Gerald Champion Regional Medical Center (GCRMC) Bond Holder Presentation. March 25, 2014

Transcription

1 Gerald Champion Regional Medical Center (GCRMC) Bond Holder Presentation March 25, 2014

2 GCRMC Presentation Index Subject Slide Number Presentation Participants 3 Hospital History 4-6 Series 2012A Bond 7 FY13 Audited Financial Results 8 Q1 & Q2 Hospital Volumes 9 Q1 & Q2 Hospital Indicators 10 GCRMC Utilization Trending 11 Statement of Operations & Change in Net Assets 12 Bond Covenant Compliance 13 Management Discussion and Analysis Consolidated Balance Sheet 18 Consolidated Statement of Cash Flows 19 2

3 Presentation Participants Borrower Gerald Champion Regional Medical Center Norm Arnold Chairman of the Board Robert ( Jim ) Heckert Chief Executive Officer jheckert@gcrmc.org Michael Rolph, CPA Interim Chief Financial Officer mrolph@gcrmc.org Peter W. Seaman, CPA Assistant Chief Financial Officer pseaman@gcrmc.org Julia Walker-Grinder, MAcc, CGAP Controller jwalker@gcrmc.org Borrower s Financing Counsel John D. Wheeler & Associates John Wheeler Lawyer jdw@jdw-law.com Underwriter Jefferies & Company, Inc. Dean Flanagan Managing Director dflanagan@jefferies.com

4 As a sole community provider, the Corporation faces little competition in its PSA. The Corporation s Service Area As a sole community provider, GCRMC faces little competition in its PSA Primary and Secondary Service Areas Lincoln County Medical Center Beds: 25 (Critical Access Hospital) Primary service area is Northeast Otero County from which approximately 84% admissions originate Current population of County is 65,703 (U.S. Census Bureau estimate for 2011) Gerald Champion Regional Medical Center Beds: 123 County encompasses 6,627 square miles and includes cities of Alamogordo and Tularosa Secondary service area covers a substantial portion of the remainder of Otero County, and the south central portion of Lincoln County In 2011, the most recent Medicare data available, GCRMC had a Medicare inpatient market share of 56.2% MountainView Regional Medical Center Beds: 168 Memorial Medical Center Beds: 286 4

5 The Corporation has benefited from strong strategic board leadership and guidance over the years Hospital opened 26 beds and three providers; innovative relationship with County; Philosophy break even, most affordable care in southern New Mexico 1985 DRG's impact; County no longer able to afford infrastructure support; Board s philosophy changed, recognizing the need to operate as a business to fund depreciation; identified requirement for professional management assistance partnership with QHR initiated Board negotiated first of its kind Department of Defense Shared Facility Agreement transferring Holloman AFB inpatient mission to the Hospital; new hospital opened in its current location 2006 Joint Ventures with local physicians in ambulatory Surgeries and Imaging centers located on Hospital s campus Opened new Gero-Psych Inpatient Unit and Outpatient Clinic; consolidation of Anesthesia, ER and Hospitalist contracts under EmCare 2011 Opened new Patient Tower; Inpatient Rehabilitation Unit; new Medical Office Building; Filed Chapter 11 Reorganization; Achieved Meaningful Use Phase 1 Year * Completed Chapter 11 Reorganization; 340B Program initiated 2013* Approved SPHN Cardiology Joint Venture; Achieved Meaningful Use Phase 1 Year 2 ($900K in Feb); Purchased Radiation Oncology; Upgraded the Linear Accelerator; 340B Retail initiated; Revenue Cycle contract with The Outsource Group; Engaged MedAssets as Revenue Consultant *Updated information from prior June 6, 2013 presentation

6 Overview of the Corporation, Facilities and Service Area Sole community provider in its primary service area with 123 licensed beds and 586 active employees Land, buildings, improvements and equipment comprised of the acute care hospital, central power plant, two medical office buildings and an outpatient surgery center; approx. 294,000 square feet of floor space on 30 acres Original facility opened in 1949; new 99-bed facility opened in 1999; new 47,860 square foot patient tower added 47 beds (35 medical / surgical, 12 inpatient rehab) single-patient private rooms in 2011 DoD Shared Facility Agreement with Holloman Air Force Base, providing inpatient and emergency room services to population of 10,000. The Corporation contracted with Quorum Health Resources ( QHR ) from 1985 through December, 2012 to oversee the operations of the Hospital Facilities; QHR provided the chief executive officer and chief financial officer to the Corporation. Effective December 15, 2012 the contract was terminated. The CEO was hired by the Corporation and consultant engaged as Interim CFO to assist with the operational improvement plan. The permanent CFO has been hired and will arrive April 14 th. Service Area 89 miles north of El Paso Only acute care hospital within 70 miles Approx. 63,000 Otero County population Approx. 25,000 County labor force 6% unemployment 56% Medicare inpatient market share; 84% of admissions from primary service area; 11% of payor mix through TRICARE/Champus/Active Duty Receives additional Medicaid payments as a designated Sole Community Provider; payments were FY13 $2.8M and FY14 $1.7M Medical Services 12-bed Geriatric-Psychiatric unit 12-bed Inpatient Rehabilitation Unit New Wound Care Center 24-hour Level III Trauma Center New, all private room patient tower Hospital-owned physician practices Inpatient and outpatient CAP-certified laboratory services Joint ventures to deliver additional imaging and surgery services New collaboration with Presbyterian Medical Services ( PMS ) for Federally Qualified Health Center in Alamogordo Medical and Radiation Cancer Center Statistics1 FY12 FY13 Net Patient Revenues $98M $101M Patient Days 14,283 14,698 Admissions 3,674 3,483 Surgical Procedures (Includes ASV2) 7,410 6,841 Emergency Room visits 28,192 27,198 Deliveries Outpatient visits (includes ASV2) 60,817 62,197 Medicare Case Mix Index Acute Average Length of Stay Revenues from OP Services 70% 72% 1 Consolidated with non-obligated ASV 6 2 Alamogordo Surgery Ventures, LLC ( ASV )

7 Plan of Finance, Bond Principal Amortization and Security Provisions Series 2012A Bond proceeds reimbursed the Corporation for $33M of prior capital expenditures related to construction of a new patient tower, central energy plant and improvements to roadways $30.6M of Bond proceeds were used to defease the Hospital s Series 2007A Bonds Concurrently with the issuance of the Series 2012A Bonds, the Corporation used its available cash to defease $5.1M outstanding Series 2007B Taxable Bonds and pay approximately $7.4M of Reorganization Plan payments Bond principal payments will commence on July 1, 2016, through July 1, 2042, with a 19.5 year estimated average life Actual Sources and Uses of Bond Proceeds ($000) Sources: Par Amount $ 71,745 Original Issue Discount $ (1,740) Equity Contributions $ 431 Total Sources of Funds $ 70,436 Uses: Project Cost $ 32,311 Refunding of Series 2007 Bonds $ 31,076 Reserve Fund $ 5,218 Cost of Issuance $ 1,831 Total Uses of Funds $ 70,436 Security Provisions Loan Agreement: Bonds secured by loan payments to be made under the Loan Agreement Revenue Pledge: Security interest in Gross Revenues Mortgage: The Mortgaged Estate totaling 30 acres generally consists of the land, buildings, improvements and equipment comprised of the acute care hospital, central power plant, two medical office buildings and parking facilities Debt Service Reserve Fund: Funded at Maximum Annual Debt Service Rate Covenant: 1.10x Long-Term MADS Debt Service Coverage Ratio Liquidity Covenant: 60 Days Cash On Hand 7

8 Audited Consolidated Financial Statements Ending June 30, 2013 and 2012 The Consolidated June 30, 2013 and 2012 Financial Statements for Otero County Hospital Association, d/b/a Gerald Champion Regional Medical Center were presented to the Board by the auditors, EideBailly on October 29, The Audited Consolidated Financial Statements have been posted to the Association DAC website for your review. The auditors have provided an opinion that the consolidated financial statements present fairly, in all material respects the financial position of Otero County Hospital Association, d/b/a Gerald Champion Regional Medical Center and the results of operations, changes in net assets and cash flows for the years then ended in conformity with accounting principles generally accepted in the United States of America. The auditors stated there were no disagreements with management. The audit report has not been included in this presentation. Management is, however, pleased to respond to any questions that are posed by participants in this call. 8

9 GCRMC FY14 Q1 & Q2 Hospital Volumes YEAR-TO-DATE Actual Prior Year Variance Var % Budget Variance Var % Patient Days - Acute 4,448 4,719 (271) -5.7% 4,619 (171) -3.7% IRF 945 1,074 (129) -12.0% 1,206 (261) -21.6% Gero-Psych 1,598 1, % 1,824 (226) -12.4% Total 6,991 7,286 (295) -4.0% 7,649 (658) -8.6% Adjusted Patient Days 20,283 23,468 (3,185) -13.6% 22,831 (2,548) -11.2% Avg Daily Census - Acute (1.5) -5.8% 25.1 (0.9) -3.7% IRF (0.7) -12.3% 6.6 (1.4) -21.9% Gero-Psych % 9.9 (1.2) -12.4% Total (1.6) -4.1% 41.7 (3.7) -8.8% Avg Length of Stay- Acute (0.3) -9.4% 3.3 (0.4) -11.2% IRF (0.4) -3.1% 11.7 (0.0) -0.2% Gero-Psych (0.7) -8.0% 9.0 (0.8) -9.3% Discharges - Acute 1,476 1, % 1, % IRF (5) -5.6% 105 (21) -20.0% Gero-Psych % 203 (11) -5.4% Total 1,752 1, % 1, % Adjusted Discharges 5,098 5,485 (387) -7.1% 5, % Admissions - Acute 1,500 1, % 1, % IRF (10) -11.0% 105 (24) -22.9% Gero-Psych % 203 (7) -3.4% Total 1,777 1, % 1, % Adjusted Admissions 5,160 5,494 (334) -6.1% 5, % Surgeries IP % % OP (44) -8.9% 501 (51) -10.2% Total % 944 (10) -1.1% ASV Surgeries 2,493 2, % 2, % Deliveries % % Emergency Visits 13,630 13,829 (199) -1.4% 14,003 (373) -2.7% Emergency - LWOBS (301) -61.4% 210 (21) N/A % of ER Visits Admitted to IP 10.6% 8.9% 1.7% 19.0% 10.2% 0.4% 3.9% Emergency IP Admissions 1,444 1, % 1, % % Admission Through ER 81.3% 72.2% 9.1% 12.6% 84.4% -3.1% -3.7% Outpatient Visits 30,585 30, % 31,938 (1,353) -4.2% OP% of Revenue 72.2% 71.1% 1.1% 1.6% 66.7% 5.5% 8.2% Observations - Acute % 485 (45) -9.3% MCU (45) -9.5% % CMI - Medicare (0.0850) -5.3% % 9

10 GCRMC FY14 Q1 & Q2 Indicators YEAR-TO-DATE Actual Prior Year Variance Var % Budget Variance Var % Net Operating Margin -0.3% -23.0% 22.7% -0.2% -0.2% EBITDA Margin 18.5% -9.0% 27.4% 18.7% -0.3% Total Net Margin -0.1% -27.2% 27.1% 0.7% -0.8% Deduction % of gross pat rev 59.5% 59.0% 0.6% 60.6% -1.1% Salaries % Net Patient Revenue 27.6% 33.8% -6.2% 28.2% -0.6% Supplies % of net revenue 17.3% 19.3% -2.0% 16.8% 0.5% Expense/Adj Admission 8,755 8, % 8, % Paid Manhours 520, ,268 15, % 448,470 72, % Paid FTEs ( includes contract ) % % FTE's per adjusted occupied bed % % Total Manhours / Adj Admission % % Net Days in A/R (a) (5.0) -8.0% % Net Revenue/FTE $90,712 $78,548 $12, % $101,758 ($11,046) -10.9% Combined Actual Prior Year Variance Var % Budget Variance Var % Paid Manhours 628, ,003 15, % 466, , % Paid FTEs ( includes contract ) % % Consolidated Actual Prior Year Variance Var % Days Payable % Covenants Curr. Mo. Prior Year Target Variance Days cash on hand (b) Debt Service Coverage (c) (0.14) Productivity (d) Actual Prior Year Variance Var % Budget Variance Var % Total Hospital & PPD 89% 83% 0 7.2% 93% (0) -4.3% CMO - Medical Affairs 99% 109% (0) -9.2% 93% 0 6.5% CNO - Clinical Operations 87% 75% % 93% (0) -6.5% CFO - Finance Operations 113% 101% % 93% % CEO - Administrative Operations 110% 102% 0 7.8% 93% % Physician Practice 74% 74% 0 0.0% 93% (0) -20.4% 10

11 GCRMC Utilization Trends 5,000 4,500 27,078 28,905 28,192 27,198 28,165 30,000 28,000 4,000 4,287 4,180 26,000 3,500 3,000 2,500 3,279 2,963 2,993 24,000 22,000 20,000 ER Visits 2,000 2,295 2,268 18,000 1,500 1,925 1,828 1,870 16,000 1,000 14, ,000 Cumulative FY10 FY11 FY12 FY13 FY14 Budget Gero Psych Discharges IRF Discharges Acute Discharges 4,287 4,180 3,279 2,963 2,993 Surgeries 2,295 2,268 1,925 1,828 1,870 ER Visits 27,078 28,905 28,192 27,198 28,165 10,000 11

12 GCRMC Combined Statement of Operations & Change in Net Assets $(000) FY 2014 Operational Performance Combined FY 2014 YTD 12/13 Actual UNRESTRICTED REVENUES and GAINS Patient service revenue (net of adjustments and discounts) 55,407 YTD 12/13 Budget FY14 Budget Adjusted Budget* FY14 Projected FY14 Variance $ $ 57,648 $ 119,640 $ 117,477 $ 111,966 $ (7,674) Charity care (578) (4,632) (8,980) (8,980) (1,736) 7,244 Provisions for bad debts (7,568) (8,003) (15,433) (15,433) (14,579) 854 Total Charity and bad debts (8,146) (12,635) (24,413) (24,413) (16,315) 8,098 Net patient service revenue 47,261 45,014 95,227 93,064 95, Other revenue 2,408 3,821 6,230 6,230 3,834 (2,396) Total revenues, gains/ other support $ 49,669 $ 48,835 $ 101,457 $ 99,294 $ 99,486 $ (1,971) EXPENSES Salaries and wages $ 17,419 $ 16,719 $ 34,589 $ 34,589 $ 34,744 $ 155 Employee benefits 2,165 2,564 5,139 5,139 4,688 (451) Professional fees/ purchased services 12,687 11,025 22,696 23,221 25,582 2,886 Utilities and maintenance 3,608 3,589 7,225 7,225 6,812 (413) Supplies 8,027 7,588 15,996 15,996 16, Insurance 1,066 1,097 2,193 2,193 2,121 (72) Leases and rentals ,572 1,572 1,117 (455) Other 1,159 1,388 2,475 2,475 2,119 (356) Interest 2,112 2,168 4,259 4,259 4,160 (99) Depreciation and amortization 5,218 4,763 9,588 9,588 10, Total expenses 53,930 51, , , ,143 2,411 OPERATING INCOME (LOSS) $ (4,261) $ (2,832) $ (4,275) $ (6,963) $ (8,657) $ (4,382) OTHER INCOME (LOSS) Reorganization Expenses $ (299) $ (210) $ (420) $ (420) $ (568) $ (148) Investment Income/Realized Gains on Assets 212 $ $ 435 (291) Donations 200 $ $ Other income (loss), net $ 114 $ 357 $ 506 $ 506 $ 68 $ (438) EXPENSES IN EXCESS OF REVENUES $ (4,147) $ (2,475) $ (3,769) $ (6,457) $ (8,590) $ (4,821) 12

13 GCRMC Bond Covenant Compliance $(000) Combined Debt Service Coverage Computation: Budget Projected Variance Excess of Expense Over Revenue $ (3,768) $ (8,590) $ (4,822) Plus: Depreciation and Amortization $ 10,000 10, Plus: Interest Expense 4,020 4, Plus: Restructuring (Reorganization) Less: Investment Income Available for Debt Service $ 10,672 $ 6,676 $ (3,996) Maximum Debt Service Requirement $ 5,744 $ 5,744 $ - Debt Service Coverage Ratio (0.70) Debt Service Requirement (1.1:1.0) Favorable (Unfavorable) Variance (0.70) Required Debt Service Coverage to Comply $ 6,318 $ 6,318 $ - Favorable (Unfavorable) Financial Gap $ 4,354 $ 357 $ (3,996) Consolidated Days Cash on Hand Computation: Budget Projected Variance Cash and Assets Available for Use 24,456 25,833 1,377 Debt Service Reserve Fund (5,218) (5,218) - Cash and Assets Available for Bond Compliance 19,238 20,615 1,377 Operating Expense less Depreciation/Amortization $ 91,143 $ 95,252 $ 4,109 Cash Operating Expenses per Day (365 days) $ 250 $ 261 $ 11 Operating Days on Hand Covenant Requirement Favorable (Unfavorable) Variance

14 Management s Discussion and Analysis of Financial Performance The Combined Operating Loss year to date December 31, 2013 of $4.3M was unfavorable to Budget of $2.8M by $1.5M. GCRMC did receive approximately $1M of sole community provider payments which improved operations in the second quarter that was in question in the first quarter. Management does expect to meet considerable challenge in attaining the Budgeted FY2014 Operating Loss of $4.3M. $1.1M in unbudgeted Locum Tenens expense is being incurred in The Center for Women s Health and Pediatrics which has had to replace the entire medical staff due to retirement, prolonged illness and resignation. The last Locum Tenens for The Center for Women s Health has been replaced with permanent staff in in January and Pediatrics will be replaced in March. Management has implemented significant operational improvement initiatives (see page15). It is management s belief that the initiatives along with the reduction in Locum Tenens, improvement in radiation therapy and Oncology net revenue will allow GCRMC to meet both the Debt Service Coverage requirement of 1.1 times Maximum Annual Debt Service and Days Cash on Hand of 60 for FY2014. On a combined basis, the projected FY2014 Operating Loss is $8.7M which is a $4.4M unfavorable variance to Budget. The projected Excess of Expenses over Revenues is $8.6M. The performance represents a $357K Favorable Financial Gap at 1.16 in meeting the Bond Covenant Maximum Annual Debt Service requirement of 1.1. The performance also is projected to attain Days Cash on Hand of 79.0, again above the Bond Covenant requirement of 60 Days. On a positive note, volumes have stabilized as we were favorable to Budget by 2.4% on an Adjusted Admission basis year to date through December 31, Also, Self Pay and Charity Care are trending below the prior year to date. The transition of Holloman Air Force Base from F22s to F16s began in June of Phase I completion is expected by June of 2014 and Phase II by June of 2015 which will result in an increase of several hundred in active duty plus families and contracted staff. This should result in additional healthcare delivery by GCRMC once the transition is complete. 14

15 Management s Discussion and Analysis of Financial Performance Management is focused on initiatives to improve operations and cash flow to comply with the Bond Covenants. Numerous initiatives are underway and many more are planned for FY 2014 to include: We have high expectations from our Revenue Cycle outsource partner, The Outsource Group, as they continue to implement significant improvements in our processes. At their direction, we contracted with MedAssets to improve our charge master, charge capture, and coding processes. MedAssets completed the first phase of the engagement in February and estimated the improvement in net revenue to exceed $1M annually. The engagement of MedAssets also meets the Bond Covenant requirement to engage a revenue consultant to improve net revenue. That requirement occurred when GCRMC did not meet the Debt Service Coverage Requirement of 1.1 to 1.0 for FY2013. Management implemented a number of changes in benefits (High Deductible Health Plan with Health Savings Account, vacation policy revision, etc.) that are producing savings in excess of $3M. New service lines are maturing and will continue to improve revenues, offsetting staffing costs and positively contributing to the bottom line. AClinical Integration Model has been initiated to reduce capital expenditures while aligning service lines with larger health systems (Sierra/Providence Health System). It is anticipated that Interventional Cardiology will begin operations in the first quarter of FY2015. The Military Inpatient psychiatric program has been postponed for further evaluation. However, Management has begun expansion of Gero-Psych capacity to an additional 5 beds which are expected to be available in April and generate a $66K favorable impact on FY2014 operations. Recent implementation of Athena EMR will improve productivity and financial performance within physician practices $400K annually beginning in the fourth quarter of FY2014. Management renegotiated managed care contracts that have begun to generate the expected $2.6M net revenue improvement in reimbursement. 15

16 Management s Discussion and Analysis of Financial Performance Continued Management initiatives to improve operations and cash flow to comply with the Bond Covenants: The Emergency Department performance has been a significant focus which has gained traction as evidenced by a 61% reduction in left without being seen, 19% increase in admission rate and improvement in customer satisfaction. Focusing on the Studer Group, ED throughput, lean management, RAP&GO and quality have driven this success. Management renegotiated the under arrangement fee with ASV Outpatient Surgery Center which is generating $1.2M in savings annually. Management engaged The Coker Group to develop and assist in the implementation of an owned physician practice strategy to include a specific focus on the Orthopedic service line which is expected to produce a multifold payback through improvement in operations The Union Collective Bargaining Agreement was approved in March by the Union membership which provided concessions to include a freeze on pay increases for FY 2014 representing an annual savings of $345K, elimination of the HMO option and acceptance of the GCRMC sponsored health plan with annual savings of $525K, elimination of the 401K match $32K and other. 16

17 Management s Discussion and Analysis of Financial Performance Recent additions to the Management Team with exceptional experience: Catherine Rhyne, VP Patient Services/CNO: Experienced CNO/CCO/COO in For-Profit/Non-Profit and CAH/Community/Tertiary Care Hospitals across the US Owner Healthcare Consulting and Interim Executive Leader Company Proven ability to develop and sustain programs to include oversight on large-scale projects Skilled at strategic alignment, leadership and planning; and operational leadership around process improvements Bashar Naser, Chief Financial Officer (April 14): Group Chief Financial Officer Southern & Western Divisions of Health Management Associates Corporate Operations Controller and Division Chief Financial Officer, Florida, Texas and Louisiana Sunlink Healthcare Director of Financial Operations Demonstrated performance improvement and revenue cycle experience Susan Hutzler, Director of Revenue Cycle: Adventist Patient Access Manager over 19 hospitals Cerner Corporate Trainer Patient Financial Services Director of several hospitals Demonstrated revenue cycle experience Accordingly, it is management s opinion GCRMC will meet the 1.1 times Maximum Annual Debt Service Coverage and the 60 Days Cash on Hand provisions of the Bond Covenants for FY

18 GCRMC Consolidated Balance Sheet ($000) 6/30/2012 6/30/ /31/2013 6/30/2014 Cash and cash equivalents $ 5,611 $ 15,716 $ 9,832 $ 10,529 Assets limited as to use Patient, net of estimated uncollectibles 13,383 12,752 13,076 14,412 Estimated third-party payor settlements Other 1,561 2,703 2, Supplies 2,789 3,166 3,203 2,705 Prepaid expenses 1,606 1, ,219 Total current assets 25,965 36,360 30,255 30,038 ASSETS LIMITED AS TO USE 10,157 15,226 15,236 15,304 PROPERTY AND EQUIPMENT, net 101,715 96,939 92,654 89,758 OTHER ASSETS Investment in affiliates Insurance recovery receivable - 3,500 3,500 3,500 Deferred financing costs, net 385 1,986 1,952 1,918 Goodwill and other intangible assets, net , Total other assets 754 5,824 6,675 6,567 Total assets 138, , , ,666 Current maturities of long-term debt 772 3,918 3,264 3,262 Accounts payable - Trade 7,960 12,048 9,065 10,577 Construction and capital payables Salaries and wages 1,284 1,556 1,438 1,734 Vacation 3,027 2,085 2,032 2,084 Interest - 1,932 1,932 1,932 Payroll taxes Other Total current liabilities 13,950 22,239 18,724 20,495 LONG-TERM DEBT, less current maturities 2,342 74,803 73,269 72,303 Insurance Claims Liability 3,500 3,500 3,500 Liabilities Subject to Compromise 50, Total Long Term Debt 52,499 78,303 76,769 75,803 Total liabilities 66, ,542 95,493 96,298 Gerald Champion Regional Medical Center 71,741 53,112 48,965 44,980 Noncontrolling Interest Total unrestricted net assets 72,142 53,806 49,327 45,368 Total liabilities and net assets 138, , , ,666 18

19 GCRMC Consolidated Statement of Cash Flows ($000) Operating Activities: FY2013 Audit YTD 12/31/13 Projected FY2014 Decrease in Net Assets $ (18,337) $ (4,479) $ (8,438) Realized and Unrealized Gains/Loss on Investments (63) (114) (184) Reoganization Expenses Foundation Donation (200) (200) Distributions to Non-Controlling Interests in ASV ,190 Depreciation/Amortization of Property, Plant & Equipment 9,898 5,272 $ 10,598 Change in Assets and Liabilities: Accounts Receivable (Net) (511) (36) 730 Supplies (377) (37) 461 Prepaid Expenses (159) Accounts Payable (1,641) (2,983) (1,471) Accrued Expenses 1,335 (220) 227 Other Payables Net Amounts Due to Third-Pary Payors (639) Net Cash from Operating Activities $ (8,466) $ (1,385) $ 3,393 Investment Activities: Purchase of Propery, Plant & Equipment (Net) $ (5,058) $ (1,991) $ (4,265) Net Investment in Assets Limited as to Use (4,379) (10) (78) Net Investment in Affiliates and Other Distributions to Noncontrolling Interests in ASV 73 (476) (1,190) Foundation Donation Realized and Unrealized Gains/Loss on Investments Net Cash from Investment Activities $ (9,324) $ (2,011) $ (5,045) Financing Activities: Proceeds from Long Term Debt Issuance $ 70,005 $ - $ - Deferred Financing Costs (2,063) - - Retirement of Long Term Debt (39,406) - - Payments on Long Term Debt (2,189) (3,156) Reoganization Expenses and Other (641) (299) (378) Net Cash From Financing Activities $ 27,895 $ (2,487) $ (3,535) Net Change in Cash $ 10,105 $ (5,883) $ (5,187) Cash Beginning Balance 5,611 15,716 15,716 Cash Ending Balance $ 15,716 $ 9,832 $ 10,529 Assets Limited as to Use 15,226 15,236 15,304 Cash and Assets Available for Use $ 30,942 $ 25,068 $ 25,833 19