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got over 600 W-2 physicians, five hospitals, and80 multispecialty medical centers in 50 communities. Our corporate -- with a big home caredivision -- and our corporate office is located inRockford, Illinois. We are a leader in magnetrecognition for excellence in nursing. Mercy hasbeen chosen as one of the top premier organizationsnationwide for our integrated care delivery model,resulting in better patient outcomes at lower costs. This isn't us saying it. It was attested toand it was determined by the United StatesDepartment of Commerce, who selected Mercy andcategorized Mercy as what they called a world classorganization getting world class patient benchmarks. The Department of Commerce chose MercyHealth as only the 76th recipient among allorganizations and company types, not just healthcare, nationwide. So over 20 years, among thousandsof organizations reviewed and studied by theDepartment of Commerce, they chose Mercy, undera program enacted by Congress, to be the76th recipient of the Malcolm Baldrige NationalQuality Award, which was presented by the presidentof the United States in the Oval Office.



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And I'm not sharing this to toot Mercy's ownhorn but, rather, just so you know that -- whenI bring a proposal to you, I want you to know thatwe've studied it; we've examined it from every whichway possible. I want you to have confidence in theproposal and that we know how to improve the carefor these 50,000 people at Crystal Lake, especiallytheir access to emergency care and stabilization.And many of the people that we give that quickaccess to at the emergency room, they'll bestabilized and then we'll be sending them back orsending them to one of the area hospitals forlonger-term convalescence, a more comprehensivehospital. But our permanent accountable care model hasallowed us to provide this coordinated careapproach, and our success is based on efficientcoordination of physicians, hospitals, and ancillaryservices, all geared to one medical record. We have decades, as I said, of experiencesuccessfully and profitably operating these smallhospitals in Harvard and Lake Geneva, Wisconsin.Both of them are profitable, and we -- have beenprofitable since three years after we opened them.



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We use evidence-based medicine, best practicestandards, industry benchmarks, and a culture ofcontinuous improvement. But a truly integrated model of care, whichis what an accountable care organization requires,under President Obama's Affordable Care Act,requires a hospital, even a small hospital. You'vegot to finish the continuum of care. And so the patients in Crystal Lake, if youapprove this proposal, will get the benefits of amultispecialty clinic, which is like one-stopstopping. It's very hard for elderly people to goto multiple locations, especially when they havevariance in transportation. It's far better forthem to get around to one location, be able to seetheir primary care doctor, the specialists, gettheir tests, and, if they need a procedure, get theprocedure. And if they need to be stabilizedbecause they're 90 years old, they can bestabilized. That is the way health care should bedelivered, and that's the way we deliver it atHarvard. That's the way we deliver it in LakeGeneva and our other facilities.



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You know, we -- our competition has talkedabout the fact that -- I'd like to just point, ifI could, to the first chart here and to show you theneed to help put it in perspective -- if you couldflip that one around. So you can see we have two communities.The first one is Crystal Lake, and there's51,000 people -- just over 51,000 -- within a3-mile radius of our proposed location. The othercommunity is Janesville, Wisconsin, which is whereI began my tenure with Mercy 30 years ago.Janesville has just over 50,000 people. The people in Crystal Lake have access to noemergency care. The people in Janesville,Wisconsin, have access to two hospitals and threeemergency rooms, and all three of those areprofitable. They're not all Mercy's. They're DeanClinic, a 500-physician group out of Madison. Butall three of those are profitable and the twohospitals. And so you -- put it in perspective.I mean, in Janesville, if you want to go up there --and some of you, I think, have been up there.Minimal traffic delays.



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Try -- as the patients and the residentstold the physicians -- or the PhD that did the studyfrom Purdue, the traffic delays on Highways 14 and30 throughout Crystal Lake are just enormous. Theyhave rush hour delays there because of Chicagolandtraffic that's unbelievable. Now, you know -- I mean, I can go on intonumerous cases. I can go on into cases of littlekids that fell off the bike, hit their head on theconcrete, get a subdural hematoma. And if theycan't get to an emergency room quickly and get theblood released, they end up a vegetable. If theycan get to the emergency room quickly, their --total recovery. It just -- it's -- I'm sorry. But in 2017this first chart should not exist. If you're astroke patient, we have medicine today that, if youhave a stroke and you -- if you start hemorrhagingin the brain -- which that's where the stroke is --if you can't get the medication, the clot-bustingmedication, fast enough, then you're going to goahead and bleed out. You're going to die or you'regoing to have severe long-term disability from astroke patient.



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Stroke patients will be able to get toour emergency room, evaluated quickly, get themedication, and then we'll be able to send them toone of the four area hospitals for a longer-termstay. So what we're proposing in this little smallhospital is, when we have a patient come in for asimple procedure, most of them will be sent homebecause they're healthy. But if they're elderly, ifthey're compromised, their health, we want to beable to -- we have to be able to stabilize themovernight. Or if they come into the emergency roomand they need to be stabilized, we can stabilizethem overnight. That really is the way health care is beingdelivered today, and that's why Dr. Dorsey called itthe first line of defense for those 50,000 people.We're not going to be replicating what the Centegrahospitals do or the Advocate hospitals. We'll bereferring to them. And as was attested to earlier, we've donethis study. And this -- even modern health care.In Crain's articles it said, "How threatening can a13-bed hospital be to these gigantic systems of



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Advocate and Northwestern?" I mean, this is abouthealth care and getting it to these people thatdon't have the access. And so -- anyway, Barb, I think if you canthrow the next chart up. This next chart shows, I believe, that, inthe state of Illinois, there's 187 emergencyrooms -- I believe I'm right. 187 emergency rooms.And 128 of those will be the same as our emergencyroom, a comprehensive emergency room. Only 57 aretrauma centers. But according to the 2015 information fromthe State of Illinois, 97 percent -- 97 percent ofall emergency cases are treated in comprehensiveemergency rooms. Only 3 percent of cases require atrauma center. So we'll be able to treat all of thesame type of emergencies that the other 128emergency rooms in the state treat or 97 percent ofall the cases. And you heard Dr. Jay MacNeal say -- who hastaught or -- yeah -- teaches paramedics and EMTs ina 15-county area. They're trained to screen people.So when they pick up a person at home or on thestreet, they know the appropriate hospital to take



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them to. They'll know if they should take them toour emergency room or if they need to take them to atrauma center. I moved along quickly here, kind ofsummarizing. Wow. I really gave you guys a brief, shortsummary here. I guess I would say, just to pretty muchwrap it up, that -- I already talked about thatwe're going to have less than 2 percent of theadmissions and less than 2 percent from the otherhospitals and that they'll -- many of those patientswill be sent back. So I think what I would probably like tosummarize with is that there's been some argumentsby Centegra today that this project will have afinancial and negative impact on them. AndI already said that this project isn't going to makea difference. They've got -- there's other reasonswhy they're suffering, but their suffering hasnothing to do with the fact that they built Huntleyor that this project occurs. And -- but remember, also, that they'remerging with Northwestern. And Northwestern's one



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of the best, but it's also one of the largest andwealthiest health systems in the state -- and I justlooked it up. Northwestern, as a system, has a netincome of over 7 million -- $700 million a year,over 700 million a year, and they have 5 million incash. So Northwestern has over $5 million in cashin reserves. MR. MORADO: I'm sorry. Can you please keepyour comments focused to the project? MR. BEA: Yeah, I am -- I am. So what I'm trying to say is I don't believethat this project is going to threaten the viabilityof Centegra because they're going to be well takencare of. And Northwestern, as a system, has -- doesless than 10 percent Medicaid. Mercy Health, as atotal system, has the largest Medicaid outside ofChicago. We do 20 percent of our patients --22 percent of our patients are Medicaid, as asystem, and another 9 percent charity. That means31 percent of Mercy Health's population, patientpopulation, is either Medicaid or charity. Almost athird of our patients are Medicaid and charity. And Mercy Health is not just helping people



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with their medical needs. For 21 years we'veoperated -- I'd like to share this with you -- ahomeless center for women, children, and families.It's not a shelter but a center that providescomprehensive services. The House of Mercy has helped over5,000 homeless women, children, and families getback on their feet. And twice the American HospitalAssociation has given national recognition forMercy's homeless program. So our history, our mission, has always beento serve the people that others really do not wantto serve -- others don't want to serve -- and,frankly, in areas that other health systems don'twant to be in. This 13-bed hospital is going to allow us toprovide accessibility to emergency room services forthe over 50,000 people who do not now have that, andthat's especially the most vulnerable, the Medicaid,the charity, the indigent, and the elderly. And you heard one speaker come up and saythat there's over 11,000 of the elderly that shehelps in Crystal Lake alone. I could tell you thatthere's over 7,500 Medicaid and charity, so we're



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getting up now to about 40 percent of the populationfalls into that vulnerable category of Crystal Lake. And, again, the studies show that -- thehealth study showed from McHenry County theirbiggest barrier to care is transportation. That'swhy we need to get that dot down there in that bigcircle, that first big circle -- if you would putthat back up, Barb. So I'd like to just share with you from animpact standpoint that our little 13-bed hospital,while making a world of difference on the residentsat Crystal Lake, is not even going to be a roundingerror on Northwestern-Centegra's bottom line. And our proposed project is a uniqueproject, it's an innovative project, and it's beendesigned to specifically meet the needs ofCrystal Lake. We spent a lot of time -- the unmetneeds, I should say. The unmet needs. A lot of those Crystal Lake people, they'restill going to be going to those other fourhospitals. They're going to be sent there by uswhen they need it. We're just trying to fill theunmet need portion of Crystal Lake. We at Mercy Health and the 50,000 people of



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Crystal Lake would be very thankful for yourapproval. Thank you very much. CHAIRWOMAN OLSON: Thank you. MR. WEBER: Madam Chairperson, I would liketo now just respond to the six negatives in theState agency report. And in the interest of getting to discussionquickly, which I know you want to do, I'd like toconsolidate these into the four causes of thesesix negatives. Number one, for the negative on performancerequirements, during our planning we were fullyaware of the regulation that new hospitals proposedin a metropolitan statistical area withmedical/surgical units should have a minimum of ahundred medical/surgical beds and four ICU beds.You've heard a lot about this today. Our projectclearly does not meet this requirement. In our discussions with State staff, formerState staff going back several decades, and otherexperts involved in the certificate of need program,none of us could explain the basis and the currentrelevance of the standard.



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As Tracey Klein mentioned, 100 of the184 hospitals in Illinois that have medical/surgicalunits have bed complements, med/surg, under ahundred. 26 of these 100 hospitals are located inmetropolitan statistical areas. The opposition has made a big deal aboutMercy not meeting a standard. This standard wasadopted -- let's look back a little bit -- at adifferent time in Illinois health care, at least35 years ago, when length of stay was more thandouble the current stay, when some patients stayingtwo weeks -- were staying two weeks then and now arebeing treated on an outpatient basis. And, Mr. Sewell, when a planning standardwas four beds for a thousand population -- you andI in our younger careers remember those days. Thoseare long gone. That was when larger hospital sizewas needed. 35 years ago was a time when hospitals werepaid on the basis of cost. Whatever the cost ofcare, that was what the insurance companies -- thereimbursement paid. That was before prospectivepayment by DRGs was instituted in the early 1980s,before the introduction of managed care in the



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1990s, and before the tremendous shift to outpatientcare over the past three decades, resulting insignificantly smaller inpatient bed units. Mercy sized the project to fit thecommunity, not the old standard. We hope you put itin this context since the majority of Illinoishospitals are now under 100 beds for med/surg. Mikeappropriately made a negative finding based on theregs, but nothing in the standard requires the Boardto reject the proposed Mercy project. You may also be thinking that the Mercyproject is a long way from a hundred beds with theproposed 11-bed med/surg unit. As you read thepermit application, average daily census is forecastto be 10 patients in the 11 beds. This forecast isbased on the number of persons in the officepractice panels of 16 primary care Mercy Healthphysicians officed in Crystal Lake and surroundingcommunities, already part of the Mercy system. Again, statewide data show that amedical/surgical service of this size is not ananomaly. Of the existing 184 hospitals in Illinoiswith med/surg units, 57 have an average dailymedical/surgical census of 10.0 or less. That's



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over 30 percent of the 184 hospitals. So as youthink about the project, please know that it is notout of line with census experience at many, manyhospitals throughout Illinois. That was the firstpoint and the longest. Second, two negatives are associated withthe project's impact on other area providers and theduplication of service. The projected 780 admissions will be drawnfrom other hospitals. The permit applicationproposes that, if these admissions were to come fromfive area hospitals -- and let's face it; probablythe Crystal Lake residents and nearby communityresidents go to beyond the five, but we used fivejust as an example -- this would be 156 admissionsper year from each of the five. 156 divided by52 weeks in a year is 3, so that would be 3 per weekat each hospital. Similar small projects are associated --similar small impacts are associated with ER visits,outpatient surgery, and diagnostic testing. It's animpact, yes, but certainly not significant, and thetrade-off is that Mercy Health patients wouldreceive coordinated care within a Mercy system, not



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fragmented as it is now. We hope you think thetrade-off is worth it. Mercy's system would then be able to providethe coordinated care that systems like Advocate,Centegra, Northwestern, and Presence haveestablished. Our patients want the same from us. Number three, there is a negative onplanning area need because the A-10 area in McHenryCounty has a computed excess of 43 medical/surgicalbeds and 3 ICU beds. Because Mercy's project is therelocation of beds in the county from Mercy'shospital in Harvard, it does not affect the excess.People have said that the current excess is duelargely to Centegra Hospital in Huntley. Pleasedon't hold Mercy accountable for that project. Fourth and finally, Mercy's projected ICUbed utilization is responsible for two of thesix negatives. We consciously added a secondICU room only to accommodate the anticipated timesthat there will be a second patient requiringintensive care. Please consider this second bed asessential for quality medical care. The second negative related to the ICUs isthe assurance letter that Mr. Bea signed. The



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letter affirms that Mercy will meet the occupancystandard for med/surg beds. Mercy could not attestto meeting the ICU bed standard because of the pointjust made. The project meets all other standards.Clinical services meet all size standards. Allexcept ICU meet the utilization standards. Theentire project meets the State's construction andcost standards. Please do not misunderstand. We are notcasual about the State's standards and regs, nor arewe asking you to be as you exercise your judgmentand Board discretion. In closing, I want to express ourappreciation to staff for their guidance as wedeveloped our permit applications. CHAIRWOMAN OLSON: Thank you. MR. WEBER: Thank you. MR. BEA: That's all of the preparedremarks -- CHAIRWOMAN OLSON: Okay. MR. BEA: -- but we're open for questions ifyou'd like. CHAIRWOMAN OLSON: Sure. Sure.



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Questions from Board members? Mr. Sewell. VICE CHAIRMAN SEWELL: Yes. I wanted to talk about this performancerequirement. You know, I don't know, either, whythis standard exists the way it does, but it is thestandard. The way you deal with something likethis, I think, is sort of a collective interplaybetween this Board and the provider community shouldrevisit the standards from time to time. You went through a whole history of reformin the system with prospective payment, rise inmanaged care, and all that. And while this was astandard before all that, it seems like, in all thistime, somebody should have said, "Well, why is therea requirement for an MSA you've got to have ahundred-bed minimum hospital?" But -- I think that this Board has beenreasonable about responding to suggested changes tothe standards. So the problem with, I think, yourargument is that, even though it's an old standard,it's the standard. And maybe sometime, through all thoseyears -- I believe it was -- what, 1983? You know,



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at some point we probably should have beenchallenged and maybe -- in revisiting this. And I'msaying this without knowing why we have thestandard. I don't know. Maybe it's because of theexistence of critical care hospitals and they didn'twant those in an MSA -- I don't know. That's onething. The other thing I guess I wanted to hear --I think you're saying that the two intensive carebeds are there just for quality care because, youknow, if you just had one, you'd have no flexibilityin those instances where there might be anotherpatient. I think I get that. But it looks like what the -- I don't wantto put words in Mike's mouth. It looks like it'sthe failure to provide documentation to justify thetwo. Is that -- I guess I'd turn the question tothe staff. You're saying here that the Applicant wasunable to provide documentation that the twointensive care -- two-bed intensive care unit willbe at the target occupancy. MR. CONSTANTINO: Yeah. They couldn'tprovide the number of referrals required.



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VICE CHAIRMAN SEWELL: I see. And that's alittle different than the issue of havingflexibility to enhance quality of care. MR. WEBER: Yeah. Mr. Sewell, I want tomake sure that, really, the -- the way you asked thequestion was -- provided -- didn't provide thedocumentation to support the justification. We did provide the documentation. And, youknow, the ratio of intensive care unit patients tomed/surg patients, I think we went all through thatvery analytically in the permit application. The second part of it is it doesn't justifythe utilization. As you know, ICUs are --60 percent utilization is the standard. I think wehave 126 patient days, if I remember. That's about34 percent so one justified. And the way the staff does the work is, ifyou've got one unit, even if it doesn't get up tothe threshold, you meet the standard. But if youadd a second one, then you don't. So we had a dilemma. Do we just do one andmeet the standard? And what do you do, then, withthe 30 or 40 times a year when you've got a secondpatient in the hospital requiring intensive care?



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So we looked at the Walworth experience --again, similar-sized hospitals -- and the ratio ofbeds there, and that's where we came up with this30-or-so times a year that it was going to beneeded. So we had to make a decision. We knew wewere going to get a negative, but sometimes doingthe right thing is more important -- VICE CHAIRMAN SEWELL: No, I get it. MR. WEBER: -- than making the standard. VICE CHAIRMAN SEWELL: And the final thingI had was about the bed -- the unnecessaryduplication of service. It's almost like we'retalking about Centegra as a project instead of anexisting hospital that's in the inventory. Do you see what I mean? Or will be. And so, you know, this standard is not metbecause of what we know. It's not like theopponents of the inventory are going to be proposingat some point in the future. MR. WEBER: Sure. VICE CHAIRMAN SEWELL: It's there. SoI think that's a valid finding by the State agencystaff on your project.



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And this thing about innovation, you know,in terms of, you know, very small hospitals -- youknow, I think you could probably always calculatethe kind of -- the number of beds that would respondto what your vectors are that create demand, butthat's not all there is. There are other things, and I think thissort of takes everything into consideration. Now,we could argue with this hundred-bed issue in an MSAas an artifact or something from a bygone era, butall of us, I guess -- this Board, the providercommunity -- had quite a while to look at that andsay, "I wonder where that came from." So that's all I have. CHAIRWOMAN OLSON: Other questions orcomments? Doctor. MEMBER GOYAL: Thank you, Madam Chair. My name is Arvind Goyal, and I representMedicaid on this Board, and I do not vote. So my questions are -- I did not see in yourapplication or any presentations if you're doing anyOB, pediatrics, or behavioral health. Could youamplify that?



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MR. WEBER: There is -- yeah. There is no OB or pediatrics in this -- verymuch this project is a translation of what are theexisting programs at the Harvard Hospital. There isno OB there or pediatrics. Behavioral health is something that Mercy isvery much looking at. They have a behavioral healthoutpatient program, an individual -- I think youheard from her at -- in the -- at Harvard. And theyare looking at that because that is a significantneed in the community. MR. BEA: We have pediatric outpatients,just not inpatient. MEMBER GOYAL: Right. I understand. So looking at your Medicaid projections of11 percent -- I think I saw that. MR. WEBER: Yes. MEMBER GOYAL: May I have you project alittle bit further and see where that Medicaidportion of the population you serve as inpatientwill come from? MR. WEBER: We know that resident -- thereare 7500 residents of Crystal Lake who are Medicaid.The broader Medicaid place of McHenry County is a



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very healthy 49,000. In fact, I think I saw 52,000in a figure yesterday for year 2016. I think that -- when Javon Bea mentionedearlier the largest Medicaid provider outside ofChicago, I think he meant that at the RockfordMemorial Hospital they have the largest percentageof Medicaid at Rockford. Is that -- or is it the system? MR. BEA: The total system, yeah -- MR. WEBER: Total system. MR. BEA: -- parts in Rockford. MEMBER GOYAL: I didn't understand the lastthing you said about second largest -- MR. BEA: We're the largest Medicaidprovider outside of Chicago as a total system,22 percent Medicaid, 9 percent charity, as a totalsystem. But a good portion of that is in Rockfordand also at Harvard. And a good portion iselsewhere, too. MEMBER GOYAL: In absolute numbers that isprobably not true. But let's leave that alone; it'snot relevant. But I have two other comments to make. One



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is -- or a question first. Do you participate in all Medicaid MCO plansat this time? MR. COOK: Yes. Yes, we do. MR. BEA: Yes, we do. MEMBER GOYAL: All 12 of them? MR. COOK: Yes. MEMBER GOYAL: Okay. THE COURT REPORTER: Who are you, please?I'm sorry. MR. BEA: John Cook is the CFO. THE COURT REPORTER: Thank you. MR. BEA: He's saying, yes, we do, all 12 ofthem. We participate in all MCO Medicaid plans. MEMBER GOYAL: Okay. Good. Now, you have two operating rooms from whatI understood. MR. BEA: Yes. MEMBER GOYAL: And you have two ICU beds? MR. WEBER: Yes. MR. BEA: Yes. MEMBER GOYAL: And your emergency room inaddition? MR. BEA: Seven stations, yes.



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MEMBER GOYAL: So I'm going to take a littledifferent tack. Do you think that your two ICU beds areenough in cases where both of your operating roompatients might need intensive care? MR. BEA: I'll let Jeni probably talk onthis a little bit more. But, basically, we tookthis very much out of the two similar hospitals thatwe've been operating for decades at Harvard andLake Geneva. And so the type of cases that we bring inthat we do surgery on through the prescreen -- wedon't seek out cases there that are going to requirea lot of intensive care. That's more when a patientcomes into the emergency room and needs that. But I'll let Jeni go ahead and comment onthat. MS. HALLATT: Yes. Hi. Jeni Hallatt. Every facility with high utilization alwaysruns the fear of "What if you need that one morebed?" and it certainly stands true for the ICU, aswell. In our planning we felt as though ourvolumes could easily justify, as Ralph had



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explained, the one ICU bed. We felt it necessary tohave the duplication of a second in that -- in thatevent that we needed a second. And there may be atime when we need a third, and we would certainly,as Mr. Bea had indicated, appropriately care for thepatients in that facility. And if somebody were to come and still needthat intensive care and be on a ventilator, then wewould continue to work closely with our providersand other area hospitals to provide the care to thatpatient. MEMBER GOYAL: So I wanted you to really saythat. You heard from your area hospitals? Do you think you will go in the neighborhoodwhere you will get any cooperation from your areapartners? Or would you have a tertiary backup ofany kind? MR. BEA: Yeah. I mean, right now ourdoctors that are going to be on staff here are onstaff at those hospitals. You've heard them attestto that themselves. So our doctors are all on theirmedical staffs right now, so, of course, there wouldbe that backup. Our doctors can choose to admit tothose hospitals versus this small hospital.



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We really are trying to get the emergencyservices in Crystal Lake, and we need to have those13 beds to be able to stabilize somebody overnightor for less complicated surgery when someone needsto be stabilized overnight. That's really the pointof it. But if our doctors see that someone's goingto be -- that they need to get to a morecomprehensive hospital, they're already on thestaffs at those hospitals. MEMBER GOYAL: Thank you. CHAIRWOMAN OLSON: Other questions orcomments? MEMBER MC GLASSON: Yes. CHAIRWOMAN OLSON: Please, John. MEMBER MC GLASSON: Mr. Udy -- I believe ishis name -- and then you reiterated his statisticsabout Medicare and ACOs. MR. BEA: ACO, yes. MEMBER MC GLASSON: Bear in mind whatMark Twain said about statistics. Do you actually expect to be able to deliverquality -- better quality care at lower costs thanthe --



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MR. BEA: I don't -- MEMBER MC GLASSON: -- other hospitals inthe area? MR. BEA: Yeah, I don't mean to be --whatever. I don't expect that we'd be doing that.As attested to by the ACO reporting by CMS, we'vebeen doing it. And that's why we received nationalrecognition for being one of the only health plansto be able to lower our premiums to the exchangesubscriber. We've been doing that. MEMBER MC GLASSON: Thank you. CHAIRWOMAN OLSON: Joel. MEMBER JOHNSON: Back to, I think, a pointMr. Sewell was making -- I just wanted to make sureI understand. Unnecessary duplication. Is it yourposition that, with the creation of the beds in thisapplication and the reduction of the beds inHarvard, that, essentially, it's a shift of beds,and, therefore, the duplication exists already whichexists and, if anything, you're making it better? MR. BEA: Yes. We -- that's exactly right,sir. We're moving them to where they're more --most needed. That's right.



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MR. WEBER: Let me -- Mr. Johnson, ifI could add to that related to duplication ofservice is the criteria called maldistribution. And we think of that in two ways in a miniactivity in the Mercy system. The beds are inHarvard. They needed to be -- they're not beingutilized as much in Harvard. So I've heard, in ourplanning meetings, a maldistribution of the MercyHealth beds. But the broader and the appropriateregulatory definition of "maldistribution" includesa statement that says "Maldistribution existswhen the ratio of beds to thousand population is1 1/2 times the State average." In McHenry County,Planning Area A-10, those ratios are less -- not1 1/2 times but less than State average. The -- I had them here moments ago but --here they are: Med/surg in Illinois, 1 med/surg bedfor 593 residents. In McHenry County, 1 per 1123.ICU is, in Illinois, 1 per 3700 roughly. In McHenryCounty, 1 per almost 8,000 residents. So thatshould fit into your thinking about maldistribution. MEMBER JOHNSON: A follow-up question: Withthis -- I appreciate the cost of construction and



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the fact that this project comes into the scope interms of the financials. But for the number of beds proposed for thisproject, is there thought of future growth andexpansion within the walls of this facility? Andhow will that impact the planning area? MR. BEA: Yeah. Well, we always, you know,have our walls so that they're expandable andthere's a lot of -- there's a lot of extra landaround, so it's easy to expand. And I think thatthe criteria -- correct me if I'm wrong -- is10 percent every two years. But I just can't -- it's hard to emphasize,unless I get really boring with statistics andnumbers, the movement from inpatient care tooutpatient care. I mean, I'm a physical therapist. You know,that's really where I started. And we used to --when I was treating total hip patients, we kept themin the hospital for 10 to 12 days doing therapytwice a day. I had my total hip done, and I got kickedout in 18 hours. And I was given a homeinstruction, you know, on -- for my physical



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therapy. I mean -- and so that's -- our open-heartprocedures today might average between two andthree days length of stay. It's just -- themovement from the need for inpatient beds is just --and the technology just continues to escalate such. And that's why I give you the example thatwe could -- and look at all of you. We could do aprocedure -- so many procedures that you needed tobe in the hospital four or five or six days just nottoo many years ago, and we'll send you home in aday. But we get a 90-year-old grandmother inwho's got a lot of other metabolic, you know,issues, that's where they need to be watched.That's where they need to be watched longer. Soit's just -- the movement to outpatient surgery isphenomenal, and you just don't need a lot of beds. And I go back to Mr. Sewell's commentabout -- I can't emphasize enough that if the Boardcould stress to the staff or to whoever -- but thatstandard today that causes providers to say, "Oh,we'd better meet that standard, let's go in, youknow, with a high-cost, hundred-bed hospital" --



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they're just not needed today. They are not needed. And so, anyway, to answer your question,Mr. Johnson, we think that, when we look at ourstatistics and growth, that normal statistic allowedunder the regulations of 10 percent in beds everytwo years would be more than able to satisfy ourneed. MS. KLEIN: And I think we thought,Mr. Johnson, that would be 1.3 beds a year. So, youknow, it -- we don't think that there's much dangerthat, over two years, that there would be -- thiswould open the floodgates to a bigger facility. The other thing, just to amplify what wassaid on duplication and maldistribution, we are notgoing to -- whatever we do here, whatever you dohere today as a Board will not change the fact thatthere are 43 excess beds unless, with the approvalof this project, if we can run at our 91 percentoccupancy in both facilities, then we estimate thatthe utilization of the 13 beds will actually reducethe excess capacity in the planning area. So wethink that would be a positive thing. If you don't approve it, we're still goingto have the 13 underutilized beds. Nothing will



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change there. So the other thing that we would also say --it's interesting because when you're tackling -- andrightfully so -- you bring up this issue ofduplication. And so I was asking one of ourassociates, "Please find the definition of'duplication.' I want to know exactly what thedefinition is." And I can't find one in yourregulations. But what I can tell you is, if you look atthe dictionary, it says "act or process of doing thesame thing another person has already done." So,effectively, it focuses on service. If you go back to Mr. Bea's earliercomments, we think that this is well within thepurposes of the act because it's going to eliminateduplication when it comes to services because of theintegrated model of care and the medical -- theelectronic medical record and the ability to engagein care management. MEMBER JOHNSON: I'd just tell you to focuson the word "unnecessary" more than the word"duplication." MR. BEA: You could say --



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MEMBER JOHNSON: It's "unnecessaryduplication." MR. BEA: That's right. But a lot of thatcomes from -- the patient shows up, I don't have thetest results from the other provider, so I have todo it all over again. That adds tremendously to thehealth care cost, and there's always a risk to thepatient oftentimes. CHAIRWOMAN OLSON: Mr. Burzynski. MEMBER BURZYNSKI: Thank you. Well, first of all, let me congratulate youon being innovative and looking for a differenthealth care model as we move forward here. Having said that, I do agree with Mr. Sewellrelative to the standards that we have in placetoday. Maybe we all need to sit down and look atthose. And I know the legislature has a lot more todeal with on their hands than looking at our rulesor whatever, but that's something that we reallyneed to address in the future if that's not anadequate standard today. Having said that, I've got a couple ofquestions. First of all, I think I've heard -- and in



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the testimony that was given in the hearing, thiswas referred to as a microhospital. Now, I alsothink today I heard that this is not amicrohospital. MR. BEA: Right. MEMBER BURZYNSKI: So can somebody pleaseexplain where -- are we just talking about usingterminology in a different way or whatever -- MR. BEA: Yeah. People use that termhowever they want. If you really do a literature search, it'sreally -- I think the industry is struggling withthis idea of the fact that there's significantlyless beds needed today. But I think, as you heardMatt Sanders' comment from AECOM who did a nationalsearch -- and we've actually contacted organizationsthat have tried to use that term, contacted some outwest that have these throughout the mountains --what they're really oftentimes talking about areambulatory care centers with like recovery beds. And then there's -- as Mr. Sanders said,lots of times they won't have emergency rooms, theywon't have surgery suites, they won't have -- it'sreally a way to -- and oftentimes they may have an



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outpatient surgery and they know that -- rememberthe grandmother that needs a longer stay? They'llkeep them in for those rare, few patients that needto stay in for 20 hours or 23 hours, to try to stayin there 24 hours -- and they'll have the foodservice kind of brought in from the outside. So it isn't an apples-to-apples comparison.That's why that term is really a term that ismisused and thrown all over the place. And this --because it's a -- because we feel that the greatestunmet need in this city of 50,000 people is a lackof an emergency room, we've geared all of ourservices downstream to be able to deal and offer acomprehensive emergency room. That's why we've got, you know, the ORs, theprocedure rooms, the full diagnostic and radiology,et cetera, to be able to offer a comprehensiveemergency room. So this isn't a microhospital, butthis is appropriately sized and scaled to the unmetneeds. MEMBER BURZYNSKI: Okay. Because yourtestimony was where I saw "microhospital" first. MR. BEA: Yeah. I -- you know, I probablyshouldn't have used -- you mean today or --



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MEMBER BURZYNSKI: No, at the hearing. MR. BEA: Yeah. I've been thrashed andadequately disciplined for using that term. AndI've had the -- I've had that literature brought tome, and so I stand corrected. MEMBER BURZYNSKI: Just a couple of otherthings very quickly. You know, you're not -- you're really notasking us to approve one hospital that doesn't meetthose standards that we've already got in place, butyou're asking us to have two hospitals because youwould have the Harvard Hospital, as well, as thesecond hospital that wouldn't meet that bed --minimum bed requirement. MS. KLEIN: I think -- I don't think that'sactually correct because Harvard must be out of theMSA, and that rule applies only as wide as theMSA -- MEMBER BURZYNSKI: You're right, yeah. MS. KLEIN: -- because it's a critical-access hospital. MEMBER BURZYNSKI: Critical access. MS. KLEIN: Yeah. MEMBER BURZYNSKI: And that was another



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question I had. What does this do to the critical-access status of the Harvard hospital? Anythingat all? MS. HALLATT: Doesn't affect it. MS. KLEIN: Doesn't affect it. MR. BEA: Doesn't -- nothing at all.Doesn't change it. MEMBER BURZYNSKI: And then I did have onemore, and I think it was touched on very briefly. But would there be -- can you add additionalbeds at Crystal Lake in the future without comingback to this Board? MR. WEBER: The -- could I speak to that? MR. BEA: Sure. MR. WEBER: There's a 20-bed rule -- andthis is more current than the ancient rules. Thereused to be a 10-bed rule that, in a period of24 months, you could add 10 beds. That was expandedabout 8 years, 10 years ago to 20 beds or 10 percentof a service, whichever is less. So with an 11-bed medical/surgical serviceor a 2-bed ICU service, that's like 1.3 beds, as wetalked about before, every two years. So it would take a lot of -- this is not a



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foot in the ground to build a big hospital. Itcan't be done. MEMBER BURZYNSKI: Thank you. MR. MORADO: I'll just speak to that,Member Burzynski. He's absolutely correct. It's 10 percent or20 beds, whichever is the lower amount. I would also like to note -- it sounds likeit's a concern whether the 43 excess beds -- if theBoard was inclined to do so, they could place acondition on the permit itself with a set conditionfor a set period of time saying that the Applicantwould have to come back before this Board if theywanted to add additional beds in the future. Now, of course, it would be incumbent uponthe Applicant to either accept that condition or not. MS. KLEIN: Senator, just to amplify, too,on your question, we did quite a lot of researchregarding this project, and there are healthsystems -- large health systems all over thecountry -- that are looking at this whole conceptof -- some places they call this more a small formathospital. One of the things that you probably noted



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from Mr. Bea's testimony is that, in addition to thesurgical suites, the procedure rooms, there's a fullsuite of imaging in this facility, a fulllaboratory, an in-house pharmacy. So one of thesesmall format or small hospitals is not the same asthe next. That's what we've learned for sure. And the -- this is truly a small -- wedecided -- it was a small hospital, in keeping withthe other model that has been used by Mercy verysuccessfully. CHAIRWOMAN OLSON: So I just want to makesure -- Mike, this is for you because much has beenmade here about the cost of this project. But they met all the criteria related tocost and financial -- MR. CONSTANTINO: They met the gross-square-footage cost, yes. CHAIRWOMAN OLSON: And then back to Juan'spoint, so -- if I understand correctly, if they wereat 91 percent utilization, they could add 1.2 bedsevery two years if they met that utilizationthreshold? MR. MORADO: I don't think they need to meetthe threshold.



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MR. CONSTANTINO: No. There's noutilization threshold. MR. MORADO: They could come in everytwo years and add either 10 beds -- CHAIRWOMAN OLSON: But what you're --I think what you're saying there is that's not theintention. But would you be willing to come back tothe Board if you -- MR. BEA: Yeah, if you want us to. Imean -- you know, in other words, one bed everytwo years is not -- CHAIRWOMAN OLSON: Yeah. MR. BEA: It's not going to have an impact. If you want us to stay here for time forthat, we'd be willing to adhere to that condition. But, certainly, we don't have any intentionto come back and say, "Oh, geez, we need to add" --you know -- "50 beds or 20 beds" -- whatever. Butwe're -- CHAIRWOMAN OLSON: It doesn't sound likethat's your model anyway. MR. BEA: Yeah, right. We're open eitherway. We're open either way. We can just stay with the one bed every



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two years or, you know, if we need an extra bed, wecan come back to you every two years, to theBoard -- or not. It all depends on the need. CHAIRWOMAN OLSON: What -- does anybody haveany thoughts on that, or is that not reallyrelative? (No response.) CHAIRWOMAN OLSON: No? Okay. Just throwingit out there. Other questions or comments? (No response.) CHAIRWOMAN OLSON: Okay. Seeing none,I would ask for a roll call vote. MR. ROATE: Motion made by Mr. Johnson;seconded by Senator Demuzio. Senator Burzynski. MEMBER BURZYNSKI: I really -- I've lookedlong and hard at our staff report and recommendations,and they do -- you know, there's some valid issuesthere that need to be addressed. But I also think some of those validissues -- the standard for a hundred hospitals[sic], that needs to be addressed, as well, by uslooking towards the future.



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I do have a few concerns relative to thesize, but I think that, certainly, looking at allthe information we've been provided with today,I'm going to vote in favor. MR. ROATE: Thank you. Senator Demuzio. MEMBER DEMUZIO: Sorry about that. I have to -- I agree with Senator Burzynski.I think that you've answered some of the questionsthat we had concerning some of the findings that thestaff had. I feel fairly comfortable with that. Your financials are in good shape, soI think that says a lot in terms of where you're at. So I am going to go ahead and vote yes. MR. ROATE: Thank you. Mr. Johnson. MEMBER JOHNSON: I'm also going to vote yesbased on the testimony heard here today, primarilyin answering many of the issues raised by the staffreport. And it does cause us to perhaps take a lookat the regs and make sure that they meet today'shealth care needs. MR. ROATE: Thank you. Mr. McGlasson.



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MEMBER MC GLASSON: I'm going to vote yesbased on the testimony regarding the ability to,hopefully, lower costs in health care. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Based on the findings in thereport that were positive and based on theApplicant's response to the negative findings andespecially the comments from the community in favor,I'm going to vote yes. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: I'm going to vote no.I think the way this process works is that we changethe rules and then we apply them to prospectiveapplications. MR. ROATE: Thank you. VICE CHAIRMAN SEWELL: So I vote no. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I'm also going to voteyes based on the fact this is not changing the bedneed area in the planning area. I don't believe that a 13-bed facility is



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going to have a huge impact on the larger providers.I think the ED access is necessary. I applaud theaccess for Medicaid and charity care recipients, andI believe that individuals in that area deservelocal access to health care. So I vote yes, as well. MR. ROATE: Thank you, Madam Chair. That's 6 votes in the affirmative, 1 in thenegative. CHAIRWOMAN OLSON: The motion passes. Congratulations. (Applause.) - - -



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CHAIRWOMAN OLSON: Okay. Moving on,Project H-02 -- do we need a break? Okay. Now you can cheer. (A recess was taken from 3:30 p.m. to3:38 p.m.) CHAIRWOMAN OLSON: Next, we haveProject 17-001, Mercy Health Hospital medical officebuilding. May I have a motion to approve Project 17-001. MEMBER BURZYNSKI: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER JOHNSON: Second. CHAIRWOMAN OLSON: And I believe everybodyat the table has already been sworn in. MR. BEA: Yes, ma'am. CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chairwoman. The Applicants are proposing to construct amedical office building in Crystal Lake. Themedical office building will have 42 examinationrooms accommodating 15 physicians. Clinical serviceat the medical office building will include physicaltherapy, occupation therapy, and infusion therapy.



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The total cost of the project isapproximately $18.9 million. The completion date isNovember 30th, 2020. There were no findings. We did have apublic hearing on this project, and there wassupport and opposition regarding the project. CHAIRWOMAN OLSON: Thank you, Mr. Constantino. Mr. Bea. MR. BEA: Sure. My comments will be verybrief because of our extensive discussion regardingthe hospital. This is really the idea of, again,coordinating care. We have five different locationswithin the city of Crystal Lake where we have thesephysicians located. And, again, it's hard on people to try toget to the different locations to see a primarydoctor here and then go over to this one for aspecialist, so this is the idea of bringing ourphysicians together for better efficiencies andcoordination of care for both the patients as wellas the providers. And we're right now at 43,000 patientvisits, and we see that growing to 73,000 patient



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visits in this facility by 2022 or two years afterthe project opens. We did specifically, because of the highelderly population, put in the therapies that werementioned, as well as infusion chemotherapy, so thisis going to be, I think, greatly appreciated. It'sgoing to eliminate duplication of testing betweenand among the different facilities, and it's goingto be, I think, very much appreciated, kind of aone-stop shopping concept. The other thing it's going to do, obviously,is have these physicians right next to the hospital,adjoined to the hospital, so that when they need tobe called to the emergency room, they can see apatient there. And as Mr. Constantino said, there were nonegative findings. And we're open for anyquestions. CHAIRWOMAN OLSON: Thank you. Questions from Board members? (No response.) CHAIRWOMAN OLSON: I just have a point ofclarification. Somebody said earlier that this was going to



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be the top two floors of the hospital. But it'snot? It's a separate building? MR. BEA: Right. It is -- but attached,part of it, right. CHAIRWOMAN OLSON: All right. Okay. Seeing no further questions, I'd askfor a roll call vote. MR. ROATE: Thank you, Madam Chair. Motion made by Senator Burzynski; secondedby Mr. Johnson. Senator Burzynski. MEMBER BURZYNSKI: Yes, based on staff'sreport. MR. ROATE: Thank you. Senator Demuzio. (No response.) MR. ROATE: She's absent. Mr. Johnson. MEMBER JOHNSON: Yes, based on the staffreport. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on thepositive report.



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MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on the staffreport. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: Yes. No findings. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, based on nofindings. MR. ROATE: Thank you. That's 6 votes in the affirmative. CHAIRWOMAN OLSON: The motion passes. Congratulations. MR. BEA: Thank you very much. Thank youall very much. (Applause.) - - -



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CHAIRWOMAN OLSON: Next I'll call to thetable Project 17-009, Silver Oaks Hospital. May I have a motion to approve Project 17-009,Silver Oaks Hospital, to establish a hundred-bed AMIhospital in New Lenox. MEMBER BURZYNSKI: So moved. VICE CHAIRMAN SEWELL: Second. CHAIRWOMAN OLSON: If I can get theApplicant to move to the table and be sworn in,please. THE COURT REPORTER: Would you raise yourright hands, please. Would you raise your right hands, please. (Seven witnesses sworn.) THE COURT REPORTER: Thank you. CHAIRWOMAN OLSON: Thank you. Mr. Constantino, your report. MR. CONSTANTINO: Thank you, Madam Chairwoman. The Applicants are proposing theestablishment of a hundred-bed acute mental illnesshospital in New Lenox, Illinois, at a cost ofapproximately $24.3 million. The anticipatedcompletion date is December 31st, 2018. There were no findings -- excuse me. There



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was no public hearing, no opposition letters. Anumber of support letters were received by the StateBoard staff. And we did have findings regardingthis project. CHAIRWOMAN OLSON: Thank you, Michael. Comments for the Board? MS. COLBY: Good afternoon, Madam Chairman,and good afternoon, members of the Board. My name is Ruth Colby, and I'm the chiefstrategy officer at Silver Cross Hospital, and I'dlike to introduce the team that's here with metoday. To my right is Mr. Edward Green, counsel toSilver Cross from Foley & Lardner. To my left isDr. Richard Kresch, who is the CEO of US HealthVest.Next to him is Martina Sze, who is the executivevice president from US HealthVest. Next to her is Mark Silberman, counsel toUS HealthVest from Benesch. Next to him isJames Cha, chief financial officer fromUS HealthVest. And at the end is Dr. David Mikolajczak, whois the medical director of EMS, emergency medicalservices, Region 7, and an emergency room physician



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at Silver Cross Hospital. So thank you for the opportunity. We feelvery privileged to be before you today to bringProject 17-009, which is to build a hundred-bedpsychiatric hospital on the Silver Cross campus inNew Lenox, Illinois. I'd like to provide just a quick, briefoverview of the project. We know you've had a longday. And I will address some of the limitedfindings in the State agency report, and thenDr. Kresch will speak about US HealthVest and theIllinois operation at Chicago Behavioral Hospital inDes Plaines. And then, lastly, Dr. Mikolajczak willtalk about the impact of the mental health crisisand how it's affecting emergency departments in EMSRegion 7. As our application details, there is a direneed for mental health services, not only inPlanning Area A-13 but across the entire country.One in four Americans suffer from a mental healthcondition. Silver Cross Hospital's been an activeparticipant in the Will County Department of PublicHealth's collaborative to assess the needs of the



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community, and year after year the number one needis -- that's not met -- is mental health services. Our emergency rooms in the community arefilled with people waiting for placement. In fact,70 percent of the health care providers that weresurveyed said they refer people with mentalillnesses to hospital EDs because of access issues.There's absolutely nowhere else for people to go. The court system has cried out to hospitalsin Will County. They basically said, "Help us.Help us provide safe quality, high-quality servicesfor people that we care for." They pleaded with usto do something transformational in the community. As documented in the application, there are75 acute mental illness beds in Planning Area A-13,which has a population well over 700,000 people,resulting in a ratio of 10.5 beds per hundredthousand people. In Illinois the ratio's closer to35 beds per hundred thousand and, in the literature,mental health experts recommend a ratio closer to 40to 50 beds per hundred thousand. We're not challenging the Board'scalculation of needs; we're merely highlighting thecrisis that we're experiencing in the community. It



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is real and it's having a devastating impact onpatients, families, health care workers, emergencymedical providers, physicians, police, and thejails. Silver Cross has had a 20-bed inpatientmental health unit for many years, and it's just toosmall. We're not able to accommodate all thespecialized services that really cross the continuumof care in mental health. As you know from workingwith us over the past -- oh, I don't know --12 years, it's been our position to partner with thebest of the best. That's what we did with pediatrics withLurie; it's what we did with Northwestern inneurosciences; it's what we did in oncology with theUniversity of Chicago. And that's exactly whatwe're bringing to you today in mental healthservices, by partnering with US HealthVest. Learning about the work that US HealthVesthas done at Chicago Behavioral Hospital prompted aconversation with their leadership, and, thus, ajoint venture partnership was created to expandservices. I personally have visited ChicagoBehavioral Hospital and was extremely impressed with



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the culture, the interaction between patients andstaff, and the dedication of the leadership team. Our chief nursing officer, our chiefoperating officer, and our vice president of humanresources made unannounced visits to ChicagoBehavioral Hospital and felt exactly the same way.We can confidently say that it's our privilege andour honor to be co-Applicants with US HealthVest andhave them run the Silver Oaks Psychiatric Hospitalon our campus. US HealthVest has made strong commitments toserve all patients, regardless of their ability topay. Mayor Baldermann had hoped to be here thismorning -- he was going to be here at ten o'clockand it got switched to 11:00, and he couldn't makeit. But he instructed me to tell you that theVillage of New Lenox welcomes this hospital. Hepersonally has met with Dr. Kresch, and the zoningis in place for it to be on our campus. Over 100 agencies, schools, legislators,Judges, fire chiefs, police chiefs, social workers,physicians provided letters of support todemonstrate the need for this hundred-bed hospital.Not one letter of opposition was received for this



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project. And we understand that according to --Administrative Code 1110.730(c)(3)(b) requires thatthey have zip codes attached to patients forreferrals as well as letters signed by physicians.Many of the referring agencies do not collect thiskind of information. We've reached out to all ofthem; they've confirmed their commitment. We knowthat sometimes physicians are not the only peoplethat refer people to a psychiatric hospital. In fact, last week we submitted an affidavitfrom the medical director at Chicago BehavioralHospital where he stated that less than 1 percent ofthe inpatient referrals to that hospital comedirectly from a doctor. Instead, 99 percent of thereferrals come from other hospitals, crisis socialworkers, and other nonphysicians. I'd like to emphasize again that there wasno opposition to this project. Lastly, I wanted to touch on the negativefindings on some of the financial ratios forSilver Cross and US HealthVest and the joint ventureorganized. Please understand that those technicalratio issues will not impact this project. As the



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Board staff stated in the State agency report, theApplicants have the cash, the funding available tostart and finish this project on time without anydelays. Of all the projects over the years thatSilver Cross has brought to this Board, from the newhospital to the professional office building to thecancer center and, most recently, the ambulatorysurgery center, in my mind this is the mostimportant application and will have the mostpositive impact on the community we serve. We have the vision, we have the commitment,the resources, and the desire to see Silver OaksHospital become a reality. And, most importantly,the community and residents in Planning Area A-13are depending on us to do this. So now I'd like to ask Dr. Kresch to say afew words about Chicago Behavioral Hospital. DR. KRESCH: Good afternoon and thank youvery much for taking the time to hear us today. I am Dr. Richard Kresch, a psychiatrist andCEO of US HealthVest. I've had the privilege ofbeing -- appearing before this Board before and ampleased to bring another project to Illinois to



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serve those suffering from mental illness andaddiction issues. Chicago Behavioral Hospital was approved fora change of ownership by the Board in 2014. Sincethe Board's approval, we have committed significantcapital -- made a significant capital investment inthe hospital and have expanded our service offeringsto include care to all -- patients of all ages, fromadolescents on through seniors. When we acquired Chicago Behavioral Hospitalnearly three years ago, there were only fourpatients being treated in the hospital. Today, thehospital has average census of almost 125, hoveringaround that number, and has been running at90 percent occupancy. We are just as confident about the prospectsfor Silver Oaks Hospital. Indeed, the support forthis project has been overwhelming. No oppositionof any sort has been put forward. As Ruth said, we are committed to servingall patients, regardless of their insurance orability to pay. We are thrilled with the responsefrom the Silver Cross emergency department andwill ensure a continuity of care between the two



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facilities. Both Silver Cross Hospital andUS HealthVest are dedicated to ensuring thatpatients receive care at the right place at theright time every time. My management team has worked together forover 20 years. We understand the needs of patients,and we serve the special needs of diversepopulations. It is our plan to dedicate unitswithin the hospital to pediatrics and adolescents,to women who have suffered traumatic events, tosenior citizens, and to those suffering fromsubstance abuse in self-contained areas withspecialized staff. Our design allows forflexibility in number of beds and number of unitsbased on the needs of our patient cohort. We will support patients once they have beendischarged from the hospital. We have held numerousmeetings with community agencies and follow-up careresources to ensure that the discharge back into thecommunity is a smooth and effective one. At the same time and for the purposes offull disclosure, we hope to deliver the same qualityprogram to the Northbrook community, but we havefaced some unexpected zoning problems in that city.



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US HealthVest has just filed a status report to theBoard and will continue to advise the Board on thestatus of that application. Fortunately, from a zoning point of view,Silver Oaks Hospital will sit in a hospitaldistrict, and those special district zoningregulations in New Lenox clearly allow for theconstruction of Silver Oaks Hospital. Now, I'd like to turn the microphone over toDr. Dave Mikolajczak. Dr. Mikolajczak is thedirector of emergency medical services, Region 7,and an emergency room physician at Silver Cross.Dr. Mikolajczak is also a member of the Silver CrossHospital board of directors. DR. MIKOLAJCZAK: Thank you. Good afternoon and thanks for giving us theopportunity to speak to you today. As mentioned,I'm an emergency physician and I practice currentlyat Silver Cross about 35 hours a week, and I want tolet you know that I'm strongly in favor of theproposed 100-bed hospital on the Silver Crosscampus. EMS providers know firsthand what the crisisis in our community revolving around mental health



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and addiction patients and the difficulty in gettingthese patients placed appropriately in the currenthealth care atmosphere. The promise that we made tobring these patients directly to Silver OaksHospital, knowing they'll be cared for by thededicated staff sensitive to their needs, willchange our community dramatically. Let me just describe a little bit about whatit's like for a mental health patient in communityhospitals today on many occasions. There's a great need for mental healthservices. Patients typically arrive to our door intheir worst hour of need. They've run out ofresources, they burned bridges with family, withfriends, and within their community, and they cometo us in their hour of need. And they have nowhereto go, so they come to the emergency department. Many times they don't have access topsychiatric care or to their medications. They maynot have the funds for the medications or be on thecorrect medications and their diseases are out ofcontrol. These patients, unfortunately, may spendanywhere from 6 to 48 hours in the emergency



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department awaiting placement for appropriatefacilities because, as you're aware, mental healthservices in the state of Illinois have beendecreased over the last decade or so with closuresof our State-supported hospitals. Hopefully, we'llbe able to fill that void with Silver Oaks. So what happens in the emergency department?Unfortunately, the patients may spend a day and ahalf or two days waiting for placement, and,hopefully, Silver Oaks will be able to alleviatethat concern. We do our best to care for those patientswhile they're in the emergency department. Weprovide sitters, social services, and ourtechnicians who are trained to deal with theirissues as well as the emergency physicians andnurses; however, this isn't the ideal situation, asyou can imagine. US HealthVest will accept ambulances,they'll accept patients, as mentioned, with noconsideration for what their insurance status is,and we'll have a continuum of care between theemergency department at Silver Cross and theSilver Oaks Hospital. Our goal is to keep the



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patients in the community and provide them with theappropriate care, and I'm certain that the careprovided at the Silver Oaks Hospital withUS HealthVest will deliver on that promise. So as an emergency physician and a member ofthe community, I urge you to accept and approve thisproposal. Thank you. CHAIRWOMAN OLSON: Thank you, Doctor. MS. COLBY: We'd be happy to answer anyquestions. CHAIRWOMAN OLSON: Sure. Questions? Mr. Sewell. VICE CHAIRMAN SEWELL: Yes. I want to skip over to the 1120 criteria onthe financial viability. There's a finding here that you don't meetthat, and it looks like -- I don't need for you tounpack the distinction between Silver Oaks Hospitaland Silver Oaks Realty, but it looks like there'stwo issues here. One is you don't have historical financialinstruments, and the other is you don't meet the net



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margin ratio. So could you explain to us what thatis -- what that ratio is and what the significanceof not making it is for the financial viability ofyour hospital? MR. CHA: With regard to those two entities,Silver Oaks Behavioral and Silver Oaks BehavioralRealty, both are new entities created for thepurpose of establishing this hospital, and, as such,they don't have historical financial information. And as it relates to the net marginrequirement -- so that would require the entityitself to be profitable, and there was a questionthat was raised -- a legitimate finding in the staffreport -- that Silver Oaks Behavioral Realty doesnot meet that requirement. And the reason for that,the realty company and Silver Oaks Behavioral shouldactually be considered on a combined basis becausethe realty company -- its only function is to managethe real estate, to own and lease the property. So, in fact, the revenue that is generatedby the realty company is a somewhat arbitrary numberbecause that rent is paid by the hospital to therealty company, and it gets eliminated uponconsolidation because the revenue for the realty



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company is canceled out by the rent that's paid bythe hospital. So we could -- since -- it could be the casethat we could increase the rent, which would just bean intercompany rent paid between the two entities,and, thereby, the realty company would meet that netmargin criteria. VICE CHAIRMAN SEWELL: So am I overreachingto say that you don't satisfy this particular ratiobecause you don't have historical financialstatements? Or is it that those two entities needto be treated as combined? And that's what you justsaid, with internal transactions with respect torent. MR. CHA: Yes. It's my understanding thatit's the latter. THE COURT REPORTER: Could you state yourname for me, please. MR. CHA: My name is James Cha. I'm the CFOof US HealthVest. THE COURT REPORTER: Thank you. VICE CHAIRMAN SEWELL: So would -- Mike, doyou agree with that? MR. CONSTANTINO: Yeah. We can't combine



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them because we look at the Applicants andco-Applicants. VICE CHAIRMAN SEWELL: Okay. All right. I'm done. CHAIRWOMAN OLSON: Other questions? (No response.) CHAIRWOMAN OLSON: I just want to clarifysomething. I think -- did I hear you correctly? Didyou say there's 75 AMI beds in this planning areafor 70,000 residents? MS. COLBY: 700,000. There's more than700,000 residents. CHAIRWOMAN OLSON: And only 75 AMI beds? MS. COLBY: That's correct. CHAIRWOMAN OLSON: Okay. And I thinkI read, also, in the application that you'reanticipating 27 percent Medicare and 37 percentMedicaid. MS. COLBY: That is correct. CHAIRWOMAN OLSON: Thank you. I don't have any other questions. Doctor. MEMBER GOYAL: Thank you, Madam Chair.



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My name is Arvind Goyal. I representMedicaid and I have two questions for you. The Medicaid part of your population asprojected, would you be able to save those beds forMedicaid? Because we run into a situation whereentities or patients need to be admitted to an AMIbed and, when somebody contacts them, then they'retold, "Well, we don't have any beds available." Atthe same time they may be able to admit commercialinsured patients and not Medicaid. So what kind of commitment are you able togive under oath at this time? DR. KRESCH: Our policy, as enacted on adaily basis at Chicago Behavioral Hospital, is weadmit every patient that comes to the hospital ifthey meet admission criteria as they come,regardless of ability to pay or whether they have --type of insurance. Whether it's Medicaid, Medicare,managed care, or no insurance, each patient istreated as they come. So we will admit any patients that thathappens. So the -- using the model of ChicagoBehavioral Hospital, the bulk of our patients are



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Medicaid patients. Many of them are managedMedicaid patients but, ultimately, still Medicaidpatients. We treat patients as patients. We treat,really, anyone who comes to the hospital withoutregard to pay. Our experience at Chicago BehavioralHospital is that the hospital is full and wefrequently have to divert patients because there areno available beds that will fit the need of aparticular patient. It could be a male; we onlyhave female beds or something like that. So we do take every patient, and it wouldnot be needed to save beds because we don'tdiscriminate between Medicaid and other payers. MEMBER GOYAL: Thank you very much. And my second question is, if you were toadmit a substance abuse disorder patient, which maybe a part of your specialty hospital, if you will,then would you always ensure a continued outpatientfollow-up? Or is it "We've treated you, not much wecan do, go see somebody else" and "Here's a list"? DR. KRESCH: No patient leaves the hospitalwithout a follow-up appointment within -- preferablywithin a few days at the most.



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They're accompanied by a family member or arepresentative if they're living in an institutionalsetting. And a fail-safe, sort of worst-casescenario, the hospital itself has a day hospitalprogram, an IOP and PHP. And if we have difficultyfinding a good disposition, proper disposition forthe patient, we'll take care of that patientourselves. MEMBER GOYAL: Thank you very much. CHAIRWOMAN OLSON: Joel and then -- eitherone. Go ahead. Ladies first. MEMBER MURPHY: I have a question about730(d)(1), the unnecessary duplication of services. And -- I don't know. Maybe it's just anumbers thing and I'm not getting it. But your testimony seems to say that there'sjust really this need; however, our report saysthere's only a calculated need for 16 beds. Ifthere are currently 75, there's a need for 16,you're proposing a hundred, but you're going todiscontinue 20, so it's basically an 80-bed gain. So where's the difference between the 16 and80? Your numbers make it sound -- I mean, when you



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said 75 for 750,000 people, how did -- is thisanother one of those standards that we don't knowwhere it came from but supposedly we only need 16? MR. CONSTANTINO: No. There's 75 AMI bedsright now. MEMBER MURPHY: Right. MR. CONSTANTINO: They've got 20 AMI beds inoperation at the Silver Cross Hospital. Once thisproject is finished, that will be deleted. They'llbe discontinued -- MEMBER MURPHY: Right. MR. CONSTANTINO: -- those 20 beds. That'swhere those 20 beds come from. MEMBER MURPHY: Right. But then -- MR. CONSTANTINO: And they're proposing -- MEMBER MURPHY: So your standard that's notmet says you only need 16, but you're proposing ahundred. That's -- MR. CONSTANTINO: Okay. If you take -- ifyou look at it like that, there would be the 16 and20 that they're going to discontinue or the 36 -- MEMBER MURPHY: Right. MR. CONSTANTINO: -- beds available.



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MEMBER MURPHY: Right. MR. CONSTANTINO: Okay. So they'reessentially adding the difference between thehundred they're requesting and the 36 that would beavailable. CHAIRWOMAN OLSON: I think what she's sayingis, if there's only 75 AMI beds for 700,000 residents,how can there be not a 700-bed need or something?I guess is what we're trying to get at. Right? MEMBER MURPHY: Right. Why does it mean they did not meet thiscriteria? Because you say there's a calculated needfor 16 beds, and you're proposing a hundred. And I would seem to think that it would bebetter, considering the issues and the population,so -- your justification for a hundred beds -- MS. COLBY: Excuse me. I think -- I'll askMike to talk about the State standards, but, as weall know, this crisis in mental health is growingextremely rapidly, especially as it pertains toopiates and drug abuse and people not finding aplace to go. MEMBER MURPHY: Right. MS. COLBY: So what we did was we reached



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out to all the agencies in the area and the firedepartments and the police and the courts. And wesaid, "What are you seeing? Where -- how manypeople do you believe need an AMI bed?" And that'swhere all these referral letters came, where we wereable to justify -- I think the State has accepted --what was it, Mike? 2400 or something? -- of thereferrals -- MEMBER MURPHY: Right. MS. COLBY: -- which is well beyond the needfor 16 beds. MEMBER MURPHY: Right. MS. COLBY: And then it depends on thelength of stay. We used a very conservative lengthof stay. Chicago Behavioral Health Department --Chicago Behavioral Hospital has shown that, with alonger length of stay, there's less recidivism. Soif we look at that, we can justify the hundred bedsreal easy. Because it's really based on thecommunity needs and the letters that have comeforward. MEMBER MURPHY: I mean -- I agree with you.So it's basically numbers versus reality?



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MS. COLBY: Yes. CHAIRWOMAN OLSON: Joel. MEMBER JOHNSON: You touched on what I wasgoing to ask. What is your anticipated length of stay orwhat -- MS. COLBY: Yes. MEMBER JOHNSON: -- is Chicago Behavioral'slength of stay -- MS. COLBY: Yes. So -- oh, I'm sorry. MEMBER JOHNSON: And then, while you answerthat, I guess the other thing is, what percentage ofthese 100 beds do you anticipate being crisisoriented? Or will that shift based on need? MS. COLBY: I'll let you answer the crisispart. But I can tell you the length of stay atSilver Cross has been 6.4 in our psychiatric unitand Chicago Behavioral is 9.6. DR. KRESCH: So, essentially, all of ourpatients are in crisis when they're admitted. Theadmission criteria for psychiatric hospitalinpatient service is that a patient has to be adanger to themselves, others, or so disorganized



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that they can't take care of themselves. So all of our patients come in in an acutestate of disorganization or a threat, generally, tosomeone. Depression is our most common admittingdiagnosis, and suicidal behavior or ideation is akey indicator for admission. The length of stay at Chicago BehavioralHospital is a little bit more than Silver Cross.Chicago Behavioral sees a very high-acuity patientpopulation. In fact, the patient population thereis so high -- the acuity is so high -- that we havedifferent levels of intensive care units. So as apatient is stabilized, we're able to move them alongto greater independence. But the length of stay will -- typically, ona national basis, length of stay averages abouteight to nine days. MEMBER JOHNSON: So, then, what's theutilization of Silver Cross' 20 beds? What's theaverage census? MS. COLBY: In the State report it was at80 percent occupancy. We have been -- we havemany days here that we're full, all 20 beds arefull. And sometimes we'll be at 15, 16, somewhere



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around there because, as described before, therecould be gender match issues, or somebody who isextremely psychotic can't be placed with somebodywho is a young teenager who may have some othertypes of issues. (An off-the-record discussion was held.) MS. COLBY: Oh, 85 percent this year.I'm sorry. CHAIRWOMAN OLSON: Mr. Sewell. VICE CHAIRMAN SEWELL: Yes. I'm having a little trouble understandingthis finding on page 3 of the State agency reportabout unnecessary duplication of services. These facilities, they are not AMIfacilities? They're just hospitals? MR. CONSTANTINO: They have AMI units. VICE CHAIRMAN SEWELL: Yeah. Within that? MR. CONSTANTINO: Yeah. VICE CHAIRMAN SEWELL: Okay. That's alittle misleading, you know, because it makes itlook -- so the 53 percent occupancy is overall forthose facilities? MR. CONSTANTINO: That's correct, yeah. VICE CHAIRMAN SEWELL: Okay. I'm going to



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disregard that one. (Laughter.) CHAIRWOMAN OLSON: You're entitled, sir. MR. CONSTANTINO: Now, our bed need formulaincludes those beds -- VICE CHAIRMAN SEWELL: I know. That's inthe other one, though. MR. CONSTANTINO: Yeah. That bed needformula includes these beds, yeah. VICE CHAIRMAN SEWELL: Okay. Yeah. CHAIRWOMAN OLSON: Any other questions orcomments? (No response.) CHAIRWOMAN OLSON: I'd ask for a roll callvote, please. MR. ROATE: Thank you, Madam Chair. Motion made by Senator Burzynski; secondedby Mr. Sewell. Senator Burzynski. MEMBER BURZYNSKI: I'm going to vote yesbased on the testimony we've heard today and theneed and the support from the community. MR. ROATE: Thank you. Senator Demuzio.



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MEMBER DEMUZIO: I'm going to go ahead andvote yes based upon the testimony that I've heard. MR. ROATE: Thank you. Mr. Johnson. MEMBER JOHNSON: I'm also going to vote yesbased on the testimony. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I'm voting yes based onthe testimony. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on today'stestimony. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: I'm going to vote nobased on projected utilization and planning areaneed. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I'm going to vote yesbased on the testimony and the fact that there wasno opposition despite the findings.



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MR. ROATE: That's 6 votes in theaffirmative, 1 in the negative. CHAIRWOMAN OLSON: The motion passes. Congratulations. MS. COLBY: Thank you. Thank you very much. MS. SZE: Thank you very much. CHAIRWOMAN OLSON: Good luck. - - -



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CHAIRWOMAN OLSON: Next, I'll call H-04,Project 17-010, Mercy Circle. May I have a motion to approve Project 17-010,Mercy Circle, to remove a CCRC variance. MEMBER DEMUZIO: Motion. MEMBER JOHNSON: Second. CHAIRWOMAN OLSON: And will you please swearin the Applicant. THE COURT REPORTER: Would you raise yourright hands, please. (Three witnesses sworn.) THE COURT REPORTER: Thank you. CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chairwoman. The Applicants are requesting the Board toremove a CCRC variance and a defined populationvariance that was part of Permit No. 11-008, MercyCircle. At that time the Board approved a 23-bedlong-term care facility. The anticipated project completion date isDecember 30th, 2017. There is no cost to thisproject. There was no opposition, no publichearing. And we did have one finding, an



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unnecessary duplication of service on page 3. Thank you, Madam Chairwoman. CHAIRWOMAN OLSON: Thank you, Michael. Comments for the Board, please. MS. LACHOWICZ: Good afternoon. Thank youfor your time today. I know it's late so we'll bevery brief. My name is Frances Lachowicz. I'm theexecutive director at Mercy Circle. To my right isBillie Paige and Ira Rogal. They are our CONconsultants. We're asking that the lifting of therestrictions -- or stipulations be removed. MadamChairwoman and members of the Board, Mercy Circleis a continuing care retirement community inEvergreen Park on the southwest side of Chicago. Our application is before you today becausethe number of men and women religious is decliningand is going to continue to decline. Mercy Circleis the only faith-based continuing care retirementcommunity in our area, and it does not require anentrance fee or a buy-in. Many of the familymembers living in the area are interested in sendingtheir loved ones or themselves into a faith-based



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long-term -- continuing care retirement community. A response to the negative in the report isthat this is only 23 beds. The planning area doeshave 4500 beds. We are just asking that thesestipulations be lifted and that they wouldn't havemuch impact on our other facilities in the area. We appreciate your kind consideration today. CHAIRWOMAN OLSON: Thank you. Questions? Richard. VICE CHAIRMAN SEWELL: Okay. Everybody elsehere understands this except me. I'm not getting the connection between theaction we're supposed to be taking of removing thesevariances and this finding about the excess beds inthe planning area. MR. CONSTANTINO: The variances were put inplace because they were only going to serve thereligious order when this facility was originallybuilt. That was part of the long-term care rules,the variance to calculated need. VICE CHAIRMAN SEWELL: Yeah. MR. CONSTANTINO: They've come to find outthey need -- they don't need that variance. They



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need to make these beds available to the entirecommunity. So that is the reason why we have thefinding, because now they're going to be competingwith the others in the community, other nursinghomes in the community. VICE CHAIRMAN SEWELL: But if we remove thisvariance, what if -- I mean, I don't get the so-whatquestion. I mean -- MR. CONSTANTINO: The variance -- they canonly -- right now, they can only accept nuns fromthis religious order. VICE CHAIRMAN SEWELL: Oh. MR. MORADO: The CCRC variance creates aclosed community, so it kind of feeds within itself.And what they want to do is take that away so theycan open the doors. VICE CHAIRMAN SEWELL: I get that. But whydoes it matter if there's an excess of beds in theplanning area? MR. CONSTANTINO: Because we're adding morebeds to that area. VICE CHAIRMAN SEWELL: Oh, the beds thatthey have?



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MR. CONSTANTINO: Yeah. VICE CHAIRMAN SEWELL: Okay. Thank you. Everybody -- just bear with me. Everybodyelse got that, just not me. CHAIRWOMAN OLSON: Is the light on? Thelight came on. Other questions? (No response.) CHAIRWOMAN OLSON: Seeing none, I'd ask fora roll call vote. MR. ROATE: Thank you, Madam Chair. Motion made by Senator Demuzio; seconded byMr. Johnson. Senator Burzynski. MEMBER BURZYNSKI: I vote yes based on myunderstanding of the explanation. MR. ROATE: Thank you. Senator Demuzio. MEMBER DEMUZIO: Yes, based on whatever --what you said before. (Laughter.) MR. ROATE: Thank you. Mr. Johnson. MEMBER JOHNSON: Yes, based on the



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explanation provided by the testimony. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on reasonspreviously stated. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on today'stestimony. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: I'm going to vote yesand blame it on the Kentucky public school system. (Laughter.) MEMBER DEMUZIO: What? MR. ROATE: Thank you. MR. MORADO: That's the public school systemwe're just so impressed with. One more reason? VICE CHAIRMAN SEWELL: No, the reason isthat I understand it and I think it's appropriate -- MR. MORADO: Thank you. VICE CHAIRMAN SEWELL: -- what they'redoing. MR. ROATE: Madam Chair -- thank you.



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Madam Chair. CHAIRWOMAN OLSON: Yes, based on the reasonsstated by Mr. Sewell, the second one. MR. ROATE: That's 7 votes in theaffirmative. CHAIRWOMAN OLSON: The motion passes. Congratulations. MS. LACHOWICZ: Thank you so much. Weappreciate it. (Applause.) - - -



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CHAIRWOMAN OLSON: Okay. Next, I'll callProject 17-011, Carle-Staley Road medical officebuilding. And I will mention there are noopposition and no findings to this project. May I have a motion to approveProject 17-011 -- MEMBER JOHNSON: So moved. CHAIRWOMAN OLSON: -- Carle-Staley Roadmedical office building. Okay. Great. And this is in Champaign. We have a motion. And a second? MEMBER DEMUZIO: Second. CHAIRWOMAN OLSON: Mr. Constantino. MR. CONSTANTINO: Thank you, Madam Chairwoman. The Applicants are proposing to establish amedical office building in Champaign, Illinois, at acost of about $66.8 million. The project completiondate is August 31st, 2019. No opposition, no public hearing, and nofindings. Thank you. CHAIRWOMAN OLSON: Thank you, Michael. MS. COOPER: Hello. I'm Anne Cooper --



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THE COURT REPORTER: Hold on. CHAIRWOMAN OLSON: Hold on. Before youbegin -- I'm sorry. We're getting way ahead ofourselves. (Three witnesses sworn.) THE COURT REPORTER: Thank you. CHAIRWOMAN OLSON: Anne. MS. COOPER: I'm Anne Cooper fromPolsinelli. I'm counsel to Carle. To my right -- or left -- is Collin Andersonand Nick -- sorry -- Crompton. Given the fact that this project has nofindings, no opposition, we would like to deferproviding any comments on this project, and we'd behappy to answer any questions. CHAIRWOMAN OLSON: Thank you, Anne.I appreciate that. Are there questions or comments regardingthis? (No response.) CHAIRWOMAN OLSON: Okay. I'll take a rollcall vote. MR. ROATE: Thank you, Madam Chair. Motion made by Mr. Johnson; seconded by



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Senator Demuzio. Senator Burzynski. MEMBER BURZYNSKI: Yes. There were no stafffindings and -- negative findings -- and noopposition. MR. ROATE: Thank you. Senator Demuzio. MEMBER DEMUZIO: Yes, based upon the -- on avery good application. MR. ROATE: Thank you. Mr. Johnson. MEMBER JOHNSON: Yes, based on the Stateagency report. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on the Stateagency report. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on the Stateagency report. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: Yes. No findings.



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MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes. No findings. MR. ROATE: That's 7 votes in theaffirmative. CHAIRWOMAN OLSON: Thank you. And thank you for staying all day -- MS. COOPER: Thank you. CHAIRWOMAN OLSON: -- for that five minutes. - - -



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CHAIRWOMAN OLSON: Next, Project 16-058,Dialysis Center of McHenry. May I have a motion to approve 16-058,Dialysis Center of McHenry, to establish a14-station end stage renal dialysis facility inMcHenry. MEMBER DEMUZIO: So moved. CHAIRWOMAN OLSON: May I have a second,please. MEMBER MURPHY: Second. CHAIRWOMAN OLSON: The Applicant will besworn in, please. THE COURT REPORTER: Would you raise yourright hands, please. (Five witnesses sworn.) THE COURT REPORTER: Thank you. CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chairwoman. The Applicants are proposing to establish a14-station in-center hemodialysis facility to belocated in McHenry, Illinois, at a cost ofapproximately $1.2 million and a completion date ofMarch 31st, 2018.



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There was no public hearing. There wereletters of support and opposition received for thisproject, and we did have State Board findings. Thank you, Madam Chairwoman. CHAIRWOMAN OLSON: Thank you. Comments for the Board? Please introduceyourselves, please. DR. SALAKO: Sure. Good afternoon, MadamChair and members of the Board. I am Dr. Babajide Salako. I am the CEO ofDialysis Care Centers. To my right is Dr. FarhanBangash, who is the medical director of our clinic. To my left is Mr. Asim Shazzad, who is mychief operating officer. To his left isMs. Melissa Smith, who is my area manager. And toher left is Ms. Kristin Paoletti, who is my directorof clinical operations and chief nursing officer. Thank you for giving us the opportunity tospeak on this project. I know it's been a very longday. I will say that we appreciate the opportunityto present our case to the CON Board. Despite the findings of the State agencyreport in opposition, we want to categorically saythat we in the McHenry market -- we are interested



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in this. This project is of particular interest tous because of what we believe we are going to bringto the market. Dr. Bangash's practice is heavily focused onhome dialysis, and in the last few years what wehave discovered is that several of our patients,when they have gone into the in-centers, to some ofour competitors -- ARA, Fresenius, DaVita -- severalof those patients have been talked out of hometherapies. Those patients have remained to stay onin-center dialysis. It's well known in the community of ESRDpatients that patients do much better on hometherapies, either peritoneal dialysis or homehemodialysis, and transplant rates are also high inthose patients. Those patients tend to work longerand are less of a burden onto society. One of the reasons why we want to pursuethis project is there's a continuum of carephilosophy that we have that, when our patients dogo into in-center, they will be there for atransient period of time and, when there's a needfor them to go back and do peritoneal or any kind ofhome dialysis, it will be a very seamless



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transition. We also believe that this project isextremely important because it allows this -- sincethis dialysis company is physician owned andphysician managed, there's a strong emphasis onquality. We're not bean counters, whereby we arealways looking at the bottom line with appropriatetreatment and types of policies and procedures thatare not in the interests of the patients. We've been very successful in this model inother clinics outside the state of Illinois, and wewould like to bring that same standard of care andpractice to the Illinois dialysis environment. I would like Dr. Bangash, the medicaldirector, to say a few words. CHAIRWOMAN OLSON: Thank you. DR. BANGASH: Thank you, Dr. Salako. Andthanks for letting us have the opportunity to speak. My name is Farhan Bangash. I'm a board-certified nephrologist in McHenry County for thepast five years. I'm here to support Dialysis Care Center,which is a physician-owned, physician-manageddialysis unit that would provide care to dialysis



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patients in McHenry County. With a physician-owned and physician-runmodel, this dialysis unit would put patients firstand not treat patients like a one-size-fits-allmodel that, unfortunately, is seen in other dialysisunits in the area. I'll give a little background about mypractice. When I started the practice five yearsago, I started from scratch, and at that timeeveryone said, "You must be crazy. There's too manynephrology groups in the area, not enough patients,"just, basically, "Don't do it." I'm from the area, decided to pursue thepractice anyways, and now, five years later, thepractice has done well. We have three physicians,one nurse-practitioner, multiple employees, multipleoffices, and we're looking to grow. What kind of shocked me when I first startedthe practice was the lack of knowledge that ourpatients knew about dialysis. It seemed like everydialysis patient I had met only knew about in-centerhemodialysis, and this included young individualswith families who are working. They had not evenheard that transplant or even home dialysis was an



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option. So they were going to the center for fourto six hours three times a week and had to, youknow, quit their jobs and just stay on in-centerhemodialysis. I trained with one of the renownedphysicians during my fellowship in home dialysis,Dr. Fufoxer [phonetic], and I've just always been afirm believer in home dialysis. So when I saw thatthe patients in McHenry County did not have theright, really, education about home dialysis, that'swhen I really wanted to pursue my own home dialysisprogram. So five years later here, we have now thelargest home dialysis population in McHenry County. Just a little background: The United Statesis the only country that uses in-center hemodialysismore than home dialysis, and we know that it costsa significant amount more to run in-centerhemodialysis units. Unfortunately, you would think, "Okay.Maybe, if the outcomes are better, then we shouldkeep doing that." We actually have worse outcomes.So we're spending more with worse outcomes. So, you know -- the other thing, I guess,that I want to go over, these patients that are home



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dialysis patients, they almost become like family tous. We see them multiple times a month, once amonth when we do our interdisciplinary rounding withthem. It's me, the dialysis nurse, social worker,dietician. We're all sitting around a table. We goover all of these aspects in one sitting. I have most of my patients' cell phonenumbers. They have my cell phone numbers. Ournurses have their cell phone numbers. They'recommunicating at all times with any issues, and theydo great, really, on home dialysis. Now, the issue that I have seen is,unfortunately, the home dialysis patients cannot beon home dialysis forever. This is -- it's usually abridging to transplantation or, for a variety ofmedical reasons, they then eventually need to goonto hemodialysis, and this is where I really sawthe problem and where this project kind of startedfrom. When our patients in the home program weregoing to the in-center hemodialysis units in thearea, even if it was just for a couple weeks and tobuy them some time until they get back at home, theyautomatically went into the algorithm that these



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major companies -- ARA, DaVita, Fresenius -- havewhere it's -- honestly, it's all about the bottomline. So these patients would go in there, they'dget multiple testing done, they'd be told that theycan't go back to home dialysis, they'd be sent forunnecessary procedures, told that they needed afistula and that home dialysis was done for them. On multiple occasions I had to stop thisprocess. Unfortunately, some testing had alreadybeen done. Me, not being a medical director at anyof these dialysis units, I cannot make any changesto how they run their units, and that is what I haveto deal with. So, really, what this dialysis centerproject would do for my home dialysis patients inparticular and future dialysis patients is it wouldtake the one-size-fits-all model away and we wouldtreat each dialysis patient as an individual. We know that men dialyze differently thanwomen. Elderly dialyze differently than youngerindividuals. Patients with higher body mass dialyzedifferently than patients with lower body mass. But in -- unfortunately, with ARA,



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Fresenius, DaVita, it's all the same. It's just analgorithm. You go in, do dialysis, and everyone isthe same. This dialysis unit would serve to changethat. We would treat each patient as an individual.We would keep continuity of care from my homedialysis population who eventually would need to gointo the in-center. They would be dealing with thesame nurses, same physicians, and, really, kind ofkeep the same quality of care that they'd beenreceiving. DR. SALAKO: Before I pass it over to myclinical team to say one or two things, I want totalk about the State agency report. There's anissue there about no backup agreement. Those agreements where they're part ofCentegra-McHenry, it takes a while. It has to gothrough their legal processes, their lawyers, theirinternal systems. But a transfer agreement, usuallya standard practice, you wouldn't get certified --get a CMS certification -- if you don't have one,and we don't anticipate any problems with that. In terms of utilization, from ourperspective, what we've always looked at is, if you



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look at the McHenry community there with over50,000 patients, it continues to grow. At themoment that community has upward of about250 dialysis patients; again, it grows about5 percent. That means that, if you combine a plangroup, 5 percent ESRD relationship which isnationwide, and you look at the decrease inmortality of patients on dialysis, patients thatstay longer on dialysis, you're going to see that,in the next five years, you're going to double thenumber of patients you have on dialysis in McHenryCounty. So utilization, I think, is somethingthat's -- it's -- there's a lot there, but it'swithin -- you don't want an institution in which thelag -- where the legitimate time it takes to buildthe clinic and the need -- there's a significant lagof 18 to 24 months. So you want to keep abreast ofwhat's there. Another thing that's also very important ismost of these patients don't have a choice. If youwant an institution in which, if you're a patient,you can say, "Hey, I want to dialyze Monday,



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Wednesday, Friday, first shift, second shift,third shift" -- or Tuesday, Thursday, Saturday,first shift, second shift, third shift -- you don'twant a situation in which, once you start todialyze, you're forced into a certain shift. What tends to happen with that is, if theperson is working, they will usually lose their jobbecause it's very few employers that will say, "Oh,Mr. Jones, Dr. Salako, you can't come to work -- youcan't come to work at a certain time three days --three times a week." So you need the flexibilitythere. And you also -- going back to what we said,from our point of view, the focus on also using thisas a tool to actually get our patients home and tokeep our patients at home is a big factor in doingthis project. I'll hand over to Ms. Melissa Smith and tosay a few words. MS. SMITH: Okay. Thank you for your time. I'm just going to look at it from a patientcare standpoint. I have trained the majority of thehome program patients in our clinic. I started with -- when Dr. Bangash began his



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practice, about two years into it. We've grown theprogram tremendously, and his comments on howattached the patients become to their care team arehuge in dialysis. If you have any family members or friendsthat are using dialysis currently, you know that itbecomes a huge part of their life. It's somethingthat they don't get to ever stop doing unless theyget a transplant or pass away. So when they are connected to their careteam, it's traumatic for them -- let's say if theycan't be a home patient anymore. And now not onlycan they not be on their home therapy anymore, butthey can't even be involved in your program anymorebecause you don't have the option to send them to anin-center facility that is run under the samestandards and quality care that they provide forthem currently. So this would just give them an opportunityto -- even though we're giving them other traumaticnews, that they can no longer stay on the homeprogram, but it's okay because your care team isgoing to go with you to where we're transitioningyou.



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MS. PAOLETTI: Hello and thank you for yourtime. Basically, everybody covered everything thatI was going to say -- basically, everybody coveredeverything that I was going to say. My main thing is think of the patients whenyou're considering your decision. It's superimportant. Thank you. CHAIRWOMAN OLSON: Thank you. Mr. Sewell, a question? VICE CHAIRMAN SEWELL: Is this applicationbefore us too soon? Shouldn't you have gotten thewritten agreements for inpatient and other hospitalservices before? Because if we approve this, youcould actually get started before you had it. MR. SHAZZAD: I would say -- I would referthis to Mike Constantino to comment on thisquestion. Me and him had this discussion aboutthis. MR. CONSTANTINO: Yeah. They can't operatethis facility without that agreement. VICE CHAIRMAN SEWELL: Okay. MR. SHAZZAD: So we wouldn't.



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VICE CHAIRMAN SEWELL: The other thing --I'm okay with that. The other thing is, is it correct to saythat you're asking us to approve this in spite ofthese findings because you're doing home dialysis? DR. SALAKO: No. What we're asking you tosay, we're -- we are trying to highlight a newenvironment in which dialysis care is beingprovided. Okay? And we're looking at a group of patients.We're saying, "Hey, this is what's commonplace atthe moment. If you" -- Fresenius or DaVita own90 percent of the clinics here in Illinois. Allright? ARA owns three. But they're big deals.They own the terrain. They do not have -- they have less than10 percent of their patients dialyzing at home.Okay? Dr. Bangash has close to 60 patientsdialyzing at home. Different -- you know, differentthing completely. All right? So we're telling you that what we've noticedis that, if you are a home patient now and you say,for instance, had a bout of peritonitis -- okay? --and you needed to have your PD catheter removed --



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and you said, "Okay; fine" -- you need to have hometherapy for -- in-center dialysis for four weeksbefore your PD duct is replaced. Or if you are ahome hemo patient, your caregiver is your wife.Your wife needs to go on vacation -- she's tired --and you want to go into an in-center for two weekswhile your wife goes on vacation. We're telling you that what's happening nowis, when the patient gets to that in-center, thatpatient is going to become a cookie-cutterin-patient, and they're going to tell the patient,"Oh, come in here, become dependent, becomedependent on nursing care, become dependent oncoming in." And we can tell you -- there's a lot ofdata to support it -- that that patient's outlook isa whole lot less. If we have -- Dr. Bangash becomes medicaldirector and comes back with this program, he knowshis patients. His practice is growing. He hasthree physicians; two more are coming in to join himnext year. Those physicians will know that Mr. Jones iscoming in, he's going to get dialysis for fourweeks, he's going to get his PD catheter, he's going



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to go back home. Mr. Jones' wife is going to comeback from vacation, he's going to continue his homehemodialysis. We are going to continue to focus on homeeven with our in-center. It's going to become atool in our toolbox in providing dialysis care forour patients, not just a single line of therapy,which is what you're getting with Fresenius orDaVita or ARA. We're just trying to change the paradigm andhow everybody thinks about dialysis care, about howthey should manage patients. That's all we'reasking. VICE CHAIRMAN SEWELL: Now, does theliterature talk about roughly what proportion ofdialysis patients meet the criteria for homedialysis? In general. Not what DaVita and Freseniushave. But is there any research on that? DR. SALAKO: I can -- in the United States,about 10 percent of our patients are on hometherapies. In Mexico, next door, 75 percent. Okay?In Hong Kong it's over 90 percent. Okay? So the focus is driven by the physician and



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the providers. If I'm at Fresenius or DaVita,I have these big boxes, I build 200 clinics a year,I need to fill those clinics. I'm going to pushthose patients to come to work -- to the in-center.What happens is they lose their freedom; they loseconvenience; most of them stop working. It'sexpensive. They're a bigger burden on the taxsystem. DR. BANGASH: I will also add to thatthere's very relative -- there's only a fewcontraindications to not doing dialysis at home. It is -- it's tougher for the physicians tostart it. It's more work for us. You have toreally keep an eye on them. It's easier to just putthem in the center. You just say, "Okay" -- youknow, put a catheter in, "Go to the center threetimes a week." It's all in the algorithm, "Do this,do that." In home dialysis you have to take more timewith them. You have to know the patients, get toknow them. You have to individualize theprescription for them. But we have people in their 90s, their early90s, that are dialyzing at home.



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CHAIRWOMAN OLSON: Joel. MEMBER JOHNSON: So to the State findingaround projected utilization, I think you just saidthat you have an estimate of 60 home dialysispatients. DR. BANGASH: I think you -- it was a totalof 60 dialysis patients, and then 38 are in our homeprogram. MEMBER JOHNSON: So 38 in your home program. And the projected -- or historical referralsof 53 patients, does that include those homedialysis patients? MR. SHAZZAD: I was going to say the Statedoes not count home dialysis patients into theirnumber. DR. BANGASH: They were just looking at ourStage III, Stage IV kidney disease patients, so theywere not looking at those 38 patients. MEMBER JOHNSON: That's the point I wastrying to get at. So these are not including those38 patients. And so what you're asking us to do is toconsider the fact that in -- for this proposal --that at a point in time in your model of treatment



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the home dialysis patients will need in-center care,and you'd like to allow them the opportunity totransition back to home dialysis care as opposed tobeing stuck in the scenario where they're boundto -- DR. SALAKO: Absolutely, absolutely. MR. SHAZZAD: Correct. CHAIRWOMAN OLSON: Doctor. MEMBER GOYAL: Two questions from me: One,could you give us a price differential from aconsumer or insurance point of view of -- for homeversus hemodialysis? DR. SALAKO: Well, you know, in terms ofreimbursement, Medicare pays essentially the samerate. What happens is hospitalization in patientsat home is a whole lot less. So if you're American patient and you aregetting paid -- the providers are getting paidX amount of money, the burden on Medicare, on theMedicaid, any other State provider is much higherbecause these patients typically are spending about14.4 days a year in hospital as against your homepatients, who are spending somewhere between 3.5 to5.5 days a year in hospitals.



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So the burden really -- because of betteroutcomes and reduced hospitalizations, that's whereit's less expensive on the payer. MEMBER GOYAL: You didn't answer my questionyet. Is there a price differential between homedialysis cost versus hemodialysis? You can answerit for commercial or for any plan or generally. DR. SALAKO: Payer or cost? Payer or cost? In terms of how they pay -- MEMBER GOYAL: Cost. Just a generaldifferential in terms of, "Hey, home costs a dollarand hemodialysis in a center costs a dollar and ahalf." DR. SALAKO: It's cheaper to dialyze athome. MEMBER GOYAL: How much cheaper? DR. SALAKO: I couldn't tell you off the topof my head right now. MEMBER GOYAL: Any fractions any of youhave? DR. SALAKO: I tell you about -- it's about.75 to .8 of an in-center cost. MEMBER GOYAL: Okay. My final question



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is -- you are basically asking the Board to look atyour plan as encouraging and promoting home dialysisover hemodialysis. DR. SALAKO: At hemodialysis in-center, yes. MEMBER GOYAL: I understand that. So how would the Board on your approval --if you are granted that, how would we be able tomonitor that you're really doing this after thisperiod? DR. SALAKO: I think, you know, the easiestway is over the -- the local network here can alwayscommunicate with the Board a year or two years orthree years into this and come back and say, "Hey,look at this particular clinic. How are they doing?What is the percentage of that? What are theyreporting to the ESRD network as a percentage oftheir patients that are home?" And once you can see that variance, I'll behappy to bring back data to say -- a year from now,18 months again, two or three years from now --"This is the percentage of our patients at home,"you know, two or three times the national average.In our clinics outside the state of Illinois, that'swhat we're experiencing thus far, so we're very



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confident that we can repeat that in the state ofIllinois. MEMBER GOYAL: Thank you. CHAIRWOMAN OLSON: Other questions? MEMBER BURZYNSKI: Just a follow-up realquick? CHAIRWOMAN OLSON: Yes. MEMBER BURZYNSKI: Thank you. Just a follow-up for Mike, clarificationfor me. So if we approve this today, they stillcannot move forward until they receive the -- CHAIRWOMAN OLSON: Affiliation agreement. MEMBER BURZYNSKI: Yeah, the affiliation,the -- MR. CONSTANTINO: Yeah. MEMBER BURZYNSKI: Yeah. Okay. CHAIRWOMAN OLSON: Other questions orcomments? (No response.) CHAIRWOMAN OLSON: Seeing none, I'd ask fora roll call vote. MR. ROATE: Thank you, Madam Chair. Motion made by Senator Demuzio; seconded by



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Ms. Murphy. Senator Burzynski. MEMBER BURZYNSKI: I vote aye. I think thisis a good way to go in the future, and I'm pleasedto support it. MR. ROATE: Thank you. Senator Demuzio. MEMBER DEMUZIO: I'm going to vote aye,also, based on Senator Burzynski's comments. MR. ROATE: Thank you. Mr. Johnson. MEMBER JOHNSON: I'm going to vote yes, aswell, based on the testimony here today. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on testimony. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on testimony. MR. ROATE: Thank you. Mr. Sewell. VICE CHAIRMAN SEWELL: I'm going to abstainon this one. We don't have a category of service in the



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rules called "Home Dialysis." But based on thetestimony, it seems like something that is a viableoption for a significant number of patients. AndI don't want to vote against it, but I don't thinkI can vote for it because of some of the otherfindings. So I abstain. MR. ROATE: Thank you, sir. Madam Chair. CHAIRWOMAN OLSON: I'm going to vote yes. I was actually given the assignment of beingin charge of patient advocacy and access on thisBoard, and I think this gives patients anotherchoice. And I applaud what you're doing. I thinkit's important that patients have a choice. MR. ROATE: Thank you, Madam Chair. That's 6 votes in the affirmative, 1 vote topass. CHAIRWOMAN OLSON: The motion passes. Congratulations. DR. SALAKO: Thank you. MR. SHAZZAD: Thank you. - - -



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CHAIRWOMAN OLSON: Okay. We don't have any applications subsequent todeny. We don't have any other business. Are we going to do rules with Jeannie nothere or -- MR. MORADO: We can. CHAIRWOMAN OLSON: Okay. MR. MORADO: So we're going to be seekingapproval to move forward with the filing of changesto the 1130 rules specifically. This is going to be a change to 1130.525,which requires a health care facility that'sdiscontinuing to give notice to local media. Thiswas put forth by a representative, I believe, fromthe Rockford area. And what we're looking to do is make achange in rule that's already been made in statute,so we're seeking a motion to move forward with thefiling at this time. CHAIRWOMAN OLSON: May I have a motion. MEMBER BURZYNSKI: So moved. CHAIRWOMAN OLSON: Second? MEMBER MURPHY: Second.



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CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Motion passes. Handbook, Juan? MR. MORADO: Yes. So the handbook. I presented before you back in Bloomingtonand laid out a bunch of different directives thathad been given to IDPH employees and made a numberof suggestions on whether or not those things shouldbe incorporated into the handbook. In front of you you have a copy of theupdated handbook. What I did with regard to two ofthose directives specifically was take that languageand insert it right into our handbook. So there's nothing new. You have copies ofthe handbook; you have copies of the old directives.Specifically I made changes regarding personal andprofessional conduct and against fraud prevention. So nothing new, nothing controversial here.We're just looking for approval of the updatedhandbook. CHAIRWOMAN OLSON: May I have a motion toapprove the updated handbook.



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MEMBER JOHNSON: So moved. VICE CHAIRMAN SEWELL: So moved. MEMBER JOHNSON: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The motion passes. You have your financial report -- THE COURT REPORTER: Use your mic, please.I can't hear you. MEMBER BURZYNSKI: Oh, my. CHAIRWOMAN OLSON: I made it all the waythis far. You have your financial report to review.If you have any questions, please contact Courtney. The IDPH/HFSRB intergovernmental agreement. Juan. MR. MORADO: I'm seeking a motion to getapproval for the IGA at this time. There weretwo changes made and one edit. The changes made took the language thatalready exists and was approved by this Board lastyear and put it in a different section. That wasmade by the -- at the request of IDPH.



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The second edit -- or second change,rather -- would make the reporting of financialreports go from a monthly basis to a quarterlybasis. Courtney, I believe, had a discussion withBill about that already. As you will notice fromyour financial reporting, they already provide it ona quarterly basis. So we've also been told that, inthe event that we need information from the financefolks, that we can request it. So other than that, there's no other changesto the IGA, and we're seeking a motion for itsapproval at this time. CHAIRWOMAN OLSON: May I have a motion toapprove the intergovernmental agreement. MEMBER DEMUZIO: Motion. CHAIRWOMAN OLSON: Second, please. MEMBER MURPHY: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Motion passes. I'm looking for a motion to recommend thatthe executive meeting transcripts from 2015 and 2016



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remain closed. MR. MORADO: Yes. CHAIRWOMAN OLSON: May I have a motion. MEMBER JOHNSON: So moved. VICE CHAIRMAN SEWELL: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The motion passes. Theexec meeting transcripts will remain closed. MR. MORADO: And very, very quickly, just sothe folks who don't -- aren't aware of why we'redoing this -- the Open Meetings Act requires us to,on an annual basis, review our executiveclosed minutes and then determine whether or not wewant to keep them closed or release them to thepublic. CHAIRWOMAN OLSON: You have been given alist of the 2018 meeting dates with potentiallocations. MS. AVERY: Yes, potential locations. The only major change that diverts from thepast is the April meeting, which was normally heldin Bloomington-Normal. I thought it might be nice



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if we met in Springfield for that April meetingduring the time that the legislature is in session.Just in case we want to do visits or say hello. CHAIRWOMAN OLSON: You don't think they'regoing to be in session in the summer; hm-m? MS. AVERY: Yes, I do. CHAIRWOMAN OLSON: Okay. So you have thosemeeting dates and times. Please put them on yourcalendar. Okay. I'm looking for a motion to correctSt. Anthony's Hospital, Effingham. They want tocorrect their profile for the 2014-2015 AHQ profiles. May I have a motion to approve thatcorrection. That's right, Jesse? That's what we'redoing; right? MR. NUSS: I'm sorry? CHAIRWOMAN OLSON: Is it Jesse or Nelson? MR. ROATE: Yes. CHAIRWOMAN OLSON: May I have a motion toapprove those corrections. MEMBER MURPHY: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER JOHNSON: Second.



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CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: I would entertain amotion to adjourn. MEMBER JOHNSON: So moved. CHAIRWOMAN OLSON: Oh, wait, wait, wait.All right. MS. AVERY: Okay. I'll just go real quick.We're almost done. For the legislative update, I just wanted tolet you all know that House Bill 763 is onconcurrence and, hopefully, it will be signed thisweek or next week. That's our initiative for theBoard. VICE CHAIRMAN SEWELL: Do we get paid? MS. AVERY: No. No pay. MEMBER BURZYNSKI: So moved. CHAIRWOMAN OLSON: May I have a motion toget paid -- may I have a motion to adjourn. MEMBER JOHNSON: So moved. CHAIRWOMAN OLSON: And a second? MEMBER MURPHY: Second. CHAIRWOMAN OLSON: All those in favor



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say aye. (Ayes heard.) CHAIRWOMAN OLSON: We're adjourned. See youin Springfield. (Off the record at 4:53 p.m.)



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CERTIFICATE OF SHORTHAND REPORTER

I, Melanie L. Humphrey-Sonntag, CertifiedShorthand Reporter No. 084-004299, CSR, RDR, CRR,CRC, FAPR, the officer before whom the foregoingproceedings were taken, do certify that theforegoing transcript is a true and correct record ofthe proceedings, that said proceedings were taken byme stenographically and thereafter reduced totypewriting under my supervision, and that I amneither counsel for, related to, nor employed by anyof the parties to this case and have no interest,financial or otherwise, in its outcome.

IN WITNESS WHEREOF, I have hereunto set myhand this 5th day of July, 2017.

My CSR commission expires: May 31, 2019.

_____________________________Melanie L. Humphrey-Sonntag



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133:17, 133:23,150:6, 157:21,174:10, 181:8,181:10, 183:13,183:15, 186:3,217:21, 217:22,218:2, 225:2,225:3, 225:5,234:7, 242:18,294:12accessibility76:22, 189:17accessible111:18, 139:23,156:11accessing79:23accommodate195:19, 235:7accommodating226:22accommodation124:13accompanied250:1accomplish102:19accordance134:13according60:8, 81:20,114:14, 155:22,186:12, 237:2account17:6accountable64:24, 107:1,107:6, 172:3,179:24, 181:15,182:5, 195:15accounting23:6, 41:9accurately48:4, 98:5accused20:24achieve90:2, 172:22

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146:22, 252:3,263:21addition24:8, 25:10,58:19, 82:12,152:17, 204:23,220:1additional11:9, 46:7,48:18, 49:4,50:22, 122:9,218:10, 219:14additionally49:18, 77:24,93:23, 112:23,130:13address45:17, 59:23,65:9, 84:19,109:12, 156:14,177:7, 214:20,233:9addressed17:18, 222:20,222:23addresses110:20, 146:15addressing155:1adds38:10, 214:6adequate34:14, 110:14,133:15, 214:21adequately217:3adhere148:5, 221:15adjoined228:13adjourn301:5, 301:20adjourned7:19, 302:3adjournment5:9adjust84:18

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11:20, 85:11advocacy53:4, 113:15,294:12advocate31:12, 50:8,55:14, 57:24,58:14, 59:8,59:22, 60:22,61:1, 61:3,61:13, 61:19,62:2, 64:14,67:8, 67:13,68:19, 71:1,71:2, 74:21,74:24, 80:4,107:6, 107:14,107:17, 115:13,128:20, 141:24,142:8, 143:15,171:11, 185:19,186:1, 195:4advocate's60:23, 61:6,63:18, 94:15,108:3advocates18:17aecom97:16, 215:15affect59:2, 81:15,195:12, 218:4,218:5affecting11:10, 11:18,233:15affidavit237:11affiliation103:9, 292:13,292:14affirmation165:23affirmative163:6, 165:17,167:16, 225:8,230:13, 259:2,



266:5, 270:5,294:18affirms196:1affluent62:16, 71:11,71:12, 114:3afford22:5, 22:16,58:9, 83:18,114:5, 114:11,126:12, 151:12affordable38:10, 83:16,88:20, 105:9,150:7, 172:4,172:6, 182:6affording63:21affords100:6after23:19, 40:18,92:5, 119:15,121:7, 124:11,130:10, 181:24,228:1, 234:1,291:8afternoon81:10, 83:4,85:2, 90:16,108:21, 108:22,116:3, 130:24,136:3, 141:2,147:18, 161:6,169:16, 232:7,232:8, 238:19,241:16, 261:5,272:8again16:15, 17:24,18:15, 18:23,20:21, 22:21,23:5, 24:3,24:19, 25:14,25:17, 26:15,29:2, 31:11,35:6, 41:8,

41:10, 41:22,46:21, 49:8,49:15, 49:23,52:3, 64:8,84:11, 97:11,101:15, 107:16,110:12, 135:23,147:11, 179:21,190:3, 193:20,200:2, 214:6,227:12, 227:16,237:18, 280:4,291:20against45:5, 289:22,294:4, 296:19age79:13, 79:14,126:20aged79:15agencies78:13, 175:8,236:20, 237:6,240:18, 253:1agency162:13, 162:17,162:21, 191:7,200:23, 233:10,238:1, 256:12,269:13, 269:17,269:21, 272:22,279:14agenda3:10, 10:1,10:2, 45:14,47:21agenda's10:10ages118:11, 150:8,239:8aggressive133:19aggressively93:8agility139:3

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128:22, 130:5,134:10, 142:4,142:18, 145:8,148:21, 150:9,150:15, 150:16,150:18, 151:4,151:5, 152:20,153:24, 154:17,187:23, 188:1,193:11, 203:19,213:2, 215:2,219:8, 222:21,223:17, 224:21,241:13, 247:17,258:5, 273:15,274:2, 280:21,281:13, 281:14,287:9, 293:9,298:8alteration4:3, 164:2alternative95:18, 149:13,172:11alternatively69:11although25:2alton159:11, 159:12always15:6, 131:14,141:6, 189:11,201:3, 205:19,210:7, 214:7,249:19, 274:7,276:7, 279:24,291:11amazed34:6, 36:9amazing21:3ambulance51:3, 133:22ambulances243:19ambulatory62:21, 100:5,

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answers20:21anthony159:10anthony's300:11antibiotics121:8anticipate161:17, 161:19,254:13, 279:22anticipated195:19, 231:22,254:5, 260:21anticipating247:18any14:9, 20:5,27:3, 42:6,43:23, 47:22,48:1, 61:5,88:4, 107:22,120:21, 136:15,137:1, 144:17,161:22, 174:16,201:22, 206:15,206:17, 221:16,222:5, 228:17,238:3, 239:19,244:10, 247:22,248:9, 248:22,257:11, 268:14,268:15, 273:23,277:10, 278:11,278:12, 279:22,282:5, 286:19,289:20, 290:8,290:20, 295:2,295:4, 297:15,303:11anybody222:4anymore17:23, 282:12,282:13, 282:14anyone21:23, 249:5anything8:16, 40:3,

43:21, 208:21,218:2anyway186:4, 212:2,221:21anyways275:14anywhere32:11, 129:23,139:10, 242:24apparently143:10appearing238:23appendicitis128:16appendix148:9applaud225:2, 294:15applause225:12, 230:18,266:10apples-to-apples107:8, 171:10,216:7applicable33:16applicant169:19, 198:19,219:12, 219:16,231:9, 260:8,271:11applicant's224:8applicants39:23, 160:13,168:14, 168:23,226:19, 231:19,238:2, 247:1,260:16, 267:16,271:20application11:16, 17:19,30:11, 30:17,31:11, 38:18,39:20, 46:9,46:24, 66:19,

71:5, 71:6,72:13, 81:18,82:4, 87:16,88:7, 92:9,113:10, 122:10,127:16, 142:21,143:24, 144:14,145:3, 148:17,193:14, 194:10,199:11, 201:22,208:18, 233:17,234:14, 238:10,241:3, 247:17,261:17, 269:9,283:12applications4:8, 4:16,30:7, 30:21,31:1, 31:4,32:1, 39:8,87:21, 87:22,89:22, 120:15,143:22, 154:15,168:2, 169:20,196:16, 224:16,295:2applied56:7, 141:15applies217:17apply30:16, 144:19,224:15applying30:12appointment249:23appointments128:7appreciate28:7, 42:22,43:16, 55:15,112:11, 113:16,154:24, 155:6,209:24, 262:7,266:9, 268:17,272:20appreciated13:1, 228:6,

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244:6, 260:3,267:5, 271:3,283:15, 284:4,292:11, 296:24,298:15, 300:13,300:21approved3:18, 9:6,9:21, 10:10,16:4, 31:19,74:13, 84:9,86:24, 88:2,98:22, 99:3,99:7, 99:18,143:23, 144:6,145:14, 152:9,159:2, 159:5,175:18, 176:3,179:11, 239:3,260:19, 297:22approves62:13, 89:22approving69:1, 72:16,122:10approximately7:13, 28:11,29:8, 32:18,111:15, 112:18,137:10, 169:1,171:13, 227:2,231:22, 271:23april299:23, 300:1ara45:9, 46:15,47:14, 49:3,273:8, 278:1,278:24, 284:14,286:9arbitrary245:21architect97:16architectural74:9area17:11, 19:17,

23:9, 26:12,28:12, 33:23,45:18, 45:20,46:1, 46:2,46:6, 46:8,48:1, 49:20,58:20, 59:3,59:5, 59:7,59:8, 59:9,59:10, 60:14,62:19, 62:22,63:1, 73:17,75:12, 79:4,79:11, 81:15,82:15, 90:21,91:3, 93:3,93:10, 101:12,110:17, 112:2,114:23, 119:24,120:13, 126:7,132:17, 139:4,142:9, 142:21,144:13, 144:16,144:20, 150:4,152:21, 153:24,154:13, 157:19,170:2, 181:12,185:4, 186:22,191:15, 194:7,194:12, 195:8,206:10, 206:13,206:15, 208:3,209:15, 210:6,212:21, 224:23,225:4, 233:19,234:15, 238:15,247:10, 253:1,258:18, 261:21,261:23, 262:3,262:6, 262:16,263:20, 263:22,272:15, 275:6,275:11, 275:13,277:22, 295:16area's144:22areas41:2, 55:19,

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223:18, 224:2,224:6, 224:7,224:22, 229:12,229:19, 229:23,230:3, 230:10,240:15, 253:20,254:14, 257:21,258:2, 258:6,258:9, 258:13,258:18, 258:23,264:15, 264:19,264:24, 265:4,265:8, 266:2,269:8, 269:12,269:16, 269:20,293:9, 293:13,293:16, 293:19,294:1basically14:8, 24:18,31:13, 161:11,205:7, 234:10,250:22, 253:24,275:12, 283:3,283:4, 291:1basis40:11, 111:23,126:6, 136:11,191:23, 192:13,192:20, 245:17,248:15, 255:16,298:3, 298:4,298:8, 299:14bea88:23, 103:6,169:12, 169:14,170:14, 170:23,188:10, 195:24,196:19, 196:22,202:12, 203:3,203:9, 203:11,203:14, 204:5,204:11, 204:13,204:18, 204:21,204:24, 205:6,206:5, 206:18,207:19, 208:1,208:4, 208:22,

210:7, 213:24,214:3, 215:5,215:9, 216:23,217:2, 218:6,218:14, 221:9,221:13, 221:22,226:15, 227:8,227:9, 229:3,230:16bea's213:14, 220:1bean274:6bear207:20, 264:3bears87:4beautiful14:12, 179:1became79:14because14:11, 16:23,20:24, 21:22,23:16, 34:12,34:20, 35:2,35:11, 37:1,40:14, 40:21,42:13, 54:5,58:8, 59:1,61:2, 63:10,67:24, 91:17,93:4, 93:7,115:3, 139:11,145:13, 173:11,174:8, 174:13,182:19, 184:5,185:9, 188:13,195:8, 195:10,196:3, 198:4,198:10, 200:18,202:10, 213:3,213:16, 213:17,216:10, 216:21,217:11, 217:16,217:20, 220:12,227:10, 228:3,234:7, 243:2,

245:17, 245:22,245:24, 246:10,247:1, 248:6,249:8, 249:13,252:12, 253:20,256:1, 256:20,261:17, 262:18,263:4, 263:21,273:2, 274:3,281:8, 282:15,282:22, 283:15,284:5, 289:21,290:1, 294:5become18:11, 30:7,84:15, 104:17,140:12, 238:14,277:1, 282:3,285:10, 285:12,285:13, 286:5becomes17:5, 17:20,126:16, 126:19,128:6, 282:7,285:17becoming119:10bed16:7, 16:10,16:18, 17:4,17:5, 19:21,19:22, 20:2,26:11, 26:14,29:13, 69:23,84:1, 84:7,84:12, 85:18,86:21, 87:6,87:12, 87:24,96:18, 101:14,102:13, 109:9,141:12, 143:16,143:17, 144:11,144:17, 145:2,145:21, 146:2,146:22, 148:14,159:9, 168:8,168:24, 177:19,177:22, 179:1,



179:6, 185:24,189:16, 190:10,192:3, 193:3,193:13, 195:17,195:21, 196:3,200:12, 205:21,206:1, 209:18,217:13, 217:14,218:15, 218:17,218:21, 221:10,221:24, 222:1,224:22, 224:24,235:5, 241:21,248:8, 250:22,252:8, 253:4,257:4, 257:8,260:19bedside139:19been11:18, 12:20,20:24, 23:8,23:22, 24:9,25:18, 25:24,26:13, 26:22,30:23, 32:11,32:20, 34:3,37:2, 37:15,48:4, 48:6,49:6, 54:3,65:5, 86:24,90:1, 90:7,93:5, 96:4,97:20, 99:17,116:4, 118:9,119:21, 120:12,121:18, 127:21,129:13, 138:15,142:4, 147:24,148:2, 150:11,152:12, 165:22,171:3, 175:7,175:8, 175:24,176:20, 179:21,179:23, 180:7,181:23, 183:23,187:15, 189:11,190:15, 197:18,

198:1, 205:9,208:7, 208:10,217:2, 220:9,220:12, 223:3,226:14, 233:22,235:11, 239:14,239:18, 239:19,240:16, 243:3,254:18, 255:22,272:19, 273:9,274:10, 276:7,278:11, 279:10,295:18, 296:9,298:8, 299:18before11:3, 12:2,25:1, 30:2,31:7, 31:9,32:16, 33:14,39:8, 39:13,39:14, 39:20,55:22, 145:11,161:10, 165:18,176:4, 192:22,192:24, 193:1,197:14, 218:23,219:13, 233:3,238:23, 256:1,261:17, 264:20,268:2, 279:12,283:13, 283:15,283:16, 285:3,296:7, 303:5began23:19, 105:11,183:11, 281:24begin12:2, 73:9,116:1, 169:12,170:24, 268:3beginning161:17begun10:24, 140:7,142:2, 155:20behalf30:24, 52:20,111:11, 127:11,

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51:10, 102:11,107:8, 121:14,182:1, 188:1,235:12, 243:12bette125:7, 125:10,125:13, 125:17better26:17, 39:21,39:23, 41:17,42:20, 63:13,93:16, 93:19,108:15, 108:16,109:3, 110:24,122:5, 134:3,138:7, 172:20,180:9, 182:14,207:23, 208:21,211:23, 227:20,252:15, 273:13,276:20, 290:1between27:13, 27:19,32:1, 61:19,85:16, 116:18,116:23, 124:5,131:24, 132:1,132:7, 177:21,179:8, 197:9,211:3, 228:7,236:1, 239:24,243:22, 244:20,246:5, 249:14,250:23, 252:3,262:13, 289:23,290:6beyond194:14, 253:10big27:24, 66:9,91:24, 180:3,190:6, 190:7,192:6, 219:1,281:16, 284:14,287:2bigger212:12, 287:7biggest131:10, 177:11,

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280:17, 287:2building4:10, 4:14,13:22, 17:11,19:4, 19:6,19:18, 20:3,20:16, 20:20,21:13, 21:14,25:22, 26:4,26:9, 26:10,27:12, 29:17,46:17, 48:15,49:9, 65:5,65:10, 91:11,102:18, 111:13,118:18, 153:15,154:14, 155:2,226:8, 226:20,226:21, 226:23,229:2, 238:7,267:3, 267:9,267:17buildings14:2, 15:1,15:17, 18:19,20:9, 21:2,26:9, 26:10built49:23, 97:21,97:23, 150:5,150:10, 176:15,178:23, 179:1,179:6, 187:21,262:20bulk248:24bunch296:8bunnell73:7, 77:11burden83:19, 109:18,273:17, 287:7,289:19, 290:1burned242:14burzynski1:14, 6:19,

6:20, 7:9, 8:11,10:4, 160:8,162:5, 162:7,162:8, 166:4,166:9, 166:10,166:11, 214:9,214:10, 215:6,216:21, 217:1,217:6, 217:19,217:22, 217:24,218:8, 219:3,219:5, 222:16,222:17, 223:8,226:10, 229:9,229:11, 229:12,231:6, 257:17,257:19, 257:20,264:14, 264:15,269:2, 269:3,292:5, 292:8,292:14, 292:17,293:2, 293:3,295:22, 297:11,301:18burzynski's293:9business4:4, 4:17,4:19, 5:3, 7:1,7:24, 9:24,10:20, 34:13,35:3, 36:8,36:10, 41:12,43:1, 70:24,114:7, 153:7,153:13, 157:4,157:10, 157:11,165:2, 295:4businesses153:22, 154:6buy11:5, 18:22,18:23, 19:1,277:23buy-in261:22buyers32:21

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112:22, 113:3,127:21cary's111:16case48:6, 96:20,114:4, 173:1,246:3, 272:21,300:3, 303:12cases21:15, 98:8,133:16, 175:3,184:8, 186:14,186:15, 186:19,205:4, 205:11,205:13casey125:7, 125:9,127:20cash15:12, 33:3,188:6, 238:2casual196:11categorically272:23categories104:3categorized180:13category100:23, 190:2,293:24catheter284:24, 285:24,287:16cause76:7, 223:20caused130:11causes191:10, 211:22causing133:6cautionary92:7ccrc260:4, 260:17,

263:14celebrating102:5cell277:7, 277:8,277:9census49:15, 71:23,142:11, 173:15,173:18, 177:21,193:14, 193:24,194:3, 239:13,255:20centegra72:5, 72:8,80:3, 81:14,81:15, 81:19,82:1, 82:18,83:5, 84:5,84:8, 84:18,85:5, 86:11,92:12, 92:24,93:4, 103:2,105:21, 107:5,107:14, 107:17,114:8, 114:9,142:8, 143:16,155:11, 171:11,176:14, 178:24,185:18, 187:16,188:13, 195:5,195:14, 200:14centegra's58:18, 92:5,94:15, 142:4,155:16, 177:3centegra-mchenry115:13, 279:17centegra-woodsto-ck99:2, 115:12center3:15, 4:15,9:8, 38:12,40:21, 44:4,44:23, 45:10,45:13, 45:16,46:10, 46:11,



47:20, 53:4,53:6, 62:21,65:19, 74:15,74:16, 129:9,129:16, 131:20,138:14, 144:7,144:8, 149:9,154:16, 156:23,159:11, 159:14,159:16, 159:18,159:19, 161:11,161:19, 171:22,178:5, 179:9,186:16, 187:3,189:3, 189:4,238:8, 238:9,271:2, 271:4,274:22, 276:1,278:15, 287:15,287:16, 290:13centerpoint53:22centers46:19, 57:6,58:23, 61:14,62:20, 63:14,65:23, 67:6,67:7, 67:15,67:21, 96:2,96:3, 132:4,138:18, 180:2,186:11, 215:20,272:11central98:11, 131:3ceo83:5, 169:18,232:15, 238:22,272:10certain26:3, 76:19,244:2, 281:5,281:10certainly25:16, 40:7,42:2, 42:8,42:15, 48:17,48:20, 65:4,

71:12, 72:10,174:16, 194:22,205:21, 206:4,221:16, 223:2certificate102:8, 109:8,111:4, 125:20,156:22, 157:16,161:9, 191:22,303:1certification38:20, 38:21,279:21certified45:9, 132:17,274:20, 279:20,303:3certify303:6cetera74:8, 216:17cfo170:6, 204:11,246:19cha232:20, 245:5,246:15, 246:19chain32:18chair6:6, 6:21, 8:5,28:3, 104:9,111:8, 135:6,151:20, 159:4,159:21, 162:4,163:3, 166:7,167:13, 201:18,224:20, 225:7,229:8, 230:9,247:24, 257:16,258:21, 264:11,265:24, 266:1,268:23, 270:2,272:9, 292:23,294:9, 294:17chairman1:13, 6:8,8:10, 9:16,

12:3, 12:6,12:7, 12:17,40:5, 42:23,54:17, 55:13,150:20, 152:23,155:8, 162:24,166:2, 167:10,169:14, 169:15,197:3, 199:1,200:9, 200:11,200:22, 224:13,224:18, 230:7,231:7, 232:7,244:15, 246:8,246:22, 247:3,256:10, 256:17,256:19, 256:24,257:6, 257:10,258:17, 262:11,262:22, 263:7,263:13, 263:18,263:23, 264:2,265:12, 265:19,265:22, 269:24,283:12, 283:23,284:1, 286:14,293:22, 297:2,299:5, 301:16chairperson191:5challenge38:9, 137:3challenged56:23, 62:15,71:22, 100:20,198:2challenges34:20, 58:19,103:6challenging128:6, 234:22chamber156:20, 157:1,157:2, 157:14chamber's156:21champaign267:11, 267:17

chances119:20change13:6, 15:14,24:23, 69:9,70:12, 70:13,112:21, 154:12,159:7, 159:15,159:16, 212:16,213:1, 218:7,224:14, 239:4,242:7, 279:4,286:10, 295:12,295:18, 298:1,299:22changed121:7changes40:14, 42:2,83:15, 197:19,278:12, 295:10,296:18, 297:20,297:21, 298:11changing56:11, 224:22characteristics85:9charge67:9, 91:12,91:18, 91:19,294:12charged109:11charges22:24, 29:18charity63:3, 72:5,114:6, 115:7,177:8, 177:12,188:20, 188:22,188:23, 189:20,189:24, 203:16,225:3charles12:10, 151:21chart23:14, 183:3,184:16, 186:5,



186:6charts24:7cheaper290:15, 290:17cheer226:3chemotherapy228:5cheryl52:17, 59:20chicago28:12, 32:19,38:5, 114:7,132:4, 146:20,188:18, 203:5,203:15, 233:12,235:16, 235:20,235:23, 236:5,237:12, 238:18,239:3, 239:10,248:15, 248:23,249:6, 253:16,253:17, 254:8,254:19, 255:7,255:9, 261:16chicagoland184:5chief81:13, 88:15,104:11, 161:7,170:8, 232:9,232:20, 236:3,272:14, 272:17chiefs236:21children53:7, 77:22,121:3, 189:3,189:7children's53:4, 99:6choice60:15, 106:8,155:16, 280:22,294:14, 294:16choices106:2, 126:3

choose132:1, 132:7,206:23chose180:15, 180:20chosen180:7christ80:4chronic61:14, 62:23,65:14, 65:18,76:20chuck155:7circle4:12, 190:7,260:2, 260:4,260:19, 261:9,261:14, 261:19circuit96:17circumstances148:20cited97:22, 144:3cities133:7, 153:8,177:16citizen146:11citizens13:8, 50:15,77:6, 100:20,133:23, 152:7,240:11city72:6, 133:24,154:9, 174:6,174:7, 175:6,216:11, 227:14,240:24claim59:23, 63:6,63:15, 72:3claims60:17clare159:12, 161:9

clarification228:23, 292:9clarify45:2, 73:22,247:7clark-lindsay8:22clark-lindsey8:6, 8:9, 8:19class114:5, 180:13,180:14classification112:17classified112:16clear7:16, 20:23,141:21, 155:17clearly44:1, 77:4,82:2, 108:15,141:12, 144:3,172:3, 191:19,241:7clients126:7, 126:20,127:4, 131:12climate157:4clinic65:13, 65:17,65:22, 78:10,91:15, 98:14,102:14, 109:9,116:8, 118:9,118:20, 119:23,120:14, 120:17,121:13, 121:17,122:4, 122:7,122:10, 125:22,127:2, 127:8,129:4, 130:21,157:17, 169:20,172:15, 178:12,178:17, 182:11,183:18, 272:12,280:18, 281:23,

291:14clinical20:15, 41:16,73:23, 87:10,87:13, 88:4,100:22, 116:20,117:17, 140:14,161:14, 161:16,171:20, 172:1,196:6, 226:22,272:17, 279:13clinically72:20clinician117:18, 117:22,118:8clinicians116:19, 116:23clinics67:15, 88:24,274:11, 284:13,287:2, 287:3,291:23close32:22, 79:12,79:14, 97:13,111:21, 112:1,121:10, 125:16,138:4, 142:15,150:24, 173:6,176:5, 284:18close-by57:5closed7:3, 53:14,263:15, 299:1,299:10, 299:15,299:16closely64:20, 206:9closer26:15, 40:10,47:10, 57:1,57:20, 63:8,79:17, 118:23,126:24, 127:2,155:4, 234:18,234:20



closest70:11closing40:16, 140:10,149:16, 196:14closures38:3, 243:4clot-busting184:20cmo100:1cms208:6, 279:21co-applicants236:8, 247:2co-pays58:9code161:12, 237:3codes237:4coffee15:13cohesive18:12cohort240:15colby232:7, 232:9,244:10, 247:12,247:15, 247:20,252:17, 252:24,253:10, 253:13,254:1, 254:7,254:10, 254:15,255:21, 256:7,259:5colette64:7, 64:9,66:14collaboration139:6collaborative233:24collateral34:1, 34:7colleague121:9, 121:11

collect237:6collecting176:21collective155:24, 197:8collin268:10colonoscopy76:9combination32:8, 100:5combine246:24, 280:6combined87:21, 245:17,246:12come8:2, 12:18,39:8, 39:20,56:20, 92:11,134:18, 168:4,177:18, 185:7,185:12, 189:21,194:11, 202:21,206:7, 219:13,221:3, 221:7,221:17, 222:2,237:14, 237:16,242:15, 242:17,248:17, 248:21,251:13, 253:21,255:2, 262:23,281:9, 281:10,285:12, 286:1,287:4, 291:13comes61:4, 91:4,103:19, 171:15,179:19, 205:15,210:1, 213:17,214:4, 248:16,249:5, 285:18comfort61:9comfortable40:23, 223:11coming15:19, 23:13,

52:9, 52:11,218:11, 285:14,285:20, 285:23comment40:6, 88:16,205:16, 211:19,215:15, 283:18commentary147:23comments43:18, 43:24,44:4, 44:10,44:22, 80:6,81:5, 103:12,123:16, 123:20,160:24, 166:24,169:10, 188:9,201:16, 203:24,207:13, 213:15,222:10, 224:9,227:9, 232:6,257:12, 261:4,268:14, 268:18,272:6, 282:2,292:19, 293:9commerce36:8, 152:4,156:20, 157:2,157:14, 157:19,180:12, 180:15,180:20commercial105:4, 248:10,290:8commission303:18commitment76:13, 77:15,110:3, 144:18,237:8, 238:12,248:12commitments236:11committed142:14, 239:5,239:20committee16:1, 18:1,

20:4, 39:17,99:7, 150:21,151:5, 154:24,155:9committee's12:20common31:6, 35:6,38:12, 69:5,69:12, 255:4commonly85:9commonplace284:11communicate116:20, 117:11,291:12communicating277:10communities37:8, 59:6,59:7, 76:2,76:14, 77:17,78:2, 79:5,113:3, 123:10,180:2, 183:6,193:19community29:22, 32:24,34:16, 36:20,36:22, 36:23,37:3, 40:20,50:13, 53:22,62:15, 62:16,66:17, 68:14,71:10, 71:11,75:21, 76:4,76:5, 76:17,76:18, 77:1,78:6, 78:24,80:14, 82:22,83:14, 84:16,84:20, 92:1,109:13, 109:24,110:17, 110:22,113:15, 114:14,114:20, 114:22,118:11, 119:21,



119:23, 120:3,120:18, 122:14,123:3, 123:7,123:13, 124:2,129:14, 131:11,133:10, 133:14,137:20, 137:21,139:21, 145:22,146:8, 146:16,146:24, 155:8,157:5, 157:13,175:8, 177:17,183:10, 193:5,194:13, 197:9,201:12, 202:11,224:9, 234:1,234:3, 234:13,234:24, 238:11,238:15, 240:18,240:20, 240:23,241:24, 242:7,242:9, 242:15,244:1, 244:6,253:21, 257:22,261:15, 261:21,262:1, 263:2,263:5, 263:6,263:15, 273:12,280:1, 280:3community's36:24, 84:10companies192:21, 278:1company85:11, 105:7,180:17, 245:16,245:18, 245:21,245:23, 246:1,246:6, 274:4compare18:4, 98:1,156:1compared21:13, 35:18comparison27:17, 75:16,107:8, 171:11,216:7

comparisons98:20compassionate138:1compdata72:4competence139:7competing93:8, 263:4competition93:2, 93:9,106:5, 141:14,145:1, 145:17,155:18, 183:1competitive98:16, 104:23competitors107:19, 108:12,133:5, 134:15,145:15, 172:23,273:8complements192:3complete161:11, 161:16,165:13, 165:16completed120:24, 154:1completely284:20completeness166:12completes154:4completion169:2, 227:2,231:23, 260:21,267:18, 271:23compliance3:6, 7:24,96:10, 96:12,96:20, 148:19complicated25:21, 207:4component24:21, 25:4,25:11, 25:20,

26:20, 26:22,176:16components24:18, 98:4comprehensive77:18, 94:18,95:7, 101:11,112:16, 133:13,144:21, 178:2,178:3, 181:13,186:10, 186:14,189:5, 207:9,216:14, 216:17compromised82:3, 185:10computed195:9computer117:11, 117:21con16:4, 46:24,67:8, 74:17,89:22, 146:15,152:5, 169:23,173:16, 175:15,261:10, 272:21conceded141:23concept100:18, 219:21,228:10concern59:24, 219:9,243:11concerned50:21, 71:20,145:20concerning223:10concerns36:2, 55:16,109:13, 128:10,223:1conclude57:13, 66:8,68:12, 72:24,75:4, 80:21,95:6, 99:20,

101:21, 104:1,106:4, 106:7,115:11, 120:4,122:15, 124:21,135:1, 138:5,140:18, 147:5,149:14, 149:17,156:12concludes158:3conclusion61:17, 92:13,103:18concrete184:10concurrence301:13condition117:6, 119:6,219:11, 219:16,221:15, 233:21conditional4:6, 167:19conditions20:9, 20:15,76:20, 121:15,134:19, 136:22conduct161:14, 296:19conducted78:22conference38:5conferred112:17confidence181:5confident239:16, 292:1confidently236:7confirmed88:21, 109:14,237:8confused134:16confusion51:8, 133:2,



133:5, 133:6,133:11, 134:11congested124:4congestive65:15, 117:14congratulate214:11congratulations225:11, 230:15,259:4, 266:7,294:21congress33:20, 35:10,180:21congressman's33:21connect178:22connected282:10connection169:19, 262:13connections40:13consciously195:18conservative253:14consider72:19, 98:20,100:8, 135:3,143:14, 148:16,149:7, 195:21,288:23considerable62:5consideration79:13, 143:1,154:19, 201:8,243:21, 262:7considered245:17considering24:10, 98:1,124:1, 252:15,283:7consistency25:9

consistent145:12, 146:14consistently56:6consists16:11consolidate178:10, 191:10consolidation245:24constantino2:8, 43:19,81:6, 135:6,160:11, 160:12,160:22, 168:19,168:21, 198:23,220:16, 221:1,226:16, 226:18,227:7, 228:16,231:17, 231:18,246:24, 251:4,251:7, 251:12,251:15, 251:20,251:24, 252:2,256:16, 256:18,256:23, 257:4,257:8, 260:13,260:15, 262:17,262:23, 263:10,263:21, 264:1,267:14, 267:15,271:17, 271:19,283:18, 283:21,292:16construct154:16, 226:19constructed81:23, 86:24constructing142:6construction33:15, 73:24,89:24, 98:6,153:3, 153:23,154:1, 179:5,179:12, 196:8,209:24, 241:8consultant169:23

consultants261:11consulting85:12consumer93:16, 289:11consumers17:8, 93:20,106:2, 145:18contact42:21, 128:9,297:15contacted215:16, 215:17contacts248:8contend130:12context71:4, 113:19,193:6contiguous172:18contingencies74:11contingent4:6, 167:19continue17:15, 21:22,41:7, 41:12,42:9, 84:16,84:18, 135:16,141:15, 154:10,157:11, 206:9,241:2, 261:19,286:2, 286:4continued78:4, 154:8,249:19continues211:6, 280:2continuing261:15, 261:20,262:1continuity60:18, 76:20,120:19, 239:24,279:6

continuous182:3continuum28:13, 60:1,60:20, 61:4,61:12, 61:13,61:18, 63:17,77:20, 182:8,235:8, 243:22,273:19contracting107:2contractors153:22contracts63:20contraindications287:11contrary49:11contrast67:18contributes110:15, 171:24,172:1contributor157:1control242:22controlled24:14, 54:6controls105:21controversial296:20convalescence181:13convenience34:24, 100:7,111:22, 122:8,287:6convenient113:2conversation34:18, 42:10,235:21conversations42:16



convert88:4converted16:21convey153:1conveys144:4convoluted25:21cook88:11, 88:14,88:15, 170:6,204:4, 204:7,204:11cookie-cutter285:10cooper267:24, 268:8,270:8cooperation206:15coordinated63:19, 100:18,120:16, 181:16,194:24, 195:4coordinating227:13coordination105:18, 127:3,181:18, 227:21coordinations116:18copies296:16, 296:17copy296:12corporate111:16, 152:17,180:3, 180:4corporation152:1, 152:9corps54:17correct149:8, 210:11,217:16, 219:6,242:21, 247:15,

247:20, 256:23,284:3, 289:7,300:10, 300:12,303:7corrected217:5correction142:2, 300:14corrections5:8, 300:21correctly220:19, 247:9corridors123:24cost23:18, 24:2,24:4, 24:11,24:21, 25:18,26:10, 26:14,27:16, 29:16,31:17, 35:15,36:14, 37:24,56:18, 63:14,66:20, 67:19,68:14, 73:23,82:20, 85:15,86:4, 87:7,87:9, 87:12,88:20, 89:2,90:10, 93:22,98:5, 98:6,99:4, 99:13,104:18, 107:4,107:24, 108:5,110:24, 124:11,142:1, 144:2,144:4, 148:4,148:8, 148:9,156:10, 160:18,169:1, 171:24,172:20, 179:5,179:10, 179:13,179:19, 179:20,192:20, 196:9,209:24, 214:7,220:13, 220:15,220:17, 227:1,231:21, 260:22,

267:18, 271:22,290:7, 290:9,290:10, 290:11,290:23cost-cutting90:6cost-effective104:22cost-effectivene-ss179:20cost-reimbursed25:11costing63:24, 108:13costly67:14costs24:13, 25:14,27:18, 27:19,29:8, 30:4,31:24, 33:10,34:10, 36:15,46:12, 46:14,54:9, 66:17,67:4, 73:24,74:12, 74:18,89:24, 90:8,98:19, 110:16,116:15, 120:20,122:1, 171:13,179:4, 179:12,180:9, 207:23,224:3, 276:16,290:12, 290:13could25:5, 25:6,29:21, 37:10,38:2, 44:9,52:5, 53:6,55:23, 63:13,65:22, 69:1,115:3, 121:18,140:10, 183:3,183:4, 189:23,191:23, 196:2,201:3, 201:9,201:23, 205:24,

209:2, 211:8,211:21, 213:24,218:13, 218:18,219:10, 220:20,221:3, 245:1,246:3, 246:4,246:17, 249:10,256:2, 283:16,289:10couldn't166:16, 198:23,236:15, 290:18council12:15counsel2:6, 3:8, 8:7,8:9, 68:19,86:11, 141:4,143:9, 161:9,166:24, 170:7,232:13, 232:18,268:9, 303:11counsel's167:3counselors78:2count133:22, 288:14counter56:17counters274:6counties75:16, 83:9,105:12, 149:24,150:19, 175:12counting17:2country35:8, 58:4,60:7, 73:19,85:22, 97:22,103:1, 116:11,133:8, 219:21,233:19, 276:15country's29:5, 151:11county14:24, 45:20,



45:21, 45:22,53:1, 53:12,53:20, 54:21,69:22, 71:11,75:14, 75:15,75:17, 75:21,76:8, 76:17,77:3, 78:6,78:13, 84:2,90:20, 91:9,93:3, 93:9,105:14, 105:22,107:20, 107:23,108:11, 108:23,109:6, 109:15,109:16, 113:1,113:5, 114:2,114:15, 120:23,122:24, 123:1,123:5, 123:15,123:16, 123:18,126:2, 126:4,131:6, 131:13,131:19, 131:20,131:23, 132:6,132:10, 132:11,132:17, 134:12,142:9, 146:23,150:1, 150:16,150:17, 151:3,151:24, 152:3,152:8, 152:23,153:15, 154:14,155:7, 155:11,155:12, 155:20,155:23, 156:2,156:3, 156:4,156:5, 165:10,175:11, 175:14,186:22, 190:4,195:9, 195:11,202:24, 209:14,209:19, 209:21,233:23, 234:10,274:20, 275:1,276:9, 276:13,280:13county's78:12, 114:17

couple18:24, 214:22,217:6, 277:22course118:19, 121:24,142:2, 206:22,219:15court11:24, 43:16,43:20, 44:1,44:12, 52:6,53:17, 53:18,54:6, 96:17,97:7, 97:10,135:24, 155:4,161:2, 161:5,166:16, 166:20,168:15, 168:18,170:18, 170:21,204:9, 204:12,231:11, 231:15,234:9, 246:17,246:21, 260:9,260:12, 268:1,268:6, 271:13,271:16, 297:9courtney2:7, 297:15,298:5courts53:16, 86:19,253:2cover14:10, 112:18coverage30:13, 30:14,30:22, 131:24,132:2, 132:3,132:8covered283:3, 283:4covers149:24crackoo141:7crain's58:14, 58:17,92:5, 114:7,

141:24, 142:5,185:23cranley97:4, 104:9,104:10, 106:5,106:8, 106:11crash179:4crazy275:10crc303:5create51:8, 73:2,82:10, 93:10,94:6, 157:3,157:7, 157:18,201:5created34:11, 53:14,235:22, 245:7creates263:14creating49:9, 153:2creation81:24, 208:17creque135:20, 141:2,141:3, 141:9,143:3cried234:9crisis38:4, 54:20,54:21, 233:14,234:24, 237:16,241:23, 252:19,254:13, 254:15,254:21criteria56:14, 62:11,86:6, 95:24,96:9, 96:10,148:20, 209:3,210:11, 220:14,244:16, 246:7,248:17, 252:12,

254:22, 286:16criterion148:6, 148:8critical53:5, 54:3,63:11, 110:9,122:4, 132:21,134:23, 157:21,198:5, 217:20,217:22, 218:1critical-access70:5, 70:8,138:17critically134:17crompton268:11cross3:17, 52:20,53:3, 55:6,55:7, 232:10,232:14, 233:1,233:5, 233:22,235:5, 235:8,237:22, 238:6,239:23, 240:1,241:12, 241:13,241:19, 241:21,243:23, 251:8,254:18, 255:8,255:19cross-trained139:2crr1:24, 303:4csr1:24, 303:4,303:18culture182:2, 236:1cumpata151:20, 151:22,151:23current49:4, 79:18,99:13, 120:22,123:22, 191:23,192:11, 195:13,



218:16, 242:2currently15:15, 23:3,33:6, 36:5,48:5, 77:17,110:4, 112:20,119:3, 127:5,134:12, 155:12,241:18, 250:20,282:6, 282:18cuts36:1cvs93:15, 113:21cycle176:20

Dd)(1250:14d-e-n143:10d-i-r-k149:21d-o-r-s-e-y99:24dad124:14, 124:22daily29:9, 126:6,136:10, 173:18,177:21, 193:14,193:23, 248:15dan88:10, 95:11danger94:9, 212:10,254:24dante's54:18dart2:2data24:22, 33:13,79:9, 106:20,107:11, 108:16,116:20, 117:17,117:20, 193:20,

285:15, 291:19database27:17date169:2, 227:2,231:23, 260:21,267:19, 271:23dated49:12dates5:7, 299:19,300:8daughter130:5dave135:22, 145:8,241:10david47:13, 81:4,81:11, 232:22davita273:8, 278:1,279:1, 284:12,286:9, 286:18,287:1day27:20, 29:8,31:18, 70:1,77:21, 77:23,100:15, 121:18,134:18, 142:11,210:21, 211:12,233:9, 243:8,250:4, 270:7,272:20, 303:16day-to-day40:11days33:6, 50:20,92:3, 104:17,121:22, 155:24,156:2, 192:16,199:15, 210:20,211:4, 211:10,243:9, 249:24,255:17, 255:23,281:10, 289:22,289:24

dc33:19deal15:10, 16:5,192:6, 197:7,214:18, 216:13,243:15, 278:14dealing12:21, 22:3,279:8deals284:14dealt15:4dean183:17deanna1:15death76:8debate91:1debt33:11, 58:8decade243:4decades34:3, 102:20,172:14, 179:24,181:20, 191:21,193:2, 205:9december49:13, 231:23,260:22decided140:8, 220:8,275:13decides26:2decision92:8, 200:6,283:7decisions14:13, 18:7,21:7, 51:9,89:17declaratory4:4, 164:3

decline261:19declines58:6declining58:4, 58:5,59:3, 59:13,261:18decrease37:19, 280:8decreased106:2, 243:4decreases24:8, 27:11decreasing37:12, 73:21,116:15, 121:24dedicate240:8dedicated115:7, 136:13,240:2, 242:6dedication236:2deductibles58:9deem165:13, 165:15deemphasizing141:18deeply65:7, 142:13defense100:9, 185:17defer268:13deficit58:17defined18:14, 260:17definitely119:19, 171:4definition79:14, 209:11,213:6, 213:8del36:20delavan179:8



delay33:8, 63:12,119:19delayed58:11, 130:13delays38:24, 100:17,183:24, 184:3,184:5, 238:4deleted251:9deliberate143:14deliver90:10, 108:11,142:15, 144:12,182:22, 182:23,207:22, 240:22,244:4delivered101:3, 136:22,182:22, 185:16delivering100:10, 108:17,112:12, 141:19delivery94:4, 94:13,94:18, 95:8,95:15, 95:18,100:4, 107:9,116:10, 180:8demand16:24, 17:7,19:7, 201:5demands106:9demographically56:23demographics71:9demonstrate106:20, 236:23demonstrated45:24, 110:3demuzio1:15, 6:17,6:18, 8:23,9:14, 10:3,

10:13, 162:9,162:10, 166:14,166:15, 166:18,168:11, 222:15,223:6, 223:7,229:15, 257:24,258:1, 260:5,264:12, 264:18,264:19, 265:15,267:13, 269:1,269:7, 269:8,271:7, 292:24,293:7, 293:8,298:16den135:21, 143:7,143:8, 143:13,145:5, 170:6denied31:21, 86:6,88:7denies122:10denominator38:12densely112:24density123:9deny4:16, 57:15,58:1, 59:15,68:15, 84:22,295:3department1:1, 50:22,57:1, 60:4,63:7, 67:14,74:2, 79:2,79:12, 79:16,79:19, 80:6,80:13, 80:14,80:18, 80:24,82:13, 82:16,95:22, 100:5,101:23, 109:11,110:11, 110:19,112:9, 112:15,

123:11, 129:24,133:4, 133:14,133:23, 136:13,137:4, 139:24,140:19, 161:13,169:17, 175:9,180:12, 180:15,180:20, 233:23,239:23, 242:17,243:1, 243:7,243:13, 243:23,253:16departments50:18, 123:22,132:5, 133:8,136:6, 136:15,136:24, 146:12,233:15, 253:2depend53:18dependent285:12, 285:13depending25:22, 26:1,26:11, 120:24,238:16depends25:6, 25:7,222:3, 253:13depleted30:19deployment104:24depreciation179:15depression255:4deprived137:8des160:4, 160:16,233:13describe51:18, 242:8described256:1describes85:13, 95:14

deserve50:16, 51:19,108:14, 136:12,137:17, 137:19,225:4design73:19, 76:4,85:13, 97:17,161:12, 240:13designated60:10, 66:21designed75:20, 76:24,86:19, 90:12,94:21, 98:14,172:5, 190:16desire34:16, 46:20,126:23, 238:13desired112:8despite133:19, 258:24,272:22destabilizing94:13detail42:5detailed22:8, 62:7details233:17detection76:10determination31:1, 31:5,31:10, 31:15,165:9determine25:23, 30:18,299:15determined31:8, 180:11detox77:21devastating235:1develop22:7, 132:22



developed114:15, 150:21,196:16developers97:23development4:18, 70:24,85:4, 94:22,112:6, 151:5,152:1, 152:9,157:12deviates68:21, 69:2devoted105:24diabetes65:15diagnosis100:17, 255:5diagnostic74:3, 76:8,127:8, 194:21,216:16dialysis3:15, 4:15,17:10, 44:4,44:23, 45:10,45:11, 45:13,45:15, 46:7,46:9, 46:11,47:14, 47:16,47:18, 47:22,48:16, 48:19,49:7, 49:10,159:17, 159:19,271:2, 271:4,271:5, 272:11,273:5, 273:11,273:14, 273:24,274:4, 274:13,274:22, 274:24,275:3, 275:5,275:20, 275:21,275:24, 276:6,276:8, 276:10,276:11, 276:13,276:16, 277:1,277:4, 277:11,

277:13, 277:14,278:6, 278:8,278:12, 278:15,278:16, 278:17,278:19, 279:2,279:4, 279:7,280:4, 280:9,280:10, 280:12,282:4, 282:6,284:5, 284:8,285:2, 285:23,286:6, 286:11,286:16, 286:17,287:11, 287:19,288:4, 288:7,288:12, 288:14,289:1, 289:3,290:7, 291:2,294:1dialyze47:3, 278:20,278:21, 278:22,280:24, 281:5,290:15dialyzing284:17, 284:19,287:24diaper15:14dichotomy14:4dictate78:5, 93:21dictionary213:11die137:11, 184:22dietary25:13, 41:19,74:7dietician277:5difference27:18, 146:10,176:11, 177:21,179:11, 187:19,190:11, 250:23,252:3

differences98:2, 98:7different15:11, 24:18,27:10, 38:22,39:10, 72:15,93:6, 93:17,114:2, 174:23,192:9, 199:2,205:2, 214:12,215:8, 227:13,227:17, 228:8,255:12, 284:19,296:8, 297:23differential289:10, 290:6,290:12differentiation13:7differently171:16, 278:20,278:21, 278:23difficult118:14, 119:10,126:19, 128:24,143:11, 146:9difficulties121:4difficulty79:23, 80:5,80:12, 131:14,140:12, 242:1,250:5dilemma199:21dilts44:7, 44:17,47:7, 47:12dilute50:22diluting48:21dire233:17direct25:16, 36:3,39:4, 67:11,67:18, 80:23,

113:2, 132:23direction56:10, 132:24,134:13directives296:8, 296:14,296:17directly11:23, 28:22,92:11, 110:20,152:17, 237:15,242:4director90:18, 92:23,106:18, 125:19,131:2, 132:15,136:5, 138:13,170:4, 171:7,175:9, 232:23,237:12, 241:11,261:9, 272:12,272:16, 274:15,278:11, 285:18directors152:9, 157:15,241:14dirk147:10, 147:11,149:21disabilities125:24disability184:23disadvantaged109:19disagree29:23disappointed151:7discharge119:15, 240:19discharged101:10, 172:11,240:17discharging21:17, 21:19discipline89:16



disciplined217:3disclosure240:22discontinue159:11, 159:13,250:22, 251:22discontinued251:10discontinuing295:14discounted93:24discovered172:15, 273:6discretion96:14, 96:15,96:19, 96:21,196:13discriminate249:14discussed18:1discussion135:7, 191:8,227:10, 256:6,283:19, 298:5discussions20:21, 191:20disease49:7, 61:14,62:24, 65:18,288:17diseases242:21disheartened147:23disobeying54:5disorder249:17disorganization255:3disorganized254:24disposition250:6disregard257:1

disregarding56:16distance119:1, 126:18,130:13distinction244:20district165:11, 241:6diverse18:9, 240:7divert249:8diverting82:6diverts299:22divided194:16division180:4divisional47:8divisions37:17dmg159:14, 159:16docs101:3doctor47:5, 48:11,50:1, 51:22,102:1, 118:2,177:10, 182:16,201:17, 227:18,237:15, 244:9,247:23, 289:8doctors127:5, 129:5,172:17, 173:24,178:8, 206:19,206:21, 206:23,207:7documentation198:16, 198:20,199:7, 199:8documented75:21, 234:14

documents12:4dog15:13doing13:2, 21:8,73:17, 73:18,121:12, 144:10,165:12, 168:6,176:24, 178:24,200:7, 201:22,208:5, 208:7,208:10, 210:20,213:11, 265:23,276:21, 281:16,282:8, 284:5,287:11, 291:8,291:14, 294:15,299:13, 300:16dollar151:9, 151:11,176:17, 179:15,290:12, 290:13dollars15:8, 54:10,55:2, 74:11,98:24, 99:4,99:10, 104:22,146:1, 176:22domestic53:17done14:21, 24:1,43:13, 78:24,81:7, 101:22,117:10, 121:13,121:18, 129:2,165:10, 172:14,172:21, 175:23,177:10, 185:21,210:22, 213:12,219:2, 235:20,247:4, 275:15,278:5, 278:8,278:11, 301:10door242:12, 286:22doors55:20, 263:17

dorsey97:4, 99:23,99:24, 101:19,101:22, 170:7,170:9, 170:11,170:16, 185:16dot178:22, 190:6double192:11, 280:11double-occupancy98:15doug115:18, 115:20douglas120:9down24:19, 25:6,38:19, 66:10,103:19, 190:6,214:16downsizing19:16downstate32:19downstream216:13dr44:7, 44:8,44:16, 44:17,44:22, 45:7,45:8, 47:2,48:12, 49:12,49:19, 50:3,50:4, 78:19,80:20, 80:22,97:4, 99:23,101:19, 101:22,115:17, 115:18,115:20, 116:2,118:1, 118:5,118:6, 120:3,120:5, 120:9,122:13, 122:16,123:19, 125:8,125:9, 132:14,134:23, 135:2,135:20, 136:3,



136:4, 138:4,138:6, 138:10,170:4, 170:7,170:9, 170:11,170:16, 185:16,186:20, 232:15,232:22, 233:11,233:13, 236:18,238:17, 238:19,238:21, 241:10,241:13, 241:15,248:14, 249:22,254:20, 272:8,272:10, 272:11,273:4, 274:14,274:17, 276:7,279:12, 281:9,281:24, 284:6,284:18, 285:17,286:20, 287:9,288:6, 288:16,289:6, 289:13,290:9, 290:15,290:18, 290:22,291:4, 291:10,294:22dramatically242:7drawn194:9dregs54:1drgs192:23drive14:22, 47:19,58:21, 64:18,79:20, 80:8,121:14, 126:11,126:14, 126:16,130:3, 130:8,131:12, 140:8driven58:6, 286:24driving45:21drug53:18, 252:21

ducker73:7duct285:3due80:6, 88:21,89:18, 126:8,126:14, 176:15,195:13dupage14:24, 150:16,150:17duplication48:7, 82:11,94:7, 94:10,94:24, 95:2,179:17, 194:8,200:13, 206:2,208:16, 208:20,209:2, 212:14,213:5, 213:7,213:17, 213:23,214:2, 228:7,250:14, 256:13,261:1during12:5, 31:14,46:23, 119:13,124:20, 144:5,153:3, 191:13,276:6, 300:2duty147:21

Ee-159:7, 159:8,159:10, 159:12,159:14, 159:16e-c-k153:13e-n-g-e-r149:22each31:18, 46:16,79:9, 82:6,88:24, 113:21,116:20, 137:9,

138:18, 172:18,194:16, 194:18,248:20, 278:19,279:5ear121:8earlier129:17, 170:1,171:6, 175:10,185:21, 203:4,213:14, 228:24early76:9, 192:23,287:23easier287:14easiest291:10easily100:14, 111:18,177:3, 205:24east113:4, 120:11easy76:8, 129:5,210:10, 253:20echo117:10echocardiogram117:7eck151:20, 153:12,154:20economic151:24, 152:3,152:8, 152:10,152:19, 153:4,154:3, 157:9,157:20economical67:1, 94:22,154:9economically53:21, 100:19economics93:16, 94:3,155:10economy141:17, 153:21,

157:6ed74:1, 100:21,101:2, 101:3,126:23, 133:16,225:2edit297:20, 298:1eds234:7education11:9, 12:19,28:5, 39:15,276:10educational3:12, 10:21edward232:13eesley81:3, 83:4,83:5effect20:22, 157:20effective240:20effectively53:7, 213:13effects38:24efficiencies122:8, 138:24,227:20efficiency100:7, 110:24efficient84:15, 101:4,101:17, 181:17effingham300:11effort35:2efforts42:11, 42:17eight6:23, 58:20,118:10, 119:22,168:17, 255:17eight-month159:18, 159:20



either15:1, 19:17,24:4, 24:6,25:23, 31:2,39:9, 39:19,69:14, 118:13,132:1, 188:22,197:5, 219:16,221:4, 221:22,221:23, 250:10,273:14elderly15:11, 100:19,101:16, 109:20,118:12, 177:12,182:12, 185:9,189:20, 189:22,228:4, 278:21electronic61:6, 116:22,119:12, 213:19elevating130:14elgin130:4eligibility31:2, 31:3,31:8, 31:19,31:20eligible83:17eliminate141:13, 155:18,213:16, 228:7eliminated245:23eliminating179:17else8:16, 234:8,249:21, 262:11,264:4elsewhere97:21, 203:20embracing154:12emergencies186:17

emergent130:18emily115:18, 115:20,118:6emphasis274:5emphasize210:13, 211:20,237:18empires143:18employed32:13, 90:24,303:11employees104:24, 275:16,296:9employer12:13employers104:24, 281:8employment58:12empowered96:4ems51:8, 132:15,132:16, 132:18,132:20, 133:2,134:7, 134:12,134:13, 134:15,232:23, 233:15,241:23emtala93:24emts186:21enable137:24enables139:8enacted22:11, 95:22,180:21, 248:14encourage154:17encouraged28:7

encourages111:22encouraging291:2end21:20, 49:6,78:17, 142:10,184:12, 232:22,271:5ends26:5, 108:13,123:23enemy20:24enforcement54:4engage39:23, 213:19engages89:23enger147:10, 147:11,149:20, 149:21enhance63:4, 152:2,199:3enhanced82:21, 122:7enhancing154:6enjoys103:10enormous108:8, 184:4enough37:3, 110:18,174:16, 184:21,205:4, 211:20,275:11enrolled89:14enrollees89:14, 114:16ensure20:12, 20:17,21:6, 104:21,239:24, 240:19,249:19

ensuring134:8, 240:2ent178:16enter30:1, 30:13,36:10entering30:1enters172:9entertain301:4entire72:18, 94:13,113:9, 116:16,121:17, 143:18,196:8, 233:19,263:1entities245:5, 245:7,246:5, 246:11,248:7entitled257:3entity102:24, 245:11entrance261:22environment14:8, 15:20,40:14, 142:7,274:13, 284:8environments138:16, 139:3,139:8envision100:13epidemic30:23epilepsy131:3, 131:5,131:6, 131:11,131:15, 131:18,131:20, 132:3,132:11, 146:12equates98:23



equation126:18equipment46:14, 74:10er97:24, 118:23,123:6, 124:2,124:15, 140:5,194:20era201:10error146:3, 190:13errors119:20escalate211:6escape172:24especially18:10, 100:18,111:19, 145:21,151:3, 181:7,182:13, 189:19,224:9, 252:20esrd49:14, 49:22,273:12, 280:7,291:16essence31:11essential195:22essentially55:24, 208:19,252:3, 254:20,289:14establish56:1, 65:13,65:22, 85:7,94:17, 159:9,168:8, 231:4,267:16, 271:4,271:20established195:6establishing78:9, 245:8

establishment45:11, 47:16,160:15, 168:24,231:20estate26:20, 26:21,245:19estimate212:19, 288:4estimated31:23et74:8, 216:17eterno1:18ethical147:21evaluate101:15evaluated101:9, 185:2even13:9, 24:5,30:1, 36:9,49:15, 61:9,80:8, 84:7,87:1, 89:13,97:24, 98:17,103:1, 126:19,128:6, 146:3,178:13, 182:7,185:22, 190:12,197:21, 199:18,275:23, 275:24,277:22, 282:14,282:20, 286:5evenings124:11, 124:20event206:3, 298:9events240:10eventually277:16, 279:7ever29:22, 30:2,32:16, 33:14,48:6, 83:23,

282:8ever-increasing126:21evergreen261:16every24:23, 26:4,26:6, 82:15,84:12, 89:6,112:1, 134:18,137:6, 139:13,150:11, 181:4,205:19, 210:12,212:5, 218:23,220:21, 221:3,221:10, 221:24,222:2, 240:4,248:16, 249:12,275:20everybody7:16, 45:3,64:12, 226:13,262:11, 264:3,283:3, 283:4,286:11everybody's43:10everyone21:23, 275:10,279:2everything70:4, 128:11,165:21, 201:8,283:3, 283:5evidence-based109:12, 138:1,182:1evidenced114:18evident79:15evolved23:2, 136:21ex2:1exactly65:17, 90:11,208:22, 213:7,

235:16, 236:6exaggerating142:10examination226:21examined181:4example16:19, 17:10,19:2, 32:17,33:4, 33:18,68:2, 91:16,117:2, 119:3,120:21, 194:15,211:7examples97:22, 103:7exceedingly66:20exceeds115:12excellence180:6except15:3, 26:22,196:7, 262:12exceptionally104:3excess41:13, 56:2,195:9, 195:12,195:13, 212:17,212:21, 219:9,262:15, 263:19exchange105:8, 208:9excited129:15excuse38:21, 74:24,231:24, 252:17exec8:2, 299:10execution89:19executive3:5, 5:6, 7:1,7:12, 7:17,



7:20, 131:2,232:16, 261:9,298:24, 299:14executives114:9exemption3:23, 164:2exercise21:11, 196:12exhausted30:15exist20:2, 32:6,77:4, 184:16existence198:5existing50:23, 56:2,57:2, 57:5,62:21, 63:1,65:23, 81:16,82:9, 82:23,93:18, 94:11,101:11, 112:9,142:1, 144:15,193:22, 200:15,202:4exists31:18, 61:19,197:6, 208:20,208:21, 209:12,297:22exit43:14exodus156:6expand78:4, 93:5,122:9, 210:10,235:22expandable210:8expanded218:18, 239:7expanding111:20expansion99:1, 152:4,

210:5expect207:22, 208:5expectancy36:18expected89:1, 130:10,169:2expedient134:20expended141:11expenses41:13expensive35:16, 35:20,56:17, 57:4,57:9, 67:2,67:4, 68:1,68:21, 111:23,287:7, 290:3experience72:14, 104:18,116:14, 132:19,181:20, 194:3,200:1, 249:6experienced178:20experiencing83:14, 234:24,291:24expertise140:14experts38:6, 191:22,234:20expire31:7expires303:18explain79:24, 100:3,140:11, 191:23,215:7, 245:1explained206:1explaining58:14

explanation87:20, 264:16,265:1exponential35:10express50:5, 100:2,109:7, 111:12,153:19, 156:20,196:14expressed32:21, 126:23,144:23extended67:16, 100:24extension3:22, 164:1extensive134:7, 227:10extra15:10, 101:14,177:22, 210:9,222:1extreme49:13, 49:22,123:22extremely18:9, 104:23,129:19, 131:14,235:24, 252:20,256:3, 274:3eye287:14

Ff-o-j-t-i-k116:3f-o-l-e-y12:11face131:10, 194:12faced240:24facilitate139:3, 152:20facilities1:2, 12:14,13:10, 17:8,

20:23, 26:16,28:11, 32:18,32:22, 33:2,33:5, 35:17,37:7, 38:7,39:9, 39:10,40:16, 46:15,47:14, 47:18,56:5, 59:3,59:9, 59:12,74:6, 85:24,94:11, 94:23,94:24, 95:4,98:3, 98:13,98:17, 102:24,111:3, 142:14,145:13, 152:13,156:11, 176:1,182:24, 212:19,228:8, 240:1,243:2, 256:14,256:15, 256:22,262:6facility10:21, 21:24,29:10, 29:12,29:13, 30:1,30:15, 31:15,32:13, 33:22,34:2, 34:8,38:3, 45:12,46:2, 46:4,46:7, 46:21,47:17, 47:23,48:2, 49:10,51:5, 51:14,53:9, 60:22,61:3, 63:23,73:19, 74:6,76:24, 78:8,81:22, 82:10,82:14, 87:6,89:9, 97:23,98:21, 99:6,100:4, 100:6,100:8, 100:13,118:15, 139:15,140:6, 144:12,



146:2, 150:11,155:15, 157:8,175:24, 176:16,176:24, 179:14,205:19, 206:6,210:5, 212:12,220:3, 224:24,228:1, 260:20,262:19, 271:5,271:21, 282:16,283:22, 295:13facility's175:23facing34:20, 39:18,58:4, 58:18,59:3, 131:17fact17:3, 34:17,60:23, 72:7,87:1, 93:18,114:7, 133:5,170:24, 171:12,172:1, 176:15,179:13, 183:2,187:21, 203:1,210:1, 212:16,215:13, 224:22,234:4, 237:11,245:20, 255:10,258:23, 268:12,288:23factor281:16factors29:24, 38:11facts28:20, 59:1,148:20faculty78:23fail-safe250:3failed87:5failing102:22fails56:14

failure54:10, 65:15,117:14, 198:16fairly223:11faith-based261:20, 261:24fall100:22falls190:2familiar23:10, 132:20familiarity139:8families21:6, 83:11,105:10, 146:6,146:16, 189:3,189:7, 235:2,275:23family30:20, 32:24,86:13, 105:3,118:8, 121:23,155:21, 242:14,250:1, 261:22,277:1, 282:5family's129:8fapr1:24, 303:5far46:14, 53:24,57:3, 57:4,68:21, 69:2,79:19, 80:1,107:21, 114:8,124:4, 154:5,156:4, 157:10,171:3, 182:14,291:24, 297:13farhan272:11, 274:19farther130:13, 140:6fast128:17, 184:21

faster21:18, 21:19favor7:10, 8:12,9:2, 9:17, 10:7,10:16, 223:4,224:9, 241:20,296:1, 297:4,298:19, 299:6,301:1, 301:24favorable70:6, 137:22fear35:8, 205:20federal22:11, 29:6,33:20, 35:22,35:23, 37:13,38:10, 70:7,171:1, 171:9fee261:22feed154:2feeds263:15feel80:24, 216:10,223:11, 233:2feels22:22, 134:11fees74:9feet85:20, 85:21,85:22, 87:7,87:8, 87:24,99:8, 189:8fell184:9fellowship276:6felt129:22, 140:5,205:23, 206:1,236:6female80:9, 123:21,

124:1, 147:13,147:17, 249:11few13:3, 93:14,140:9, 144:9,216:3, 223:1,238:18, 249:24,273:5, 274:15,281:8, 281:19,287:10field48:19, 132:20fields159:20fifth149:12fighting15:6figure40:13, 203:2filed24:24, 87:15,241:1filing26:6, 295:10,295:20fill25:8, 75:20,76:24, 85:23,92:10, 114:12,190:22, 243:6,287:3filled234:4fills112:9final3:7, 3:9, 8:1,8:18, 8:21, 9:6,9:8, 9:12, 9:13,9:21, 200:11,290:24finally9:7, 25:20,26:19, 63:21,72:16, 76:17,92:2, 195:16finance62:2, 66:14,



298:9financial5:4, 30:9,32:3, 32:6,32:16, 33:1,33:13, 34:12,35:11, 58:16,58:17, 58:19,81:13, 88:15,88:17, 89:23,102:23, 103:9,142:18, 187:17,220:15, 232:20,237:21, 244:17,244:23, 245:3,245:9, 246:10,297:8, 297:14,298:2, 298:7,303:13financially22:16, 62:15,71:21, 90:9,103:13financials210:2, 223:12financing19:24find32:23, 41:4,96:10, 102:9,115:3, 118:14,134:10, 146:7,213:6, 213:8,262:23finding166:18, 193:8,200:23, 244:18,245:13, 250:6,252:21, 256:12,260:24, 262:15,263:4, 288:2findings62:12, 160:22,163:1, 169:6,169:7, 223:10,224:6, 224:8,227:4, 228:17,230:7, 230:11,

231:24, 232:3,233:10, 237:21,258:24, 267:4,267:21, 268:13,269:4, 269:24,270:3, 272:3,272:22, 284:5,294:6fine285:1fingers125:2finish43:8, 182:8,238:3finished251:9fire236:21, 253:1firm23:7, 95:12,97:17, 276:8firms85:12first7:1, 12:17,29:23, 29:24,32:17, 44:1,44:3, 45:6,53:5, 62:10,65:13, 73:22,82:13, 95:19,100:8, 102:14,111:20, 127:7,132:21, 147:9,148:3, 149:21,160:2, 161:1,161:20, 176:7,183:3, 183:7,184:16, 185:17,190:7, 194:4,204:1, 214:11,214:24, 216:22,250:12, 275:3,275:18, 281:1,281:3first-ever110:11

firsthand128:3, 134:15,241:23fiscal23:19, 81:21,89:6, 89:16fistula278:8fit193:4, 209:22,249:9fitch52:2, 52:5,61:24, 62:1,64:2, 103:11fitness74:15, 144:8,149:9, 179:9fits13:20five17:12, 31:6,48:5, 49:8,50:21, 53:16,62:17, 62:19,62:21, 63:1,71:21, 71:22,82:7, 82:23,83:13, 85:24,93:6, 135:18,135:19, 149:24,174:8, 176:6,177:24, 180:1,194:12, 194:14,194:16, 211:10,227:13, 270:9,271:15, 274:21,275:8, 275:14,276:12, 280:11five-bed72:20fix40:8fixed27:23, 34:10flattened84:11flexibility100:7, 139:5,

198:11, 199:3,240:14, 281:11flip107:15, 183:5floodgates212:12floors87:18, 229:1flow33:3, 34:13focus76:18, 79:4,83:10, 148:3,213:21, 281:14,286:4, 286:24focused188:9, 273:4focuses213:13focusing141:18fojtik115:18, 115:20,116:2, 116:3,118:1foley12:10, 232:14folks39:11, 39:19,52:19, 298:10,299:12follow40:6, 48:3,57:15, 61:6,134:8follow-up122:2, 128:22,209:23, 240:18,249:20, 249:23,292:5, 292:9following28:5, 44:6,143:14, 159:5follows85:14, 143:21follows:7:22food15:8, 98:9,



216:5foot87:12, 99:10,130:14, 148:9,219:1footage98:23, 220:17football128:14footnote176:2, 176:12footprint108:4for-profit18:15forced32:22, 281:5forecast193:14, 193:15foregoing303:5, 303:7forever277:14forgetting14:16forgotten109:22form19:2, 143:21format219:22, 220:5former150:16, 191:20forming54:17formula16:7, 16:10,16:11, 16:17,17:2, 17:4,17:5, 25:22,26:13, 257:4,257:9forth295:15fortunately241:4forward11:8, 23:22,

42:3, 42:16,56:20, 65:10,78:8, 78:15,154:11, 214:13,239:19, 253:22,292:12, 295:10,295:19foster56:4fosters139:6found72:5, 117:13,148:6foundation131:3four17:12, 44:6,46:20, 50:18,51:23, 51:24,60:15, 74:16,86:20, 88:9,97:2, 151:19,174:18, 185:4,190:20, 191:10,191:17, 192:15,211:10, 233:20,239:11, 276:1,285:2, 285:23fourth63:6, 149:2,195:16fox79:6fraction46:13, 160:18,179:5fractions290:20fragile30:9, 174:22fragmented171:17, 195:1frail126:1frame28:17framed54:15

frances261:8frankly65:11, 149:8,171:15, 172:13,172:21, 189:14franks152:23fraterrigo64:7, 64:9,66:13, 66:14,68:13fraud296:19free93:10, 93:14,93:24, 94:2,113:20freedom287:5freestanding28:14, 67:7freeze23:20freezes27:10frequent68:2, 126:21frequently70:17, 93:21,249:8fresenius159:7, 273:8,278:1, 279:1,284:12, 286:8,286:18, 287:1friday281:1friends242:15, 282:5front15:12, 38:17,44:9, 44:18,51:10, 296:12frozen26:23fufoxer276:7

fulfill56:5full60:20, 61:13,81:21, 98:10,105:17, 105:19,108:11, 153:19,159:6, 178:3,216:16, 220:2,220:3, 240:22,249:7, 255:23,255:24full-service57:2, 63:9full-time128:5fully105:16, 127:12,154:15, 191:13function245:18functioning12:20functions66:22fund54:10funded22:11, 54:24funding33:15, 38:4,238:2funds30:16, 32:4,242:20further27:12, 36:15,42:16, 59:2,72:2, 88:5,93:24, 101:14,110:8, 118:23,202:19, 229:6future28:8, 42:3,122:6, 154:10,200:20, 210:4,214:20, 218:11,219:14, 222:24,



278:17, 293:4G

gaffner12:12, 28:3,42:24gain250:22gained20:5gallbladder174:17game128:14, 128:15gap27:13, 112:9,172:2gaps75:20, 76:5,77:1, 77:3,77:4, 85:23gastroenterology3:21, 160:4gave187:6geared181:19, 216:12geez221:17gender256:2general2:6, 11:13,85:21, 86:11,94:20, 95:21,96:4, 96:8,116:3, 141:4,143:9, 170:7,286:18, 290:11generally39:2, 255:3,290:8generate89:17, 145:24,152:15generated152:11, 245:20generates173:11

geneva80:3, 136:8,173:3, 178:21,178:23, 179:2,179:8, 181:22,182:24, 205:10gentleman19:3gentlemen62:1geographical142:19geographically56:23, 80:15geographies60:6george2:9, 159:3,159:22, 166:6george's43:6geriatric66:2, 66:4geriatrics62:23getting16:4, 121:4,126:7, 126:18,137:7, 137:9,146:7, 177:13,180:14, 186:2,190:1, 191:8,242:1, 250:16,262:13, 268:3,286:8, 289:18gigantic185:24give11:4, 11:21,35:12, 39:16,40:2, 43:24,44:10, 90:21,119:3, 142:24,151:1, 165:13,176:2, 181:9,211:7, 248:13,275:7, 282:19,289:10, 295:14

given15:19, 15:20,42:9, 54:3,78:14, 144:3,151:8, 189:9,210:23, 215:1,268:12, 294:11,296:9, 299:18gives150:6, 294:13giving23:15, 176:24,177:2, 241:16,272:18, 282:20glad69:24glasgow52:1, 52:3,52:23, 52:24,55:2, 55:8glasson1:17, 10:6,162:16, 167:3,207:14, 207:16,207:20, 208:2,208:11, 224:1,229:23, 258:9,265:4, 269:16,293:16glenn135:20, 136:4go7:3, 12:3,14:14, 15:9,16:13, 21:24,23:23, 25:5,25:6, 40:20,43:9, 44:10,45:6, 64:10,72:1, 81:9,88:12, 97:5,106:16, 108:12,116:2, 118:4,125:11, 127:19,133:12, 136:2,171:18, 171:21,175:22, 179:13,182:12, 183:22,

184:7, 184:8,184:21, 194:14,205:16, 206:14,211:19, 211:23,213:14, 223:14,227:18, 234:8,242:17, 249:21,250:11, 252:22,258:1, 273:21,273:23, 276:24,277:5, 277:16,278:4, 278:6,279:2, 279:7,279:17, 282:23,285:5, 285:6,286:1, 287:16,293:4, 298:3,301:9goal21:23, 101:4,243:24goals100:12, 102:19,112:5, 145:12godsend53:9, 53:10,53:13goes16:17, 25:21,56:17, 285:7gone27:2, 27:7,161:12, 192:17,273:7good12:6, 15:3,20:6, 20:7,20:8, 20:10,45:7, 50:3,50:8, 50:9,52:23, 55:13,55:15, 57:19,57:21, 59:6,59:20, 61:1,61:5, 61:24,64:12, 64:14,64:16, 64:22,65:16, 66:14,



68:18, 70:22,74:24, 78:19,80:3, 80:10,81:10, 83:4,85:2, 90:16,99:23, 106:17,108:21, 108:22,113:13, 115:13,116:3, 118:5,125:3, 128:20,130:24, 136:3,141:2, 145:18,147:18, 150:6,153:6, 153:21,161:6, 169:16,170:14, 203:18,203:19, 204:15,223:12, 232:7,232:8, 238:19,241:16, 250:6,259:7, 261:5,269:9, 272:8,293:4gordon64:6, 64:9,70:22, 70:23,72:23, 73:1gotten283:13governing14:4, 148:7government35:22, 37:13,63:24, 70:7,91:21, 113:14,171:1, 171:9government-spons-ored83:17governmental93:23governor95:21, 96:8goyal2:3, 6:2, 7:20,201:18, 201:19,202:14, 202:18,203:12, 203:21,

204:6, 204:8,204:15, 204:19,204:22, 205:1,206:12, 207:11,247:24, 248:1,249:15, 250:9,289:9, 290:4,290:11, 290:17,290:20, 290:24,291:5, 292:3grandmother174:21, 211:13,216:2granted118:22, 150:5,291:7grants36:2great15:10, 50:18,51:13, 74:22,89:19, 112:1,128:4, 138:20,140:12, 242:11,267:10, 277:11greater32:15, 84:8,105:1, 255:14greatest123:9, 216:10greatly118:18, 228:6green232:13grew150:13groggy130:10gross102:16gross-square220:16ground219:1group18:10, 18:12,18:13, 19:16,26:2, 43:15,

49:8, 58:12,90:19, 91:2,91:9, 91:16,110:2, 161:8,183:18, 280:7,284:10groups65:3, 76:18,275:11grove45:22, 79:6grow157:12, 275:17,280:2growing14:11, 110:17,112:6, 114:6,114:18, 119:22,120:3, 227:24,252:19, 285:19grown282:1grows280:4growth14:1, 49:13,84:11, 89:5,153:5, 154:8,210:4, 212:4guarantee124:13guarantees94:19guess170:9, 170:14,187:8, 198:8,198:17, 201:11,252:9, 254:12,276:23guidance78:11, 196:15guide78:13guided134:12guiding134:12guys187:6

gyms14:15, 16:22

Hh45:14, 47:20,168:3, 226:2,260:1h-a-l-l-a-t-t73:11h-a-y-d-e-n141:3h-e-u-v-e-l143:10h-o-w-a-r-d129:13hadley81:4, 85:3haefs125:8, 125:9,127:20half38:19, 58:23,87:9, 87:13,243:9, 290:14hall93:12, 106:13,106:15, 113:13,113:14, 115:12,115:16hallatt73:6, 73:10,73:11, 75:5,170:1, 205:18,218:4hand170:19, 281:18,303:16handbook4:20, 296:5,296:6, 296:11,296:13, 296:15,296:17, 296:22,296:24handle137:1hands161:3, 168:16,



214:18, 231:12,231:13, 260:10,271:14hanley97:3, 102:3,103:24, 104:2,104:5, 147:10,147:12, 147:13happen13:15, 20:11,22:1, 40:15,281:6happened130:2, 176:10happening140:11, 285:8happens20:2, 38:19,107:5, 148:10,243:7, 248:23,287:5, 289:15happy88:14, 244:10,268:15, 291:19hard15:14, 21:12,182:12, 210:13,222:18, 227:16hardly71:22hardship27:24harvard56:22, 62:16,63:3, 71:12,71:14, 71:22,71:23, 72:2,72:6, 72:7,72:9, 73:14,75:5, 76:3,89:8, 89:11,89:12, 130:7,136:9, 138:14,139:16, 140:4,144:18, 146:17,173:1, 173:7,173:10, 173:18,173:24, 174:6,

174:9, 177:22,178:1, 178:20,181:22, 182:23,195:12, 202:4,202:9, 203:19,205:9, 208:19,209:6, 209:7,217:12, 217:16,218:2harvard's115:8, 140:5hayden135:20, 141:3head102:3, 128:14,145:19, 184:9,290:19head-on103:6healing165:8health's77:13, 85:6,85:15, 85:20,86:3, 88:17,93:12, 102:13,103:5, 104:20,105:18, 109:23,110:10, 111:4,115:5, 115:8,116:7, 120:14,120:17, 121:13,123:6, 128:4,129:8, 129:15,130:20, 143:8,143:17, 143:20,144:15, 145:2,153:20, 155:15,156:21, 188:21,233:24healthvest53:11, 232:15,232:17, 232:19,232:21, 233:11,235:18, 235:19,236:8, 236:11,237:22, 238:22,240:2, 241:1,

243:19, 244:4,246:20healthy66:5, 78:6,110:22, 114:14,114:20, 123:2,123:13, 157:5,174:16, 185:9,203:1hear43:6, 62:5,92:13, 92:14,97:7, 97:11,122:21, 144:2,147:23, 155:4,198:8, 238:20,247:9, 297:10heard7:11, 8:14,9:4, 9:19, 10:9,10:18, 40:18,67:20, 107:1,117:9, 140:4,149:2, 150:23,177:17, 186:20,189:21, 191:18,202:9, 206:13,206:20, 209:7,214:24, 215:3,215:14, 223:18,257:21, 258:2,275:24, 296:3,297:6, 298:21,299:8, 301:3,302:2hearing39:14, 93:13,144:5, 169:3,215:1, 217:1,227:5, 232:1,260:24, 267:20,272:1hearings53:14heart51:4, 51:17,65:15, 117:6,117:7, 117:14,

133:18, 133:21,136:19, 137:6,137:8heating41:19heavily123:24, 273:4hectic128:7held96:17, 135:7,169:3, 240:17,256:6, 299:23hell54:19hello129:12, 143:7,151:23, 267:24,283:1, 300:3help22:15, 25:23,115:6, 118:20,183:4, 234:10,234:11helped189:6helpful45:5helping188:24helps78:12, 189:23hematoma184:10hemo285:4hemodialysis271:21, 273:15,275:22, 276:4,276:15, 276:18,277:17, 277:21,286:3, 289:12,290:7, 290:13,291:3, 291:4hemorrhaging184:18henning115:18, 115:21,



120:9, 120:10,122:13, 122:16here6:8, 6:10,6:12, 6:15,6:18, 6:20,6:22, 23:10,23:12, 40:4,42:6, 43:4,45:10, 47:15,48:15, 50:10,52:19, 52:24,53:12, 55:16,58:10, 59:23,71:1, 85:5,86:11, 95:13,100:2, 106:19,109:7, 111:11,116:7, 118:6,120:13, 121:16,123:16, 124:14,128:2, 129:3,133:4, 136:11,145:9, 145:16,146:12, 149:1,150:2, 150:3,150:10, 150:12,150:24, 151:8,151:14, 151:15,153:16, 155:2,156:20, 161:10,166:19, 170:9,170:11, 173:5,175:10, 176:4,176:13, 183:3,187:4, 187:7,198:19, 206:19,209:17, 209:18,212:15, 212:16,214:13, 220:13,221:14, 223:18,227:18, 232:11,236:13, 236:14,244:18, 244:22,255:23, 262:12,274:22, 276:12,284:13, 285:12,291:11, 293:13,

295:6, 296:20here's32:17, 35:14,107:12, 107:15,249:21hereunto303:15herself170:1heuvel135:21, 143:7,143:8, 143:13,145:5, 170:6hey280:24, 284:11,290:12, 291:13hfsrb4:20, 5:5, 9:9,297:16hi45:7, 77:11,97:6, 102:3,120:9, 122:22,127:20, 205:18high66:20, 90:10,107:12, 107:16,109:16, 139:7,139:12, 139:17,171:24, 173:7,205:19, 228:3,255:11, 273:15high-acuity255:9high-cost211:24high-deductible83:20high-paying157:7high-quality83:12, 89:10,234:11higher21:16, 34:17,34:23, 62:11,63:2, 63:23,67:22, 68:3,

68:6, 91:12,91:20, 91:21,139:4, 171:14,278:22, 289:20higher-income71:14highest75:12, 88:20,107:20, 112:16,137:18highlight13:4, 123:20,284:7highlighting234:23highly65:2, 67:1,113:7, 113:23,136:24highways184:3hill106:13, 106:14,108:21, 108:22,109:2, 109:5hills79:6himself119:9hinders124:5hip210:19, 210:22hire34:21, 41:17historical244:23, 245:9,246:10, 288:10historically32:11history23:15, 28:20,34:5, 72:2,88:19, 189:11,197:11hit37:22, 184:9hm-m300:5

hmo105:4, 105:12hold60:24, 195:15,268:1, 268:2hollinger135:20, 138:12,140:16, 140:19,140:23home16:4, 16:19,19:22, 20:13,21:24, 22:12,22:14, 22:24,23:8, 25:17,26:2, 27:13,27:18, 30:13,34:1, 34:7,37:9, 37:16,40:20, 40:22,41:2, 61:10,69:22, 79:12,101:10, 111:21,112:1, 126:24,130:11, 130:13,138:4, 140:8,140:9, 150:20,156:5, 174:18,180:3, 185:8,186:23, 210:23,211:11, 273:5,273:9, 273:13,273:14, 273:24,275:24, 276:6,276:8, 276:10,276:11, 276:13,276:16, 276:24,277:11, 277:13,277:14, 277:20,277:23, 278:6,278:8, 278:16,279:6, 281:15,281:16, 281:23,282:12, 282:13,282:21, 284:5,284:17, 284:19,284:22, 285:1,285:4, 286:1,



286:2, 286:4,286:16, 286:21,287:11, 287:19,287:24, 288:4,288:7, 288:9,288:11, 288:14,289:1, 289:3,289:11, 289:16,289:22, 290:6,290:12, 290:16,291:2, 291:17,291:21, 294:1homeless189:3, 189:7,189:10homeowner's20:7homes15:20, 16:15,16:17, 17:12,19:16, 23:12,24:15, 25:3,27:2, 27:23,41:2, 263:6honest16:1, 141:10honestly278:2honesty147:22hong286:23honor119:21, 236:8honorable52:1, 52:3,52:4hope40:11, 54:22,105:13, 151:3,193:5, 195:1,240:22hoped236:13hopeful132:9hopefully224:3, 243:5,

243:10, 301:13horizontally104:14horn181:2hospital's82:5, 233:22hospital-based67:20, 67:24,77:20, 91:19hospital-huntley81:20, 82:1,84:5hospitalization141:18, 289:15hospitalizations119:18, 290:2hospitals21:17, 35:15,50:23, 56:1,56:2, 56:19,57:2, 57:5,58:3, 58:20,59:10, 60:15,62:17, 62:20,62:22, 63:1,63:9, 67:2,68:22, 69:6,69:10, 69:13,69:16, 69:21,72:18, 72:19,75:15, 75:16,81:15, 81:16,82:7, 82:9,82:23, 83:8,83:13, 86:1,88:24, 91:18,92:3, 93:6,101:11, 103:14,103:17, 103:18,103:20, 116:23,119:18, 126:4,134:19, 136:8,138:17, 142:6,155:23, 172:18,180:1, 181:12,181:18, 181:22,183:15, 183:20,

185:4, 185:19,187:12, 190:21,191:14, 192:2,192:4, 192:19,193:7, 193:22,194:1, 194:4,194:10, 194:12,198:5, 200:2,201:2, 205:8,206:10, 206:13,206:20, 206:24,207:10, 208:2,217:11, 220:5,222:22, 234:9,237:16, 242:10,243:5, 256:15,289:24hot15:13hottest54:18hour21:14, 80:13,184:5, 242:13,242:16hours16:2, 45:23,67:16, 100:24,101:14, 124:12,174:19, 210:23,216:4, 216:5,241:19, 242:24,276:2house35:24, 189:6,301:12housekeeping25:13hovering239:13howard125:7, 125:10,129:12however16:17, 18:14,26:8, 31:20,65:7, 71:9,72:12, 85:8,

93:9, 94:16,124:9, 137:3,146:5, 153:17,215:10, 243:17,250:18hrsa60:4, 60:8huge225:1, 282:4,282:7human60:5, 150:21,236:4humphrey-sonntag1:23, 303:3,303:23hundred54:1, 69:10,82:5, 141:22,172:16, 191:17,192:4, 193:12,222:22, 234:17,234:19, 234:21,250:21, 251:18,252:4, 252:13,252:16, 253:19hundred-bed68:24, 148:12,197:17, 201:9,211:24, 231:4,231:20, 233:4,236:23hundreds153:3huntley36:20, 81:16,84:8, 92:6,176:16, 179:1,187:21, 195:14hurdles142:19hurt129:18hurting48:20

Ii-l-t-s47:13



iceberg37:22icf13:22icu71:21, 139:2,191:17, 195:10,195:16, 195:19,196:3, 196:7,204:19, 205:3,205:21, 206:1,209:20, 218:22icus195:23, 199:13idea175:5, 215:13,227:12, 227:19ideal243:17ideation255:5identical87:24identified28:19, 34:11,46:12, 46:13,76:11, 78:7,110:21, 114:20,114:23, 123:4identifies60:6identify34:21idhp155:22idph2:2, 2:8, 2:9,5:5, 98:18,134:14, 296:9,297:16, 297:24iffy14:19iga297:19, 298:12ignoring102:11ihfs2:3

ihfsrb155:22iii113:24, 288:17ilene52:18, 57:23ill100:19, 134:17ill-suited142:6illinois1:1, 1:6,11:14, 12:15,13:5, 16:6,18:6, 23:1,23:10, 23:12,28:24, 29:12,32:7, 32:11,32:15, 33:8,33:23, 35:10,35:11, 36:4,37:14, 37:21,38:1, 38:4,38:14, 47:15,53:18, 58:10,60:9, 69:23,72:15, 72:18,75:13, 78:21,83:9, 86:19,86:24, 94:4,94:23, 96:17,102:6, 103:1,103:15, 105:12,109:6, 109:10,111:3, 112:17,116:5, 127:21,131:3, 136:9,139:11, 143:18,149:23, 149:24,151:2, 152:13,160:16, 161:13,169:1, 169:19,180:5, 186:7,186:13, 192:2,192:9, 193:6,193:22, 194:4,209:18, 209:20,231:21, 233:6,

233:12, 234:18,238:24, 243:3,267:17, 271:22,274:11, 274:13,284:13, 291:23,292:2illness53:24, 54:6,126:14, 231:20,234:15, 239:1illnesses124:19, 234:7illustrate140:3images61:7imagine47:22, 137:14,243:18imaging67:7, 68:3,98:9, 178:3,220:3immediate50:12, 50:20,50:23, 57:11,62:20, 63:14,67:6, 67:15,100:23, 118:24,119:16, 124:3,128:11, 133:17,133:22immediately117:15, 140:20impact28:18, 28:21,35:10, 36:3,38:12, 142:10,142:12, 146:5,152:10, 187:17,190:10, 194:7,194:22, 210:6,221:13, 225:1,233:14, 235:1,237:24, 238:11,262:6impacts28:22, 194:20

impasse58:10imperative54:14implement102:22, 105:16important17:7, 18:20,22:13, 41:3,60:5, 62:9,62:11, 66:4,79:11, 83:10,100:18, 101:16,111:17, 119:2,120:16, 139:20,147:3, 200:8,238:10, 274:3,280:21, 283:8,294:16importantly56:15, 64:18,238:14impossible29:18, 29:24,30:5impressed235:24, 265:18improve20:8, 20:14,20:15, 41:16,110:1, 112:22,116:14, 116:15,116:18, 116:19,127:3, 181:6improvement41:18, 112:3,116:13, 182:3improvements26:3, 152:20improves118:18, 119:12,157:21improving90:8in-center271:21, 273:11,273:21, 275:21,276:3, 276:15,



276:17, 277:21,279:8, 282:16,285:2, 285:6,285:9, 286:5,287:4, 289:1,290:23, 291:4in-centers273:7in-house178:4, 220:4in-patient285:11inability34:9, 35:3inaccurate98:1inadequate54:2inappropriate30:19incentive26:16, 27:11inclined219:10include77:19, 103:7,112:5, 121:19,226:23, 239:8,288:11included80:2, 98:8,275:22includes59:5, 79:5,102:18, 144:21,156:7, 209:11,257:5, 257:9including47:15, 47:19,57:6, 64:24,76:3, 76:19,81:15, 89:20,92:11, 105:3,105:20, 109:19,139:5, 144:2,149:9, 150:1,288:20income71:14, 89:2,

89:6, 152:15,152:18, 173:14,176:8, 188:4inconvenient121:4incorporated296:11increase19:18, 25:3,26:5, 66:16,110:6, 114:19,119:20, 144:17,246:4increased24:14, 31:5,33:10, 36:14,80:11, 110:23,113:5, 122:8,123:8increases24:6, 25:24,26:7, 68:13,79:14, 111:21increasing30:4, 34:10,36:18, 48:21,106:1increasingly119:10incredible18:9incrementally88:3increments141:22incumbent219:15incurring33:10indeed61:19, 93:16,117:16, 141:23,239:17independence255:14independent14:3, 14:7,28:13, 37:2,

37:8, 65:3,66:5, 90:19,92:15indicated74:18, 79:22,80:17, 206:5indicating46:20, 79:18indicator255:6indigent63:2, 71:8,72:3, 109:20,173:7, 189:20individual54:11, 105:3,140:7, 202:8,278:19, 279:5individualize287:21individuals18:10, 30:22,76:15, 101:6,131:5, 131:15,131:21, 132:1,132:3, 132:6,132:11, 225:4,275:22, 278:22industry11:11, 11:18,15:15, 18:14,39:20, 67:3,67:18, 83:16,152:5, 182:2,215:12inferno54:18inflationary24:6influx15:16, 61:17information5:8, 12:24,18:4, 21:8,21:18, 22:6,22:8, 23:1,29:2, 39:1,39:13, 39:22,

41:23, 129:1,165:20, 171:20,186:12, 223:3,237:7, 245:9,298:9infrastructure152:20infusion226:24, 228:5ingram's6:16initial4:8, 168:2initiative301:14initiatives90:6injuries124:18injury128:14, 130:2,130:6innovate157:12innovation46:12, 201:1innovative69:4, 69:8,77:5, 143:21,143:22, 145:2,145:12, 146:21,149:4, 154:11,190:15, 214:12inpatient71:17, 73:24,77:20, 85:24,100:6, 101:13,119:14, 159:13,172:17, 173:19,193:3, 202:13,202:20, 210:15,211:5, 235:5,237:14, 254:23,283:14inpatients75:14insert296:15



instance144:11, 284:23instances198:12instantly129:22instead106:24, 118:24,171:16, 200:14,237:15instituted192:23institution280:16, 280:23institutional38:8, 250:2institutions33:12instructed236:16instruction210:24instruments244:24insurance58:12, 83:20,105:8, 105:13,118:13, 126:13,192:21, 239:21,243:21, 248:19,248:20, 289:11insured248:11insurers107:3integral157:5integrate172:16integrated88:21, 104:14,104:21, 105:16,119:11, 139:12,179:22, 180:8,182:4, 213:18integration172:7intend46:17

intended30:17intends53:12intensity37:9intensive84:3, 159:10,195:21, 198:9,198:21, 199:9,199:24, 205:5,205:14, 206:8,255:12intent4:16intention221:7, 221:16intentions21:9interaction236:1intercompany246:5interdependent87:17interdisciplinary277:3interest28:8, 32:20,33:11, 38:8,58:13, 95:16,179:16, 191:8,273:1, 303:12interested261:23, 272:24interesting213:3interests274:9intergovernmental5:5, 297:16,298:15intermediate13:23intern2:10internal246:13, 279:19

internist116:4interplay197:8intersection111:13intervening27:1intervention134:24interventions134:1interviewed34:22introduce10:22, 11:21,169:21, 232:11,272:6introduced169:24introduction192:24inventory144:17, 200:15,200:19invest27:11invested89:8, 173:8investment36:22, 89:18,90:4, 102:4,102:5, 152:16,152:18, 239:6investors103:11invitation28:4involved18:18, 23:8,48:22, 191:22,282:14iop250:5iowa131:3ira261:10

ironic134:10ironworkers149:23isolated62:15issue15:23, 17:17,46:6, 115:6,144:3, 144:5,155:1, 179:14,199:2, 201:9,213:4, 277:12,279:15issues3:6, 7:24,11:10, 11:11,12:22, 13:16,15:3, 18:21,39:4, 39:18,40:10, 76:19,115:1, 128:21,161:19, 211:15,222:19, 222:22,223:19, 234:7,237:24, 239:2,243:16, 244:22,252:15, 256:2,256:5, 277:10item43:1, 45:14,47:20items3:18, 3:19,159:1, 159:5,160:1itself16:11, 39:12,58:14, 81:17,148:15, 219:11,245:12, 250:4,263:15iv288:17

Jj-e-n-i73:11



j-e-n-s-e-n122:23jack152:23jail53:15jails235:4james44:7, 44:16,47:7, 52:1,52:3, 78:20,88:10, 232:20,246:19janesville77:19, 136:8,183:10, 183:12,183:14, 183:22january23:20, 24:3,28:6, 29:3jason170:4javon103:6, 169:18,203:3jay125:8, 125:9,132:14, 186:20jeannie295:5jen106:13, 106:15jeni73:6, 73:11,170:1, 205:6,205:16, 205:18jennifer93:12, 113:14jensen115:23, 122:21,122:22, 124:18,124:23, 125:3jesse2:10, 300:15,300:18jim52:24, 92:23

job1:21, 54:4,71:2, 281:7jobs150:2, 152:15,152:18, 153:3,153:24, 157:7,157:18, 276:3joe64:7, 64:8,68:18joel1:16, 208:12,250:10, 254:2,288:1john1:17, 54:16,88:11, 88:15,97:3, 97:4,99:23, 102:3,147:10, 147:12,147:13, 170:5,170:7, 204:11,207:15johnson1:16, 6:14,6:15, 7:7, 9:1,10:15, 160:9,162:6, 162:11,162:12, 166:22,166:23, 168:10,208:13, 209:1,209:23, 212:3,212:9, 213:21,214:1, 222:14,223:16, 223:17,226:12, 229:10,229:18, 229:19,254:3, 254:8,254:11, 255:18,258:4, 258:5,260:6, 264:13,264:23, 264:24,267:7, 268:24,269:11, 269:12,288:2, 288:9,288:19, 293:11,293:12, 297:1,

297:3, 299:4,300:24, 301:6,301:21join285:20joined7:20joint235:22, 237:22jones281:9, 285:22,286:1joseph115:17, 115:20,116:2jr2:6juan2:6, 8:2, 9:23,10:22, 22:9,23:14, 40:5,41:23, 43:21,51:23, 64:5,165:3, 296:5,297:17juan's43:2, 220:18judge150:22judges236:21judgment150:23, 196:12july23:16, 24:3,26:23, 303:16june1:7, 26:4jurisdiction14:1, 39:5justification199:7, 252:16justified199:16justify49:9, 49:23,56:16, 69:1,69:7, 198:16,

199:12, 205:24,253:6, 253:19

Kk-a-r-o-l48:12k-e-l-l-y129:13kane45:21, 45:22,83:9karen52:2, 52:4,55:14karol44:7, 44:17,48:12kathy1:12keep27:6, 34:7,42:20, 65:19,83:10, 129:4,129:6, 148:1,188:8, 216:3,243:24, 276:21,279:6, 279:10,280:19, 281:16,287:14, 299:16keeping220:8kelly125:7, 125:10,129:12kennedy54:16kentucky265:13kept101:12, 210:19kevin52:2, 52:4,62:1key62:8, 76:9,144:1, 255:6kicked210:22



kidney288:17kids184:9kind13:2, 13:4,14:18, 22:5,23:15, 38:18,40:5, 83:21,104:17, 136:15,148:1, 187:4,201:4, 206:17,216:6, 228:9,237:7, 248:12,262:7, 263:15,273:23, 275:18,277:18, 279:9kindly175:17kinds17:13, 22:2,53:19kirby98:21kishwaukee74:15, 179:9klein147:10, 147:11,147:18, 147:19,149:12, 149:15,149:18, 169:24,192:1, 212:8,217:15, 217:20,217:23, 218:5,219:17knew36:10, 129:20,200:6, 275:20,275:21knowing15:5, 51:12,130:17, 198:3,242:5knowledge40:12, 275:19knowledgeable38:1known9:9, 24:22,

40:22, 60:4,151:4, 273:12knows285:18kong286:23kownick106:13, 106:14,111:8, 111:9kresch232:15, 233:11,236:18, 238:17,238:19, 238:21,248:14, 249:22,254:20kristin272:16

Ll-a-c-k131:2l-a-d-d106:18lab121:2, 178:4labor34:10laboratory220:4labs118:16lachowicz261:5, 261:8,266:8lack27:11, 61:4,76:19, 86:2,110:14, 123:3,123:7, 126:8,131:11, 131:17,156:10, 216:11,275:19lacking85:24, 123:17lacrosse128:14ladd106:12, 106:14,

106:17, 171:7ladies61:24, 250:12lag280:17, 280:18laid296:8lake's99:17, 154:2lakeshore3:21, 160:3lambert52:2, 52:4,55:12, 55:14,57:8, 57:11,57:14land74:9, 210:9landscape39:21language296:14, 297:21lardner232:14large27:23, 57:3,66:24, 90:6,93:20, 110:18,113:4, 118:12,121:7, 121:10,126:8, 133:7,138:17, 139:11,150:1, 219:20largely195:14larger71:4, 108:2,174:8, 192:17,225:1largest33:5, 145:19,146:20, 150:18,188:1, 188:17,203:4, 203:6,203:13, 203:14,276:13last16:14, 23:17,

24:10, 27:16,36:21, 40:6,40:14, 40:22,44:2, 46:10,46:15, 46:24,47:12, 52:15,86:14, 89:2,103:3, 105:6,105:11, 119:22,126:1, 130:5,131:1, 143:9,143:11, 149:22,156:17, 203:12,237:11, 243:4,273:5, 297:22lastly46:23, 233:13,237:20late261:6later84:6, 117:8,117:13, 275:14,276:12latest103:7latter246:16laughter124:24, 141:8,143:5, 143:12,257:2, 264:21,265:14laundry25:13lavenda12:9, 23:5,23:6law54:4, 54:5,54:8, 54:12,95:12, 95:22,124:19lawler88:10, 95:11lawn159:18lawyers147:21, 279:18



layout101:5lead119:19leader180:5leaders76:18, 114:22,146:11leadership60:24, 64:23,139:5, 235:21,236:2leading76:7, 83:23,121:4leads134:24learned220:6learning235:19lease245:19leased25:23, 98:3least41:5, 86:20,91:20, 93:6,111:23, 114:8,192:9leave35:12, 43:19,61:8, 175:10,177:22, 203:22leaves249:22leaving34:22, 37:1,71:20led103:6left232:14, 268:10,272:13, 272:14,272:16legal3:8, 8:7, 8:9,

68:19, 148:4,148:18, 279:18legislative4:21, 36:21,301:11legislators236:20legislature94:4, 214:17,300:2legitimate245:13, 280:17lender19:24lending20:1, 33:12length192:10, 211:4,253:14, 253:18,254:5, 254:9,254:17, 255:7,255:15, 255:16lenox231:5, 231:21,233:6, 236:17,241:7les161:7less24:15, 35:20,48:23, 57:9,63:13, 67:10,69:10, 69:17,81:23, 98:23,142:11, 173:7,174:6, 175:13,187:10, 187:11,188:16, 193:24,207:4, 209:15,209:16, 215:14,218:20, 237:13,253:18, 273:17,284:16, 285:16,289:16, 290:3lest35:16let's15:18, 108:2,

143:20, 192:8,194:12, 203:22,211:23, 282:11letter49:17, 49:18,195:24, 196:1,236:24letters49:11, 169:5,232:1, 232:2,236:22, 237:5,253:5, 253:21,272:2letting274:18level14:16, 16:18,29:6, 34:17,57:6, 110:1,113:24, 133:3,133:11, 138:18,139:7, 139:13levels13:14, 37:4,63:2, 126:21,132:7, 133:9,172:9, 255:12levers106:22liaison42:18license16:20, 19:9,19:15, 19:23,63:22licensed13:23, 16:16,16:18, 20:1,69:17, 97:16,110:6, 142:8,143:15, 144:15,155:13life21:21, 36:18,54:8, 54:12,112:4, 137:16,151:1, 152:6,161:12, 282:7

life-threatening63:11lifeboat37:20lift157:21lifted262:5lifting261:12light264:5, 264:6likely36:10, 87:20,142:5limit20:1, 135:24limited37:13, 51:16,63:11, 76:20,98:9, 109:20,160:15, 233:9limiting114:23line27:6, 31:13,41:15, 74:12,100:8, 185:17,190:13, 194:3,274:7, 278:3,286:7linen25:13list69:16, 249:21,299:19listen76:3literature215:11, 217:4,234:19, 286:15litigated96:19little23:9, 23:24,32:20, 38:7,38:23, 86:23,146:1, 176:2,



184:8, 185:6,190:10, 192:8,199:2, 202:19,205:1, 205:7,242:8, 255:8,256:11, 256:20,275:7, 276:14live54:7, 57:1,63:8, 75:14,127:2, 128:9,142:16, 146:6,147:1, 150:4lived127:22lives112:22, 133:24,134:24, 136:10,137:23, 138:7living14:3, 14:7,17:21, 21:1,28:14, 40:20,76:15, 78:24,250:2, 261:23llp23:7loan20:3local58:13, 83:12,102:15, 112:8,117:3, 130:16,130:18, 146:10,147:3, 149:23,149:24, 150:9,153:9, 153:14,153:21, 154:20,225:5, 291:11,295:14locally103:2, 110:15,112:20locate142:14located32:19, 45:15,64:17, 111:15,

121:16, 180:4,192:4, 227:15,271:22location63:9, 79:24,98:2, 100:11,139:14, 171:18,175:20, 178:11,182:15, 183:9locations5:7, 80:1,120:23, 120:24,127:6, 182:13,227:13, 227:17,299:20, 299:21lombard159:16long18:22, 37:3,80:7, 88:19,112:8, 112:9,112:10, 119:1,130:11, 136:14,137:3, 153:4,175:7, 179:21,192:17, 193:12,222:18, 233:8,272:19long-standing76:12, 77:15,78:14, 178:6long-term3:12, 10:20,11:1, 11:10,11:12, 11:18,11:20, 12:13,12:15, 12:22,13:13, 13:18,13:19, 13:22,15:5, 15:6,15:9, 15:10,17:8, 17:10,18:13, 18:19,21:24, 28:8,28:10, 28:16,28:24, 29:6,29:10, 29:12,30:10, 30:16,

31:14, 32:1,32:7, 32:15,32:18, 33:2,33:5, 33:7,34:1, 34:8,34:9, 35:1,35:17, 36:6,36:19, 37:10,37:14, 37:18,37:21, 38:3,38:13, 39:9,39:19, 104:18,153:24, 159:13,184:23, 260:20,262:1, 262:20longer29:22, 34:14,37:8, 49:20,101:19, 126:11,126:12, 211:16,216:2, 253:18,273:16, 280:10,282:21longer-term181:13, 185:4longest194:5longtime34:4look13:17, 14:12,17:15, 21:10,42:3, 42:16,54:9, 54:23,71:3, 78:15,102:10, 171:8,174:16, 192:8,201:12, 211:8,212:3, 213:10,214:16, 223:20,247:1, 251:21,253:19, 256:21,280:1, 280:8,281:21, 291:1,291:14looked15:24, 27:16,79:13, 188:3,

200:1, 222:17,279:24looking14:14, 16:3,17:9, 22:3,41:21, 78:8,171:15, 202:7,202:10, 202:15,214:12, 214:18,219:21, 222:24,223:2, 274:7,275:17, 284:10,288:16, 288:18,295:17, 296:21,298:23, 300:10looks21:11, 198:14,198:15, 244:19,244:21lose82:15, 281:7,287:5losing34:21, 92:5,126:15loss29:15, 29:18,82:17, 82:18,176:7, 176:15losses103:2, 176:6lost114:8, 176:14lot13:6, 24:12,24:15, 25:8,26:16, 27:1,27:4, 39:10,42:9, 72:7,129:19, 131:22,176:9, 190:17,190:19, 191:18,205:14, 210:9,211:14, 211:18,214:3, 214:17,218:24, 219:18,223:13, 280:15,285:14, 285:16,



289:16lots69:5, 215:22loudest43:6loudly43:17loved14:13, 14:14,261:24low37:14, 47:3,59:4, 59:12,90:10, 104:23,105:9, 107:13,107:17low-acuity51:2low-cost67:14lower35:15, 58:6,63:14, 67:19,71:13, 71:16,83:22, 105:7,171:13, 172:20,180:9, 207:23,208:9, 219:7,224:3, 278:23lower-cost67:5lower-level63:14lowering67:4lowest29:1, 32:9,107:21luck259:7lunch135:10lurie99:6, 235:14lutheran80:3lymph121:7

lymphoma121:23

Mm-a-r-g-a-r-e-t156:17m-a-r-y156:17m-a-u-l-e156:18ma'am226:15mac132:14, 134:23,135:2macneal125:8, 125:9,132:14, 186:20madam6:6, 6:21, 8:5,28:3, 104:9,111:8, 135:6,151:19, 159:4,159:21, 160:12,160:20, 162:4,163:3, 166:7,167:13, 168:21,169:8, 169:14,191:5, 201:18,224:20, 225:7,226:18, 229:8,230:9, 231:18,232:7, 247:24,257:16, 258:21,260:15, 261:2,261:13, 264:11,265:24, 266:1,267:15, 268:23,270:2, 271:19,272:4, 272:8,292:23, 294:9,294:17made24:17, 27:21,31:10, 31:20,31:21, 39:11,82:6, 83:16,97:20, 105:6,

113:18, 128:22,128:24, 148:23,162:5, 165:10,166:8, 192:6,193:8, 196:4,220:13, 222:14,229:9, 236:5,236:11, 239:6,242:3, 257:17,264:12, 268:24,292:24, 295:18,296:9, 296:18,297:12, 297:20,297:21, 297:24madison183:18magnet180:5main79:4, 107:19,121:13, 283:6mainly177:6maintain21:20, 41:5,54:20, 126:12maintaining144:18maintenance25:14major55:23, 67:13,83:15, 112:24,114:22, 123:1,123:4, 131:16,278:1, 299:22majority48:24, 66:21,113:4, 133:15,139:16, 193:6,281:22make13:12, 13:15,15:7, 18:7,20:4, 20:11,20:23, 21:7,22:1, 29:21,29:24, 31:1,

35:4, 39:1,39:6, 40:13,41:18, 42:2,42:19, 43:14,43:20, 43:23,44:20, 45:1,51:9, 54:4,71:3, 81:6,89:17, 93:18,128:7, 176:12,187:18, 199:5,200:6, 203:24,208:14, 220:11,223:21, 236:15,250:24, 263:1,278:12, 295:17,298:2makes35:9, 157:10,256:20makeup23:24making14:13, 32:3,32:14, 92:7,119:1, 129:5,138:6, 190:11,200:10, 208:14,208:21, 245:3malcolm88:22, 180:22maldistribution94:8, 94:10,209:3, 209:8,209:11, 209:12,209:22, 212:14male52:10, 147:15,249:10man121:21manage54:11, 105:17,150:13, 172:8,179:18, 245:18,286:12managed105:23, 192:24,



197:13, 248:20,249:1, 274:5management61:14, 62:24,65:16, 103:4,103:5, 103:19,103:24, 104:16,159:15, 176:11,176:23, 213:20,240:5manager57:24, 59:21,77:12, 272:15managing104:18, 176:20manner101:5, 112:12,136:23manufacturing36:8many20:20, 29:20,36:18, 37:17,43:8, 56:14,56:24, 60:21,65:3, 78:1,98:8, 102:9,102:24, 118:14,123:20, 137:12,137:23, 139:1,148:16, 150:7,150:8, 151:14,153:16, 181:9,187:12, 194:3,211:9, 211:11,223:19, 235:6,237:6, 242:10,242:18, 249:1,253:3, 255:23,261:22, 275:10march48:23, 271:24marcum23:7margaret156:16margin36:5, 36:11,

89:13, 245:1,245:10, 246:7margins36:15, 94:12,103:17mariann115:19, 115:21marianne1:18mark106:13, 106:14,111:9, 207:21,232:18marked30:23market13:19, 93:11,93:14, 94:2,94:15, 98:17,99:13, 102:10,102:17, 102:20,106:6, 113:20,272:24, 273:3marketing78:20marketplace13:5, 13:17markets110:4, 145:17martina232:16mary151:20, 156:16mass41:1, 278:22,278:23massive90:5master139:18match256:2material179:4, 179:12math29:14mathematical16:12

matt170:8, 215:15matter8:6, 8:19,8:22, 263:19matters92:24, 103:4matthew88:11, 90:17,97:3, 97:15,147:10, 147:12,147:15maule151:20, 156:16maybe56:11, 197:23,198:2, 198:4,214:16, 250:15,276:20mayo172:15mayor52:10, 86:15,111:9, 236:13mc1:17, 10:6,162:16, 167:3,207:14, 207:16,207:20, 208:2,208:11, 224:1,229:23, 258:9,265:4, 269:16,293:16mcglasson6:11, 162:15,167:2, 223:24,229:22, 258:8,265:3, 269:15,293:15mchenry3:15, 4:15,44:4, 45:10,45:12, 45:13,45:15, 46:2,46:6, 46:8,47:17, 47:18,47:23, 48:14,49:5, 75:14,

75:21, 76:8,77:3, 78:6,78:11, 80:2,81:17, 83:8,84:2, 90:20,91:9, 93:3,93:8, 105:14,105:22, 107:19,107:23, 108:10,108:23, 109:6,109:15, 109:16,113:1, 113:5,114:2, 114:14,114:15, 114:22,122:24, 123:15,123:16, 123:18,124:8, 126:4,131:6, 131:13,131:19, 131:20,131:23, 132:6,132:10, 132:11,134:12, 142:9,150:1, 151:3,151:24, 152:3,152:8, 152:23,153:15, 154:14,155:11, 155:12,155:19, 155:20,155:23, 156:2,156:3, 156:4,175:11, 175:14,190:4, 195:8,202:24, 209:14,209:19, 209:20,271:2, 271:4,271:6, 271:22,272:24, 274:20,275:1, 276:9,276:13, 280:1,280:12mclean165:10mco105:4, 204:2,204:14mcride124:8, 124:9,124:10



mds24:23mdss25:8mean21:12, 25:5,40:17, 46:1,61:3, 91:23,183:22, 184:7,186:1, 200:16,206:18, 208:4,210:17, 211:2,216:24, 221:10,250:24, 252:11,253:23, 263:8,263:9meaning131:20, 131:24meaningful138:22means48:1, 82:14,91:21, 107:21,112:17, 113:4,132:6, 188:20,280:6meant203:5measure107:3measured102:16, 110:5mechanisms20:11med58:22, 71:21,96:22, 192:3,193:7, 193:13,193:23, 196:2,199:10, 209:18media295:14medicaid11:16, 11:17,22:10, 22:14,22:15, 22:23,23:11, 23:15,23:21, 23:24,

24:17, 27:14,27:22, 27:23,28:18, 28:24,29:9, 29:11,29:14, 29:17,30:2, 30:13,30:14, 30:16,31:2, 31:7,31:16, 31:19,31:20, 32:7,32:10, 34:16,35:9, 36:1,37:12, 37:14,38:4, 38:18,38:21, 39:16,58:11, 66:18,67:21, 71:16,71:18, 72:5,72:8, 72:11,74:22, 75:1,75:6, 76:21,93:21, 105:4,114:16, 114:21,114:24, 115:4,115:8, 118:13,131:24, 132:4,146:17, 146:19,146:20, 173:6,173:12, 177:8,177:12, 188:16,188:17, 188:19,188:22, 188:23,189:19, 189:24,201:20, 202:15,202:19, 202:23,202:24, 203:4,203:7, 203:14,203:16, 204:2,204:14, 225:3,247:19, 248:2,248:3, 248:5,248:11, 248:19,249:1, 249:2,249:14, 289:20medicaid-heavy38:7medicaid-pending30:7, 30:11,

30:21, 31:24medical4:10, 4:13,47:24, 48:1,60:19, 61:7,74:7, 78:10,84:2, 84:3,84:7, 91:11,96:13, 100:9,102:14, 111:13,114:5, 114:11,115:3, 116:22,119:6, 119:12,119:17, 128:21,129:5, 129:9,129:16, 129:20,130:1, 132:15,132:20, 132:23,134:13, 136:4,138:1, 138:14,139:2, 139:12,148:14, 152:12,154:16, 155:24,156:1, 156:23,159:7, 161:8,170:4, 170:8,172:12, 172:19,180:2, 181:19,189:1, 191:16,191:17, 192:2,193:21, 193:24,195:9, 195:22,206:22, 213:18,213:19, 218:21,226:7, 226:20,226:21, 226:23,232:23, 235:3,237:12, 241:11,267:2, 267:9,267:17, 272:12,274:14, 277:16,278:11, 285:17medically60:11, 63:2medicare22:14, 22:17,22:18, 22:19,22:20, 37:21,

38:20, 66:17,67:21, 89:15,93:20, 107:3,107:7, 107:15,107:22, 108:1,108:3, 108:5,108:7, 118:13,207:18, 247:18,248:19, 289:14,289:19medication184:20, 184:21,185:3medications242:19, 242:20,242:21medicine132:18, 136:10,136:20, 137:15,182:1, 184:17medicine-trained134:20medline33:4meet34:10, 62:10,73:20, 74:18,76:15, 77:1,81:21, 85:9,86:5, 89:1,98:17, 106:8,144:10, 148:10,190:16, 191:19,196:1, 196:6,196:7, 199:19,199:22, 211:23,217:9, 217:13,220:23, 223:21,244:18, 244:24,245:15, 246:6,248:17, 252:11,286:16meeting1:4, 5:6, 5:7,6:4, 10:11,10:12, 33:19,42:13, 78:16,144:1, 192:7,



196:3, 298:24,299:10, 299:19,299:23, 300:1,300:8meetings7:5, 11:3,16:2, 18:23,42:3, 42:20,149:10, 209:8,240:18, 299:13meets69:19, 99:14,144:4, 196:5,196:8melanie1:23, 303:3,303:23melissa272:15, 281:18members1:11, 2:1,11:19, 12:18,28:4, 30:20,32:24, 33:20,39:17, 39:24,40:4, 47:21,55:13, 57:22,60:19, 63:18,66:13, 70:23,83:6, 104:9,111:8, 149:20,150:3, 150:4,150:6, 150:7,151:15, 154:23,157:3, 157:19,161:24, 169:16,169:21, 171:10,197:1, 228:20,232:8, 261:14,261:23, 272:9,282:5membership18:8memorial175:19, 176:5,203:6memory14:3, 14:8,

28:15men261:18, 278:20mental53:16, 53:17,53:24, 54:5,76:11, 76:13,77:20, 77:24,78:7, 78:15,101:7, 231:20,233:14, 233:18,233:20, 234:2,234:6, 234:15,234:20, 235:6,235:9, 235:17,239:1, 241:24,242:9, 242:11,243:2, 252:19mention46:15, 74:20,267:3mentioned24:17, 39:3,39:4, 49:2,124:9, 150:11,192:1, 203:3,228:5, 241:17,243:20mercy's50:5, 51:1,59:23, 63:6,63:15, 63:16,67:16, 71:4,72:2, 82:20,87:5, 88:6,92:10, 92:16,111:12, 154:15,172:21, 181:1,183:17, 189:10,195:3, 195:10,195:11, 195:16mercy-employed60:21mercycare105:2, 105:6,105:11merely87:17, 234:23

merger89:21, 142:3merging90:6, 187:24messages42:1met112:20, 200:17,220:14, 220:16,220:21, 234:2,236:18, 251:17,275:21, 300:1metabolic211:14metabolism174:21method138:23methods79:7metrics90:9metro56:1, 90:20metropolitan56:9, 191:15,192:5mexico286:22mic47:9, 97:9,297:9michael2:8, 43:19,44:8, 44:17,50:4, 64:7,64:8, 81:3,106:13, 106:14,108:22, 109:5,232:5, 261:3,267:23micro86:4microhospital50:6, 61:16,63:10, 85:8,85:10, 86:3,86:22, 95:14,

146:2, 152:11,215:2, 215:4,216:18, 216:22microhospitals56:9, 85:13,96:9, 97:21,97:23microphone43:17, 109:1,125:15, 241:9microphones11:24mics12:1middle24:12, 80:8,128:15middle-income105:10might128:12, 137:2,198:12, 205:5,211:3, 299:24migrates149:5mike12:7, 64:13,83:4, 169:9,193:7, 220:12,246:22, 252:18,253:7, 283:18,292:9mike's198:15mikolajczak232:22, 233:13,241:10, 241:13,241:15mile111:16miles55:21, 64:17,70:9, 70:11,79:17, 79:19,81:23, 86:1,121:15million29:16, 32:1,



32:2, 58:15,66:9, 74:1,74:2, 74:3,74:4, 74:5,74:8, 74:14,74:15, 85:16,85:17, 85:18,87:7, 87:9,87:12, 89:9,92:5, 98:22,98:24, 99:3,99:8, 108:1,108:6, 114:8,137:10, 144:7,149:9, 160:19,169:1, 173:8,173:13, 176:6,176:7, 176:8,176:14, 179:2,179:8, 179:10,188:4, 188:5,188:6, 227:2,231:22, 267:18,271:23millions74:11, 176:22milos135:20, 136:3,136:4, 138:4,138:6, 138:10mind130:17, 170:15,207:20, 238:9mine28:20mini209:4minimal183:24minimizes100:16minimum24:22, 68:24,124:12, 148:12,148:14, 191:16,197:17, 217:14minute45:15, 46:2,

46:21, 58:21,64:18, 101:4,121:14, 130:3,130:8, 135:10,137:7, 137:8,137:9, 137:11,175:4minutes7:13, 7:18,43:5, 43:7,43:13, 46:4,47:1, 50:19,50:21, 55:1,57:7, 57:8,57:10, 59:17,60:15, 64:1,66:7, 68:11,70:16, 72:22,75:3, 79:20,80:19, 84:23,95:3, 99:16,101:18, 103:23,106:3, 115:10,117:24, 120:2,121:15, 122:12,124:17, 127:10,130:2, 130:4,134:22, 137:12,138:3, 140:9,140:15, 143:2,143:3, 145:4,146:8, 147:2,149:11, 156:9,270:9, 299:15misleading45:19, 256:20miss43:11, 43:12missing52:8, 108:10,115:22mission110:8, 152:2,152:17, 157:2,189:11misstatements148:2misunderstand196:10

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momentum154:3monday280:24money20:5, 20:13,20:14, 64:2,121:24, 150:14,289:19monitor291:8monopoly143:16, 155:12month277:2, 277:3monthly298:3months13:3, 16:2,31:7, 32:12,32:13, 33:2,33:6, 48:24,81:19, 144:6,218:18, 280:19,291:20monticello98:22moody's103:11morado2:6, 8:4, 8:17,9:7, 9:12, 9:22,10:23, 12:2,38:16, 43:22,44:16, 44:20,44:24, 51:24,52:17, 55:10,64:6, 73:6,81:3, 88:10,97:3, 106:12,115:17, 115:23,125:6, 147:9,151:19, 158:5,165:4, 188:8,219:4, 220:23,221:3, 263:14,265:17, 265:21,295:7, 295:9,



296:6, 297:18,299:2, 299:11moral54:14, 54:20,54:21more8:20, 11:13,18:12, 22:7,25:4, 30:2,31:7, 33:13,35:3, 35:4,39:16, 39:22,42:4, 44:14,52:16, 56:14,56:22, 56:23,57:4, 60:14,62:16, 64:2,64:18, 68:1,71:12, 72:5,72:7, 75:13,83:16, 83:23,84:15, 84:17,86:18, 88:9,97:19, 98:20,100:14, 108:13,109:14, 115:23,116:24, 117:1,117:21, 126:19,132:9, 135:11,138:22, 144:5,144:19, 146:17,151:19, 154:5,156:3, 157:10,181:13, 192:10,200:8, 205:7,205:14, 205:20,207:8, 208:23,212:6, 213:22,214:17, 218:9,218:16, 219:22,247:12, 255:8,263:21, 265:18,276:16, 276:17,276:22, 285:20,287:13, 287:19morning12:6, 45:7,50:3, 52:23,

55:13, 57:19,57:21, 59:20,61:24, 62:6,64:12, 68:18,70:22, 78:19,99:23, 106:17,113:13, 118:5,161:6, 236:14mortality280:9mortar14:15, 21:10mortgage33:24mortgaged34:7most13:5, 16:17,17:7, 19:22,24:13, 35:14,38:8, 58:3,59:7, 63:8,63:11, 67:3,70:3, 74:17,83:9, 85:12,87:20, 105:23,107:11, 110:7,111:1, 112:24,115:1, 127:23,131:12, 146:24,185:8, 189:19,208:24, 238:8,238:9, 238:10,238:14, 249:24,255:4, 277:7,280:22, 287:6mothballed174:3mother128:5motion7:3, 7:6, 8:8,8:15, 8:18,8:21, 8:23, 9:5,9:10, 9:14,9:20, 10:2,10:3, 10:5,10:11, 10:13,

10:19, 130:12,160:6, 162:5,163:7, 165:24,166:8, 167:17,168:7, 168:12,222:14, 225:10,226:9, 229:9,230:14, 231:3,257:17, 259:3,260:3, 260:5,264:12, 266:6,267:5, 267:12,268:24, 271:3,292:24, 294:20,295:19, 295:21,296:4, 296:23,297:7, 297:18,298:12, 298:14,298:16, 298:22,298:23, 299:3,299:9, 300:10,300:13, 300:20,301:5, 301:19,301:20motions8:2motivation155:16mountains215:18mouth198:15move31:13, 40:19,42:13, 42:15,43:12, 44:15,52:21, 155:4,168:1, 175:20,177:23, 214:13,231:9, 255:13,292:12, 295:10,295:19moved7:7, 8:10,20:3, 40:19,86:13, 160:8,166:2, 168:10,187:4, 226:10,

231:6, 267:7,271:7, 295:22,297:1, 297:2,299:4, 300:22,301:6, 301:18,301:21movement20:5, 20:12,41:1, 106:23,210:15, 211:5,211:17moving11:8, 14:10,20:9, 67:4,67:18, 73:20,171:4, 208:23,226:1mri91:16mris91:14msa197:16, 198:6,201:9, 217:17,217:18much15:11, 18:11,18:12, 42:11,42:22, 56:22,62:11, 71:12,74:12, 91:19,91:21, 116:24,117:1, 117:21,125:4, 156:13,187:8, 191:3,202:3, 202:7,205:8, 209:7,212:10, 220:12,228:9, 230:16,230:17, 238:20,249:15, 249:20,250:9, 259:5,259:6, 262:6,266:8, 273:13,289:20, 290:17multifaceted156:7multifacility33:7, 33:17



multiple62:20, 74:10,75:16, 120:24,127:5, 128:1,139:3, 182:13,275:16, 277:2,278:5, 278:9multispecialty109:9, 121:17,125:21, 127:1,127:8, 156:23,178:9, 178:12,180:2, 182:11murphy1:18, 6:9,6:10, 162:19,162:20, 167:6,167:7, 224:5,224:6, 230:2,230:3, 250:13,251:6, 251:11,251:14, 251:16,251:23, 252:1,252:10, 252:23,253:9, 253:12,253:23, 258:12,258:13, 265:7,265:8, 269:19,269:20, 271:10,293:1, 293:18,293:19, 295:24,298:18, 300:22,301:23murphy's124:19muscle137:15must30:16, 41:11,84:13, 84:15,105:19, 124:12,130:19, 157:11,217:16, 275:10

Nname12:6, 12:9,12:10, 23:5,

43:10, 43:11,43:18, 44:1,44:2, 44:11,44:19, 47:7,47:12, 48:12,50:4, 52:6,52:23, 57:23,64:13, 70:23,75:9, 81:11,85:3, 86:10,88:14, 90:17,92:23, 95:11,97:6, 97:11,97:15, 104:10,106:17, 111:9,113:13, 116:2,118:5, 120:9,122:22, 125:13,125:17, 127:20,129:12, 130:24,131:1, 132:14,135:24, 136:3,141:3, 143:9,145:7, 149:21,149:22, 151:23,153:12, 155:7,156:16, 156:17,161:7, 201:19,207:17, 232:9,246:18, 246:19,248:1, 261:8,274:19names43:3, 44:6,44:14, 143:11naperville159:15nation29:1, 32:9nation's33:4national35:13, 38:6,89:1, 97:17,105:6, 180:22,189:9, 208:7,215:15, 255:16,291:22

nationally116:11nationwide36:6, 47:15,133:20, 171:2,180:8, 180:18,280:8navigate140:1neal132:14, 134:23,135:2near58:23, 68:23nearby57:11, 68:23,83:13, 194:13nearest51:12, 70:9,80:12, 130:3,134:9nearly87:24, 89:7,130:4, 146:24,239:11nebraska131:4necessarily116:17necessary66:3, 101:14,116:9, 121:19,124:3, 142:15,144:13, 206:1,225:2necessity37:18needed14:17, 55:2,62:18, 62:23,63:7, 71:18,89:17, 110:7,112:8, 119:24,121:12, 124:15,129:20, 134:2,139:10, 141:21,141:22, 144:23,146:24, 165:21,

175:6, 175:7,175:21, 192:18,200:5, 206:3,208:24, 209:6,211:9, 212:1,215:14, 249:13,278:7, 284:24needing101:19needs15:23, 17:16,17:17, 17:24,60:17, 65:14,76:1, 76:6,76:15, 77:1,78:4, 78:16,83:10, 84:19,100:22, 101:2,101:7, 109:13,110:21, 112:19,133:9, 137:20,139:4, 139:20,146:15, 155:11,165:17, 178:15,189:1, 190:16,190:18, 205:15,207:4, 216:2,216:20, 222:23,223:22, 233:24,234:23, 240:6,240:7, 240:15,242:6, 253:21,285:5needy126:1negative36:16, 62:12,187:17, 191:12,193:8, 195:7,195:23, 200:7,224:8, 225:9,228:17, 237:20,259:2, 262:2,269:4negatively81:15negatives191:6, 191:11,



194:6, 195:18negotiating105:24neighborhood206:14neighbors9:8neither69:7, 90:23,303:11nelson300:18neonatal159:9nephrologist45:9, 48:2,48:14, 274:20nephrologists46:17, 46:20nephrology48:19, 275:11nerve121:11net102:16, 173:13,176:8, 188:3,244:24, 245:10,246:6network12:13, 28:10,291:11, 291:16neurons137:10neurosciences235:15neutrality54:20, 54:22never86:24, 151:10new5:3, 16:4,21:18, 26:9,26:10, 26:16,33:15, 34:4,34:6, 39:9,47:20, 48:16,49:6, 49:7,49:9, 49:23,

53:11, 56:1,56:10, 59:2,60:1, 61:18,62:18, 63:17,67:17, 68:21,71:5, 71:15,76:24, 82:14,86:22, 92:6,95:14, 95:16,95:19, 95:23,96:3, 107:2,109:24, 112:23,114:12, 119:23,141:9, 141:17,146:22, 149:2,149:3, 153:5,154:5, 157:10,171:2, 173:9,173:10, 175:22,191:14, 231:5,231:21, 233:6,236:17, 238:6,241:7, 245:7,284:7, 296:16,296:20newborn118:12news105:6, 282:21next7:23, 9:24,10:20, 13:2,25:5, 43:1,43:15, 47:6,48:11, 50:2,51:23, 51:24,52:21, 55:5,55:10, 57:18,59:19, 60:17,61:23, 63:15,64:5, 64:6,66:1, 68:17,70:21, 73:5,75:8, 77:10,81:3, 83:3,85:1, 86:9,88:9, 90:15,92:20, 93:15,

93:18, 95:10,97:2, 99:22,102:2, 104:8,106:12, 108:20,111:7, 113:12,113:21, 115:17,116:17, 118:3,120:8, 122:20,125:6, 127:18,135:18, 135:19,138:11, 141:1,147:8, 159:1,160:1, 186:5,186:6, 220:6,226:6, 228:12,231:1, 232:16,232:18, 232:19,260:1, 267:1,271:1, 280:11,285:21, 286:22,301:14nice299:24nick268:11nicu113:24, 159:9night80:9, 128:15nightmare53:15nimby151:6nimc80:2nine255:17ninja124:14, 124:21node121:7, 121:10,121:23non-con38:9nonclinical66:22, 66:24,88:4none17:12, 137:14,

162:2, 191:23,222:12, 264:9,292:21nonexistent123:18nonhospital68:4nonphysicians237:17normal23:17, 212:4normally299:23north28:11, 131:3northbrook99:7, 240:23northern14:23, 19:7,19:15, 33:23,34:19, 78:21,149:24northwestern142:3, 186:1,187:24, 188:3,188:6, 188:15,195:5, 235:14northwestern's187:24northwestern-cen-tegra's190:13nose121:8not-for-profit18:16, 41:11note146:18, 219:8noted76:18, 169:7,219:24nothing40:17, 86:18,113:22, 167:18,187:21, 193:9,212:24, 218:6,296:16, 296:20notice165:4, 295:14,



298:6noticed74:13, 284:21november143:23, 169:2,175:17, 227:3nowhere68:23, 234:8,242:16number11:10, 11:19,12:21, 30:21,31:4, 38:22,45:18, 49:22,54:1, 62:12,64:21, 69:12,114:24, 169:5,191:12, 193:16,195:7, 198:24,201:4, 210:3,232:2, 234:1,239:14, 240:14,245:21, 261:18,280:12, 288:15,294:3, 296:9numbers16:13, 38:2,53:20, 54:23,71:3, 71:4,72:4, 74:23,82:14, 203:21,210:15, 250:16,250:24, 253:24,277:8, 277:9numerous68:22, 150:3,184:8, 240:17nuns263:11nurse138:15, 140:14,277:4nurse-practition-er275:16nurse-practition-ers78:3

nurses21:15, 139:2,139:19, 243:17,277:9, 279:9nursing15:20, 16:4,16:15, 16:17,17:12, 19:22,21:14, 22:12,22:13, 22:24,23:8, 23:11,24:20, 25:4,25:10, 25:17,26:2, 27:13,27:18, 30:13,40:20, 41:1,41:2, 98:14,138:13, 139:16,139:18, 150:19,180:6, 236:3,263:5, 272:17,285:13nuss2:10, 300:17

Oo'clock135:8, 236:14oak159:18oaks4:11, 111:14,113:2, 152:21,231:2, 231:4,236:9, 238:13,239:17, 241:5,241:8, 242:4,243:6, 243:10,243:24, 244:3,244:20, 244:21,245:6, 245:14,245:16oath151:14, 248:13ob201:23, 202:2,202:5obama172:5

obama's182:6objective108:16obligation94:14, 94:16obscured98:6observation38:5, 98:15,101:12, 101:20obstetric71:17obstetrics84:2obtain57:4obviously148:18, 228:11occasions242:10, 278:9occupancies59:12occupancy15:22, 17:20,17:22, 48:5,58:22, 58:24,59:4, 69:18,69:20, 81:22,196:1, 198:22,212:19, 239:15,255:22, 256:21occupation226:24occur153:5occurring35:8occurs116:24, 187:22odd144:2off-the-record135:7, 256:6offer34:17, 38:9,71:17, 77:17,77:24, 118:23,

133:3, 133:8,157:15, 216:13,216:17offered35:17, 35:18offering67:13, 105:11offerings105:14, 239:7offers105:2, 157:9office4:10, 4:13,26:5, 33:22,54:15, 61:8,65:5, 78:10,91:11, 111:13,121:9, 131:7,152:12, 172:10,180:4, 180:24,193:16, 226:7,226:20, 226:21,226:23, 238:7,267:2, 267:9,267:17officed193:18officer53:8, 81:13,88:15, 104:12,161:8, 170:8,232:10, 232:20,236:3, 236:4,272:14, 272:17,303:5offices16:22, 275:17officials144:23officio2:1offloading175:22often31:9, 71:18,102:23, 114:4,119:16, 121:3oftentimes214:8, 215:19,



215:24oh6:12, 7:14,69:5, 211:22,221:17, 235:10,254:10, 256:7,263:13, 263:23,281:8, 285:12,297:11, 301:7okay44:13, 44:24,50:3, 52:15,52:17, 55:9,55:12, 80:22,81:10, 97:15,122:21, 125:6,135:19, 151:22,160:23, 170:11,196:21, 204:8,204:15, 216:21,222:8, 222:12,226:1, 226:2,229:6, 247:3,247:16, 251:20,252:2, 256:19,256:24, 257:10,262:11, 264:2,267:1, 267:10,268:21, 276:19,281:20, 282:22,283:23, 284:2,284:9, 284:18,284:23, 285:1,286:22, 286:23,287:15, 290:24,292:17, 295:1,295:8, 300:7,300:10, 301:9old4:19, 21:13,38:7, 41:9,176:1, 182:19,193:5, 197:21,296:17older79:16, 125:24,126:9olympia159:19

on-scene132:23on-site178:17once24:2, 43:11,78:10, 101:9,135:23, 240:16,251:8, 277:2,281:4, 291:18oncology235:15one-half111:16one-minute47:19one-size-fits-all275:4, 278:18one-stop182:11, 228:10one-third67:10, 98:23,99:9ones14:13, 14:14,133:6, 261:24ongoing33:20, 116:9,157:1, 176:18only17:3, 21:5,25:11, 46:12,46:21, 51:2,58:20, 64:22,69:18, 70:1,71:21, 72:9,74:16, 82:8,85:22, 91:9,91:18, 93:7,95:23, 99:8,100:2, 105:7,108:7, 119:8,119:24, 127:4,128:21, 141:13,143:11, 148:7,150:18, 154:12,173:19, 179:14,180:16, 186:10,

186:15, 195:19,208:8, 217:17,233:18, 237:9,239:11, 245:18,247:14, 249:10,250:19, 251:3,251:17, 252:7,261:20, 262:3,262:18, 263:11,275:21, 276:15,282:12, 287:10,299:22open1:4, 7:5, 7:21,47:24, 48:4,50:20, 53:6,87:19, 91:9,91:11, 196:22,212:12, 221:22,221:23, 228:17,263:17, 299:13open-heart61:15, 211:2opened15:1, 15:2,53:4, 55:20,81:19, 91:14,181:24opening46:11, 90:3,92:6, 93:17,161:19opens228:2operate47:24, 98:13,124:10, 131:6,179:16, 283:21operated104:15, 189:2operates47:14, 58:21,130:6, 155:13operating16:18, 16:24,24:13, 33:14,36:5, 36:14,46:3, 46:11,

46:16, 58:23,74:16, 78:11,89:2, 89:5,89:13, 89:24,103:17, 104:12,161:7, 176:8,178:1, 181:21,204:16, 205:4,205:9, 236:4,272:14operation28:22, 34:1,34:8, 89:10,102:6, 176:18,233:12, 251:8operational138:24operations20:16, 64:14,82:13, 90:18,176:9, 272:17operator20:19, 28:1operators41:5, 41:20opiates252:21opinion48:17, 50:5,90:21, 165:6,165:14opinions14:19opponents77:2, 113:16,114:1, 114:15,141:12, 141:23,148:3, 148:11,172:24, 176:13,200:19opportunities11:6, 40:19opportunity11:21, 12:23,12:24, 22:6,40:2, 55:16,57:24, 83:7,138:21, 152:6,



153:22, 154:24,157:3, 165:14,233:2, 241:17,272:18, 272:20,274:18, 282:19,289:2oppose45:11, 47:16,48:15, 50:10,65:4, 65:7,71:1, 95:13,102:9, 145:16opposed86:16, 289:3opposing141:12, 155:17opposite123:23opposition62:3, 62:7,81:12, 85:5,92:22, 93:5,103:12, 133:1,134:10, 147:24,150:10, 160:22,169:5, 192:6,227:6, 232:1,236:24, 237:19,239:18, 258:24,260:23, 267:4,267:20, 268:13,269:5, 272:2,272:23optimal152:6optimum102:11option108:15, 108:17,111:24, 126:23,128:18, 276:1,282:15, 294:3options13:7, 17:13,67:14, 128:8,132:9or-so200:4

order3:3, 6:4, 7:1,7:23, 8:18,8:21, 9:6, 9:8,9:12, 9:13,9:21, 9:24,10:20, 44:11,58:15, 73:19,105:17, 108:11,120:21, 122:4,165:15, 262:19,263:12ordered117:6, 121:1,130:14orderly94:17, 94:22orders3:7, 3:9, 8:1,61:7organization19:4, 33:17,60:6, 63:19,65:1, 102:16,125:23, 172:4,173:11, 179:24,180:14, 182:5organizations13:11, 18:16,37:15, 41:11,180:7, 180:17,180:19, 215:16organized237:23oriented254:14original13:21originally262:19ors173:9, 216:15orthoillinois90:18orthopedic91:2, 173:23,178:16osf159:12

other4:4, 4:17,14:22, 17:5,18:3, 18:17,22:3, 37:1,37:4, 39:19,41:2, 52:13,53:23, 56:20,68:6, 69:4,69:12, 71:24,73:18, 84:12,90:5, 92:11,96:3, 107:3,113:3, 113:21,116:20, 118:15,118:17, 118:20,119:7, 119:8,119:17, 120:22,134:5, 144:22,151:7, 153:8,172:11, 172:18,174:24, 175:12,177:15, 178:22,182:24, 183:9,186:17, 187:11,187:19, 189:14,190:20, 191:21,194:7, 194:10,196:5, 198:8,201:7, 201:15,203:24, 206:10,207:12, 208:2,211:14, 212:13,213:2, 214:5,217:6, 220:9,221:10, 222:10,228:11, 237:16,237:17, 244:24,247:5, 247:22,249:14, 254:12,256:4, 257:7,257:11, 262:6,263:5, 264:7,274:11, 275:5,276:23, 282:20,283:14, 284:1,284:3, 289:20,292:4, 292:18,

294:5, 295:4,298:11others13:12, 18:20,27:6, 30:20,36:7, 65:19,126:11, 146:12,146:18, 147:17,189:12, 189:13,254:24, 263:5otherwise54:13, 303:13ought70:14ourselves250:8, 268:4ourth64:7, 64:8,68:18, 70:17,72:16out8:2, 16:23,22:16, 23:14,24:7, 24:16,25:8, 40:13,40:20, 41:1,65:20, 66:6,72:16, 117:13,117:16, 117:19,150:12, 153:17,175:19, 183:18,184:22, 194:3,205:8, 205:13,210:23, 215:17,217:16, 222:9,234:9, 237:7,242:13, 242:21,246:1, 253:1,262:23, 273:9,296:8outcome38:13, 303:13outcomes83:21, 134:3,180:9, 276:20,276:21, 276:22,290:2outdated141:16



outlived30:3outlook285:15outlooks35:12outmigration75:13, 75:18outpatient63:22, 65:23,67:18, 67:22,68:3, 68:8,68:10, 73:20,77:24, 78:9,91:13, 98:13,99:6, 121:19,149:6, 172:17,173:20, 174:23,192:13, 193:1,194:21, 202:8,210:16, 211:17,216:1, 249:19outpatients67:3, 67:17,202:12outside14:1, 56:18,56:19, 67:23,75:15, 97:14,98:9, 109:15,119:18, 146:20,155:20, 156:3,156:4, 188:17,203:4, 203:15,216:6, 274:11,291:23outsourced98:11outstanding78:12oval180:24over13:2, 23:2,23:9, 27:7,28:2, 31:5,31:11, 37:6,38:19, 39:5,

41:13, 42:14,43:4, 43:24,47:14, 55:20,78:2, 79:10,85:17, 87:9,89:2, 89:3,89:8, 97:10,99:9, 103:3,108:1, 108:6,118:10, 119:22,123:13, 126:1,132:19, 138:15,139:4, 139:22,172:16, 172:22,177:7, 178:8,178:9, 179:16,180:1, 180:18,183:8, 183:12,188:4, 188:5,188:6, 189:6,189:18, 189:22,189:24, 193:2,194:1, 212:11,214:6, 216:9,219:20, 227:18,234:16, 235:10,236:20, 238:5,240:6, 241:9,243:4, 244:16,276:24, 277:6,279:12, 280:1,281:18, 286:23,291:3, 291:11overactive121:23overall107:9, 116:14,256:21overarching76:19overbedded16:6, 17:14overcapacity48:18overdelivering112:13overdue112:10

overhead25:12overlapping131:23overnight101:12, 174:15,174:22, 185:12,185:14, 207:3,207:5overreaching246:8oversee136:7overview233:8overwhelming239:18own16:19, 34:7,37:15, 37:16,61:9, 91:16,93:21, 96:6,104:15, 114:3,121:9, 149:8,150:14, 181:1,245:19, 276:11,284:12, 284:15owned98:4, 274:4owner26:2, 33:16,33:22, 34:4owner-operator34:3owners41:4ownership159:8, 159:15,159:17, 239:4ownerships19:22owns155:13, 284:14oxygen137:8

Pp-a-t-r-i-c-k104:10

packages86:21packets165:5page3:2, 4:2, 5:2,24:19, 38:19,169:7, 256:12,261:1pages1:22paid26:24, 63:23,68:6, 192:20,192:22, 245:22,246:1, 246:5,289:18, 301:16,301:20paige261:10pain128:16, 129:20,159:14pam151:20, 151:23panels193:17panic140:2panicked129:22paoletti272:16, 283:1par153:7paradigm286:10paramedics132:22, 134:4,186:21paraphrasing54:18parent121:3parents121:22, 142:16,142:17park53:13, 261:16



part13:15, 14:23,16:3, 19:5,19:7, 19:12,19:15, 19:23,26:1, 34:18,34:19, 39:6,60:22, 71:2,94:1, 107:6,113:1, 116:12,124:8, 124:19,126:8, 157:5,193:19, 199:12,229:4, 248:3,249:18, 254:16,260:18, 262:20,279:16, 282:7participant233:23participate75:22, 76:1,153:23, 204:2,204:14participation3:14, 42:14,43:2, 43:5,135:11, 135:17,158:3particular39:15, 96:1,110:2, 112:2,112:7, 246:9,249:10, 273:1,278:17, 291:14particularly101:15parties303:12partly114:10partner23:6, 95:12,235:11partnering235:18partners53:5, 139:17,139:18, 206:16

partnership235:22parts53:23, 203:11pass12:3, 31:9,279:12, 282:9,294:19passed23:14, 35:23passes8:15, 9:5,9:20, 10:19,163:7, 167:17,225:10, 230:14,259:3, 266:6,294:20, 296:4,297:7, 298:22,299:9passion138:6past31:6, 49:8,87:5, 99:18,145:23, 193:2,235:10, 274:21,299:23pat97:4pathologist165:8pathology178:4patient25:6, 46:5,49:15, 51:2,51:4, 51:10,51:11, 51:13,61:5, 61:8,61:12, 66:23,67:12, 68:14,98:15, 100:21,101:2, 102:16,103:21, 104:19,107:16, 107:17,107:18, 116:15,116:16, 117:3,117:5, 117:6,

117:8, 117:13,117:15, 117:23,119:4, 134:1,134:2, 139:4,139:13, 140:20,142:20, 155:16,155:24, 156:2,156:7, 161:20,172:9, 172:10,174:15, 175:1,178:8, 178:15,179:15, 180:9,180:14, 184:17,184:24, 185:7,188:21, 195:20,198:13, 199:15,199:24, 205:14,206:11, 214:4,214:8, 227:23,227:24, 228:15,240:15, 242:9,248:16, 248:20,249:10, 249:12,249:17, 249:22,250:7, 254:23,255:9, 255:10,255:13, 275:21,278:19, 279:5,280:23, 281:21,282:12, 284:22,285:4, 285:9,285:10, 285:11,289:17, 294:12patient's117:17, 119:17,285:15patient-centered144:19patient-specific139:9patrick104:10paul135:21, 143:7,170:6pay14:9, 22:16,25:15, 27:22,

35:3, 35:4,58:9, 114:11,126:12, 236:13,239:22, 248:18,249:6, 290:10,301:17payer13:14, 67:12,68:14, 290:3,290:9, 290:10payers22:13, 58:7,91:22, 106:6,249:14paying24:16, 37:23,106:23, 106:24,113:17payment31:18, 31:19,31:21, 33:3,33:6, 33:8,58:7, 68:2,192:23, 197:12payments32:4, 32:10,32:14, 37:19,58:11, 91:21pays22:18, 22:19,67:22, 289:14pd284:24, 285:3,285:24peace54:17, 130:17peak71:23pediatric71:18, 202:12pediatrician120:10pediatrics159:11, 201:23,202:2, 202:5,235:13, 240:9people14:12, 14:19,



18:18, 20:17,21:20, 25:7,40:19, 40:21,41:1, 42:1,42:14, 43:4,43:9, 52:8,53:21, 54:4,54:17, 79:10,83:17, 100:9,146:22, 147:1,150:10, 151:7,151:12, 173:8,175:6, 175:10,177:1, 177:17,181:7, 181:9,182:12, 183:8,183:12, 183:13,183:14, 185:17,186:2, 186:22,188:24, 189:12,189:18, 190:19,190:24, 195:13,215:9, 216:11,227:16, 234:4,234:6, 234:8,234:12, 234:16,234:18, 237:9,237:10, 251:1,252:21, 253:4,287:23peoria75:17per-bed148:4percent15:21, 17:19,17:21, 17:22,27:7, 29:12,29:15, 34:13,35:16, 35:20,36:7, 36:12,46:3, 46:5,46:16, 47:2,48:6, 49:2,68:3, 69:19,75:1, 75:6,75:14, 75:17,79:10, 80:11,

80:16, 82:5,82:18, 89:3,89:13, 90:3,103:16, 105:22,109:14, 112:19,114:17, 114:19,115:1, 115:8,123:14, 133:20,133:21, 142:12,144:22, 155:13,171:13, 171:14,173:6, 173:12,173:19, 173:20,175:3, 175:10,175:13, 176:17,179:14, 186:13,186:15, 186:18,187:10, 187:11,188:16, 188:18,188:19, 188:20,188:21, 190:1,194:1, 199:14,199:16, 202:16,203:16, 210:12,212:5, 212:18,218:19, 219:6,220:20, 234:5,237:13, 237:15,239:15, 247:18,255:22, 256:7,256:21, 280:5,280:7, 284:13,284:17, 286:21,286:22, 286:23percentage27:10, 71:16,109:17, 118:12,139:18, 203:6,254:12, 291:15,291:16, 291:21percentages75:13perceptions156:7performance191:12, 197:4performed67:23

performs126:2perhaps39:22, 223:20peril32:16perilous34:12period27:8, 31:6,101:20, 148:24,218:17, 219:12,273:22, 291:9peritoneal273:14, 273:23peritonitis284:23permanent157:7, 181:15permission73:13permit3:20, 67:9,159:17, 159:18,159:19, 159:20,160:2, 160:6,160:14, 160:17,161:10, 193:14,194:10, 196:16,199:11, 219:11,260:18permits4:7, 104:24,167:19permitted87:1, 148:24person45:6, 126:13,186:23, 213:12,281:7personal30:15, 30:18,33:24, 138:22,296:18personally128:19, 153:1,235:23, 236:18persons125:24, 193:16

perspective28:18, 35:4,35:13, 41:10,91:1, 110:13,150:14, 183:4,183:21, 279:24pertains252:20petitions142:23pharmacy22:20, 37:16,74:7, 178:4,220:4phd184:2phenomenal211:18philosophy273:20pho60:23phone277:7, 277:8,277:9phonetic141:7, 276:7php250:5physical101:8, 159:13,174:24, 210:17,210:24, 226:23physician50:7, 59:21,59:24, 61:5,63:15, 64:14,65:5, 67:16,91:4, 99:24,118:17, 120:15,128:23, 136:10,136:15, 171:18,183:18, 232:24,241:12, 241:18,244:5, 274:4,274:5, 286:24physician-hospit-al63:18, 65:1



physician-managed274:23physician-owned274:23, 275:2physician-run275:2physicians59:8, 60:14,60:19, 60:21,60:24, 61:2,61:18, 63:16,64:20, 64:21,65:2, 76:21,90:19, 90:23,91:8, 92:4,92:15, 114:23,117:20, 118:21,134:21, 136:17,140:20, 178:9,178:11, 178:14,180:1, 181:18,184:2, 193:18,226:22, 227:15,227:20, 228:12,235:3, 236:22,237:5, 237:9,243:16, 275:15,276:6, 279:9,285:20, 285:22,287:12pick186:23picks22:23piece22:20, 108:10pieces16:11pioneer179:22place14:20, 15:8,21:6, 21:12,25:3, 54:19,69:22, 119:8,134:7, 153:7,177:14, 202:24,214:15, 216:9,

217:10, 219:10,236:19, 240:3,252:22, 262:18placed32:14, 242:2,256:3placement234:4, 243:1,243:9places219:22placing93:15plaines160:4, 160:16,233:13plan67:1, 67:16,104:15, 133:3,171:2, 240:8,280:6, 290:8,291:2planned61:15planning28:4, 45:18,45:20, 45:24,56:3, 56:4,57:23, 73:17,75:10, 75:12,82:15, 87:2,87:22, 89:19,93:3, 93:10,94:17, 94:21,144:16, 145:13,148:6, 148:24,153:16, 191:13,192:14, 195:8,205:23, 209:8,209:15, 210:6,212:21, 224:23,233:19, 234:15,238:15, 247:10,258:18, 262:3,262:16, 263:20plans83:18, 89:19,104:12, 105:3,

105:4, 105:5,204:2, 204:14,208:8playing128:9pleaded234:12please6:5, 10:14,10:22, 11:23,43:14, 43:17,43:23, 44:11,44:20, 47:10,51:23, 52:5,55:3, 57:13,64:3, 66:8,68:12, 72:24,73:8, 75:4,80:21, 81:5,81:9, 83:1,84:22, 88:12,92:14, 92:16,95:6, 97:5,99:20, 101:21,104:1, 106:4,106:7, 106:16,109:1, 115:11,115:24, 118:4,120:4, 120:5,122:15, 124:21,125:11, 127:19,130:20, 135:1,135:24, 136:2,138:5, 140:18,140:23, 143:13,147:5, 149:14,156:12, 161:3,166:3, 166:6,168:4, 168:14,168:16, 169:13,170:17, 170:19,188:8, 194:2,195:14, 195:21,196:10, 204:9,207:15, 213:6,215:6, 226:11,231:10, 231:12,231:13, 237:23,

246:18, 257:15,260:7, 260:10,261:4, 271:9,271:12, 271:14,272:6, 272:7,297:9, 297:15,298:17, 300:8,300:23pleased238:24, 293:4pleasure53:2plenty91:3ploszek64:7, 64:8,64:12, 64:13,66:9, 66:12ploy86:18, 88:6pluralistic171:17plus110:18, 124:11,153:4pocket20:7, 22:16point19:9, 19:10,23:21, 96:15,96:16, 107:13,117:16, 117:19,121:16, 141:24,183:2, 194:5,196:3, 198:1,200:20, 207:5,208:13, 220:19,228:22, 241:4,281:14, 288:19,288:24, 289:11pointed72:16points24:7, 45:17,106:20police235:3, 236:21,253:2



policies56:6, 134:14,274:8policy55:23, 56:10,70:12, 70:13,248:14polsinelli268:9poor110:15, 123:15,131:14poorly124:8popularity14:11populated113:1population27:24, 71:8,72:4, 75:2,103:21, 104:16,104:19, 104:20,106:18, 106:23,112:7, 114:6,114:16, 114:18,115:8, 123:9,142:20, 144:20,153:6, 171:7,173:7, 177:24,188:21, 188:22,190:1, 192:15,202:20, 209:13,228:4, 234:16,248:3, 252:15,255:10, 260:17,276:13, 279:7populations109:19, 109:21,110:13, 111:1,115:7, 116:16,240:8portion25:12, 26:19,158:4, 190:23,202:20, 203:18,203:19position36:16, 139:24,

208:17, 235:11positions60:24, 64:23positive35:14, 35:21,41:15, 89:5,103:17, 112:21,154:2, 157:4,157:12, 212:22,224:7, 229:24,238:11possible11:5, 21:8,29:22, 105:15,181:5potential32:21, 48:20,101:7, 108:7,122:9, 299:19,299:21power40:12, 112:21ppo105:5practice50:8, 60:22,116:4, 118:8,119:11, 182:1,193:17, 241:18,273:4, 274:13,275:8, 275:14,275:15, 275:19,279:20, 282:1,285:19practices49:20practicing120:12, 139:19practitioner165:8precedence73:1precedent55:23, 56:1,70:18, 149:3precedential155:1precondition148:13

predators53:8predictable56:6preferably117:22, 249:23prehospital134:5premier29:5, 180:7premium104:22, 104:23premiums208:9prep74:9prepared139:17, 139:19,196:19prescreen205:12prescreens126:3prescription287:22presence3:21, 160:3,161:8, 195:5present1:11, 2:1, 2:5,6:2, 31:23,49:5, 104:11,144:5, 165:15,272:21presentation11:15, 12:5,39:7, 39:14,42:12, 88:23presentations201:22presented38:6, 40:9,87:6, 180:23,296:7presenting101:6presents100:21

president47:8, 55:14,62:2, 64:13,70:24, 73:12,75:10, 85:4,93:12, 99:24,113:14, 143:8,149:22, 151:24,156:19, 170:2,172:5, 180:23,182:6, 232:17,236:4press113:17pressing115:6pressures102:23pretty71:11, 187:8prevention296:19previous176:6previously265:5price100:11, 289:10,290:6prices93:21, 104:23,106:2primarily63:22, 67:17,174:8, 223:18primary56:3, 59:6,79:4, 79:10,94:9, 100:23,120:15, 128:23,136:17, 139:7,171:18, 171:21,182:16, 193:17,227:17prior24:5, 121:11,127:22, 149:10priorities110:21



priority76:12, 78:7,109:12privacy101:6private27:22, 58:7,91:2, 91:22,92:15private-pay14:8, 15:20,29:19, 29:21,30:1, 30:6,31:16privilege236:7, 238:22privileged233:3privileges46:18proactive111:23probably22:21, 174:18,187:14, 194:12,198:1, 201:3,203:22, 205:6,216:23, 219:24problem16:14, 30:8,58:16, 80:1,114:22, 123:1,131:22, 137:2,146:21, 177:3,197:20, 277:18problems40:8, 60:2,109:2, 123:21,131:17, 240:24,279:22procedure121:20, 174:23,178:2, 182:17,182:18, 185:8,211:9, 216:16,220:2procedures67:11, 211:3,

211:9, 274:8,278:7proceed96:6proceedings7:21, 303:6,303:8process11:17, 28:5,30:12, 30:17,31:1, 38:18,96:2, 102:8,121:18, 141:9,153:23, 213:11,224:14, 278:10processes279:18productive54:12products105:12profession34:4professional60:10, 238:7,296:19professionals38:1, 134:5,134:7, 134:16professor78:20proficiently134:5profile5:8, 300:12profiles300:12profit41:10, 41:11,41:13profitability41:5, 90:2profitable181:23, 181:24,183:17, 183:19,245:12profitably181:21

program11:5, 22:10,22:15, 23:2,30:2, 35:9,36:1, 37:21,98:2, 98:7,107:7, 126:3,126:5, 180:21,189:10, 191:22,202:8, 240:23,250:5, 276:12,277:20, 281:23,282:2, 282:14,282:22, 285:18,288:8, 288:9programmed99:12programming76:4programs14:9, 41:20,77:18, 146:11,202:4project's194:7projected56:24, 84:1,84:10, 194:9,195:16, 248:4,258:18, 288:3,288:10projections81:24, 202:15projects62:13, 74:13,82:12, 87:5,89:20, 90:1,97:18, 98:1,99:15, 102:9,109:23, 110:10,122:4, 122:7,128:3, 128:4,129:4, 131:9,145:10, 145:11,149:7, 153:20,153:21, 154:11,155:17, 157:6,194:19, 238:5

prominent60:24promise242:3, 244:4promised46:23promote94:21, 152:2promoting95:16, 291:2prompted235:20promptly135:13proper94:5, 96:21,250:6proper-sized144:12properly176:21properties32:21property34:11, 245:19proportion30:23, 286:15proposal85:15, 85:20,86:18, 87:6,87:8, 110:5,110:20, 112:11,129:15, 142:10,143:21, 181:3,181:6, 182:10,244:7, 288:23proposals87:9, 88:1,111:5, 116:8,120:18, 125:21,157:16, 157:24propose177:19proposed35:22, 45:14,46:3, 46:21,47:20, 50:6,50:19, 55:21,



57:2, 58:21,58:23, 59:5,64:17, 64:19,65:5, 65:8,68:23, 70:10,71:15, 82:9,85:8, 86:1,86:3, 86:17,88:17, 90:1,90:22, 99:1,99:2, 99:5,99:12, 109:23,110:10, 111:12,111:15, 112:23,113:8, 118:19,131:9, 133:3,144:12, 153:20,154:16, 174:12,183:9, 190:14,191:14, 193:10,193:13, 210:3,241:21proposes75:19, 194:11proposing50:15, 71:13,73:15, 84:5,85:7, 87:11,133:13, 160:13,168:23, 177:5,185:6, 200:19,226:19, 231:19,250:21, 251:15,251:17, 252:13,267:16, 271:20proprietor19:11, 19:13,19:14prosecute53:8prospective192:22, 197:12,224:15prospects239:16protect14:17, 94:14,102:10

protectionist144:24protest27:5protocols132:23, 134:7,134:11proud65:16, 150:20proven104:2provide11:9, 12:19,12:24, 21:4,33:14, 41:7,41:22, 56:7,60:18, 62:22,63:2, 63:4,66:3, 71:7,83:13, 83:24,84:14, 101:17,103:21, 105:18,110:5, 110:11,111:17, 120:18,122:7, 123:7,126:4, 131:5,133:12, 133:15,134:3, 139:9,139:12, 153:24,155:16, 181:16,189:17, 195:3,198:16, 198:20,198:24, 199:6,199:8, 206:10,233:7, 234:11,243:14, 244:1,274:24, 282:17,298:7provided31:17, 37:13,63:3, 69:15,93:22, 98:12,102:20, 110:15,199:6, 223:3,236:22, 244:3,265:1, 284:9provider28:7, 32:23,

33:7, 33:9,34:16, 35:15,100:15, 115:3,146:20, 197:9,201:11, 203:4,203:15, 214:5,289:20provider-based91:18providers18:17, 27:4,29:6, 30:10,32:15, 34:9,34:18, 35:7,36:6, 48:21,51:8, 73:18,93:3, 94:1,100:15, 100:24,106:9, 130:17,131:24, 132:5,132:21, 172:8,194:7, 206:9,211:22, 225:1,227:22, 234:5,235:3, 241:23,287:1, 289:18provides56:15, 105:9,136:21, 138:20,189:4providing17:17, 29:9,29:16, 30:5,36:14, 37:24,61:5, 68:8,76:13, 77:16,78:15, 113:2,133:22, 138:23,151:13, 268:14,286:6proximity32:23psychiatric233:5, 236:9,237:10, 242:19,254:18, 254:22psychiatrist136:18, 238:21

psychiatrists78:3, 136:17psychotic256:3public1:1, 3:14,13:23, 42:14,43:2, 43:4,58:7, 76:22,93:13, 94:20,95:22, 96:7,108:23, 109:5,110:12, 122:24,123:3, 123:14,123:17, 124:7,131:13, 133:19,135:11, 135:17,144:23, 155:9,158:3, 161:13,169:3, 169:17,175:9, 227:5,232:1, 233:23,260:23, 265:13,265:17, 267:20,272:1, 299:17publicized142:4pull15:22, 30:6,47:9, 57:20,97:9, 125:15pulled72:4pulmonologist117:5, 117:12purdue78:23, 177:11,184:3purported60:2purpose13:11, 41:22,56:3, 56:6,65:19, 85:13,85:23, 86:5,146:14, 245:8purposes71:7, 148:21,



213:16, 240:21pursuant7:4pursue273:18, 275:13,276:11push154:10, 287:3pushing36:15put16:9, 20:6,21:3, 23:15,23:20, 25:2,26:3, 28:17,40:1, 113:18,173:9, 183:4,183:21, 190:7,193:5, 198:15,228:4, 239:19,262:17, 275:3,287:14, 287:16,295:15, 297:23,300:8puts27:24putting113:21

Qqualify22:17, 26:4,70:7quality21:21, 28:22,38:13, 88:20,89:1, 90:8,90:10, 94:19,102:21, 107:3,107:12, 107:20,112:3, 113:6,118:19, 137:18,150:6, 151:1,152:6, 156:8,171:14, 172:20,180:23, 195:22,198:10, 199:3,207:23, 234:11,

240:22, 274:6,279:10, 282:17quarter24:23, 25:1,25:5, 25:6quarterly298:3, 298:8question16:6, 17:5,17:20, 21:9,149:4, 198:17,199:6, 204:1,209:23, 212:2,218:1, 219:18,245:12, 249:16,250:13, 263:9,283:11, 283:19,290:4, 290:24questioning21:5questions18:3, 19:20,20:20, 39:23,40:2, 42:6,161:22, 161:24,196:22, 197:1,201:15, 201:21,207:12, 214:23,222:10, 223:9,228:18, 228:20,229:6, 244:11,244:13, 247:5,247:22, 248:2,257:11, 262:9,264:7, 268:15,268:18, 289:9,292:4, 292:18,297:15quick15:8, 134:1,140:16, 181:9,233:7, 292:6,301:9quicker117:23quickly30:2, 79:21,130:17, 140:11,

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Rr-o-n153:12r-o-s-n-e-r48:13radiology178:3, 216:16radius183:9raise48:20, 68:9,161:2, 168:15,170:18, 231:11,231:13, 260:9,271:13raised48:14, 223:19,245:13raises19:20raising128:6ralph169:23, 205:24ramification33:1, 33:12ramifications32:6, 33:8ranalli161:9randall80:7

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17:13, 17:22,18:13, 37:20,39:24, 45:5,128:10, 138:21,175:7, 175:16,185:15, 187:6,189:12, 199:5,206:12, 207:1,207:5, 210:14,210:18, 214:19,215:11, 215:12,215:19, 215:24,216:8, 217:8,222:5, 222:17,227:12, 235:8,249:5, 250:18,253:20, 276:10,276:11, 277:11,277:17, 278:15,279:9, 287:14,290:1, 291:8realty244:21, 245:7,245:14, 245:16,245:18, 245:21,245:23, 245:24,246:6reason14:10, 39:6,47:3, 47:22,126:15, 156:6,175:1, 245:15,263:3, 265:18,265:19reasonable89:18, 197:19reasonably37:23reasons16:21, 22:17,50:14, 58:1,59:15, 65:9,65:11, 68:15,102:14, 111:2,111:20, 126:10,157:14, 163:4,167:7, 167:10,167:14, 187:19,

265:4, 266:2,273:18, 277:16rebasing24:1rebasings23:22, 24:9recall11:2recap62:8receive31:16, 37:9,115:2, 119:1,134:19, 137:24,194:24, 240:3,292:12received20:14, 31:18,33:18, 67:8,86:23, 107:23,108:4, 130:1,156:4, 169:4,208:7, 232:2,236:24, 272:2receivership32:20receives27:13receiving20:18, 27:3,30:14, 34:23,35:1, 36:21,83:22, 123:2,123:5, 126:16,130:11, 137:5,279:11recent38:5, 58:13,58:16, 74:14,92:4, 107:11,141:24, 155:19recently10:24, 15:1,33:23, 67:8,93:13, 99:7,117:2, 121:6,128:19, 140:3,179:10, 238:8

recess135:14, 226:4recidivism253:18recipe106:1recipient180:16, 180:22recipients114:21, 225:3recognition94:3, 180:6,189:9, 208:8recognized85:9recognizes67:24recommend104:5, 234:20,298:23recommendation167:4recommendations11:4, 222:18recommended95:20recommends113:9reconsidering73:19reconvene11:7, 135:12record7:14, 38:2,46:10, 61:7,78:14, 116:22,129:5, 150:12,172:12, 172:19,181:19, 213:19,302:5, 303:7recorded156:2records74:7, 119:12,119:15, 119:17,128:22recover29:18



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141:16reflects142:22reform33:21, 35:23,56:18, 197:11reg148:20regard80:5, 245:5,249:6, 296:13regarding33:20, 55:17,79:1, 133:2,169:5, 219:19,224:2, 227:6,227:10, 232:3,268:18, 296:18regardless139:6, 139:14,236:12, 239:21,248:18regards113:23region79:1, 83:12,113:9, 152:16,153:6, 157:10,232:24, 233:16,241:11region's84:7regional90:7, 90:18,134:14, 136:4regionally116:11register15:12regs193:9, 196:11,223:21regular94:2regulation191:14regulations36:13, 134:14,

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16:16, 24:11,25:19, 27:17,56:13, 56:14,78:22, 79:9,117:10, 144:3,160:11, 162:13,162:17, 162:21,165:5, 166:23,168:20, 191:7,222:18, 223:20,224:7, 226:17,229:13, 229:20,229:24, 230:4,231:17, 233:10,238:1, 241:1,245:14, 250:18,255:21, 256:12,260:14, 262:2,269:13, 269:17,269:21, 271:18,272:23, 279:14,297:8, 297:14reported1:23, 58:17,71:23, 79:16,80:11, 114:7,142:5, 171:6,176:4, 176:19reporter11:24, 43:16,43:20, 44:1,44:12, 52:6,97:7, 97:10,136:1, 155:4,161:2, 161:5,166:16, 166:20,168:15, 168:18,170:18, 170:21,204:9, 204:12,231:11, 231:15,246:17, 246:21,260:9, 260:12,268:1, 268:6,271:13, 271:16,297:9, 303:1,303:4reporting171:8, 208:6,

291:16, 298:2,298:7reports4:6, 24:2,24:4, 167:18,298:3represent12:14, 18:13,147:20, 151:14,201:19, 248:1representative28:6, 31:12,153:13, 250:2,295:15representatives35:24, 74:21,169:17representing13:10, 13:11,97:17, 114:17represents18:15, 18:17,29:5, 173:19,176:17request69:15, 111:2,146:14, 156:22,160:17, 161:10,165:13, 165:16,165:19, 166:1,166:12, 175:15,297:24, 298:10requesting73:13, 252:4,260:16requests3:20, 3:22,3:23, 4:3,109:8, 160:3,164:2, 164:3require68:24, 116:12,123:23, 126:20,136:22, 186:15,205:13, 245:11,261:21required33:24, 37:10,

87:22, 148:5,198:24requirement34:6, 70:8,148:15, 191:19,197:5, 197:16,217:14, 245:11,245:15requirements36:13, 93:23,144:2, 171:9,191:13requires31:10, 96:13,96:18, 96:23,149:3, 172:12,182:5, 182:7,193:9, 237:3,295:13, 299:13requiring33:13, 71:16,130:6, 195:20,199:24research18:2, 29:4,109:12, 219:18,286:19researched95:20resemblance87:4reserved54:19, 87:10,87:13reserves188:7residence14:23resident14:17, 29:9,31:9, 31:15,112:2, 127:21,202:22residential96:2residents15:19, 15:23,22:12, 22:24,



26:18, 28:23,29:17, 29:19,30:1, 32:22,36:22, 36:24,50:17, 51:19,55:18, 78:16,78:24, 79:3,79:22, 89:11,108:14, 109:15,111:17, 111:22,112:22, 113:5,114:2, 123:2,123:7, 123:20,124:12, 133:2,136:12, 137:17,137:24, 140:4,144:22, 146:17,151:2, 154:1,155:19, 156:2,156:4, 174:9,184:1, 190:11,194:13, 194:14,202:23, 209:19,209:21, 238:15,247:11, 247:13,252:7residing37:7resolution152:10resource111:18resources30:3, 56:22,58:5, 59:13,60:3, 62:14,92:2, 105:1,109:24, 112:14,141:11, 236:5,238:13, 240:19,242:14respect153:17, 246:13respected85:12respectfully111:2respects144:1

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serve26:17, 56:18,63:1, 67:17,71:15, 72:3,74:22, 76:2,76:14, 77:17,79:11, 81:13,82:2, 84:20,90:19, 102:11,103:22, 119:21,119:24, 122:5,122:13, 133:10,141:4, 142:21,151:23, 189:12,189:13, 202:20,236:12, 238:11,239:1, 240:7,262:18, 279:4served55:18, 62:17,62:19, 75:1,75:6, 86:14,115:9, 126:1serves125:24service59:5, 59:7,59:8, 76:5,77:1, 77:3,79:4, 79:19,83:8, 83:13,84:17, 85:23,86:2, 98:10,103:11, 118:16,126:19, 132:17,159:11, 175:6,193:21, 194:8,200:13, 209:3,213:13, 216:6,218:20, 218:21,218:22, 226:22,239:7, 254:23,261:1, 293:24serving110:3, 115:7,118:10, 146:19,239:20session1:4, 3:5, 3:13,

7:2, 7:4, 7:13,7:17, 7:20,7:21, 8:3,10:21, 39:15,300:2, 300:5set24:22, 55:23,55:24, 67:11,70:18, 219:11,219:12, 303:15sets149:2setting35:1, 35:19,67:5, 68:5,91:17, 103:22,141:20, 149:6,172:12, 250:3settings35:14, 37:2,67:2, 67:19,68:7settlement3:6, 7:24seven7:15, 14:24,165:17, 165:23,204:24, 231:14several16:2, 18:22,38:6, 92:14,102:14, 126:10,128:9, 148:2,191:21, 273:6,273:8severe128:16, 128:20,184:23sewell1:13, 6:7, 6:8,8:10, 9:16,162:23, 162:24,166:2, 166:8,167:9, 167:10,192:14, 197:2,197:3, 199:1,199:4, 200:9,200:11, 200:22,



208:14, 214:14,224:12, 224:13,224:18, 230:6,230:7, 231:7,244:14, 244:15,246:8, 246:22,247:3, 256:9,256:10, 256:17,256:19, 256:24,257:6, 257:10,257:18, 258:16,258:17, 262:11,262:22, 263:7,263:13, 263:18,263:23, 264:2,265:11, 265:12,265:19, 265:22,266:3, 269:23,269:24, 283:11,283:12, 283:23,284:1, 286:14,293:21, 293:22,297:2, 299:5,301:16sewell's211:19sexual101:8sexually53:7shape125:3, 223:12share12:23, 22:6,23:1, 32:5,32:17, 34:15,36:7, 40:9,55:16, 58:1,59:1, 74:23,87:18, 94:15,102:10, 106:19,189:2, 190:9shared29:7, 33:23,34:5, 35:7,107:7sharing170:24, 181:1

shazzad272:13, 283:17,283:24, 288:13,289:7, 294:23sheet38:17, 146:4shelter189:4sheltered13:24, 14:7shen115:18, 115:20,118:5, 118:6,120:3, 120:5shepherd50:8, 50:9,55:15, 59:6,61:1, 64:15,64:16, 64:22,65:16, 66:15,74:24, 80:3,80:10, 115:14,128:20shepley81:4, 86:10,148:23sherman59:8, 62:2,67:8, 80:2shift71:13, 193:1,208:19, 254:14,281:1, 281:2,281:3, 281:5shifting82:8, 146:23shifts56:21, 62:14,82:22, 83:15shocked275:18shopping228:10shore28:12short117:9, 187:6short-stay174:14

shortage36:19, 59:24,60:10, 63:15shortages33:3shortfall29:10shorthand303:1, 303:4shortly15:2, 23:19shortness117:4should14:13, 21:7,21:20, 22:22,58:1, 69:9,72:19, 86:6,88:6, 91:11,92:6, 92:7,98:19, 118:22,128:18, 133:5,134:15, 145:14,151:10, 151:12,169:12, 179:7,182:21, 184:16,187:1, 190:18,191:16, 197:9,197:15, 198:1,209:22, 245:16,276:20, 286:12,296:10shouldn't216:24, 283:13show56:21, 108:16,128:2, 183:3,190:3, 193:20showed71:9, 79:13,190:4shown253:17shows56:13, 175:13,186:6, 214:4sic88:11, 155:22,

222:23sicker21:19sickness130:12side107:15, 146:18,175:24, 261:16sign44:11, 44:20,52:5signature-ir0o4303:19signed142:22, 195:24,237:5, 301:13significance245:2significant30:8, 70:13,80:17, 82:17,98:7, 103:2,109:18, 112:3,112:21, 114:4,117:4, 117:14,157:20, 194:22,202:10, 239:5,239:6, 276:17,280:18, 294:3significantly31:5, 68:9,80:15, 87:15,110:23, 193:3,215:13silberman232:18silver3:17, 4:11,52:20, 53:3,55:6, 55:7,231:2, 231:4,232:10, 232:14,233:1, 233:5,233:22, 235:5,236:9, 237:22,238:6, 238:13,239:17, 239:23,240:1, 241:5,



241:8, 241:12,241:13, 241:19,241:21, 242:4,243:6, 243:10,243:23, 243:24,244:3, 244:20,244:21, 245:6,245:14, 245:16,251:8, 254:18,255:8, 255:19similar98:14, 99:15,153:8, 175:16,194:19, 194:20,205:8similar-sized200:2similarly68:5simple29:14, 174:23,185:8simplest19:2, 86:17simply13:19, 16:23,19:8, 21:1,30:3, 82:22,103:13, 143:19,144:14since11:6, 24:5,25:18, 26:14,26:23, 29:2,55:19, 84:10,104:15, 114:19,127:24, 136:20,176:3, 176:13,181:24, 193:6,239:4, 246:3,274:3single33:16, 33:22,69:19, 105:21,116:21, 150:11,286:7sinking37:22

sir155:3, 208:23,257:3, 294:8sit214:16, 241:5site46:3, 58:21,58:23, 64:17,64:19, 65:6,65:8, 78:10,86:2sites18:19, 50:19,67:5, 98:19sitters243:14sitting17:11, 277:5,277:6situation34:12, 35:11,40:24, 41:16,93:15, 113:20,130:18, 243:17,248:6, 281:4situations14:18, 102:9,132:24six33:6, 62:11,66:9, 174:19,191:6, 191:11,195:18, 211:10,276:2six-bed173:9six-month160:4, 160:13sixth53:1size13:20, 74:10,79:8, 85:19,86:4, 87:3,87:23, 99:9,102:15, 102:17,102:22, 124:2,133:9, 133:24,

139:14, 142:14,153:8, 192:17,193:21, 196:6,223:2sized73:15, 193:4,216:19skilled13:22, 21:13,21:14, 28:15,137:1skills136:22skip244:16skyrocketing58:8, 110:16slack125:7, 125:10,130:24, 131:1sleep178:5slicing124:14slightly41:6slow32:10slowdown30:24small36:11, 46:12,48:16, 49:10,56:1, 69:6,69:12, 69:16,69:19, 69:21,70:3, 72:14,73:15, 91:23,102:18, 103:18,110:19, 116:8,120:14, 120:17,121:3, 121:17,122:6, 133:7,134:18, 138:17,138:20, 139:1,150:12, 155:15,173:2, 173:3,177:5, 181:21,

182:7, 185:6,194:19, 194:20,201:2, 206:24,219:22, 220:5,220:7, 220:8,235:7smaller103:20, 193:3smallest72:17, 72:19smith272:15, 281:18,281:20smooth240:20so-called116:13so-what263:8social142:19, 236:21,237:16, 243:14,277:4society273:17sold19:19sole19:11, 19:13,19:14solution146:21solutions41:4solve60:2, 177:3solved177:3solves146:21some11:2, 11:6,11:9, 11:11,11:13, 12:4,12:19, 12:21,12:24, 14:19,16:3, 16:21,18:17, 21:2,



21:15, 22:3,23:1, 24:9,24:13, 25:3,25:14, 25:24,27:21, 27:22,38:23, 39:3,39:16, 39:17,40:2, 40:13,41:4, 41:5,41:20, 41:24,42:4, 62:8,71:5, 72:4,72:10, 96:14,112:2, 123:16,126:11, 130:12,131:10, 147:23,172:11, 174:14,183:23, 187:15,192:11, 198:1,200:20, 215:17,219:22, 222:19,222:21, 223:9,223:10, 233:9,237:21, 240:24,256:4, 273:7,277:23, 278:10,294:5somebody15:7, 19:17,20:19, 42:19,49:21, 64:10,73:8, 88:12,115:24, 125:11,197:15, 206:7,207:3, 215:6,228:24, 248:8,249:21, 256:2,256:3someone14:10, 30:12,38:20, 49:22,127:19, 207:4,255:4someone's207:7someplace41:3something14:20, 17:24,

18:1, 36:11,41:6, 54:15,69:11, 175:13,176:5, 197:7,201:10, 202:6,214:19, 234:13,247:8, 249:11,252:8, 253:7,280:14, 282:7,294:2sometime179:7, 197:23sometimes14:16, 15:14,16:8, 32:12,69:3, 101:13,120:24, 126:13,200:7, 237:9,255:24somewhat27:5, 245:21somewhere17:18, 26:11,255:24, 289:23son127:24, 128:5,128:9, 128:13,129:17, 140:5soon283:13sore128:12sorely123:17sorry7:14, 9:13,97:11, 135:22,142:16, 160:24,166:16, 184:15,188:8, 204:10,223:7, 254:10,256:8, 268:3,268:11, 300:17sort197:8, 201:8,239:19, 250:3sought173:17

souls139:22sound221:20, 250:24sounds219:8source13:14sources38:8southern19:5, 19:12,34:18southwest261:16space66:21, 66:24,87:10, 87:13,88:4span28:11, 28:13spare137:13speak11:23, 52:20,108:24, 131:7,140:10, 153:18,218:13, 219:4,233:11, 241:17,272:19, 274:18speaker189:21speakers56:20, 153:16speaking39:2, 43:17,45:2, 45:4,62:3, 77:13,81:7, 81:11special136:22, 240:7,241:6specialist121:2, 132:2,171:19, 178:17,227:19specialists137:1, 182:16

specialized113:23, 139:9,235:8, 240:13specialties118:17specialty53:16, 102:5,122:2, 136:21,160:15, 249:18specific11:12, 48:19,62:7specifically79:3, 95:24,131:8, 143:24,190:16, 228:3,295:11, 296:14,296:18spectrum105:17, 105:19,108:11speech165:7spell43:18, 43:24,44:11, 52:5spelled143:9, 149:21spend12:18, 107:21,127:23, 137:9,242:23, 243:8spending27:15, 276:22,289:21, 289:23spent18:22, 107:15,137:7, 190:17spillover157:20spin-off153:4spite284:4spoke16:14, 40:15,123:19, 147:16spoken74:21



sports128:1, 128:10springfield300:1, 302:4square85:19, 85:20,85:22, 87:7,87:8, 87:11,87:23, 98:23,99:8, 99:10,148:9square-foot87:16sr1:17st48:23, 80:4,159:10, 159:12,231:23, 267:19,271:24, 300:11stabilization181:8stabilize51:4, 134:1,174:15, 185:11,185:13, 207:3stabilized101:9, 117:16,174:22, 181:11,182:18, 182:20,185:13, 207:5,255:13staff2:8, 2:9, 15:4,15:6, 15:15,15:18, 34:21,41:17, 48:1,59:9, 60:19,61:5, 64:21,64:22, 74:17,90:23, 126:2,134:21, 165:5,165:14, 165:20,169:4, 169:7,169:16, 191:20,191:21, 196:15,198:18, 199:17,200:24, 206:19,

206:20, 211:21,222:18, 223:11,223:19, 229:19,230:3, 232:3,236:2, 238:1,240:13, 242:6,245:13, 269:3staff's56:13, 69:15,229:12staffed136:15, 136:16,136:24staffing18:21, 25:7,34:20staffs206:22, 207:10stage49:6, 271:5,288:17stagnant176:1stand217:5standard46:13, 46:14,116:24, 144:11,148:5, 148:10,148:12, 148:14,148:18, 191:24,192:7, 192:14,193:5, 193:9,196:2, 196:3,197:6, 197:7,197:14, 197:21,197:22, 198:4,199:14, 199:19,199:22, 200:10,200:17, 211:22,211:23, 214:21,222:22, 251:16,274:12, 279:20standards74:19, 81:22,87:22, 98:18,99:14, 144:1,144:4, 144:9,

148:16, 149:3,182:2, 196:5,196:6, 196:7,196:9, 196:11,197:10, 197:20,214:15, 217:10,251:2, 252:18,282:17standing15:12standpoint190:10, 281:22stands205:21start19:18, 23:3,28:5, 31:11,37:5, 45:2,45:6, 49:14,52:19, 55:10,64:11, 65:12,88:13, 88:14,97:10, 137:5,184:18, 238:3,281:4, 287:13started18:11, 37:17,150:12, 210:18,275:8, 275:9,275:18, 277:18,281:24, 283:16starting23:16starts49:7state3:19, 14:23,15:21, 19:5,19:7, 19:12,19:15, 22:11,22:24, 23:20,26:12, 26:17,28:9, 28:19,30:8, 30:24,31:10, 31:21,32:3, 34:19,35:12, 52:5,53:23, 55:2,

58:11, 60:9,60:11, 66:3,71:24, 72:18,72:23, 74:18,81:20, 84:6,84:11, 84:13,94:23, 95:16,95:20, 96:7,99:14, 99:18,103:1, 103:15,116:5, 135:24,140:1, 144:1,145:20, 150:18,160:2, 162:12,162:16, 162:20,165:5, 169:4,169:6, 175:12,186:7, 186:13,186:18, 188:2,191:7, 191:20,191:21, 200:23,209:14, 209:16,232:2, 233:10,238:1, 243:3,246:17, 252:18,253:6, 255:3,255:21, 256:12,269:12, 269:16,269:20, 272:3,272:22, 274:11,279:14, 288:2,288:13, 289:20,291:23, 292:1state's52:24, 144:3,196:8, 196:11state-funded22:10state-supported243:5stated113:19, 115:2,146:8, 163:4,167:7, 167:11,167:14, 237:13,238:1, 265:5,266:3statement54:16, 80:23,



92:21, 148:22,209:12statements39:11, 246:11states13:6, 18:3,18:5, 38:9,50:14, 66:1,71:6, 82:4,86:23, 102:7,180:11, 180:24,276:14, 286:20statewide32:2, 193:20station271:5, 271:21stations45:19, 48:18,49:4, 204:24statistic212:4statistical191:15, 192:5statistics54:3, 155:23,207:17, 207:21,210:14, 212:4stats150:23status4:6, 167:18,218:2, 241:1,241:3, 243:21statute31:10, 295:18stay119:14, 173:24,174:1, 174:2,185:5, 192:10,192:11, 211:4,216:2, 216:4,221:14, 221:24,253:14, 253:15,253:18, 254:5,254:9, 254:17,255:7, 255:15,255:16, 273:10,276:3, 280:10,

282:21staying192:11, 192:12,270:7steiner52:18, 57:19,57:21, 57:23stellar173:11stenographically303:9step44:9, 116:17steps38:22sterile98:11stern161:6, 161:7,163:9steve12:9, 23:4,23:6, 28:19,29:7, 34:11stiffed114:10still81:21, 96:9,97:12, 117:8,125:1, 125:3,127:23, 141:21,145:18, 190:20,206:7, 212:23,249:2, 292:11stipulations261:13, 262:5stomach128:20stop43:8, 278:9,282:8, 287:6stoplights69:23stopping182:12storage66:23stores34:24

story40:18strategic89:17, 89:19strategy59:21, 64:14,85:4, 232:10streamline179:18street53:15, 186:24streng81:4, 85:2,85:3strength103:5stress94:1, 211:21stressors48:22striking87:4stringent89:23stripped-down97:22, 97:24stroke51:3, 51:16,133:18, 133:20,136:19, 137:10,184:17, 184:18,184:19, 184:24,185:1strong103:10, 104:3,109:7, 116:7,144:10, 157:5,236:11, 274:5strongest106:22strongly122:3, 122:16,135:2, 151:16,157:23, 241:20structure67:10, 142:1,143:19structured112:12

struggle126:7struggles114:5, 131:10struggling215:12stuck289:4students78:23studied180:19, 181:4studies190:3study71:9, 75:22,75:23, 76:11,76:18, 78:6,78:22, 110:22,114:15, 114:20,123:3, 123:13,123:19, 177:10,178:5, 184:2,185:22, 190:4subcommittee3:12, 10:21,11:1, 11:20,12:8, 12:16subdural184:10subject95:23subjects22:7submitted165:19, 165:20,237:11subscriber208:10subsequent4:8, 4:16,168:2, 295:2subsidize37:18subsidy37:14subspecialist131:19



subspecialists131:18subspecialty132:18substance240:12, 249:17substantial96:10, 96:12,96:20, 148:19success181:17successful173:2, 178:19,274:10successfully46:11, 142:15,181:21, 220:10sue73:6, 75:9suffer233:20suffered110:14, 240:10suffering83:19, 133:18,187:20, 239:1,240:11suffers128:14sugar45:22suggest56:11, 149:5suggested197:19suggestions296:10suicidal255:5suite220:3suites174:1, 215:23,220:2summarize187:15summarizing187:5

summary99:11, 117:19,122:3, 187:7summer300:5sundays124:10super143:16, 283:7supervision303:10supervisory139:1supplement105:4supplier33:9suppliers33:5supply33:2support23:23, 24:20,25:10, 49:16,49:17, 49:18,66:23, 74:5,77:5, 77:13,86:23, 98:11,100:2, 102:13,106:21, 109:7,110:19, 111:12,116:7, 118:6,120:13, 125:20,127:12, 128:2,131:8, 140:23,142:23, 145:9,149:18, 151:16,152:10, 153:5,153:20, 154:15,156:21, 157:12,157:15, 157:23,169:5, 199:7,227:6, 232:2,236:22, 239:17,240:16, 257:22,272:2, 274:22,285:15, 293:5supporting49:19, 112:5,

135:3, 146:13,153:1, 154:11supportive28:14, 113:7supports49:11supposed21:4, 262:14supposedly251:3sure13:12, 20:4,21:18, 39:1,42:19, 43:20,43:23, 44:20,45:1, 54:4,73:10, 81:6,128:12, 169:10,196:24, 199:5,200:21, 208:14,218:14, 220:6,220:12, 223:21,227:9, 244:12,272:8surg58:22, 71:21,96:22, 192:3,193:7, 193:13,193:23, 196:2,199:10, 209:18surgeon130:6, 130:15,173:22, 178:16surgeons136:16, 173:23surgery58:22, 61:15,62:21, 68:5,98:8, 126:14,130:6, 130:9,161:11, 174:1,194:21, 205:12,207:4, 211:17,215:23, 216:1,238:9surgical74:2, 74:16,84:2, 84:4,

84:7, 96:13,121:19, 144:7,148:14, 155:24,156:1, 159:16,191:16, 191:17,192:2, 193:21,193:24, 195:9,218:21, 220:2surgicenter67:9surgicenters67:6surprised141:11surprising145:15surrounding18:5, 55:19,82:7, 123:10,193:18survey78:24, 79:7,79:8, 161:13,161:15, 161:16,161:18surveyed234:6survive21:22survived140:6sustainable35:5, 90:9,142:1sustained130:5swear161:1, 170:16,260:7swedishamerican159:8switched236:15swollen129:19sworn161:1, 161:4,168:14, 168:17,



170:13, 170:20,226:14, 231:9,231:14, 260:11,268:5, 271:12,271:15symptoms65:18system23:11, 25:2,41:19, 54:7,63:19, 81:14,82:19, 83:5,84:13, 84:18,85:5, 86:12,89:21, 90:24,93:1, 94:13,94:18, 95:8,103:8, 104:14,105:21, 114:12,116:10, 116:21,116:23, 117:11,117:21, 123:15,124:7, 124:9,139:12, 171:4,171:5, 171:13,171:17, 188:3,188:15, 188:17,188:20, 193:19,194:24, 195:3,197:12, 203:8,203:9, 203:10,203:15, 203:17,209:5, 234:9,265:13, 265:17,287:8system's81:16, 86:16systematic56:4systematically88:3systems67:13, 83:22,90:5, 90:7,90:10, 92:3,92:11, 92:14,93:6, 102:7,103:7, 105:24,

145:20, 145:24,170:6, 185:24,188:2, 189:14,195:4, 219:20,279:19syverson135:22, 145:7,145:8, 147:3,147:6sze232:16, 259:6

Ttable16:9, 43:14,44:19, 52:9,168:3, 168:5,169:22, 226:14,231:2, 231:9,277:5tack205:2tackle103:6tackling213:3tactics145:1take17:6, 21:16,41:8, 42:1,51:2, 51:11,51:13, 51:17,58:5, 59:14,65:14, 73:22,78:11, 122:1,132:4, 134:17,137:4, 150:22,165:3, 175:18,186:24, 187:1,187:2, 205:1,218:24, 223:20,249:12, 250:7,251:20, 255:1,263:16, 268:21,278:18, 287:19,296:14taken16:23, 18:2,

135:14, 188:13,226:4, 303:6,303:8takes201:8, 279:17,280:17taking30:12, 40:1,119:9, 123:23,177:20, 238:20,262:14tale92:7talk13:17, 22:9,88:23, 136:11,174:9, 174:11,176:9, 197:4,205:6, 233:14,252:18, 279:14,286:15talked18:21, 20:22,38:23, 146:18,172:24, 183:1,187:9, 218:23,273:9talking18:23, 18:24,113:19, 142:11,176:13, 200:14,215:7, 215:19talks17:19target34:24, 58:22,58:24, 69:20,81:22, 198:22tasked94:5taught186:21tax287:7taxes26:20, 26:21,27:2, 34:11teaches186:21

team103:5, 169:22,232:11, 236:2,240:5, 279:13,282:3, 282:11,282:22teamwork139:6technical237:23technicians243:15technology73:20, 211:6ted73:7teenager128:6, 256:4tell39:17, 45:3,133:4, 189:23,213:10, 213:21,236:16, 254:17,285:11, 285:14,290:18, 290:22telling36:23, 72:12,74:17, 129:2,155:5, 284:21,285:8temporarily126:13ten236:14tend16:16, 273:16tends281:6tens176:22tenure183:11term53:1, 67:20,107:1, 153:4,215:9, 215:17,216:8, 217:3terminology215:8



terms12:22, 28:21,33:6, 86:18,98:19, 142:12,201:2, 210:2,223:13, 279:23,289:13, 290:10,290:12terrain284:15tertiary206:16test171:20, 214:5testified53:14testimony62:5, 62:7,151:8, 215:1,216:22, 220:1,223:18, 224:2,250:17, 257:21,258:2, 258:6,258:10, 258:14,258:23, 265:1,265:9, 293:13,293:16, 293:19,294:2testing120:21, 121:1,129:2, 179:17,194:21, 228:7,278:5, 278:10tests68:3, 68:4,121:2, 171:23,182:17th26:4, 29:1,32:9, 49:13,169:2, 180:16,180:22, 227:3,260:22thankful191:1thanks57:24, 155:5,241:16, 274:18

thanksgiving124:16theirs85:17theme35:6themselves11:22, 14:14,206:21, 254:24,255:1, 261:24therapies37:16, 228:4,273:10, 273:14,286:22therapist210:17therapists78:3therapy210:20, 211:1,226:24, 282:13,285:2, 286:7thereafter303:9thereby94:12, 246:6therefore208:20theresa135:20, 138:12they'd278:4, 278:5,278:6, 279:10thin94:12thing14:22, 26:8,40:14, 77:6,141:13, 171:3,198:7, 198:8,200:8, 200:11,201:1, 203:13,212:13, 212:22,213:2, 213:12,228:11, 250:16,254:12, 276:23,280:21, 283:6,284:1, 284:3,

284:20things22:2, 22:4,22:5, 22:21,25:15, 25:16,27:10, 39:3,53:22, 71:5,72:15, 101:7,201:7, 217:7,219:24, 279:13,296:10think12:20, 13:9,17:6, 17:15,18:8, 18:9,18:20, 21:3,21:22, 42:8,42:9, 50:17,58:1, 62:9,90:24, 91:7,139:20, 154:10,171:6, 171:11,174:9, 175:11,176:10, 183:23,186:4, 187:14,194:2, 195:1,197:8, 197:18,197:20, 198:9,198:13, 199:10,199:14, 200:23,201:3, 201:7,202:8, 202:16,203:1, 203:3,203:5, 205:3,206:14, 208:13,209:4, 210:10,212:3, 212:8,212:10, 212:22,213:15, 214:24,215:3, 215:12,215:14, 217:15,218:9, 220:23,221:6, 222:21,223:2, 223:9,223:13, 224:14,225:2, 228:6,228:9, 247:9,247:16, 252:6,

252:14, 252:17,253:6, 265:20,276:19, 280:14,283:6, 288:3,288:6, 291:10,293:3, 294:4,294:13, 294:15,300:4thinking193:11, 209:22thinks286:11third33:12, 48:16,62:18, 131:22,144:14, 148:22,188:23, 206:4,281:2, 281:3third-party14:9, 22:13thompson78:20thornburg95:12thought11:7, 117:5,210:4, 212:8,299:24thoughtful112:12, 142:24thoughts222:5thousand54:1, 99:10,192:15, 209:13,234:18, 234:19,234:21thousands180:18thrashed217:2threat128:12, 143:18,255:3threaten188:12threatening185:23



three24:18, 32:5,47:15, 48:24,70:1, 79:7,90:3, 107:19,111:14, 113:1,117:8, 123:4,127:22, 152:21,172:14, 181:24,183:15, 183:16,183:19, 193:2,195:7, 211:4,239:11, 260:11,268:5, 275:15,276:2, 281:10,281:11, 284:14,285:20, 287:16,291:13, 291:20,291:22threshold199:19, 220:22,220:24, 221:2thrilled239:22throat121:9, 140:10through23:13, 29:18,35:9, 54:6,54:7, 116:10,132:21, 152:3,161:12, 197:11,197:23, 199:10,205:12, 239:9,279:18throughout97:21, 120:23,184:4, 194:4,215:18throw126:17, 186:5throwing222:8thrown216:9thursday281:2tidal37:5

tim52:1, 52:4,73:7, 78:19time8:20, 11:6,12:19, 14:20,16:14, 27:7,27:16, 28:6,31:14, 31:23,32:12, 36:17,40:1, 44:14,45:21, 51:6,54:19, 62:6,70:2, 73:3,79:8, 79:20,84:3, 84:10,118:1, 122:1,127:23, 135:24,136:20, 137:5,137:15, 137:16,140:9, 141:19,147:6, 153:17,154:19, 161:20,172:9, 172:10,175:7, 178:24,179:16, 179:21,190:17, 192:9,192:19, 197:10,197:15, 204:3,206:4, 219:12,221:14, 238:3,238:20, 240:4,240:21, 248:10,248:13, 260:19,261:6, 273:22,275:9, 277:23,280:17, 281:10,281:20, 283:2,287:19, 288:24,295:20, 297:19,298:13, 300:2time-sensitive134:23, 136:23timely119:14, 138:1times37:17, 69:4,86:20, 101:4,

124:4, 174:8,177:24, 195:19,199:23, 200:4,209:14, 209:16,215:22, 242:18,276:2, 277:2,277:10, 281:11,287:17, 291:22,300:8timing161:18tinley53:13tired285:5today8:18, 11:15,11:20, 13:4,16:18, 17:21,18:11, 22:9,28:5, 28:17,29:24, 39:7,42:12, 43:3,55:16, 56:20,65:23, 68:20,70:10, 86:11,87:11, 92:14,105:21, 107:2,109:3, 128:2,131:8, 136:11,136:23, 137:22,143:14, 145:11,147:24, 150:2,150:12, 150:22,150:24, 151:8,151:15, 152:24,153:17, 155:1,156:20, 165:12,165:22, 173:10,173:17, 174:11,175:15, 179:6,179:10, 184:17,185:16, 187:16,191:18, 211:3,211:22, 212:1,212:16, 214:16,214:21, 215:3,215:14, 216:24,

223:3, 223:18,232:12, 233:3,235:17, 238:20,239:12, 241:17,242:10, 257:21,261:6, 261:17,262:7, 292:11,293:13today's47:21, 73:20,98:23, 99:4,142:6, 223:21,258:13, 265:8together21:3, 23:15,40:1, 40:11,41:24, 227:20,240:5told129:18, 184:2,248:9, 278:5,278:7, 298:8tom115:23, 122:22tomlinson81:4, 81:10,81:11tomorrow137:23took151:14, 205:7,297:21tool24:22, 281:15,286:6toolbox286:6tools21:6toot181:1top87:18, 180:7,229:1, 290:18topics42:4total31:24, 49:6,



74:1, 79:7,87:23, 107:4,108:8, 114:16,114:17, 143:15,173:20, 175:23,184:14, 188:17,203:9, 203:10,203:15, 203:16,210:19, 210:22,227:1, 288:6totaling155:14totally29:24touch61:11, 237:20touched26:8, 218:9,254:3tougher287:12touting133:1toward97:9, 147:22towards11:13, 222:24town48:16, 49:10tracey147:9, 147:11,169:24, 192:1track46:10, 78:14,129:6, 148:1tracy147:18trade-off194:23, 195:2trades153:15, 153:18,154:15traditional15:5traditionally109:22, 142:19traffic80:7, 80:13,

121:15, 140:1,183:24, 184:3,184:6trained134:6, 186:22,243:15, 276:5,281:22transactions246:13transcript303:7transcripts3:11, 5:6,10:12, 298:24,299:10transfer19:1, 19:9,19:14, 51:5,134:2, 279:19transferred51:3, 51:14,63:12, 101:10,117:18, 117:22transfers30:19transformation116:9, 116:12,116:24transformational234:13transgresses96:21transient273:22transition274:1, 289:3transitioning282:23translation202:3transplant273:15, 275:24,282:9transplantation277:15transport132:22transportation63:4, 76:23,

109:21, 122:24,123:3, 123:8,123:15, 123:17,123:18, 124:7,126:5, 126:9,126:10, 131:12,131:13, 146:7,177:14, 182:14,190:5transported134:8trauma51:15, 57:6,138:18, 178:14,186:11, 186:16,187:3traumatic240:10, 282:11,282:20travel118:14, 119:1,119:7, 120:22,122:1, 124:4,124:5, 131:14,131:21traveled123:24traverse142:20treat53:6, 100:24,101:14, 175:2,186:16, 186:18,249:4, 275:4,278:19, 279:5treated75:15, 140:21,186:14, 192:13,239:12, 246:12,248:21, 249:20treating78:2, 136:18,210:19treatment54:7, 54:10,74:3, 77:21,77:23, 100:17,119:19, 132:22,

140:2, 274:8,288:24tremendous14:1, 19:20,54:24, 103:9,177:9, 193:1tremendously214:6, 282:2trend84:12trent64:6, 64:9,70:23triage134:6triaged100:22, 101:2tribunal147:22tried93:4, 173:16,215:17triple116:13trouble119:8, 151:11,256:11troubles142:4troublesome115:1true39:5, 98:6,103:14, 203:22,205:21, 303:7truly25:11, 122:13,182:4, 220:7truth116:21truthful54:12try28:21, 41:3,116:14, 116:15,116:17, 116:19,177:7, 184:1,216:4, 227:16



trying18:7, 80:1,80:9, 145:18,148:1, 172:24,188:11, 190:22,207:1, 252:9,284:7, 286:10,288:20tuesday1:7, 281:2turkey124:14turn28:2, 68:13,198:17, 241:9turnaround103:9turned89:9, 165:21,165:22twain207:21twice24:1, 43:11,189:8, 210:21two-bed198:21two-minute135:23two-story87:19type35:19, 56:16,86:22, 121:1,138:18, 154:8,186:17, 205:11,248:19types13:7, 13:13,18:18, 134:19,172:8, 180:17,256:5, 274:8typewriting303:10typical93:10typically62:12, 85:14,

85:19, 242:12,255:15, 289:21

Uu-d-y106:18udy106:12, 106:14,106:17, 171:7,171:12, 207:16ultimately28:22, 249:2ultrasound117:7, 121:11,121:12unable34:21, 126:10,126:14, 152:24,198:20unanimously143:23, 175:17unannounced236:5unbelievable179:6, 184:6uncertainty38:11under49:1, 70:4,85:17, 87:1,87:13, 94:16,95:19, 95:24,100:16, 103:15,103:16, 105:9,117:20, 121:14,129:4, 148:24,165:1, 167:18,171:14, 172:4,180:20, 182:6,192:3, 193:7,212:5, 248:13,282:16, 303:10undercuts72:2undergoing13:6undermine95:5

underserved60:7, 60:11,109:22, 110:4,142:20understand112:15, 133:1,142:18, 145:16,166:17, 202:14,203:12, 208:15,220:19, 237:2,237:23, 240:6,265:20, 291:5understanding142:22, 246:15,256:11, 264:16understands142:13, 262:12understood204:17underutilized73:14, 175:18,212:24unexpected240:24unfair109:18unfortunately49:14, 105:14,109:16, 133:19,242:23, 243:8,275:5, 276:19,277:13, 278:10,278:24unfounded63:7, 63:16unidentified52:10, 147:13,147:15, 147:17unique14:6, 91:1,138:22, 190:14unit17:9, 17:10,48:16, 48:24,49:12, 49:15,49:16, 49:20,49:23, 96:18,139:7, 148:14,

159:10, 165:10,173:10, 193:13,198:21, 199:9,199:18, 235:6,254:18, 274:24,275:3, 279:4united86:23, 180:11,180:24, 276:14,286:20uniting103:7units98:14, 98:15,191:16, 192:3,193:3, 193:23,240:8, 240:14,255:12, 256:16,275:6, 276:18,277:21, 278:12,278:13universally69:21university78:21, 78:23,235:16unless210:14, 212:17,282:8unlike53:23unlikely32:2unmet146:15, 190:17,190:18, 190:23,216:11, 216:19unnecessary48:7, 94:7,94:9, 94:24,95:2, 200:12,208:16, 213:22,214:1, 250:14,256:13, 261:1,278:7unpack244:20unprecedented36:1



unsupported148:22until172:10, 277:23,292:12unusual67:1, 94:3unutilized177:20unwavering153:19update4:20, 4:21,36:21, 301:11updated25:18, 26:13,296:13, 296:21,296:24upward280:3urge51:20, 61:20,77:5, 122:16,127:12, 129:8,135:2, 144:24,149:18, 157:23,244:6urgent50:9use19:3, 20:6,20:7, 20:8,20:10, 29:13,46:21, 47:4,56:24, 59:10,69:13, 97:14,104:22, 112:14,128:12, 144:19,174:4, 182:1,215:9, 215:17,297:9useful17:4uses20:13, 276:15using19:6, 19:13,24:2, 24:4,

29:3, 82:14,109:11, 173:17,215:7, 217:3,248:23, 281:14,282:6usually85:15, 277:14,279:19, 281:7utilization29:11, 29:15,46:4, 94:11,195:17, 196:7,199:13, 199:14,205:19, 212:20,220:20, 220:21,221:2, 255:19,258:18, 279:23,280:14, 288:3utilized209:7

Vv-a-n143:9vacation285:5, 285:7,286:2vacuum18:7vain82:1valid17:22, 200:23,222:19, 222:21value20:1, 65:2,82:10, 82:20,106:24, 107:9,108:17, 157:3value-based171:5van135:21, 143:7,143:8, 143:13,145:5, 170:6vanderlaan52:17, 59:20,59:21

variance182:14, 260:4,260:17, 260:18,262:21, 262:24,263:8, 263:10,263:14, 291:18variances262:15, 262:17variations17:16, 19:1variety16:20, 105:2,138:16, 277:15various26:7, 93:23,133:9, 139:8vascular173:22vast133:15vectors201:5vegetable184:12vendors33:1ventilator206:8venture235:22, 237:22verified29:2versus15:13, 20:17,98:10, 121:23,206:24, 253:24,289:12, 290:7vertical172:7vertically104:13, 139:11,179:22veterans53:17vetted90:2via51:3, 61:6

viability30:9, 88:17,188:12, 244:17,245:3viable53:21, 103:13,103:19, 154:9,154:13, 294:2vice1:13, 6:8,8:10, 9:16,47:8, 62:1,64:13, 70:24,73:12, 75:10,85:4, 93:12,99:24, 104:11,113:14, 143:8,150:20, 162:24,166:2, 167:10,170:1, 197:3,199:1, 200:9,200:11, 200:22,224:13, 224:18,230:7, 231:7,232:17, 236:4,244:15, 246:8,246:22, 247:3,256:10, 256:17,256:19, 256:24,257:6, 257:10,258:17, 262:11,262:22, 263:7,263:13, 263:18,263:23, 264:2,265:12, 265:19,265:22, 269:24,283:12, 283:23,284:1, 286:14,293:22, 297:2,299:5, 301:16victims101:8view23:3, 241:4,281:14, 289:11vieweg115:19, 115:21views79:1



village8:6, 8:9, 8:19,8:22, 111:9,111:11, 112:5,113:7, 113:9,236:17violence53:17, 101:8vision100:4, 174:5,238:12visit128:20, 128:22visited235:23visitors126:22visits82:13, 82:16,100:17, 122:2,178:8, 194:20,227:24, 228:1,236:5, 300:3vital109:24, 111:20,126:16, 133:17voice43:6, 97:14voices76:3void243:6volume50:23, 81:23,82:9, 82:17,82:18, 92:10,106:24volume-based171:4volumes59:12, 82:5,82:22, 205:24volunteer126:5vote51:20, 55:3,61:20, 64:3,70:19, 83:1,

137:22, 162:3,166:6, 166:11,201:20, 222:13,223:4, 223:14,223:17, 224:1,224:10, 224:13,224:18, 224:21,225:6, 229:7,257:15, 257:20,258:2, 258:5,258:17, 258:22,264:10, 264:15,265:12, 268:22,292:22, 293:3,293:8, 293:12,294:4, 294:5,294:10, 294:18votes163:6, 165:17,165:23, 167:16,225:8, 230:13,259:1, 266:4,270:4, 294:18voting165:12, 258:9vp66:14vulnerable101:16, 111:1,189:19, 190:2

Ww-2180:1wage34:17wages34:23wait33:2, 97:7,101:4, 301:7waiting234:4, 243:9wakes128:15walgreens93:15, 113:21walk49:21

walk-in67:15walls210:5, 210:8walmart34:24walworth200:1want10:22, 17:8,20:19, 20:23,22:9, 36:9,39:24, 40:9,40:15, 40:19,40:21, 40:24,41:12, 51:9,51:11, 65:8,65:13, 66:1,70:12, 74:20,91:24, 108:15,120:20, 122:13,131:7, 141:13,141:15, 143:16,145:17, 155:17,170:12, 176:2,176:12, 178:10,178:22, 181:3,181:5, 183:22,185:10, 189:12,189:13, 189:15,191:9, 195:6,196:14, 198:6,198:14, 199:4,213:7, 215:10,220:11, 221:9,221:14, 241:19,244:16, 247:7,263:16, 272:23,273:18, 276:24,279:13, 280:16,280:19, 280:23,280:24, 281:4,285:6, 294:4,299:16, 300:3,300:11wanted38:24, 39:6,40:1, 121:11,

145:22, 197:4,198:8, 206:12,208:14, 219:14,237:20, 276:11,301:11wanting83:11wants18:13, 19:17,137:20wash37:6washington33:19waste51:5watched211:15, 211:16watson90:16, 90:17,147:10, 147:12,147:15wave37:6waxman12:6, 12:7,12:17, 26:8,40:5, 42:23way18:3, 35:9,41:14, 56:5,107:2, 125:15,138:22, 146:17,154:12, 172:5,177:4, 181:5,182:21, 182:22,182:23, 185:15,193:12, 197:6,197:7, 199:5,199:17, 215:8,215:24, 221:23,224:14, 236:6,268:3, 291:11,293:4, 297:12ways17:16, 41:24,209:4we'll22:4, 23:3,



42:20, 43:19,135:16, 181:11,185:3, 185:19,186:16, 211:11,243:5, 243:22,250:7, 255:24,261:6we're7:12, 8:5,8:17, 9:7, 12:4,13:2, 17:21,18:6, 18:24,35:2, 37:6,40:10, 42:15,43:10, 43:12,44:3, 44:13,44:14, 52:8,53:21, 53:24,65:16, 73:15,78:8, 83:20,91:17, 92:16,108:10, 131:17,131:22, 135:9,135:12, 139:21,142:11, 142:13,147:4, 154:9,161:10, 165:22,172:24, 175:2,177:22, 185:6,185:18, 187:10,189:24, 190:22,196:22, 200:13,203:14, 208:23,212:23, 221:19,221:22, 221:23,227:23, 228:17,234:22, 234:23,234:24, 235:7,235:17, 252:9,255:13, 255:23,261:12, 262:14,263:21, 265:18,268:3, 274:6,275:17, 276:22,277:5, 282:20,282:23, 284:6,284:7, 284:10,284:11, 284:21,

285:8, 286:10,286:12, 291:24,295:9, 295:17,295:19, 296:21,298:12, 299:12,300:15, 301:10,302:3we've11:6, 18:22,37:20, 53:22,161:12, 171:3,172:14, 177:17,178:20, 179:23,179:24, 181:4,185:21, 189:1,205:9, 208:6,208:10, 215:16,216:12, 216:15,217:10, 220:6,223:3, 237:7,249:20, 257:21,274:10, 279:24,282:1, 284:21,298:8wealthiest145:20, 188:2webb36:20weber169:23, 191:5,196:18, 199:4,200:10, 200:21,202:1, 202:17,202:22, 203:10,204:20, 209:1,218:13, 218:15wednesday281:1week36:21, 194:17,237:11, 241:19,276:2, 281:11,287:17, 301:14weekends124:20weeks33:18, 35:7,93:14, 117:8,

192:12, 194:17,277:22, 285:2,285:6, 285:24welcome12:23welcomes236:17went42:12, 81:24,147:14, 197:11,199:10, 277:24west28:12, 111:16,175:24, 215:18western69:23whatever22:17, 126:15,192:20, 208:5,212:15, 214:19,215:8, 221:18,264:19wheelchair-bound119:5wheeler151:21, 154:23,155:5, 155:7,156:10, 156:13whenever93:4whereby274:6whereof303:15whether16:6, 21:5,33:16, 121:1,121:22, 219:9,248:18, 248:19,296:10, 299:15whichever218:20, 219:7whoever211:21whole70:2, 174:5,197:11, 219:21,285:16, 289:16

wide136:21, 138:16,217:17widens27:12wife119:5, 119:9,285:4, 285:5,285:7, 286:1willing137:13, 221:7,221:15wilson88:11winnebago105:13wisconsin105:2, 105:7,105:8, 136:8,136:9, 173:4,178:21, 178:23,181:22, 183:10,183:15wish48:4within28:8, 28:19,30:8, 35:1,50:19, 50:21,57:8, 58:20,60:15, 83:21,86:1, 90:2,108:8, 130:2,137:19, 144:16,150:4, 156:5,183:8, 194:24,210:5, 213:15,227:14, 240:9,242:15, 249:23,249:24, 256:17,263:15, 280:16without32:4, 37:10,41:10, 41:15,61:8, 65:24,88:4, 96:7,102:8, 105:15,112:13, 139:23,



146:22, 147:1,198:3, 218:11,238:3, 249:5,249:23, 283:22witness170:20, 303:15witnesses161:4, 168:17,231:14, 260:11,268:5, 271:15woefully54:2women189:3, 189:7,240:10, 261:18,278:21wonder201:13woodstock81:17, 121:14,130:4word156:17, 213:22words198:15, 221:10,238:18, 274:15,281:19work15:10, 15:11,27:4, 35:16,40:11, 41:24,42:12, 64:20,65:3, 69:13,76:15, 78:17,102:7, 118:11,122:1, 136:16,139:8, 143:11,149:9, 165:10,199:17, 206:9,235:19, 273:16,281:9, 281:10,287:4, 287:13worked97:18, 138:16,240:5worker4:5, 165:1,165:6, 165:16,

277:4workers235:2, 236:21,237:17workforce154:6working10:24, 18:1,42:18, 46:5,53:2, 114:5,128:5, 138:20,171:2, 235:9,275:23, 281:7,287:6works41:13, 224:14world14:5, 17:20,36:7, 146:10,180:13, 180:14,190:11worried51:7worry121:22worse276:21, 276:22worst132:24, 242:13worst-case250:3worth19:21, 195:2worthy20:18wouldn't146:3, 179:3,217:13, 262:5,279:20, 283:24wow187:6wrap145:19, 187:9write165:14write-off176:22writing61:7

written43:18, 49:12,49:19, 81:5,283:14wrong14:20, 21:12,72:12, 175:14,210:11

Xx-ray91:17x-rays91:14, 118:17,121:2

Yyeah170:14, 186:21,188:10, 198:23,199:4, 202:1,203:9, 206:18,208:4, 210:7,215:9, 216:23,217:2, 217:19,217:23, 221:9,221:12, 221:22,246:24, 256:17,256:18, 256:23,257:8, 257:9,257:10, 262:22,264:1, 283:21,292:14, 292:16,292:17year23:17, 23:19,26:6, 46:10,50:20, 82:13,84:6, 89:6,105:6, 105:11,107:11, 107:16,108:6, 114:9,126:1, 129:17,130:5, 173:13,176:7, 188:4,188:5, 194:16,194:17, 199:23,200:4, 203:2,

212:9, 234:1,256:7, 285:21,287:2, 289:22,289:24, 291:12,291:19, 297:23year-old80:9, 121:6,123:21, 124:1,127:24, 174:20,211:13yearly29:15years12:21, 21:13,23:2, 23:9,23:10, 24:2,24:11, 24:12,27:1, 29:20,31:6, 40:23,48:5, 49:8,55:20, 79:15,81:21, 84:17,86:13, 86:14,89:2, 90:3,97:19, 102:5,103:3, 105:23,116:4, 118:10,119:22, 120:13,126:22, 127:22,127:23, 129:14,132:19, 138:15,155:19, 172:16,173:16, 176:1,176:6, 180:18,181:24, 182:19,183:11, 189:1,192:10, 192:19,197:24, 210:12,211:11, 212:6,212:11, 218:19,218:23, 220:21,221:4, 221:11,222:1, 222:2,228:1, 235:6,235:11, 238:5,239:11, 240:6,273:5, 274:21,275:8, 275:14,



276:12, 280:11,282:1, 291:12,291:13, 291:20yesterday203:2yo-yo25:5young121:21, 256:4,275:22younger79:17, 192:16,278:21yourself39:3yourselves272:7

Zzahid44:7, 44:16,45:7, 45:8, 47:2zero49:16ziegler102:4, 103:14zip237:4zoning236:18, 240:24,241:4, 241:6

$$1.2271:23$1.829:16$10176:7$10,438107:18$10,909107:17$11587:9$17.274:5$18.9227:2

$2173:13$20032:1, 58:15$200,00026:11$22176:8$24,09029:10$24.3231:22$2689:9, 173:8$3.1160:19$3.674:1$3085:16$30032:2$320108:6$3498:22$3599:8, 144:7$35.674:15$4.674:14$4092:5, 176:14$43179:2$46144:7$48.7176:6$5188:6$50,00026:15$5299:3$685:18

$6627:20, 29:8$66.8267:18$67108:1$68.398:24$785:16$700188:4$7799:3$7987:12$79.5169:1$8,773107:18$8085:17$8187:7

..75290:23.8290:23

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009231:2, 231:3,233:4017:19, 168:3010260:2, 260:3011267:2, 267:6018159:7019159:802226:2020159:17021159:10022159:12, 159:19023159:14024159:1604260:105844:5, 271:1,271:30645:14, 47:20084303:4

11135:13, 135:151.2220:201.3212:9, 218:221.9137:10101:8, 3:11,3:12, 7:19,7:22, 32:18,



40:22, 75:12,81:19, 85:14,89:2, 127:23,159:9, 171:14,175:13, 188:16,193:15, 195:8,209:15, 210:12,210:20, 212:5,218:17, 218:18,218:19, 219:6,221:4, 284:17,286:2110,000173:8, 174:710.0193:2410.5234:1710029:13, 84:17,96:13, 96:19,96:23, 107:13,144:11, 148:14,192:1, 192:4,193:7, 236:20,241:21, 254:13117:5, 71:23,96:22, 193:13,193:15, 202:16,218:21, 236:15,260:1811,000126:1, 189:22111,00085:20, 87:111110.730237:31120148:9, 244:161123209:191130295:111130.525295:12115102:5

129:9, 64:18,86:1, 127:24,135:14, 204:6,204:13, 210:20,235:1112517:1, 17:3,239:13126199:151261451:21128186:9, 186:171324:11, 73:14,73:24, 85:15,86:21, 87:12,100:6, 101:13,101:17, 102:13,109:9, 135:11,141:12, 143:17,144:15, 145:2,145:21, 146:2,168:8, 168:24,174:3, 177:19,177:23, 185:24,189:16, 190:10,207:3, 212:20,212:24, 224:24,233:19, 234:15,238:1513884:8149:9, 113:3,121:6, 124:3,173:16, 184:3,271:5, 271:2114.4289:2214.7115:11540:23, 69:23,82:18, 101:4,132:17, 160:3,

160:14, 186:22,226:22, 255:2415,00085:1915016:20, 17:2151,00087:2315682:8, 194:15,194:161593:18169:9, 44:5,114:17, 129:14,159:17, 159:19,193:17, 250:19,250:20, 250:23,251:3, 251:17,251:21, 252:13,253:11, 255:24,271:1, 271:31603:21160,00087:7162,00087:81643:22, 3:23,4:3, 4:41654:51674:61684:9171:7, 81:12,85:6, 92:23,95:1, 159:7,159:8, 159:10,159:12, 159:14,159:16, 168:4,168:7, 226:7,226:9, 231:2,231:3, 233:4,

260:2, 260:3,267:2, 267:617,00082:1217660:111831:7, 32:13,58:22, 86:14,173:5, 173:17,210:23, 280:19,291:2018033:6184192:2, 193:22,194:1187186:7, 186:8194175:191980192:231983197:241990193:1199323:16199423:20199553:31996104:15199826:24199924:2, 26:241st24:3

2227:7, 33:42(c)(7:52(c)(17:4



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2014239:4, 300:12201527:16, 107:10,107:16, 108:1,143:23, 175:17,186:12, 298:24,300:12201628:21, 49:13,60:8, 72:7,203:2, 298:2420171:7, 10:12,38:2, 75:21,110:21, 123:2,184:15, 260:22,303:1620185:7, 231:23,271:24, 299:192019267:19, 303:182020169:2, 227:32022228:12087153:14, 154:20217:5, 189:122188:19, 203:162264:1023152:21, 216:4,260:19, 262:32314:112421:14, 69:19,138:15, 178:2,178:15, 216:5,218:18, 280:192400253:72519:12, 24:2,

47:2, 69:17,70:4, 97:19,103:15, 179:1,179:6250280:42649:13, 192:42604:12, 72:82674:132775:6, 78:13,89:13, 115:8,132:19, 173:6,173:12, 247:182714:1528116:42972:92954:16, 4:17,4:182964:202975:4, 5:52985:62995:72nd10:12

33226:4, 226:53,500143:153-mile183:93.5289:233.6115:13

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37.546:3, 48:63700209:2038226:5, 288:7,288:9, 288:18,288:21393149:2339679:8

44302:54.675:14026:6, 28:11,49:1, 55:20,123:14, 190:1,199:23, 234:2040,00087:1640027:7, 175:20413142:9, 143:16,155:1442226:2142.946:5433:14, 49:2,179:8, 195:9,212:17, 219:943,000178:8, 227:23431142:8443:15, 74:8,103:144558:21, 86:13,135:10, 135:13

45,503155:244500262:446149:9, 179:104869:16, 242:244929:1, 32:949,000203:149,938114:16

55,000189:75,501142:225.589:13, 289:24503:16, 19:5,19:8, 42:14,43:4, 68:3,78:2, 103:16,133:21, 180:2,221:18, 234:2150,00085:19, 100:9,139:22, 147:1,174:7, 175:6,177:1, 181:7,183:12, 185:17,189:18, 190:24,216:11, 280:2500183:1851,000183:8523:17, 135:15,194:1752,000203:152,154156:1

52.280:1152260:953256:21, 288:11,302:5553:16, 75:14,79:155696:18, 96:2057186:10, 193:2359135:14593209:195th303:16

66.2114:196.474:4, 115:14,254:1860176:1, 199:14,284:18, 288:4,288:760,000110:18600180:1604901:663123:216580:9, 109:14,144:22, 175:1065.480:16

77124:11, 124:15

7,00036:227,500177:7, 189:247087:6, 87:24,96:14, 173:17,173:20, 234:570,000247:11700188:5, 252:8700,00053:21, 234:16,247:12, 247:13,252:773,000227:24730250:147529:12, 29:15,34:13, 234:15,247:10, 247:14,250:20, 251:1,251:4, 252:7,286:2275,00085:22750,000251:17500202:237617:21, 180:16,180:22763301:127815:21, 17:21780194:9

88,000209:218096:14, 130:8,



180:2, 250:22,250:24, 255:228384:48535:16, 35:20,256:789174:2089.82107:14

99.6254:199017:19, 17:22,96:13, 182:19,211:13, 239:15,284:13, 286:23,287:23, 287:2491212:18, 220:20911134:49379:10, 176:1794.19107:1495105:22, 155:139500140:497112:19, 175:3,186:13, 186:1897.97107:1399237:159th152:8



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