ALC - PEER

All right members it's one PM we're going to get started with that I just want to do a little bit of housekeeping we're going to allow the presentation to take place and we want to ask questions during the presentation will save our questions till the end of the presentation and I just wanna make sure today what we're going to cover is an overview of how they arrived at their metrics and how they arrived at their numbers we're not going to be taking any specific questions about specific hospitals so if you're wanting to ask questions specifically about a hospital you're going to say that until it comes to peer when they make their request and then you can make sales what we want to do here is so you can understand how they arrived at their numbers so that you can make notes to yourself so that when that request is made that you'll have an understanding of what the matrix are different things that will help you understand that Senator Dismang him thanks thank you and with that if you'll introduce yourself for the record and you'll be recognized to present thank you thank you my name is Daniel Harlan I am the managing director with Alvarez and Marsal public sector service I have led our engagement with the state looking at critical access hospitals in rural hospitals across the great state of Arkansas with me today is Jon hazel and he is a director in our health care industry group John. Participated and helped lead the day to day team looking at data received from the hospitals and conducting on site reviews that we could of each of these hospitals. Yes you're recognized to start your presentation thank you thank you. I'm as was mentioned our our goal for this morning's or this afternoon's time is to provide an overview of the final report that we wrote on each of the hospitals that we reviewed as mentioned to give you a sense of the metrics that you will see in those in those final reports I understand what is meant by that information. if we move in to the presentation on slide four we want to talk about the hospitals that were included in the review that we conducted for the state. There are twenty six hospitals that are eligible to participate in this review based on criteria that was set by DHS this included a hospital's over non system critical access hospitals for non system non critical access hospitals that were located in counties with a population of fewer than fifty thousand individuals. Of the twenty six hospitals that were eligible to participate in this review eighteen hospitals agreed to participate in their shown on the slide in front of you. There was a group of critical access hospitals and which are hospitals that are smaller in size and fit a very specific definition of licensure and then there is a group of non a real non CH rural hospitals that are generally larger than the critical access hospitals that were. I'm are assessment included two phases of review the first was an analysis of the information provided by each of the hospitals that were part of this process the second phase was an on site review I will talk you through what we did in each of those two phases. I to support our initial that a review request was put out to each of the participating hospitals to provide a range of initial data for our analysis at this job data focused on general organization of the hospital financial information information about the labor in the work force at the hospital operational information about the hospital hospital plans for sustaining operations and then finally information on the physical plants of the hospital. The initial data that we requested included the trailing six months of information from July two thousand twenty two through December two thousand twenty two at that data when we received it was reviewed across six core areas general statistics about the hospital balance sheet metrics payor breakdown I information on the sustainability plan income statement metrics and quality indicators. To do this analysis I want to highlight a few things that we specifically asked hospitals for I'm from a financial perspective we ask for monthly management reports that were hopefully readily available from the leadership of each hospital we asked for audited financial statements as available from the hospital for the last two years that we ask for monthly financial statements balance sheet income statement and cash flow statements if the hospital produced that information. We also ask for the hospital calculated quick ratio which had been future and this and national our program from the fall and we ask for information the paramedics for each hospital we know that there are variations across across the state we also ask for plans around the capital expenditures and three to five years of projected expenses this could be capital expenditures to support patient care or expected capital expenditures for the physical plant. As we moved into our on site review at we requested additional financial data from each hospitals including financial statements from January twenty twenty three in February of twenty twenty three as we completed our analysis we did anchor on the period ending in February of twenty twenty three recognizing that in the time that has transpired since then hospital efforts to implement their sustainability plans other factors could have affected the current and current financial and operating condition of each of these facilities but our goal in looking at this data consistently across each of the hospitals was to allow the state to do an apples to apples comparison across these facilities with a consistent view into key metrics for each of the facilities at recognizing in some cases for good reason the hospital may have calculated metric in a different manner a good example of that would be the quick ratio that was mentioned earlier. Another another thing that came up I'm in conversation with hospitals and differences in calculations I had to do with had to do with board restricted funds that the hospital has held for a variety of reasons. After our initial review of provided data that we scheduled and completed on site reviews with the leadership of every hot each one of the eighteen hospitals that were under review. On site we met with the executive level management team of each hospital a recognized in that hospitals have different corporate structures different people in leadership roles the list provided on the slide is representative of the folks that we met with in some cases a certain executive also had responsibility for for serving as the CEO of the hospital for example. I'm as part of that review we also completed on site walk through of the physical plant walking along the building both with leadership in plant management I to understand the current. Condition of the physical plans for each of these hospitals and we felt that it was important to look at the current condition of the physical plant due to the the shock that is significant physical plant issue can have to the operating and financial stability of a hospital if a key component was to go out of service in some cases it could impact a hospital's ability to continue providing patient care or the cost to repair that significant item I could have a doctoral and detrimental impact on the hospital's current cash position and long term financial position and we felt it was important to understand that to. Overall our goal for the on site reviews was three falls we wanted to make sure that we had a solid understanding of the hospital provided data that we are interpreting it correctly we wanted to understand where there were discrepancies and metrics that we calculated versus metrics provided by the hospital we wanted to gather additional context related to the hospital's operating and financial condition in the hospital's outlook and finally as I previously mentioned to understand the physical conditions of the physical plant. As you read the final report for each of the hospitals there are quite a number of metrics that are critical to understanding the operations and the outlook for a health care facility. There are a handful of metrics that we wanted to briefly draw your attention to that as these are key indicators of the operational and fiscal sustainability of of a hospital I'm specifically I want to highlight six. Key metrics talk through how to understand those metrics and how to read the results for any one specific hospital. The first of those metrics is the quick ratio the quick ratio as an indicator of a state of a hospital's short term liquidity possession and it measures the hospital's ability to meet its short term obligations with its most liquid assets. understands the quick ratio and and the results there anything less than one I E. we'll I'm not enough a short term at liquid assets to cover its short term liabilities is a key indicator of concern for the financial well being of the facility the quick ratio from one to three is generally an indication of reasonable health associated with that facility and certainly a quick ratio above three would indicate strong financial position. Now it is important to note that an indicator like a quick ratio should not be considered the only indicator of the financial well being of the facility. most notably a facility that is struggling with its accounts receivable and collections or its cash position I could very well have a reasonable quick ratio but be struggling in other key areas the next couple met metrics deal with that the second one on the slide is days of cash on hand that's a relatively simple metric based on the available cash and cash equivalents over daily expenditures it's a measure of how long a hospital or facility could continue to operate if you didn't receive any additional revenue based on current expenditures. If you look at the averages on the right the Arkansas averages roughly seventy three days for hospitals the US averages about a hundred ninety two days now this is all facility types and generally speaking below thirty days of cash on hand is a very critical situation for a hospital. and we generally expect hospitals to be north of ninety days so north of three months of of cash on hand at any one point in time with the generally accepted target being closer to a hundred twenty days of cash on hand. The other important financial metrics that I want to draw your attention to is days in accounts receivable that. This is a measure of how efficient the hospital is in its collection of revenue from services rendered to to patients. It's important to note that this is it is knacks that sounds receivable not gross all right in a healthcare setting as many of you are likely aware the the charge the typical charge of a hospital is not always recovered from insurers in particular contractual allowances with commercial insurance insurers usually come back below a hospital's The typical charge rate I similarly hospitals factor in uncollectible certain level of uncollectible accounts so we talk about days in accounts receivable that we're talking about how long it takes to collect on revenue that the hospital expects to actually receive. If we look at if we look at targets four days in accounts receivable the averages for Arkansas and US more broadly as between forty and fifty days as a result if you see a days in accounts receivable below below that range below forty a hospital is doing an excellent job of monitoring its accounts receivable managing its revenue cycle management I if you see days in accounts receivable beyond that range so above fifty days above sixty days that starts to be an area of concern for hospital simply because it's now taking a more than two months to collect revenue for services that have been rendered and certainly changes and days in accounts receivable over time are important trends to watch for a hospital's long term sustainability. The final financial metric to highlight is operating margin this is a metric that's relatively straightforward obviously it is a measure of operating income over total operating revenue and shows how well a hospital is Is is operating Arkansas average around seven U. S. average around three we know that in the hospital space particularly with nonprofit hospitals significance operating margin is never expected the target typically is for these hospitals to to breakeven or be a little bit ahead of that the key thing to watch for here would be a negative operating margin anything above anything above zero is is obviously a hospital that is is doing a good job of its operations past the break even mark. The last two measures really get at Get at how hospital is using its labor to to support its patient volume and service volume and is an important Act aspect of assessing a hospital as it speaks to It speaks to they're operating efficiency and labor is a key input to a hospital's up operations the first of these two metrics is a measure of F. T. over adjusted occupied beds we know that in health care there is they are both inpatient services and outpatient services and we know specifically that that outpatient book of business for hospitals including the ones that we reviewed across the state as an important part of its revenue picture. This metric looks at adjusted average daily census which is a combination of both their inpatient census and in the judgment factor for their outpatient activity. this metric let you look at at at staffing relative to that patient volume as I mentioned. If we look at Arkansas average that's about four point six where the US average is closer to five point seven. I if you look at that range if you see a hospital with a nasty over just shocked paid bad towards the upper end of that range that certainly would be an area of concern where the staffing seems to not match the overall patient volume and service volume for the for the facility I staffing for the Loranger of that range or below and would back the question if a hospital is providing adequate staffing to ensure continued quality of care so it really is a range where you'd expect most hospitals to land. The last metric is related but instead of focusing simply on FTP accounts it focuses on the cost of labor relative to net patient revenue and so this is a reflection of how from a cost perspective how efficient the staffing as we all know that over the last over the last few years and flirtation is cause costs to rise I certainly it's well documented that the costs of providing care in hospitals have increased over time. And so this range this target range that we have listed of fifty to sixty percent is reflective of those increasing costs over the last few years. It's also important to note that that reliance across the healthcare industry on travel nursing contracts which were quite costly generally drove this average opt in can be a factor in a hospital having a very a higher than expected Wipper cost overnight patient revenue. I anything above this range certainly would be warrant warranty an additional follow up anything below assuming that there aren't a quality concerns or that F. T. E. per adjusted occupied bed moving to allow being on the low and is not necessarily indicate in indicator of concern. And those metrics really are invited across or write ups of each hospital that we reviewed and those are critical metrics that will give you a quick sense of the current fiscal in operating position of each hospital. What I want to do now is give you a quick orientation to the structure of each of the hospital sections in the final report at to begin with each section starts with an overview of the hospital all rights an overview of the facility its location it's licensure it's license number of beds and high level operating metrics occupancy rates some of the key high level metrics that we had talked about earlier in this presentation. I do want to highlight what we're talking about that overview that we know that hospitals often are licensed for more beds than their staff for and certainly more beds than than are occupied on an average basis but it's helpful to understand the context facing its hospital. The report then moves from that overview into an executive summary. That executive summary is a high level summary of some of the key challenges facing each of these hospitals of patient volume trends where volume has increased year over year or decreased year over year the financial status of the facility any sort of labor and technology challenges that were discussed with the leadership of each hospital during or reviews an overview of the sustainability plan developed by hospital leadership. and then an overall view of the status of the physical plant is of the hospital and any concerns related to the physical plant. Following the executive summary we provide for each hospital or drive time analysis it's a visual that shows where each hospital is located relative to other neighboring facilities specifically focusing in on a thirty minute drive time not a thirty mile radius but where where people could live to access the hospital within a thirty minute drive. That's shown in green surrounding facilities are there thirty minute drive times are shown in orange an individual you can see where there is overlap in that region with other other neighboring hospitals all right in that visual critical access hospitals are shown in blue other hospitals are shown in red and it's important to note that that visual includes hospitals that were not part of this study so there are larger system hospitals hospitals in more populous counties that are shown on that map in the overlap but we're not included in this in this review. The next two sections in the document relate to the operational and the fiscal condition of each each facility this section on observations related to operational outlook really look at key operational metrics trends and staffing levels those metrics that I mentioned earlier on in the presentation. Additionally in that section we look at trends in patient volume and snap patients services revenue over over time comparing what the last six months of looks like for the hospital relative to their last completed fiscal year I will note that throughout the report and we did use a hospital's fiscal year as they reported which times for some hospitals and in June for other office bills that ends in December. In the physical condition section we have a discussion on the current cash position as I mentioned earlier we look at days of cash on hand revenue cycle management concerns there days and accounts receivable at we have a brief discussion on the dat the current that position for the hospital revenue expense trends a brief discussion of supplemental funding that's been received over the last couple years and not a break even analysis in future capital considerations that were identified either on our on site visit or in documentation discussions with the hospital. The final section of our of our report for each hospital focuses on its sustainability plan. And this is a sustainability plan that each hospital are provided to the state and it is reflective in that discussion of the conversation that we had with leadership at each of the hospitals. I'm in the sustainability plan we provide a summary that shows shows what has been quantified in terms of opportunities by the hospital are breaking down revenue enhancement opportunities as well as expense reduction opportunities we're qualified we do show those numbers I'm I would recognize that not every hospital heads had. Want to find their sustainability plans we also where information was available showed which actions had already been taken by the hospital and which were still pending again hospitals are at various points in this process with some hospitals who have implemented and number of their sustainability plans for other hospitals are still are still planning to execute them. Throughout each of the sections there are a few key tables and charts that I do want to draw your attention to many of these I've talked about as a talk to the sections but there's a chart of key indicators and this is really out what are the key operating metrics and statistics in terms of average daily census occupancy days staffing Exxaro. There's a table that deals with specifically balance sheet metrics the balance sheet line items as of February twenty twenty three and any sort of metric calculated off the balance sheet that would include the ratio the quick ratio days cash on hand is an accounts receivable exciter. I'm the next to financial R. three financial tables include the income statement metrics based on the last completed fiscal year verses at annualized figures for the period running from September twenty twenty two through February twenty twenty three. Additionally we include a table where information was available and supplemental funding that the hospital has received and I can be from a number of different sources including cares Act funds the federal government's a provider relief funds state of Arkansas grants including of funds provided both through our time in the care sacked. The final table to draw your attention to in the report is the break even analysis and this analysis is rates based on the trailing six months of data from September twenty two through February of twenty twenty three and provides break even figures of both the twelve months and the eighteen month mark I'm it's important to note in reading the break even analysis that That we did not analyze one time events while there included because they impact the break even outlook for at for each facility they were not they were not annualized so if there was a grant payments that they received or proceeds from the sale of something those were included in the figures but they were not they were not annualized. And that is the that is a quick overview of of the final reports and the discussion that you many of you have or well read on each of each of the hospitals are included in this in this review and at that will turn it back over. Thank you for your presentation I just wanna make touch one thing if you don't mind if you'll touch again on how your matrix are going to be a little different may be that some of the matrix is that the hospitals might percent so people can understand when they're hospital presents a site but this my strict doesn't match what mine is so they can understand the differences and why we had to do it to get apples to apples absolutely I'm so again a good example of that would be the quick ratio or the days of cash on hand so as we talked with as we talked with leadership of many of the hospitals in cases hospitals maintains a board restricted accounts of funds that may have been earmarked for capital improvements or some other other reason to maintain those dollars that being said in many of those conversations it was acknowledged if those dollars for needed to be used for operating costs they could be with with board approval to give an apples to apples comparison we did calculated it's days of cash on hand a quick ratio and other metrics factoring in all of the available cash and cash equivalents that a hospital had on hand I'm so that is one of the cases where there may be some discrepancies between data data that a hospital has and maintains versus what you'll see in our final report where there were some of those discrepancies we did discuss them and certainly in our on site reviews and meetings with hospital leadership we talked about those discrepancies where we sought to understand why I figure that we calculated was different than what they calculated that the call to. We that was to make consistent calculations across each of the hospitals under review so that it would be possible to get a sense of operating in fiscal condition across all of the hospitals that reviewed to minimize some of those differences and how a certain fines or certain parts of the operation were represented in in calculated metrics thank you very much for that members do we have any questions Senator Dismang recognized thank you and it is just go back to the Page nine or five done so that's the formula is an operational context we do the Arkansas versus the rest of the world I've got a and so I just wanna make sure I understand as we're kind of a by this I mean think. to all hospitals the way that I'm reading it right now I mean if you just kind of skip the first two boxes we collect faster than the national average on our receivables we actually have a higher operating margin. Then other hospitals around the country we have fewer number of employees per your service will so we have fewer programs always per patient than others and then the labor costs net revenues generally the same. and so the ally then is our cash on hand issue which admits of I'm thinking about it. I mean are it's a revenue problem or it's an overhead problem because it's not an employee problem if it were to capital expenditure problem which backing out appreciation so I don't really think that that's what it is what would you what did you see just in general was it a common issue amongst hospitals that were struggling in was it again was it revenue related or is it over it related so it is in the. There are different conditions for each of the hospitals that were reviewed and there was uh hospitals. Across the spectrum of the critical access hospitals across the spectrum of the rural rural hospitals they fell at varying points on each of these each of these metrics so it's hard to make a broad generalization about this group of eighteen hi there are hospitals that had very low cash on hand there are hospitals that had a lot of cash on hand there are hospitals that had very long says an accounts receivable there are hospitals that were very efficient in collecting their their revenue you know these are these are averaging just admire that are shown the specifics of each hospital matter tremendously but on average because we're all billing the same essentially running through the same insurance companies and Medicaid and and everything else I mean there's a there's a lot of common pieces for each one of these hospitals be operating from and I guess what I'm. We'll see the report maybe trying to make sure that I understand is which means that one or two fixes inside a system maybe we'll solve some of the problems because it's been proven to work underneath the numbers that we have right now with the exception of cash on hand generally on average and I stand the county and all that thing will make a big difference I was just curious if there was something that you saw but it sounds like it's just across the board and everybody's getting a little bit differently maybe has a different different deficiency right there there are certainly things that are impacting the hospital industry nationally that are also true in Arkansas right there you know there certainly has been well possible publicized challenges impacting rural hospitals like the ones are included in this review nationally there's been an acceleration of rural hospital closures nationally the increase in labor costs reliance on travel nurses kind of coming out of the pandemic and through the pandemic have impacted hospitals across the across the nation so certainly there are you know systemic changes would have an impact on all these hospitals but there are also unique operating and financial conditions associated with each hospital that need to be considered okay thank you. Senator Irvin you're recognized thank you I'm over here hi a stain on page nine in the metrics and those averages. Am I reading that correctly that these averages are all of the hospitals in the state of Arkansas not just the eighteen or. Are these averages of just the eighteen that you looked at. The averages the averages for this report come from a benchmarking report from the flex monitoring team and so some of these were the the way that the flex monitoring team does the report you can just see the number of hospitals I believe that for the US average is somewhere around thirteen hundred hospitals and Arkansas was significantly lower I believe it was lower than thirty some of the facilities may be a part of that report some of them may not but this these benchmarks were pulled from a specific flex monitoring report they're not of the Arkansas average column that you see is not representative of the eighteen hospitals okay that were part of the review. Okay but we don't know which ones. I have that so not all Arkansas hospitals are listed in this average sat correct it is that is correct do we know which ones are and which aren't because to me that can be a skewed. Metric because we don't know the mix between like an urban in a rule citing and so and then also is are are like UAMS children's hospital those state supported hospitals are they part of this average list. We can we can certainly follow up with the committee on not I we don't know off the off the top of our head but the goal of these averages was to was to provide context right for for these metrics sure what what I would say again if we if we look at each individual hospital that was under under review you know if we if we look at a at a. Daily cash on hand of less than thirty days right obviously that's a that's insurer I understand that but I think more and more so what I'm looking at is the operating margin and that's that could be significantly altered OR skewed if you have included in this list of averages UAMS that would that would skew these numbers or you have all this big system hospitals and not your rule hospitals and that's gonna really skew that number two as a benchmark I mean because I I assume you're giving us these to benchmark The final report against so that we kind of know what the U. S. averages versus Arkansas average and where they stack in with that but my question is I need to really know who are the Arkansas hospitals and the Arkansas average Collins so that I know what kind of mixture they are how they're supported You know and and because that paying system is very different not everybody has cost settlements at the end of the year like UAMS or like children's does And so those costs settlements and and the way that these people are paid is very very different about that to me would skew that Arkansas average number so I am I need more information when it comes to. Creating not benchmark and Hugh those. I entities are. Thank you. Senator Hickey you're recognized thank you and my eyes go be a comment based on kind of the last to come. It's too that you all got because in looking at the thing with Arkansas average in the operating operating margin and then being where it's at and then the cash on hand you know there has to be some other underlying circumstances allow Arkansas to be that way I think so hopefully with questions Senator Irvin you know it asked will get that my other question is going to be as it relates to page twelve he says have a sustainability plan that that you receive from the hospitals themselves. But let me ask you all did you all go into that and to look into that to make sure that those were some type of realistic sustainability plans. So this is sent ability plans we did receive a sustainability plan from each hospital and we talked through each of the each of the items in that sustainability plan the hospital had included in our on site reviews we did not. We did not render a judgment on that the overall sustainability plan in terms of its likelihood to be to be achieved sustainability plans like what was provided require on going on going focus from hospital hospital leadership and monitoring to achieve the results do not agree with that my only thing is with what we're trying to do here is much the same as you know financial institution would do with the loan you know if somebody's pass the past performances been to this to even know we throw six million dollars at on that they're only going to survive for another eighteen months to two years I think that that would be something that we have to know. So I don't know if that was outside of the scope of what we were asked that we always ask for you all to do. Is there a way the if you all got what the FNA that we could incorporate something like that or maybe that's a question for D. F. and a annual but the. Like I say I see because I see the judges said that your just include Norman that was when they did but I think from our standpoint here we need to know if there even realistic. So one and what what I can tell you is that throughout the the write ups for each each hospital it's evident where you know how how well thought through the sustainability plans are based on quantification based on activities already undertaking undertaking and in actually executing not and so you'll see for each of the hospitals where initiatives whether they're qualified or not that were indicated by hospital leadership as having actually executed and acted on and some of those at some of those actions based on the financial information through February that we reviewed it certainly appeared to be impacting their their bottom line whether it was increased revenue or reduce expenses you could start to see that other items in their sustainability plans had just recently been implemented and hadn't yet I impacted their financials. Okay thank you Sir. A representative Ladyman you're recognized for a question thank you madam chair this might be for the share or staff of the report is that available or one is going to be available I don't think it's on our web page. When when we go to see the report my understanding is they're working on getting that report availability to us right now they're still working on the final details and I'm each time I ate hospital makes request we will have that report available to us. So on the agenda tomorrow one of the hospital request I believe is on their mind correct a room it's C. one B. so we won't see all of the data before we vote on one hospital. I've just been informed that DHS will bring information for us in the meeting tomorrow for that is there anyway we can get that in advance so we can look at this a lot of data to absorb during the meeting with someone either DHS come up and maybe speak to that. And when you have a seat if you're recognized introduce yourself and for the record annual recognized. Is it on that Janet man a deputy secretary and Medicaid director for DHS. Mark white chief of staff for DHS you're recognized. The wall all star and then the detector make an ad in so the report there. There are the individual hospital pieces from the report and then there's the report as a whole I know some of you may have seen some individual pieces of some hospitals because those have been part of some discussions that happened last couple weeks as we work through this to get this report pulled together and have this ready so this in a position to be used to make recommendations around funding the larger war itself is I believe still in review it's I think we've we've taken a look at part of that governor's office still reviewing so I can't guarantee you that the four port will be able for full distribution but we'll work through that seeping what we can get it make available the committee in advance of tomorrow I will add to that drew is on a different timetable because of the circumstances of where they are now and they are in a merger that is happening this is about to be culminated and so that's why we're bringing forward early so to speak more others will be coming later and that's why the report itself has been on different time timetable from group. And I would just add that we are trying to take into account the entire report in addition to looking at drew individually so wild that those details are being finalized as we work with a in in India today and others we don't have all of the details what we're trying to keep it in the realm of funding. So I think what you're telling me that drew is an emergency. Yes Sir said they and they have had financial distress for the past few months and we have all spent some time with them and going through some of their financials they do you have I think they will be here tomorrow to answer some questions they have a signed letter of intent they are intending to merge with Baptist on July one into taking that into consideration we've worked with that hospital and others for that funding. And I would add to that I think certainly they they are in a very significant financial condition but it is released to sizes but their condition but also where they are on the road to a structural reforms to address it and they just they are much farther down that process than anyone else's right now so we will get an explanation of the emergency tomorrow before we vote. Yes Sir that that is my understanding that drew will be here tomorrow to answer those questions in addition to I'm a Simba table in and if. Thank you oh one more if you don't mind. recognized up on the report some of these terms or words in here R. their definitions. In that report that define like it inventory I mean that can be a whole bunch of things it does it define some of those general terms the report does define the suite of metrics that are used and why are included throughout the report throughout each section we do explain calculations and how it was arrived at so I think you'll find that sufficient and not in the written report. Thank you thank you Mr. Any other questions members. I see no other questions thank you all for being here appreciate it and I'm sure as we move along these hospitals are way more questions and we'll do those specifically at the time the questions for those hospitals appreciate all all being here. C. and no other business we are adjourned.