Transcript of Open Session Meeting - Illinois.gov

Transcript of Open SessionMeetingDate: June 5, 2018

Case: State of Illinois Health Facilities and Services Review Board

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ILLINOIS DEPARTMENT OF PUBLIC HEALTHHEALTH FACILITIES AND SERVICES REVIEW BOARD

OPEN SESSION

Bolingbrook, Illinois 60490Tuesday, June 5, 2018

9:28 a.m.

BOARD MEMBERS PRESENT:KATHY OLSON, ChairwomanRICHARD SEWELL, Vice ChairmanBRAD BURZYNSKIBARBARA HEMMEJOHN MC GLASSON, SR.RON MC NEILMARIANNE ETERNO MURPHY

Job No. 167323BPages: 1 - 181Reported by: Paula Quetsch, CSR, RPR

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

ALSO PRESENT:JEANNIE MITCHELL, General CounselCOURTNEY AVERY, AdministratorMICHAEL CONSTANTINO, IDPH StaffANN GUILD, Compliance ManagerGEORGE ROATE, IDPH Staff

Transcript of Open Session MeetingConducted on June 5, 2018 2

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C O N T E N T S PAGECALL TO ORDER 6ROLL CALL 6EXECUTIVE SESSION 6COMPLIANCE ISSUES/SETTLEMENT ARRANGEMENTS/FINAL ORDERS Referrals to Legal Counsel 7APPROVAL OF AGENDA 8APPROVAL OF TRANSCRIPTS 8PUBLIC PARTICIPATION DaVita Rutgers Park Dialysis 9 DaVita North Dunes Dialysis 12 DaVita Salt Creek Dialysis 14 DaVita Rutgers Park 18 DaVita Salt Creek Dialysis 21 DaVita North Dunes Dialysis 23 Alden Estates of New Lenox 27 DaVita North Dunes Dialysis 28 Alden Estates of New Lenox 30 Six Corners Same Day Surgery 32 Rutgers Park/Salt Creek Dialysis 35ITEMS APPROVED BY THE CHAIRWOMAN 33



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C O N T E N T S C O N T I N U E DITEMS FOR STATE BOARD ACTION PERMIT RENEWAL REQUESTS 43 EXTENSION REQUESTS 43 EXEMPTION REQUESTS 43 ALTERATION REQUESTS 43DECLARATORY RULINGS AND OTHER BUSINESS Six Corners Same Day Surgery Center 43HEALTH CARE WORKER SELF-REFERRAL ACT 49STATUS REPORTS ON CONDITIONAL/CONTINGENT 50PERMITSAPPLICATIONS SUBSEQUENT TO INITIALREVIEW DaVita Auburn Park Dialysis 50 DaVita North Dunes Dialysis 53 DaVita Garfield Kidney Center 86 Fresenius Medical Care Elgin 90 DeKalb County Rehab and Nursing Center 94 Alden Estates in New Lenox 100 Blessing Hospital 111



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C O N T E N T S C O N T I N U E DAPPLICATIONS SUBSEQUENT TO INTENT TO DENY DaVita Rutgers Park Dialysis 122 DaVita Salt Creek Dialysis 141 Proctor Hemodialysis Center 145 FKC Waukegan Park 157 Dialysis Care Center of Elgin 157RULES DEVELOPMENT Part 1110 Amendments 173UNFINISHED BUSINESS 174OTHER BUSINESS Legislative Update 174 Bed Changes 176 Employee Handbook 176 Questionnaire Revisions 177 Intergovernmental Agreement Review 178ADJOURNMENT 180



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P R O C E E D I N G S CHAIRWOMAN OLSON: All right. Call themeeting to order. May I have a roll call, please. MR. ROATE: Thank you, Madam Chair. Senator Brad Burzynski, absent. Senator Demuzio, enjoying a cruise, absent. Ms. Hemme. MEMBER HEMME: Present. MR. ROATE: Mr. Johnson, absent. Mr. McGlasson. MEMBER MC GLASSON: Yes, sir. MR. ROATE: Dr. McNeil, absent. Ms. Murphy. MEMBER MURPHY: Here. MR. ROATE: Mr. Sewell. MEMBER SEWELL: Here. MR. ROATE: That's five -- andChairwoman Olson. CHAIRWOMAN OLSON: Sort of here. MR. ROATE: That's five in attendance. CHAIRWOMAN OLSON: Thank you. The next order of business is executivesession. May I have a motion to go into closedsession pursuant to Section 2(c)(1), 2(c)(5),



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2(c)(11), and 2(c)(21) of the Open Meetings Act? MEMBER SEWELL: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER MC GLASSON: Second. CHAIRWOMAN OLSON: All those in favor. (Ayes heard.) CHAIRWOMAN OLSON: We are now in executivesession for approximately 15 or 20 minutes. (At 9:28 a.m. the Board adjourned intoexecutive session. Members Burzynski and McNeilarrived, and open session proceedings resumed at9:53 a.m. as follows:) CHAIRWOMAN OLSON: Back in session. Arethere actions to come out of executive session? MS. MITCHELL: Yes. May I please have amotion to refer the following compliance actionsto legal: Manteno Dialysis Center, ExemptionNo. E-029-18; Presence Resurrection Medical CenterDialysis, Exemption No. E-30-18; Presence St. Mary'sHospital Dialysis, Exemption No. E-031-18;Bridgeview Health Care Center and Scottish Home. CHAIRWOMAN OLSON: May I have a motion? MEMBER MC NEIL: So moved.



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CHAIRWOMAN OLSON: And a second, please. MEMBER SEWELL: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Those will be referred. May I have a motion to approve the agenda. MEMBER MC GLASSON: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER MC NEIL: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The agenda is approvedas presented. May I have approval of the transcript fromthe April 17th, 2018, meeting, motion, please. MEMBER MC NEIL: So moved. MEMBER SEWELL: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: The motion passes andthe minutes are approved.



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The next order of business is publicparticipation. MS. MITCHELL: Yes. You will be called ingroups of about five or six. When your name iscalled, please come and sit at this table. You donot have to speak in the order in which you arecalled, but you are limited to speaking fortwo minutes only. Please at the beginning of your remarksstate and spell your name clearly for the benefitof the court reporter, and if you have handwrittenremarks, if you could leave them at the tableagain for the benefit of the court reporter so shecan make sure she types out everything you have tosay properly. First up, Project 17-014, Naveen Reddy,Omaima Degani -- I apologize for butchering yourname -- Tara Kamradt. Project 17-16, Brian O'Dea and Bill Brennan. DR. REDDY: Good morning, Madam Chair Olson,members of the Board. My name is Dr. Naveen Reddy.I'm a nephrologist. I am here today to oppose theDMG applications that are the start of theireffort to establish 84 dialysis stations in at one



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time. However, there's no doubt that there's noneed for any of them. This is clear if we simply look at under-utilization of current facilities and/or referralsor lack thereof. The applicants have repeatedlyadmitted that their referral letters do not meetthe Board's standards. The foundation for anyapplication is patients. The Board asks everyonewhere will their patients come from. The answerfor these projects is entirely from other areaproviders. In fact, at a previous Board meetingDMG brought a patient to comment. That patientstated he was already receiving excellent carefrom a nephrologist, Dr. Dejesus. Dr. Dejesus ismy partner. What makes these projects so unique is thatDMG is unable to verify a population as requiredby the Board's rules. Furthermore, the applicantsprovided additional information that increased thesize of the overlapping geographic area, but theresult was the same. These facilities cannotsucceed without decreasing utilization rates atother facilities. That violates the Board's rules.



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This fact was raised by Members Sewell,Johnson, and Olson at previous meetings, andapplicant's failure to address these concernsillustrates how poorly planned these projects are.In an affront to the Board's planning process, DMGhas used the same letter to support all of theirapplications. The referral letter used in allthese projects lacks a specific Board requirementthat it include a verification by the physicianthat the patient referrals have not been used tosupport another CON. We cannot explain why theseletters were accepted, but moreover, we cannotunderstand why they were submitted. Applicants are not allowed to double countpatients because then we would end up withunnecessary services, and facilities could onlysurvive by plundering patients from existingproviders. That type of conduct should not beallowed. You should continue to deny theseprojects. This area has an excess of dialysisstations and has been experiencing slow growth, asyou can tell from the fact that all of the localarea's dialysis providers have capacity. Approving



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these projects will have an adverse impact onpatient choice and an adverse impact uponestablished independent providers. We ask that the Board give these applicationsa final denial today. CHAIRWOMAN OLSON: Thank you. Next. DR. DEGANI: Good morning. My name isDr. Omaima Degani. I'm a nephrologist with NANI,and I am here to testify in opposition to theproposed DaVita North Dunes dialysis facility. As a medical director of Fresenius Antioch,which is a mere 25 miles from the proposed facility,I can attest that the utilization of the existingfacilities is under capacity. As the Board wellknows, in 2015 the Board approved a unit in Zionwhich currently has not even been built yet. Sobetween Antioch being underutilized and Zion noteven being built, there's no need at this time forfurther dialysis chairs in the Waukegan area. The most important thing as a practitionerin this area is to meet the needs of the patients.As part of NANI, we put patients first more thananything else, and regardless whether it's a



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DaVita facility or a Fresenius facility, we willalways put patients first and put their bestinterests first. By adding another dialysis unit, we wouldbe spreading the care for these patients, which isnot in the patients' best interests. Having beenin practice in this area for 10 years, it is anunderserved area, and we certainly feel that thecurrent dialysis facilities are adequate to meetthe needs of the patients, and there's no furtherneed for more chairs in the Waukegan area. The most important thing, as I said, is toput patient care first and do what's best for thepatients. Currently where the patients arereceiving dialysis is sufficient to meet the needsof our area. At NANI the culture of our organizationhas always been to focus on patient care, andwhether it's with Fresenius or with DaVita, as Istated, we put patients first. I thank you for your time and willingnessto consider my comments as you vote on thisproject. I respectfully request that you vote noon the DaVita North Dunes project as there is no



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need for further stations in this area. CHAIRWOMAN OLSON: Thank you, Doctor. Next. MR. BRENNAN: Hello. My name is BillBrennan. I'm a long-time NANI employee. I'm hereto oppose the two DMG DaVita projects. As you know, within the last 12 monthsDaVita/DMG has submitted eight projects totaling84 dialysis stations. There are good reasons whythe Board has already voted no on every one ofthese projects. The applicant has played gameswith the rules, repeatedly deferring considerationof applications trying to salvage these poorlyplanned projects. Regardless of how much they tryto manipulate the process, you can be confidentnothing has changed when you consider theseprojects today. Over the last nine months, again, theBoard has voted to deny these applications. Sincethen the applicant has hired new consultants. Theconsultants submitted additional information that,to their credit, admits incorrect and inaccurateinformation was previously submitted, confirmingwhat we've been saying all along. The applicants



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in their own words stated the applications containunfortunate mistakes and that incorrect data wasused to justify the projects. Unfortunately, correcting these mistakesdoes not explain how the applicant under oathmisrepresented -- made misrepresentations beforethe Board. Specifically the applicant does haveaccess to patient data despite repeated denialsunder oath. DMG's only innovation continues to beits EMR. And finally -- they finally admitted thatthey're not the only provider of dialysis serviceto IlliniCare of Lisle. Again, that was under oath. We've come before the Board every time theseprojects have been scheduled. Our commitment isto patient care, which is the core of what makesNANI unique. We urge the Board to again denythese applications and let the applicant findother ways to meet the investor expectations. Itshould not come at the expense of patient care. Thank you. CHAIRWOMAN OLSON: Thank you. Next. MR. O'DEA: Good morning, Madam Chair andmembers of the Board. My name is Brian O'Dea.



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I'm a board member of the Chicagoland ESCO.That's an ESRD patient care organization for folkson dialysis. I want to apologize for having toshow my face again. I'm sure you're probablygetting sick of seeing me. I kind of wonder ifDaVita/DMG like my talk so much they keepdeferring so they can hear it again and again. I just want to talk a little bit aboutwhat an ESCO is and the negative impact that Ibelieve that this unprecedented expansion byDaVita and DMG into dialysis would harm what we'vedone so far and what we've been able to accomplish. An ESRD is an ESCO for dialysis -- is anACO for dialysis patients. It's an alternativepayment model that was instituted by the CMS Centerfor Innovation. What we're able to do is givedialysis patients on Medicare additional care.The idea is to save money. When it was first proposed to me, I wasafraid it was going to be like the HMOs back inthe '90s where you would deny care and save moneythat way, but the whole philosophy here is we'reable to give extra care to the patients. We'reable to give them diabetic eye exams they may or



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may not be able to afford; we're able to give themfoot exams, able to provide them with transportation. There was one patient who was blinded byhis diabetes, couldn't read his mail, was missinghis signup for his drug insurance. We had themail sent to the dialysis unit and read for him.All of these things would be noncompliant withoutthe carve-outs we have in the ESCO. It would beconsidered inducement to get the patients to cometo your dialysis unit. So I think CMS has done a great job increating an ESCO. We're at risk. We're expectedto take care of these patients -- we're a nephrologygroup. We're expected to take care of thesepatients at a lower cost than CMS has taken careof them in the past by doing these extra thingsand making sure the patients are healthy. We'vebeen successful. In calendar year 2016 we saved thegovernment over $11 million. The final resultsaren't in for '17 yet; it takes a while to getdata out of Washington, but it looks like we'regoing to save $15 million dollars for Medicare.This is a fantastic program. It's centered around



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the dialysis units, and this could destroy thisprogram. CHAIRWOMAN OLSON: Thank you. Next. MS. KAMRADT: Thank you. On five separateoccasions NANI and its physicians have appearedbefore this Board -- CHAIRWOMAN OLSON: Would you introduceyourself, please. MS. KAMRADT: Yes. I'm Tara Kamradt andI've been working with NANI for 20-plus years. CHAIRWOMAN OLSON: Thank you. MS. KAMRADT: On five separate occasionsNANI and its physicians have appeared before thisBoard to oppose projects currently proposed byDMG/DaVita. Each one of these projects that hascome forward for a vote has failed and with goodreason. Like I said, I've been working with NANIfor 20 years, and I've been asked to summarizeparticularly for the benefit of the newest Boardmembers the issues that justify denying each ofthese projects. DMG with its private equity backers continues



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to try to buy their way into the marketplace ratherthan establish themselves like everybody else.DMG is proposing to add 84 new dialysis stationswith eight total applications to the service areadespite the fact that the DMG does not have theexisting nephrology patients to justify suchunprecedented expansion. And, further, NANI physicians have recentlylearned that the three experienced nephrologistsat DMG originally supporting these applicationsare now leaving DMG. These proposals are clearlydesigned to divert existing patients from theirexisting providers to DMG, and the best proof of thisis that the applicants have brought in patients totestify before this Board about not wanting tolose their quality nephrology care. The irony isthat these patients are NANI nephrology patients;they're not DMG patients. This isn't about access. These patientscurrently receive quality care at Medicare Five-Starfacilities closer to where they live. And we alsoknow these applications aren't about the patients.DMG said in their response to the Board staffquestions as to what motivated these applications,



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and I quote, "We do not currently operate anyclinics in DuPage County." This "Let us build it and we can fill it"approach was the opposite of what the Board wasestablished to do, and every staff report showedthat approving these projects will result inunnecessarily duplications. MR. ROATE: Two minutes. MS. KAMRADT: Lastly, we would implorethis Board to consider a censure of the applicantfor the intentional -- CHAIRWOMAN OLSON: I need you to conclude. MS. KAMRADT: -- misrepresentation ofmaterial information before this Board. Thank you. CHAIRWOMAN OLSON: Thank you. MS. MITCHELL: Next five. For Project 17-016, Dr. Huma Rohail. For Project 17-066, Leon Sujata,Salima Din, Scott Schiffner. For Project 18-009, Tracy Simons andNancy M. Dye. If you'd please remember to state andspell your name for the court reporter. And if



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you're speaking on many different projects, ifyou're not mentioning the project in yourtestimony -- or your speech, rather -- pleasestate it at the beginning of your speech so she'llknow which project you're referring to. DR. ROHAIL: Good morning members of theBoard. My name is Dr. Huma, H-u-m-a, Rohail,R-o-h-a-i-l, and I'm a NANI nephrologist. I'veappeared before you in April, but this is importantenough that I was willing to take a second dayaway from caring for our patients. The applicants will try to brush off ouropposition as us being against competition. Ifthat were true, then we would be opposing allfive of DaVita's applications up today but we arenot. We are opposing the DaVita DMG projectsbecause they're designed to undermine a healthcare delivery system already served by dedicatedproviders that has maintained an open competitivebalance that was driven by patient care and isfilled with patients who already have access toquality care. DMG knows all of the buzz words to say.They talk about the limitations on EMR, and being



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innovative, and stress the importance ofcomprehensive communication for patient care.It's easy to rely on lots of buzz words and saynothing meaningful. Consider that all of theirsupplemental information did not result in a staffreport that meets your standards. As far as innovative, members of the Board,putting patients -- sorry; excuse me -- puttingprofits ahead of patients is not innovative. Infact, it is what created the need for boardslike this. Yes, communication and EMR are important,and finally, after months of denials, DMG finallyadmitted in writing that the limitation on sharinginformation comes from them. They do have accessto patient data. This so-called informationsharing issue does not exist. DMG should not berewarded for solving a problem they created andmisrepresenting facts before this Board to gain anadvantage for their applications. This project is about DMG producing areturn on their investment for its private equitybackers. The problem with that is if they aresuccessful, it will inevitably increase costs on the



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Medicare program and flood the area with unnecessarystations that can only be utilized by plunderingpatients from existing providers. All of this topad the DMG bottom line. MR. ROATE: Two minutes. DR. ROHAIL: We don't come here to protectourselves from competition -- CHAIRWOMAN OLSON: Please conclude. DR. ROHAIL: We would ask you to deny thisproject, respectfully. CHAIRWOMAN OLSON: Thank you. DR. SUJATA: Good morning. My name isLeon Sujata, L-e-o-n S-u-j-a-t-a, and I'm anephrologist with NANI. I'm here to oppose theDaVita North Dunes dialysis facility. I'm the current medical director of anotherDaVita facility, DaVita Lake County in Vernon Hills,which is located approximately 10 miles from theproposed North Dunes site. Like my colleagues, Dr. Din and Dr. Degani,I'm already working with patients and other existingfacilities in the HSA, and I can confidently statehere today that there's no need for additionalstations in Waukegan.



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I have worked in this community for almostfour years, and I've developed a strong relationshipwith my patients in surrounding communities. As aNANI nephrologist, I am fortunate to work withcolleagues whose only focus is patient care. I too support the findings of your StateBoard staff report which show an excess of24 stations in the has. There's simply not enoughpatients to support another facility in the has,let alone Waukegan. I work with DaVita Lake County in VernonHills in cases where it is in the best interestsof my patients. I have other patients that Irefer to Fresenius facilities because that's what'sbest for them. I hope this Board can appreciatethe commitment that physicians have for patientsand their well-being. I believe that the plan process works becausewithout it you would not have an opportunity tohear from physicians like myself who are workingin the community caring for these patients day inand day out. I thank you for your time and willingnessto consider my comments as you vote on this



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project. I respectfully request that you vote noon DaVita North Dunes project in Waukegan, asthere's no need for additional stations in thearea. Thank you. CHAIRWOMAN OLSON: Thank you. DR. DIN: Good morning. My name isDr. Salima Din, and I'm a nephrologist at NANI andthe medical director of the DaVita Waukegan facilitylocated a short 5 miles from the proposed facility,and I'm here to testify in opposition to theproposed DaVita North Dunes facility. You may be asking yourself why the medicaldirector of a fellow DaVita facility would opposethe establishment of another DaVita facility inthe area. The answer is simple. I do not workfor DaVita; I work with them to get my patientsthe care they need. As a medical director alreadyworking in Waukegan, I can confidently state todaythat there is no need for additional stations inWaukegan. At NANI the culture of our organizationhas always been to focus on patient care. We willwork with any provider who is dedicated to improvingthe quality of life of our patients. It doesn't



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matter to us if the facility is operated by DaVita,or Fresenius, or US Renal Care because patientcare is our only concern. That is the reason weare part of the ESCO. That is why we are strongsupporters of organizations like National KidneyFoundation and why so many patients choose NANIdoctors. I can personally attest to the findings ofyour State Board staff report which indicatesthere's no calculated need for the stations inthis has. By virtue of its location alone, thisfacility cannot succeed without affecting otherexisting facilities. In this has there arefour operating facilities and a fifth one that isnot operational yet. There are shifts andstations that are available for new patients. Foranyone to sit here and state otherwise would be amisrepresentation of the facts. I thank you for your time and willingnessto consider my comments as you vote on thisproject, and I respectfully request that you voteno on the DaVita North Dunes project in Waukegan,as there's no need for additional stations in thearea. Thank you.



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CHAIRWOMAN OLSON: Thank you. MS. YEKICH: Good morning. My name isMariel Yekich, and I am the director of businessdevelopment at Silver Cross Hospital in New Lenox.I'm here to express our continued support ofSilver Cross Hospital for Alden Estates Courts ofNew Lenox. Alden's proposal for a skilled nursingfacility is the first of its kind in the villageof New Lenox. By building it adjacent to ourfacility, it will be easy for residents to accessphysician offices and ancillary service. Thefacility adds another important component to thecontinuum of care comprising the medical hub inNew Lenox. In addition, the close proximity tothe hospital makes it convenient for physicians toround on their patients. The health care delivery system and landscapeis dramatically changing for both hospitals andlong-term care providers. Hospital systems seecontinued and growing value in having as manyservices located on their campus. It gives theimpression that the postacute provider is wellpositioned as a strong partner to meet the quality



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of care the hospital views as necessary. Inaddition, the hospital desires a postacutebuilding that mirrors the amenities provided atthe hospital and helps with continuity of care. We support the request to add 26 beds overand above the already approved 140-bed facility.The new project would be 166 beds in total. Thehospital has had a successful relationship withAlden over the years and looks forward to a closerrelationship through this project. Silver CrossHospital and the surrounding community willbenefit from Alden being on our campus and wesupport this project. They will be a strong partnerwith services and amenities that match ourhospital system. Thank you. CHAIRWOMAN OLSON: Thank you. MR. SCHIFFNER: Good morning, ladies andgentlemen. Thank you for giving me a few minutesyour time this morning. My name is Scott Schiffner.That's S-c-h-i-f-f-n-e-r. Today I'm here torepresent my opposition to DaVita's North Dunesproject in Waukegan. There's a lot of projects on the docstoday for DaVita, so I'm sure it's hard to figure



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out which one it is. Today it'll be the secondone that you're going to hear about. They'reproposing to establish 12 dialysis stations inWaukegan. In October of 2017 Fresenius submitted anapplication to establish 12 stations in Waukegan.Then two months later DaVita did the exact samething. Why would I care? I'm just one guy. I docare because this is very important to me and verypersonal. Five years ago I was diagnosed withFSGS, which is a kidney disease, and Freseniuskept me very healthy, and I was able to get asuccessful kidney transplant because of them. My concern, as you can hear from myexperience, is when you have too many facilitiesin one location, the facilities could actually getunderutilized, and I think that's exactly what'sgoing to happen here. There's really no reasonfor this project for DaVita. It undermines patientcare, and in the end it results in issues otherthan patient care driving decisions. With both Fresenius and DaVita setting upshop in the same community, it will only result intwo underutilized facilities. I say let DaVita



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expand in a community that as no access. There'sno reason for this project. Thank you very much. CHAIRWOMAN OLSON: Thank you. MS. DYE: Good morning. I'm Nancy Dye.That's D-y-e. I'm economic development coordinatorfor the Village of New Lenox, and I am pleased tobe here on behalf of another Alden project, thistime a 166-bed project, which is Project No. 18-009. The Village wholeheartedly supports theseadditional beds and knows that the need exists.The rehab is so important given the proximity toSilver Cross Hospital. The old saying is, "Youknow what you know." It's not "You don't knowwhat you don't know." And both my mother and my mother-in-lawhad hip surgery, and while not everyone wouldagree with them, the situation of moving them to afar-off rehabilitation center from Silver Crosswas very stressful. And they were years apart.If they were able to have the opportunity to beable to be closer to a hospital, it might havebeen better for them. As far as additional rooms for the memorycare, New Lenox is a growing community, and as the



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population grows, so will the need to have elderlyrelatives closer to home. In the past six years,New Lenox has issued 1,000 residential housingpermits. Alden has proved to be a great communitypartner to New Lenox. A 53-unit independent livingfacility is now underway and will be opening laterthis month in New Lenox. As a testament to theamount of seniors interested, all 53 units are nowcommitted, and the facility, again, is a few weeksaway from opening. I'm sure if Alden added moreunits to this building they would also becommitted rooms. While the need that exists between theindependent living, rehab, and memory care servicesare diverse, the commonality is that in theNew Lenox area seniors are seeking age-appropriateassistance. Please allow Alden to add these bedsto maximize this need of seniors. CHAIRWOMAN OLSON: Thank you. MS. MITCHELL: Did Mariel Yekich alreadyspeak? MS. DYE: Yes. MS. MITCHELL: Okay. Sorry.



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Last two speaking on behalf of Six CornersSame Day Surgery are John McCormack and ThomasMacchione. If you could please come up. Pleaseremember to state and spell your name at thebeginning of your remarks. MR. MACCHIONE: Hi, my name is Tom Macchione.I'm representing the landlord at the 4211 Cicerobuilding. Dr. Elias I understand is here to getan extension on his CON, and we are in support ofit. However, we are in negotiations to sell himthe building by next Tuesday, the 12th, and ifthat doesn't happen, we will notify the Board ofsuch, and they can take appropriate action. But at this point we are in support of hisextension. We'd like to see him get adequate timeto reestablish the facility that he was in. Sothat's about it. CHAIRWOMAN OLSON: Thank you. Appreciatethat information. Okay. That concludes the public speakers. MS. FRIEDMAN: We have some registeredspeakers that are beyond that list. MS. AVERY: Did they submit? MS. FRIEDMAN: They signed in on Friday,



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yes, Access DuPage. MS. AVERY: Did they check in? MS. FRIEDMAN: They might not have. MS. AVERY: Let's take a break and givethem the sheet to fill out. CHAIRWOMAN OLSON: While she's doing that,can I just read the items that I approved? How many? MS. GUILD: Four. MS. AVERY: Who said that? MS. GUILD: Ann. CHAIRWOMAN OLSON: So while they'refilling out their forms, Mike, would you pleaseread off the items approved by the Chairwoman. MR. CONSTANTINO: Thank you, Madam Chair.The following items were approved by the Board Chair: Extension of Financial Commitment, ProjectNo. 16-06, Alden Estates of Bartlett. Extension of Financial Commitment, 16-012,Transitional Care of Lake County. Relinquishment of Permit, Project No. 16-055,Franciscan Alliance St. James Hospital, OlympiaFields/Chicago Heights. Relinquishment of Exemption, No. 047-17,



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Palos Community Hospital. Exemption No. 020-18, Fox ValleyOrthopedic Associates Change of Ownership. Exemption No. E-021-18, St. John's PrairieDiagnostic Cardiovascular Center, discontinuationof service. Exemption No. 022-18, Centegra Hospital-McHenry, Change of Ownership. Exemption No. 023-18, Centegra Hospital-Woodstock, Change of Ownership. Exemption No. 024-18, Centegra Hospital-Huntley, Change of Ownership. Exemption No. 025-18, Carle Richland MemorialHospital, Discontinuation, 16-bed AMI Service. Exemption No. E-026-18, Memorial Hospital-Carthage, Change of Ownership. Exemption No. 027-18, Memorial MedicalCenter, Springfield, Discontinuation, 6-StationESRD Facility. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you, Mike. If you want to start, please say and stateyour name and also the project you're speaking on. Thank you.



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MS. TORRES: My name is Ivelisse Torres,and I am outreach coordinator at Access DuPage, acoalition that works in collaboration with areaproviders. CHAIRWOMAN OLSON: Louder, please. MS. TORRES: Without practices like DuPageMedical Group, we cannot succeed in our mission ofproviding care access for DuPage County residents.On behalf of Access DuPage and those we serve, Iam here to support the proposed Rutgers Park andSalt Creek dialysis clinics. These carefullydesigned clinic proposals meet all of this Board'scriteria for approval. In my role with Access DuPage, I help connectpatients with volunteer health providers. I knowfirsthand the needs of those we serve. Oftenindividuals come to Access DuPage after many yearsof living without health care. This ischallenging for anyone but especially for thoseliving with conditions that increase their risk forkidney disease such as diabetes, cardiovasculardisease, hypertension, and obesity. The majorityof our patients have at least one of theseconditions.



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We are grateful for DMG's partnership inour efforts to care for low-level members of ourcommunity. DMG is our leading primary outreachmember. All of their specialist physicians and apanel of their primary care providers participatein Access DuPage. For many of our referred patientstheir appointments with DMG physicians are thefirst time they have had medical care in a verylong time. The first appointment can often be difficultwith patients learning that their unmanaged healthproblems are serious and may have life alteringconsequences. For those who learn they have kidneydisease, they may be seen by a nephrologist whoworks in conjunction with their primary carephysicians and other specialists at DMG. For complex patients who are trying toovercome health care access issues, DMG'smultispecialty practice and team-based approach tocare is essential because it ensures patientsreceive the care they need without the administrativeroad blocks and other challenges that often leadto treatment noncompliance. DMG's approach has been shown --



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MR. ROATE: Two minutes. MS. TORRES: -- has been shown to reducehospital -- CHAIRWOMAN OLSON: Please conclude. MS. TORRES: -- and medical complications.Thank you. CHAIRWOMAN OLSON: Thank you. Next. MS. MURPHY: Good morning. Kara Murphy,K-a-r-a M-u-r-p-h-y. My name is Kara Murphy, and I'm thepresident of DuPage Health Coalition and theAccess DuPage program. I'm here to enthusiasticallysupport two proposed DuPage County dialysisclinics on the agenda today, Rutgers Park andSalt Creek Dialysis. My understanding is your staff reports forthese two clinic proposals are wholly positive andwarrant approval on that basis. Further, with this Board's concerns of ahealth care safety net, I can personally attest tothe critical role that DuPage Medical Group playslocally in expanding and improving health careaccess for low-income and uninsured families.



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Based on knowledge gained from ourlongstanding partnership, I know that patientswith kidney failure will benefit from DMG andDaVita's attention to high-quality care andpatient outcomes. My organization, Access DuPage, is acountywide collaborative effort to provide efficientand effective health care access to DuPage County'slow-income and uninsured residents. Since ourprogram began in 2001 we've helped more than50,000 of our neighbors receive high-quality,comprehensive health care. Our program is madepossible because every dollar of direct servicethat we provide is matched by more than $10 indonated services from volunteer providers likeDuPage Medical Group. From the coalition's inception DMG has beena leading partner in this effort. Hundreds ofDuPage Medical Group physicians volunteer theirtime providing Access DuPage patients withexceptional primary and specialty care. One inevery three patients that we refer for specialtycare is treated by a DuPage Medical Group physician.I therefore know personally DMG's dialysis



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patients, and we know their medically complexpatients will receive the specialty services andattention that they need. I believe that these proposed dialysisprojects are in line with DMG's dedication toinnovation and collaboration, and I've come tounderstand that DaVita is similarly known forexceptional quality. I was impressed to learnthat DaVita is the leader in CMS's ESRD qualityincentive program and has the highest average starrating of dialysis providers in the country.DaVita's commitment to supporting patients withkidney disease education, transplant initiatives,and many other innovative care programs impresses. MR. ROATE: Two minutes. MS. MURPHY: I urge the Board to approvethe Salt Creek and Rutgers Park dialysis clinics,and I thank you for your time. CHAIRWOMAN OLSON: Thank you. Next. MR. JONATHAN HANUS: Good morning. I amJonathan Hanus, vice president of National ShoppingPlazas of which our affiliates have been developingcommunity shopping centers in the Chicagoland region



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for over 40 years. We enthusiastically supportDaVita and DuPage Medical Group's application toestablish a 12-station dialysis clinic in Villa Parkto be known as Salt Creek Dialysis. As it has been presented to us, this proposedclinic has already received a positive State Boardreport, and it's been further reported to us thattwo dozen elected officials, organizations, andindividuals took time to submit comments and lettersin support of this project, including SenatorDick Durbin, state Senators Curran, Cullerton, andnumerous organizational and individuals from theVilla Park community. DaVita has made a long-term and majorfinancial commitment into providing dialysisservices in Villa Park by seeking to establish a12-station dialysis clinic on North Avenue, one ofthe most heavily trafficked and most successfuleast/west arterial roadways in the entireChicagoland region. This prominent roadway is amajor transit hub that will potentially help makedialysis services more convenient for prospectivepatients. Additionally, DaVita's vital presence at



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this location will synergistically strengthen thelocal community and respectively encourage otherhealth care providers to locate near this facilityso that the larger community of patients will havethe potentially available additional convenienceand cotenancy which will provide increasedproperty taxes that will benefit the local schoolsand prospectively provide greater levels ofmunicipal services from the private sector taxes. We support the Review Board's approval ofthis project. Thank you very much. CHAIRWOMAN OLSON: Thank you. MR. GEORGE HANUS: Good morning. My nameis George Hanus. I have previously served and mypublic service is a twice-elected board member ofthe high school district in my own community.Thank you for your public service. I'm also president of National ShoppingPlazas, and we have been developing properties,shopping centers, medical centers in Chicagolandarea and in the Woodridge area for many years. Weenthusiastically support DaVita's application toestablish a 12-station dialysis clinic inWoodridge to be known as Rutgers Park.



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As it has been presented to us, thisproposed Woodridge clinic has already received apositive State Board report. It's also beenreported to us that nearly 2,000 electedofficials, organizations, and individuals havetaken the time to submit comments and letters insupport of this project, including the DuPageHealth Coalition, Edward-Elmhurst health, SenatorDick Durbin, and many other organizations andindividuals from the Woodridge community. DaVita is making a long-term financialcommitment to provide dialysis service in Woodridgeby seeking to establish this 12-station dialysisclinic near the intersection of Boughton Road(87th Street) and Woodward Avenue. The intersectionof Boughton and Woodward is in close proximity toa major shopping district with scores of nationaltenants and the extraordinarily busy traffic hubof Boughton Road and Route 355, which is an arterialnexus of convenience -- I say convenience -- tomultitudes of residents and which serves as aconvenient point of close accessibility to thesubstantial retail shopping centers located in theimmediate area.



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DaVita's new location at this intersectionwill also complement the other retailers andmedical providers -- MR. ROATE: Two minutes. MR. GEORGE HANUS: -- who will mutuallybenefit patients' caretakers -- CHAIRWOMAN OLSON: Please conclude. MR. GEORGE HANUS: -- who will makemultiple trips. We enthusiastically and respectfully requestthe Board's approval of this project because itwill be convenient and increase the welfare of thelarger community. Thank you very much. CHAIRWOMAN OLSON: Thank you. Please giveyour sheets to George. Next, Items for State Board Action. Wehave no permit renewal requests, no extensionrequests, no exemption requests, no alterationrequests. Under Declaratory Rulings and OtherBusiness, Jeannie? MS. MITCHELL: We have one matter,Six Corners Same Day Surgery Center. Board members, you received the summary of



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what's going on here, but I could provide a briefsummary here, as well. Six Corners Same Day Surgery Centertemporarily suspended services, and under our rulesyou can temporarily suspend services up to a year.Any temporary suspension after that point must beapproved by the Board, and so Six Corners isrequesting that -- requesting an extension at thistime, and I'll let them explain why. CHAIRWOMAN OLSON: Would you please besworn in. (Whereupon, the witnesses were thereuponduly sworn.) MS. MITCHELL: They temporarily suspendedservices, like I said. Right now they're workingon trying to buy the building where they werelocated. And so whether or not they purchase thisbuilding my understanding is contingent on whetheror not the Board approves the extension. Theyhave an agreement with IDPH where they can reopenand renew their license -- the extension isthrough August 10th, but IDPH will have to come inand do an inspection, and there's some constructionand some build-out required for that.



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So initially they were requesting anextension through August 10th like IDPH, but sincethen they requested a longer period of time sothey can do the closing, do the build-out, andreopen. CHAIRWOMAN OLSON: Comments? MR. OURTH: Thank you, Madam Chair, membersof the Board, and Jeannie for taking -- supplyingall the testimony that we were going to do. Ihave with me Dr. Elias, who is medical director atSix Corners Surgery Center, and I'm Joe Ourth,attorney at Saul Ewing Arnstein & Lehr. Six Corners is here, as Jeannie said, toask for an extension through the end of the summerfor the temporary suspension of its facility. AsJeannie said, in a related matter they worked outwith the IDPH an extension of the licensure sothat that extends through that amount of time, andwe want to similarly ask for approval for thetemporary suspension to coincide with that. Dr. Elias is here to briefly explain thestatus of that, or we can answer any questionsthat you may have. CHAIRWOMAN OLSON: So what's the actual



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date? You said the end of summer. What are youdefining as the end of summer? MR. OURTH: IDPH, the agreement with thatis through August 10th. We would like to askthrough the end of August because if for somereason that can't materialize, we recognize underthe Board's rules that we would need to file for arequest for discontinuation. CHAIRWOMAN OLSON: So August 31st. MR. OURTH: Yes. CHAIRWOMAN OLSON: And we heard from yourlandlord that the building purchase is in process? DR. ELIAS: For the record, Dr. Elias. Yes, ma'am. Hopefully we can do thepurchase next Tuesday the 12th. CHAIRWOMAN OLSON: How long has there beenno services? DR. ELIAS: Since June of last year whenwe stopped doing surgery. CHAIRWOMAN OLSON: So basically for a year? DR. ELIAS: Yes. On July the 1st is whenwe were noticed the temporary suspension, and wewere given an extension to June the 30th. But weneed two or three months to do the complex



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installation for internal and external life safetycode issues that meet DuPage County standards forreactivation of the licensure. It's really acomplex installation, so time is required. CHAIRWOMAN OLSON: Understood. Other questions or comments? (No response.) CHAIRWOMAN OLSON: Seeing none, I would askfor a motion to grant the temporary suspensionextension through August 31st of 2018. MEMBER MC NEIL: So moved. CHAIRWOMAN OLSON: Do we want a conditionthat we won't renew it after that, or are we justfine with that? MEMBER MC NEIL: There could beextenuating circumstances. Are you sure you canget it done at that time? DR. ELIAS: Well, this is when we havethis feasibility study this week, and this is whyI asked for two to three months actually because Idon't even know what the status of the sprinklersystem is, the generator, and whether there's somelead time in ordering some parts for some preppositions or locations in the facility, the gas



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lines. CHAIRWOMAN OLSON: That's why I'm tryingto ask that question because I don't want to lockyou into August 31st and then on August 31st haveyou come back and say, "Well, we didn't" -- DR. ELIAS: I think a three-monthextension -- MS. MITCHELL: If I may for a second. Hehas an agreement with IDPH to be -- to finisheverything by August 10th. That's inspections andeverything. From my understanding in discussionswith IDPH, they're not going to grant anotherextension. So if he complies with the IDPH'sAugust 10th deadline, which he would have to forhis license, I don't see why he wouldn't be ableto meet an August 31st deadline with us. CHAIRWOMAN OLSON: All right. So I made --asked for a motion. We have a motion. Do I havea second? MEMBER MC GLASSON: Second. CHAIRWOMAN OLSON: I'll have a roll callvote. MR. ROATE: Thank you, Madam Chair. Senator Burzynski.



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MEMBER BURZYNSKI: Yes.MR. ROATE: Thank you.Ms. Hemme.MEMBER HEMME: Yes.MR. ROATE: Thank you.Mr. McGlasson.MEMBER MC GLASSON: Yes.MR. ROATE: Thank you.Dr. McNeil.MEMBER MC NEIL: Yes.MR. ROATE: Thank you.Ms. Murphy.MEMBER MURPHY: Yes.MR. ROATE: Thank you.Mr. Sewell.MEMBER SEWELL: Yes.MR. ROATE: Thank you.Madam Chair.CHAIRWOMAN OLSON: Yes.MR. ROATE: Thank you.That's 7 votes in the affirmative.CHAIRWOMAN OLSON: The motion passes.MR. OURTH: Thank you.CHAIRWOMAN OLSON: Okay. We have nothing



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under the Health Care Worker Self-Referral Act. We have nothing on Status Reports onConditional/Contingent Permits. Next we have Applications Subsequent toInitial Review. I would call to the table Project 17-062,DaVita Auburn Park Dialysis. May I have a motion toapprove Project 17-062, DaVita Alden Park Dialysis. MEMBER MC GLASSON: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER SEWELL: Second. (Whereupon, the witnesses were thereuponduly sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport, please. MR. CONSTANTINO: Thank you, Madam Chair. The applicants propose to establish a12-station ESRD facility in approximately 7,000gross square feet of lease space at a cost ofapproximately $4 million. The expected completiondate is February 29th, 2020. There was no opposition, no public hearingrequested. There is a calculated need for43 stations in this planning area. The facility



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will be located in a health professional shortagearea and a medically underserved area. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you. There's no opposition and no findings. MS. FRIEDMAN: We'll introduce ourselves.I'm Kara Friedman, Polsinelli, counsel for DaVita.That's K-a-r-a F-r-i-e-d-m-a-n, and my colleaguewill pass his business card over for the spellingof his name. He is the division vice president ofDaVita. We're happy to answer any questions if youhave them. CHAIRWOMAN OLSON: Questions or commentsfrom Board members. (No response.) CHAIRWOMAN OLSON: Seeing none, I wouldask for a roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by McGlasson, seconded by Sewell. Senator Burzynski. MEMBER BURZYNSKI: Aye, based on staffrecommendations -- or findings -- excuse me. MR. ROATE: Thank you.



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Ms. Hemme. MEMBER HEMME: Yes, based on the stafffindings. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on thestaff findings. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Yes, based on the stafffindings. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on the staff'sfindings. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: Yes, based on the Stateagency report. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, based on thepositive State Board staff report. MR. ROATE: Thank you.



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That's 7 votes in the affirmative. CHAIRWOMAN OLSON: The motion passes. MS. FRIEDMAN: Thank you very much. CHAIRWOMAN OLSON: Next is Project 17-066,DaVita North Dunes Dialysis. May I have a motion to approveProject 17-066, DaVita North Dunes Dialysis toestablish a 12-station ESRD facility in Waukegan? MEMBER MC GLASSON: So moved. MEMBER MURPHY: Second. CHAIRWOMAN OLSON: Okay. Somebody joinedus at the table. (Witness sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair.The applicants propose to establish a 12-stationESRD facility in approximately 7100 gross squarefeet of lease space at a cost of approximately$3.4 million. The expected completion dateApril 30th, 2020. There was no public hearing requested, andthere's no opposition to this project. There isan excess of 24 stations in this planning area,



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and the average utilization of the existingfacilities within 30 minutes is 84 percent. Thank you, Madam Chair. CHAIRWOMAN OLSON: There was opposition tothis project in public. MR. CONSTANTINO: We didn't receive anyopposition letters. CHAIRWOMAN OLSON: All right. But therewas opposition? MR. CONSTANTINO: Yes. That's correct. CHAIRWOMAN OLSON: Okay. Comments for theBoard, please. MR. BHATTACHARYYA: My name is GauravBhattacharyya. I'm the vice president for DaVitahere in Chicago. With me today is Dr. Dalloul,our planned medical director for our facility inWaukegan, as well as our legal counsel, KaraFriedman and Anne Cooper. I would like to thank Board staff for theirreview of the planned clinic and the generallypositive State Board report. We'll touch on thesingle negative finding in the report in a moment. I would like to take this time to makethree points here today. The first is that Waukegan



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is a highly medically underserved community withall the associated socioeconomic indicators. Two,Waukegan needs more dialysis services capacity, aswe'll talk about in a second. And three, thisproposed clinic is broadly supported by communitystakeholders. So on the first point, underservedcommunity, Waukegan is by far the largestcommunity in Lake County. It is also the poorestand has been designated as a medically underservedcommunity and a health professional shortage area.As you see on the map here, the darkest shade ofgreen represents higher incidence of poverty, andWaukegan County on the far right there as you cansee is -- sorry, Waukegan Township -- and that'swhere this clinic is proposed to be established. As I was saying, it's also a medicallyunderserved community and a health professionalshortage area, and the poverty and health careaccess issues indicate that Waukegan deserves dueconsideration from this Board as your serviceaccessibility rules for ESRD care provide. As I think many of you know, people livingin poverty are 50 percent more likely to experience



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hypertension and over twice as likely to be diagnosedwith diabetes, and both of those conditions arethe two leading causes of kidney failure whichthen requires dialysis for treatment. I'd also like to comment on the red herringstatement that our competitor made today aroundthe ESCOs. Representatives of NANI emphasize thatthis ESCO is a reason to set aside our proposal.I think it would be helpful to note that DaVitaalso participates in the same ESCO program aroundthe country. The goal of the ESCOs is really toderive better clinical outcomes at lower cost, asBrian mentioned. And in Chicagoland DaVita is theprovider with the highest percentage of clinics withthree stars or more under CMS's five-star program.It's also the top performing provider under CMS'squality incentive program. In addition, DaVita is leading an effortin Congress right now on the Patient Act, which ifpassed would provide integrated value-based carefor a much larger segment of the ESRD population.So our focus on quality in outcomes is in no waylimited to the CMS initiatives here. We supportour patients with our innovative programs,



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including Kidney Smart disease education programthat's free and open to anyone in the public, aFistula First initiative, an impact program, andmost recently we collaborated with the Universityof Chicago on data sharing technology to helppatients with the kidney transplant wait listprogram. The second point on the need, as wedocumented in our submission revising the use ratesto account for the December 2017 patient census,there's a need for an additional 70 stations in thisplanning area by 2020, which as Mr. Constantinosaid is when this project will get online, and33 of those stations are needed in Lake County.This need methodology is not disputed and providesa more current picture of the needs of thiscommunity. However, due to the delay in datareporting, the Board report reflects outdated serviceneed figures based on a two-year-old snapshot. There are four clinics within a 30-miledrive of this proposed location, and the averageutilization of those clinics today is 84 percent,as Mr. Constantino said. Importantly, as indicatedin this chart that Anne is holding up, both clinics



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located in Waukegan are actually operating above90 percent today. So there clearly is a need forthese patients to get treatment. Given the Board's rules providing specialconsideration to clinics which are in health careprofessional shortage areas or medically underservedareas and with increasing use rates, we feel thatthis clinic proposal is exactly where we should belocating services. With area clinics highlyutilized beyond the target of 80 percent, thisclinic warrants approval. I'd also like to comment on the publictestimony as mentioned today. NANI and FMC opposethis project based on a lack of need, though weshould say that they themselves have a project inthe same service area on this agenda later today.This incongruous messaging is exactly what bothFMC and NANI have been doing with this Board overthe last several months really in an attempt toconfuse the issue. Based on their testimony todayI can only assume that they're going to eitherwithdraw their own application because they don'tbelieve there's a need, or they're going toretract their false statements.



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Finally, I would like to end with thesupport. This proposal received significantcommunity support, including Vista Health Systemwhich operates the only acute care and hospital inWaukegan, the Erie Family Healthy Centers, a leadingprovider of free health clinics in the Chicago areaincluding Waukegan, State RepresentativeRita Mayfield, and Waukegan Mayor Sam Cunningham,as well as numerous physicians and businessleaders, and we really appreciate their input inthe process. So with that I'd like to hand it over toDr. Dalloul, our planned medical director who hastaken time from his duties to be here today. DR. DALLOUL: Good morning. I'mDr. Dalloul, D-a-l-l-o-u-l. I'm board certifiedin internal medicine/nephrology and in practice inthe Waukegan area for the last 20 years, completingmy fellowship at Northwestern University. My patients in the Waukegan are the mostsocioeconomically disadvantaged. I participate inthe plan that allows transplants for managed carepatients in Lake County, and I provide free care forspecialties for patients of Lake County Department



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of Health. I'm also in the process of working todevelop a free clinic in Waukegan. Through thiswork and my practice I'm very engaged in improvingthe health care access issues facing these residentsin Waukegan. Families with fewer financial resourcesobviously have less access to health care and facedifficult lifestyle choices. Many of my Waukeganpatients work two jobs, travel outside of theircommunity to work, and have difficulty arrangingfor childcare, too. Cooking nutritious meals andgetting appropriate exercise is usually out ofreach of these patients. They also do not get thesame preventive health care as my patients who aremore affluent because they lack insurance andfinancial resources or they cannot afford to taketime off from work. As a result, kidney disease, which isasymptomatic until the later stages, is frequentlynot diagnosed until kidney failure is imminent.In the last few years more nephrologists, about10 of them now in Waukegan, have establishedoffice hours in Waukegan, so many more patients inthe community are getting an early diagnosis.



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Patients who do not crash into dialysis aremuch more likely to survive. This improvedphysician access is prolonging the life of thosewith kidney disease and is part of what is drivingdemand for these services. My own dialysis patientpopulation has increased about 50 percent over thelast three years. Given language, and income, and educationbarriers, residents of Waukegan face increasinghealth care resources at the preventive stage.This trend will continue. Because of this and asnoted in the Board report, the two existingfacilities in Waukegan are full, and patients arehaving difficulty scheduling their dialysis. Theseaccess issues are hurting patients becausepatients are more likely to skip sessions whenthere is limitation of appointments available. Asa result, more of my patients are ending up in thehospital, and then I have to catch them up ondialysis treatment. This seriously hurts theirlong-term prognosis. Without more facilities inWaukegan there are no private treatment optionsfor my patients in Waukegan. Finally, I really appreciate the support



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of the medical community in Waukegan. In mypractice I depend on free health clinics and ouronly acute care hospital to provide other types ofcare for these patients. Their expression ofsupport for this clinic and support of otherstakeholders in the community should help to drivehome just how essential this proposal is. Thank you for your time. CHAIRWOMAN OLSON: Thank you. MS. FRIEDMAN: Thank you. Listening to the testimony earlier I justwanted to note that there were two differentnephrologists who spoke of the facilities in thearea. One of them mentioned Lake County Dialysis.That clinic is not within 30 minutes of Waukegan,along with some other facilities that are locatedmore than 30 minutes away where those physicianswere, which they apparently expect would be anappropriate alternative for a facility Waukeganproper. It's also a little confusing as to why aWaukegan medical director would indicate thatthere's not a need for service given that ourdialysis clinic is operating at 98 percentutilization and operating a fourth shift, and



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their dialysis clinic is also operating at 98 percentutilization, and, of course, as Gaurav stated,they have an application pending. Of the 21 criteria that the Board appliedto this clinic proposal, it successfully met allexcept for a single finding based on a calculatedexcess of stations in Lake County, McHenry, andKane County. That's an area that has a populationof about 1.5 million people. So the needs of onesingle community like Waukegan are hard to parseout when you're looking at health planning from athree-county area, but that's why we're here todayto talk more specifically about what thechallenges to these patients are. As we documented in the materials that wesubmitted, Waukegan is one of the poorestcommunities in Lake County, and it's also one ofthe largest communities. It has several indicatorsof health care disparities contributing to ahigher incidence of kidney disease, and for thatreason dialysis clinics are full in Waukegan. With regard to health disparities based ondemographic and socioeconomic indicators in accessto adequate level of health care services, the



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Federal government designates Waukegan as needyfrom a health care access perspective. Waukeganhas two specific designations. One is medicallyunderserved population in area, and the other is ahealth care professional shortage area for primarycare. These are important details under yourservice accessibility details -- excuse me --under your rules. Specific to renal care, with lack of accessto primary care and health screenings there's alarger incidence of hypertension, diabetes, andkidney disease in low-income communities becausethese diseases are undetectable by the patientuntil the late stages when it's often too late tostop or slow the disease progression, and thenthose patients will require dialysis. The demographic data for this area supportsthe need, which is why this project is positive onmost of the Part 1110 criteria despite the technicalexcess of patients in the larger planning area.Over the past four years the census at the clinicswithin 30 minutes of North Dunes Dialysisincreased over 30 percent, or an annual growthrate of 7 percent, which is faster than the older



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data predicted it to grow. This trend must beexpected to continue, and projections show thatthere will be average utilization of the clinic atthe time that the clinic opens well over 90 percenttarget utilization. Because dialysis services utilization inWaukegan is so high and churning up quickly, theBoard staff made a favorable Part 1110/1430 findingthat this clinic will not duplicate other areaservices or have a negative impact on otherproviders. The DaVita clinic, as I said before, isoperating at 99 percent utilization. Since thebeginning of the year it's been operating onfour shifts. With four shifts some of the patientsare on a treatment schedule -- which is reallyincredible to me to think of like one of my80-year-old parents going to dialysis in themiddle of the night -- that requires them to leavethe facility around 1:00 in the morning. The other clinic in Waukegan is at90 percent, as well, or well over the 80 percentutilization target. Patients who need access toservices have to travel more than 30 minutes to



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find a clinic with any meaningful capacity, andtraveling this far places an undue hardship onpatients as well as their family or othercaregivers. Thank you for your consideration. We askfor your approval and can answer any questions. CHAIRWOMAN OLSON: Thank you. Questions. Let's start with Mr. Sewell.Then I'll go to the doctor. MEMBER SEWELL: Two things. In the Stateagency report on page 9, it looks like they have adirect quote from your application about thepatients who are eligible for ESRD services onMedicare because they've achieved the requisitenumber of quarters to qualify. Isn't it true that the age issue is not afactor if you have a diagnosis of ESRD? I know itwas at one time. Is that the still the case? MS. FRIEDMAN: That is -- MR. SEWELL: I mean, a 15-year-old couldqualify for Medicare. MS. FRIEDMAN: Basically, effectively10 years you have to work in order to be -- MEMBER SEWELL: I'm suggesting that's not



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true, that anyone can qualify for Medicarecoverage regardless of age, regardless of thequarters if they have a diagnosis of ESRD. Thatlaw was passed in '72. MS. FRIEDMAN: I do not -- MR. SEWELL: Did something change? MS. FRIEDMAN: I believe so because --what you're referencing would have had to haveoccurred in more recent years because I -- my mostrecent knowledge from looking this up was prettyrecent, actually about a week ago, and the10 calendar -- excuse me -- the 10 quarters werecited in the materials I was looking at. Now, wedo have an All Kids program in the state, so Iexpect them to be able to get coverage. MEMBER SEWELL: This isn't really relevantto the vote on the issue. I was just trying tocorrect the record. But you're saying that thisis correct? MS. FRIEDMAN: We'll follow up. I thinkwe actually printed some of those CMS materials,so we can share those with Mr. Constantino. MEMBER SEWELL: The other question I have,do poor people in the immediate area have difficulty



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accessing the services at the existing ESRDfacilities? Is that why you showed us the charton location and where the poverty areas are in andaround Waukegan? Do they have difficulty accessingthe existing services even though there's excesscapacity according to our calculations? MS. FRIEDMAN: There's only two facilitiesin Waukegan. One of them DaVita is operating at98 percent, which results in them operating in thefour shifts. Your Board standards indicate thatfacilities should operate on three shifts. Theother facility is operating at 90 percent. It's acompetitor facility, so we don't know exactly howthey're managing that 90 percent level. So anytime you're really going over like72 percent people have issues accessing dialysisservices because they're trying to find a spotthat the works with their caregiver's schedule andthe rest of that. Then beyond Waukegan proper there's onlytwo other facilities and those are -- MEMBER SEWELL: Within the travel time? MS. FRIEDMAN: Within the 30 minutes, right. MEMBER SEWELL: So their access is limited



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because of more high occupancy than their povertystatus? MS. FRIEDMAN: With respect to dialysisservice, I would say that's right. With respectto primary care services, to the extent that youhave a poor community, it's not as easy to attractindependent physicians to come to the community toprovide physician services. It's similarlydesignated as a dental medically underserved areabecause it's difficult to have dentists come tothe area. MEMBER SEWELL: And the final thing, itseems that you're asking this Board to approvethis in spite of the excess capacity because ourdata is old, and I don't know if you used adifferent method than we did or just more recentdata when you stated that by 2020 I think it wasthat there would be a need for 70 stations. Youdid say that, didn't you? MS. FRIEDMAN: That's right. And we didnot adopt a different methodology; we just usedmore recent data than 2015. MEMBER SEWELL: And ours is old, Mike,because of late reporting?



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MR. CONSTANTINO: No, it's based on the2015 population estimates and 2015 utilizationdata to come up with the excess of 24 stationsby 2020. MEMBER SEWELL: But that's the way we'rerequired to do it? MR. CONSTANTINO: Yes. That's the currentmethodology, yes. MEMBER MC NEIL: Okay. We can look at thisin a macro level at which a number of peopletestified on. DaVita has 2500-plus units aroundthe country, 237 internationally, 78,000 employees;I can tell you your CEO's salary. That's at amacro level. So you have the business side of it. What we really look at is the need, theaccess, and what it does for the patient. So let'sfocus on that rather than the competitive issues. If there's more competition, will it drivethe $97,500 charge per year down -- or thereabouts --because you're talking about a competitiveenvironment. MS. FRIEDMAN: When you're referring to97,500, what are you referring to? MEMBER MC NEIL: That's normally the cost



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per year for a dialysis patient in an OCC, aboutthat; is that true? Yep. And about 60,000 in-home, but I'll come to that in a minute. MS. FRIEDMAN: Well, my experience is thatthat has already occurred. The composite ratereimbursement for dialysis services has gone downsubstantially over the last several years. MEMBER MC NEIL: Would you explain how much?Because this is what I'm driving at. This is ahuge need. These patients normally live aboutfive years if they don't get a kidney transplant --I'll come back to you on that -- and that's 3.1 or3.6 years before they get that. But let's talkabout the price going down because this isavailability and an absolute need or the patientdies very quickly. We all die as far as I know. MR. BHATTACHARYYA: I'm sorry, sir; what'sthe question? MEMBER MC NEIL: The question is, how muchhas the price gone down, the 97,500, 98,000?Where we are now from where we use to be? MR. BHATTACHARYYA: I don't have thespecific numbers there, but we did look at acrossdisease states, and when you look at dialysis



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versus the other major chronic disease states,cancer, diabetes, et cetera, dialysis over thelast 10 years showed the highest improvement inclinical qualities and the highest reduction incost, system cost relative to those disease states.I don't have those specific numbers, but I do havethat comparison. MEMBER MC NEIL: So it's gone down andthat's the competitive environment and the abilityto offer services. What percentage of yourpatients do you refer where they do it in home?And I understand there are patients that don'twant the stent, don't want to do it at home, andare afraid to do it. But the percentage --because they tend to do it maybe six times a week,and your normal inpatient does it about three? MR. BHATTACHARYYA: Yes. We at DaVitaChicago are at about 10 or 11 percent, and that'strue for the broader industry across the country,as well. We would love for that percentage to besignificantly higher. And as you mentioned, there'sa patient choice element here in terms of theburden that they choose to take on to do itthemselves at home.



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From our perspective the clinical outcomesare better and patients live longer and resumetheir renal function a lot better at home. So wehave a lot of initiatives about promoting in-hometo both our medical directors and our patients,but ultimately it's whether it's the patient'sright choice. DR. DALLOUL: What I can say about homemodality for those patients, it's very difficultto find a patient who agrees to do it at homefirst even if he is fit like medically to practicethat in home safely. The two modalities areoffered in DaVita widely, and we talk to everypatient there about those modalities. For example, last week I had a patient whowas fitting perfectly well to that option for him,and he refused it because he doesn't want hiswife -- to overburden with the machine, with thefluid. So a lot of factors interfere with themodality choice at home when the patient is fittingto that modality. But we offer it up front, and I talk to mypatients up front like about all modalitiespossible. And, of course, they would need like



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the training, which would take about six toeight weeks and the training for the PD, also. Somultiple factors playing with home choice. MEMBER MC NEIL: One thing we could thinkabout would be technicians to go to homes to help.That's another way of dealing with it. It doesn'ttake an MD but a nurse practitioner, whatever froma legal standpoint to take care of it. That's oneissue. What percentage of your patients getkidney transplants? MR. BHATTACHARYYA: I think it's about5 to 7 but I -- MR. MC NEIL: That's the only way out, andI recommend everybody sign up for organ donation.It is essential. I have a friend, I've been todinner with him, at 11:00 at night he'll go do akidney transplant when one is flown in. It isessential. So we're dealing in an underserved area inthe sense of people without a lot of education,money, those things that lead to home care morewhere they can provide for themselves, all ofthat. We're setting up a competitive environment,



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we're giving additional access, and we want to seethe cost come down. I suggest you do more with a medicaltechnician to go into the home and help becausethe outcomes, as you said, are better. DR. DALLOUL: That's true. MR. BHATTACHARYYA: Absolutely. MEMBER GOYAL: My name is Arvind Goyal,and I represent Medicaid on this Board, and I donot vote, so you're safe, but I do have multiplecomments to make, and I apologize for the lengthof them. First of all, Professor Sewell when heraised the issue of your statement on page 9, Iwant to respectfully submit that he's correct andyou're not. And the reason I say that is thatdialysis services are carved out under Medicare.They have been since the program's inception, andfor those people who do not qualify for Medicarefor whatever reason, they're on Medicaid. The only people who fall through thecracks at this time are undocumented people. And,fortunately, in Illinois we have a law that allowsundocumented people to get transplants on a fast



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road if people were to refer them. And, again,one of the conditions is a family donation. If thathappens, the first day of cost of dialysis is equalto lifetime cost of dialysis. I think he madethat point very eloquently. So I wanted to putthat behind us so you recognize what the deal is. I think a question was asked of you, and Iwill modify it a little bit. Can you indicate tome what percentage of your patients are listed forkidney transplant? Not how many get them, howmany are listed. Because the average median for alife expectancy with a transplant is almost equalto a normal person who never had kidney diseaseversus dialysis where the median is about four toeight years. So could you answer that? MR. BHATTACHARYYA: Sure. I don't havethe percentage, but what I can tell you is anytimea new patient starts on dialysis, their first daywe have a program called Start Smart where we gothrough all the factors that we think will help thembe more successful on dialysis and to continue theirquality of life, and getting them on the transplantlist is a component of their Start Smart program.



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So we do it for all of our patients thatstart. Some of them, as you mentioned, Dr. Goyal,may not be eligible, and so they would come off.But the assumption is that every one of our patientsis given a chance to be on a transplant list. MEMBER GOYAL: So they are all listed atsome point if they qualify for listing? MR. BHATTACHARYYA: I'm sorry. Could yourepeat that, please? MEMBER GOYAL: What you just said, doesthat mean that all those patients who meet thecriterion for transplant, they will all be listed? MR. BHATTACHARYYA: Correct. And Imentioned we just created a partnership withUniversity of Chicago to make sure that the patientsthat are on the transplant list stay on thetransplant list. Because as you can imagine,there's lots of criteria that they have to make onan ongoing basis, and as patients get dialysis, theygo to treatment, they often miss some of theirdoctors' appointments, and they have some otherissues that could cause them to get off that list. So we're working very hard to make surethat we optimize their likelihood of getting that



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transplant by making sure that they continue tomeet all those criteria and are sharing that dataon a continual basis with the hospital to makesure that those patients have the best chance. MEMBER GOYAL: Thank you. My lastquestion -- MS. FRIEDMAN: Before we go on to the nextquestion, with respect to the Medicare/Medicaidissue -- and I have to say I couldn't quite hearwhether you were saying "care" or "aid" at the endof that -- I want to clarify that I don't believethat we have a disagreement with anyone, but afterthis consideration we will be sharing theinformation that we have about payer programeligibility to confirm that we're all on the samepage about that because I don't want there to be amisconception that we're trying to misrepresentanything. MEMBER GOYAL: Thank you for double-checking it and we always welcome that. However,I can say this to you that without knowing exactlywhat your percentage would be at this new facility,the biggest payers for you would be the Medicareor Medicaid.



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MR. BHATTACHARYYA: Absolutely. MEMBER GOYAL: Given that you're competingwith the same type of population, poor,socioeconomically less fortunate, and people incommunities like Waukegan where the disease burdenmay be higher. MR. BHATTACHARYYA: Completely agree. Weconsider serving those patients, not competing forthem but yes. MEMBER GOYAL: My next question has to dowith the comment you made about three stars. Now,that's three out of five? MR. BHATTACHARYYA: Correct. MEMBER GOYAL: The last time I looked atthe star ratings about year and a half ago at thebeginning of 2017, at that time DaVita's ratingsgenerally were no superior to your competitors. MR. BHATTACHARYYA: If you look at themost recent one that came out I believe a month orso ago, 95 percent of our clinics are three starsor above relative to 85 percent for the rest ofthe industry. MEMBER GOYAL: That's great and I didn'tmean to imply that DaVita is any less competent or



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any less qualified to provide services, but I justdidn't want to put down your competitors based onstar ratings. MR. BHATTACHARYYA: No, sir. But we dohave a 10-point incremental benefit that we'reproviding, and I don't want that to be lost,either. MEMBER GOYAL: Thank you. CHAIRWOMAN OLSON: Other questions orcomments? MEMBER SEWELL: I want to make a commentabout context in reference to what Dr. McNeilsaid. I think if we had a health economist here,I think they would say that this associationbetween competition, more competition and loweringcosts in the health care field is weak or absentdepending on the service. That needs to be said. We can't think of this as commodities thatare out in the general economy. So I don't thinkwe want to make -- we want to say a priori thatcompetition drives down costs. The answer is sortof "it depends." That's all I was going to say. MR. BHATTACHARYYA: I think our point,Dr. Sewell, would be that competition here is



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providing patient access; it's not actually a costissue. MEMBER MC NEIL: And I would add newtechnologies and the home care -- that's thereason I emphasized it -- is the big determinate.The outcomes are better but it's getting patientsto do that. The profit margin for DaVita is about6.7 percent this year. They lost 48 percent lastyear. I've already looked that up. So it's notlike -- and they reinvested a lot of money, andall of their competitors are doing the same thing.So there is a cost factor and that kind of margin --I know how we play with numbers as accountants,but having said that, it's not excessive. CHAIRWOMAN OLSON: I have a question. AndI know you've sort of addressed it. But I've beenhere for quite a while, and I've never had asituation where two employees would come up andsay there is no need for this in Waukegan. And trust me, I know there's anotherWaukegan application on the agenda here today.Zion is not open. How far is Zion from Waukegan?I'm not familiar with that area. Because Zion is



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not even open. Because over 90 percent utilizationis pretty full in the two Waukegan facilities, butI'm perplexed as to why -- MS. FRIEDMAN: I think it's about 6 milesnorth. CHAIRWOMAN OLSON: And that's not open yet? MS. FRIEDMAN: No. That's assuming thatthat facility is dedicated to CKD patients ofNANI. And, Gaurav, did you want to explain therelationship between NANI and -- MR. BHATTACHARYYA: I guess it's a goodquestion for them as to why they would oppose itgiven that they're medical directors of a facilityat 100 percent. My only hypothesis would be thateconomic interests of their employer being a jointventure partner of those clinics has overriddentheir judgment. CHAIRWOMAN OLSON: Thank you. Other questions or comments from Boardmembers. (No response.) CHAIRWOMAN OLSON: Seeing none, I wouldask for a roll call vote.



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MR. ROATE: Thank you, Madam Chair.Motion made by Burzynski, seconded by Murphy. Senator Burzynski. MEMBER BURZYNSKI: First of all, evidentlyI've been added to the roll since I got here afterthe roll was taken. CHAIRWOMAN OLSON: Yes, you have. Thankyou for joining us. MEMBER BURZYNSKI: It's just a little -- Idigress but it took eight cycles of the stoplightto get off of 55 onto whatever that road is there. CHAIRWOMAN OLSON: Everybody in the stateis traveling today. MEMBER BURZYNSKI: Anyway, this has beenan interesting education for me this morning, butI'm going to vote in support of the facility inspite of the fact that we have one findingrelative to excess -- an excess of stations. I think you've demonstrated the need basedon the demographics of the area, the service -- thepeople that you're going to serve, and certainly Ido believe it could be an access issue, so Ivote yes. MR. ROATE: Thank you.



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Ms. Hemme. MEMBER HEMME: I vote no. Knowing the areaup there and how close the Zion facility will bewhen it opens, I think it will reduce down thatrate. And I'd like to encourage you to do thehome instruction. It's got better outcomes and itwould lower the cost of just capital costs thatare overriding in our health care system today. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Firstly, this is aconversation that I've been waiting for since I'vefirst come on this Board. It's fascinating and asthe Senator said, I've learned quite a lot, and Ihope I'll have opportunities to learn a lot more. I do find in the immediate sense that thefact that this is such an underserved area verycompelling and I will vote yes. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Having looked at this, Iencourage you to do and really have a technicianfor the home support as well as those who will bethe majority that cannot do it. And I have no



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problem with -- it's an underserved area, four shiftsa day, the people that need this help really arenot in the health necessarily to show up at 6:00 inthe morning or 8:00 at night. There are all ofthese things, so I vote yes based on the staffrecommendation and the discussions. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Thank you. Based on theproject's substantial compliance with the StateBoard standards, I vote yes. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote no. I think thenew data that will allow us to calculate those userates will be out soon this year, and the applicantin my opinion can come back, and we can see ifthey'll change the need to 70 additional stations,but for now I vote no. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I vote no as well, forthe reasons that Mr. Sewell just stated, and Ialso think once the Zion facility comes online



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that that will have an impact, as well. MR. ROATE: Thank you, Madam Chair. That's 4 votes in the affirmative, 3 votesin the negative. CHAIRWOMAN OLSON: The motion failed. MS. FRIEDMAN: Can I make just one notenot particular to this application on the issue ofbringing a technician into the home? There are restrictions on what a dialysisprovider can do. So to the extent that thegovernment might be considering a different deliverymethod for dialysis, bringing a technician intothe home is not currently permitted under therules. So even though we might like to get morehome support underway, that would not be permissible. MS. MITCHELL: You'll receive an intent todeny letter stating what your next steps are. CHAIRWOMAN OLSON: Next is Project 18-001,DaVita Garfield Kidney Center. May I have a motion to approveProject 18-001, DaVita Garfield Kidney Center toreestablish a 24-station ESRD facility in Chicago. MEMBER HEMME: So moved. CHAIRWOMAN OLSON: A second, please.



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MEMBER SEWELL: Second. CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: I'd just like to makeone comment about the last discussion regardingtransplants. We do collect that information every yearfrom the facilities. So we do have transplantinformation we'd be more than happy to share withthe members here at the Board. CHAIRWOMAN OLSON: It seems like that'ssomething that would be interesting. MEMBER SEWELL: Yes. MR. CONSTANTINO: In fact, we're just inthe process of collecting it for 2017. CHAIRWOMAN OLSON: Perfect. Okay. MR. CONSTANTINO: Thank you, Madam Chair. The applicants propose to discontinue a16-station dialysis facility and establish a24-station facility approximately two minutesapart in Chicago, Illinois. The cost of the project is approximately6.2 million, and the expected completion date isJune 30th, 2020. There's a need for 43 stations



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in this planning area. This will be located in amedically unserved area and a health professionalshortage area. There was no opposition, no public hearing.Current utilization is 105 percent. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you. Do you want to just state your names againfor the record and then since there was noopposition if you have comments. Just tell us whoyou are again. MS. FRIEDMAN: Sure. Kara Friedman incase you forgot. MR. BHATTACHARYYA: Gaurav Bhattacharyya. CHAIRWOMAN OLSON: Thank you. Questions, comments from Board members? (No response.) CHAIRWOMAN OLSON: Seeing none, I'd askfor a roll call. MR. ROATE: Thank you, Madam Chair.Motion made by Ms. Hemme, seconded by Mr. Sewell. Senator Burzynski. MEMBER BURZYNSKI: I vote yes based on thestaff findings.



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MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I vote yes based on stafffindings. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes in that thestaff has indicated that it is a fit project. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: I vote yes. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: I vote yes based on thefindings. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote yes, meets all thecriteria. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I vote yes, based onthe positive State Board staff report. MR. ROATE: Thank you.



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That's 7 votes in the affirmative. CHAIRWOMAN OLSON: Project passes.Congratulations. Next is Project 18-004, Fresenius MedicalCare Elgin. May I have a motion to approveProject 18-004, Fresenius Medical Care Elgin toadd five stations to its existing 20-station ESRDfacility in Elgin, motion please. MEMBER SEWELL: So moved. CHAIRWOMAN OLSON: May have a second? MEMBER MC NEIL: Second. (Witnesses sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair. The applicants propose to add five stationsto an existing 20-station facility in Elgin,Illinois. The cost of the project is approximately$196,000. The expected completion date is theDecember 31st of 2018. There was no public hearing,no opposition. The proposal -- in a proposal to expandfive stations the State Board does not review the



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station need or excess or the utilization ofexisting facilities. The current utilization ofthis facility is 91.1 percent. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you, Mike. Comments for the Board. MS. WRIGHT: Hi, my name is Lori Wright, andI'm a CON specialist representing for FreseniusMedical Care. To my left is Colleen Muldoon, theregional vice president who oversees the Elginfacility, and to her left is Jim Easterbrook, ourdirector of market development. First off, I just want to make a commentto set the record straight. Fresenius Kidney Carehas not given today any public comments. We'venot authorized any public comments. We've notasked anybody to give any public comments on anyprojects. The comments that were given by anotherphysician's group, we do work with them, but theyare their own comments. They are not ours, and wejust wanted that on the record. Also, I encourage Board staff to maybe pullthe five-star data for Illinois and look at thenumbers themselves. We come here all the time and



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hear competitors say they're the best, they havemore. We've done the numbers, too. We don'tagree but we ask maybe if it's an important factorin approving applications that maybe Board staffcould pull the numbers right off the CMS websiteand do the math themselves. Also, we want to thank the Board staff forthe positive review of this project, and it doesmeet all your criteria, so we'd be happy to answerany questions you might have. CHAIRWOMAN OLSON: Thank you. Any questions from board members? (No response.) CHAIRWOMAN OLSON: Seeing none, I'd askfor a roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by Sewell, seconded by McNeil. Senator Burzynski. MEMBER BURZYNSKI: I vote yes. Theproject meets all criteria. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I vote yes based on thepositive staff reports.



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MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes because itmeets the criteria. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Yes, based on the datapresented. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: I vote yes based on thestaff report. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote yes, meets all thecriteria. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I vote yes based on thepositive staff report. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: The motion passes. MS. WRIGHT: Thank you very much.



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CHAIRWOMAN OLSON: Next we haveProject 18-005, DeKalb County Rehab and NursingCenter. May I have a motion to approveProject 18-005, DeKalb County Rehab and NursingCenter for a modernization/expansion project ofits long-term care facility in DeKalb, Illinois. MEMBER HEMME: So moved. MEMBER MC NEIL: Second. CHAIRWOMAN OLSON: The applicants will besworn in. (Whereupon, the witnesses were thereuponduly sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair. The applicant proposes the expansion andmodernization of a 190-bed skilled care facilityat a cost of approximately $16.8 million. Theanticipated completion date is March 31st, 2020. This facility's current five-year averageutilization is over 90 pertinence. The proposalwill add 18 beds for a total of 208 beds. We had no findings and no opposition. We



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do not consider the bed need or excess in reviewingthis project. Thank you, Madam Chair. CHAIRWOMAN OLSON: I notice you're spending$16 million. You might have a few things to say. MR. AXEL: Thank you, Madam Chair. I'vebeen practicing before this Board for a long time,and your role as chairman is something that isgreatly appreciated, and whoever has the opportunityto step in to follow you has big shoes to fill. Iappreciate it. CHAIRWOMAN OLSON: Thank you. MR. AXEL: My name is Jack Axel withAxel & Associates. I've been privileged to be thecertificate of need consultant on this project.Seated to my right is Bart Becker, the administratorof the facility. To my immediate left isGary Hanson, County Administrator for DeKalb County.To Mr. Hanson's left is Gary Winschel, health careperformance. To his left is Tracey Klein of theReinhart law firm, and to my far left is Mr. JeffWhelan of the DeKalb County Board. The DeKalb County Rehabilitation andNursing Center is a four-star rated facility by



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CMS. Over 50 percent of its patients and residentsare covered by Medicaid. The facility turns awayover 400 patient a year due to a lack of beds.This project involves the addition of 18 bedsand the renovation of much of the remainder of thefacility to maintain contemporary standards. The project is in compliance with all theapplicable criteria, and with that introductionwe'd be happy to answer any questions you have. CHAIRWOMAN OLSON: Thank you. Questions or comments from Board members? MEMBER HEMME: I'd like to make a comment.As part of my part-time job I get to go visitpeople in nursing homes around DeKalb County, KaneCounty. And recently I had the opportunity tovisit somebody who was in your nursing home, and Iwatched this patient transform from somebody whowas hunched over, ill-fed to somebody whose skinturned bright pink, who was excited to be there,and I have to say it's one of the best care givingfacilities that I've seen in my particular area.So I want to commend you for that. I think to add more beds is definitelynecessary in our area. It's a growing community



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and I think that you can provide some of the bestcare that I've seen in a long time. MR. BECKER: Thank you very much. Wereally try hard to do so. CHAIRWOMAN OLSON: Mr. McGlasson. MEMBER MC GLASSON: Yes. I have a questionnot really related to your application. How areyou doing it? And for the gentleman from theCounty Board, is your facility operating anywhereclose to profitably or in the black at least? MR. HANSON: If you don't mind, I'll takethat. I'm Gary Hanson, County administrator. We are very pleased with our facility.When we revamped it about 20 years ago, the missionwas to operate independently without property taxdollars, and not only have they done that, theyhave been able to pay off the debt on that facilityover the last 20 years, and we just finished thatbond issue. So it's a very good financial arrangement,and as the other Board member mentioned, it is thepride of the community. MEMBER MC GLASSON: May I suggest youwrite a manual?



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(Laughter.) MEMBER MC NEIL: A question. You have400 applicants that can't get in every year. Withthis new addition and modernization that is neededfor every old building, all the things we knowabout, how will this increase capacity? MR. AXEL: Bart. MR. BECKER: The initial 18 beds will helpus accommodate roughly 250 Medicare residents withan average length of stay of 20 to 25 daysdepending on how long they're with us. MR. AXEL: And these are primarily theshorter-term rehab patients. MEMBER MC NEIL: Those are in for the30-day and then back out with all the rules andregulations we have? Okay. CHAIRWOMAN OLSON: Seeing no furthercomments, I would ask for a roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by Hemme, seconded by McNeil. Senator Burzynski. MEMBER BURZYNSKI: Very familiar with thehome, obviously; it's in my district, for 20 yearsI served that area, as well as I used to do a lot



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of other things there. But anyway, because of myseat mate's testimony and in all honesty thequality of care that I know is given throughoutthat facility as well as the obvious need, I'mgoing to vote yes. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I vote yes based on knowingthe facility and encouraging you to do even better. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes because itobviously meets the criteria. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Yes, based on the datapresented. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on the positiveState Board staff report. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote yes, the State



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agency report. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, based on thepositive State Board staff report. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: The motion passes.Thank you. MR. AXEL: Thank you. CHAIRWOMAN OLSON: Next we haveProject 18-009, Alden Estates in New Lenox. May I have a motion to approve Project18-009, Alden Estate Courts of New Lenox toestablish a 166-bed long-term care facility inNew Lenox. MEMBER MC NEIL: So moved. CHAIRWOMAN OLSON: A second, please. MEMBER MURPHY: Second. (Witnesses sworn.) CHAIRWOMAN OLSON: Mr. Constantino. MR. CONSTANTINO: Thank you, Madam Chair. The applicants propose to establish a166-skilled nursing facility on the Silver Cross



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Hospital and Medical Center campus at a cost ofapproximately $39.6 million. The anticipatedcompletion date is March 31st, 2021. Alden Estates will have 114 beds dedicatedto skilled care. Alden Courts will have 52 bedsdedicated to Alzheimer's disease and relateddementia. All beds will be licensed under theIllinois Department of Public Health and certifiedby Medicare and Medicaid. As you will recall, in March of 2016 theState Board approved the applicants as part ofPermit No. 15-051 to establish a 140-bed long-termcare facility at this same location. Subsequentlythe applicants, in order to address the StateBoard's calculated bed need of 228 long-term carebeds submitted the proposed project to increasethe number of beds by 26 long-term term care beds. As of the date of this report, PermitNo. 15-051 is in compliance with all the postpermitrequirements. Should the State Board approve theproject, 18-09 -- 009 that is in front of you now,the applicants will relinquish Permit No. 15-051,and the calculated bed need in Will County will be202 long-term care beds.



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Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you,Mr. Constantino. Do you want to introduce everybody for us? MS. SCHULLO: Madam Chair, members of theBoard, I'm Randi Schullo, president of AldenManagement Services. I'm pleased to have with metoday Bob Molitor, our CEO; Tené Tillary, our RNand director of postacute services; John Kniery,our CON consultant; and Joe Ourth, our CON counsel. As always, I would first like to thankMr. Constantino and Mr. Roate for their work onthe State Board report. Two years ago the Board unanimously approvedour project to establish a 140-bed facilityNew Lenox. That the permit remains valid today,and if this project is not approved, we willproceed under the original permit to build the140-bed facility. Like the already-approved project, we areproposing a new facility in New Lenox immediatelyadjacent to Silver Cross Hospital. This projectwill be a combined skilled memory care and ageneral skilled nursing care unit. This facility



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will focus particularly on patients who aredischarged from the hospital and are expecting ashort-term stay. We are essentially requesting anaddition of 26 beds. For our original project Bob, our CEO,explained how changes in hospital reimbursement,particularly bundled patients and penalties forreadmission are causing hospitals to coordinatecare with facilities such as this. At our hearingon the original project, our director of postacuteservices had provided detailed information as tohow she and her team coordinate care with thedischarge to hospitals. You have also heard fromSilver Cross Hospital today as how we willcoordinate care. You had also heard us discuss that whilethere were some facilities with utilization belowtarget, none were in New Lenox, and this projectwill be the very first skilled nursing facility inNew Lenox. When we filed our CON application,there was a bed need in the planning area for141 beds. We applied for and received approvalfor the 140 beds. We would have preferred 166 bedsat that time, but Alden historically tries to



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respect the Board's bed need calculation. Since 2016 the bed need has grownsignificantly. You the Board have adopted a bedneed inventory currently showing 228 additionalbeds. As part of the approval for this project wewould immediately relinquish our current for140 beds and replace it with a 166-bed project weare requesting today. There will be still theneed, as Mike stated earlier, of 202 additionalbeds in this planning area. Our project today is to essentially addonly 26 beds to our already approved project.While we usually achieve this change by permitalteration, your rules preclude you from approvingan alteration when there's an increase of cost bymore than 7 percent or an increase of more than5 percent in square footage. Because we areproposing an increase in beds by 19 percent, wemust file this new CON. You will see from the State Board reportthat we have substantially complied with theBoard's rules. The only real issue that arosewith our application has to do with liabilityratios and if some facilities were operating under



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target utilization. These are the very samefindings on the project which you originally hadapproved. Hopefully we've fully addressed thesame issues when you approved the original project. Our project fully complies with all of theproject cost criteria. The only financial issueis the same finding for our financial ratio in theoriginal project. As the State Board report notes,Alden has a long track record of successfullyfinancing every project to ever come before you.We have carefully structured our project financingto comply with the stringent HUD lending requirementsof financing. We are prepared to go into additionaldetail if you have further questions regarding thefinancing ratios. The State Board report recognizes that notall facilities are operating at target utilization.Again, this was the same findings as our originalproject. The project we propose is located inNew Lenox immediately adjacent from Silver CrossHospital. There are no other skilled nursingfacilities, as you've heard, in New Lenox, acommunity consisting of approximately of 26,000residents plus another 15,000 in their township.



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Further, our location is in the planning areawhere population growth is highest in a proximityto an existing facility is yet the lowest. Thereare no comparable facilities located nearby. Most important we note that there was noopposition from any provider for our originalproject, and there has not been any opposition forthis current 26-bed addition. You are not likely to see any applicationfor a new long-term care facility that bettermeets the letter of intent of the Board's rules.Under your rules there's a calculated bed need of228 additional beds. There was no opposition forour original project or for this project, andthere has been strong support. You have heard today from the Village ofNew Lenox, Silver Cross Hospital, and in ourapplication from our State representative and ourState senator stating that there is need for thisproposed facility. Finally, we are bringing a new, innovativeservice to a growing community that currently hasno additional skilled nursing facility. We thankthe Board for its approval of our 140-bed



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facility, and we ask the Board's approval to addthe 26 beds today. In addition, we also want tolet the Board know that we are currently a part ofthe New Lenox community. As Nancy stated earlierfrom the Village, we are opening this month our53-unit affordable independent senior livingcommunity in the village. We are pleased to address any questionsyou may have. CHAIRWOMAN OLSON: Thank you. Questions from Board members? MR. CONSTANTINO: I would like to pointout on page 13 -- and it was noted in thesubmittal -- comments to State Board staff reportmade a mistake on Alden's Estates of Shorewood.All their beds are certified for Medicaid, andthat comment is included in the record. CHAIRWOMAN OLSON: Thank you. Questions? MEMBER SEWELL: I wanted to hear yourcomments on this criterion on the availability offunds and why the State agency is saying that itdoesn't appear that you have sufficient funds tofinance the proposed project.



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MR. KNIERY: That's based on the financingletter. We have actually a letter from -- HUD istwo-stage. You don't receive a final commitmentfrom HUD until you get the loan originator'scommitment. We do now have that loan originator'scommitment, correct. MS. SCHULLO: I'm not sure if you're askingthe question of the next step for our financing,but we do have our initial letter. The next stepof the process would be our final plans and specs. Currently our plans are 85 percent complete,and we are simply waiting to tell the Village ifwe're building 140 beds or 166 beds, and samething with the architect. Then we take that fullset of plans that we have and submit them to HUDfor our next phase of the financing process. MR. KNIERY: But, Mr. Sewell, it'sspecifically, though, relating to the financingletter. It's not to the equity. MEMBER SEWELL: So this is a stagingissue? It's not that you don't have the cash orthat HUD is not providing the amount of financing? MS. SCHULLO: Correct.



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MR. KNIERY: That's correct. MR. CONSTANTINO: Mr. Sewell, what I'mreluctant to approve is lenders because I'vebeen -- we, the Board, has been burned more thanonce regarding letters received from a bank, andultimately the financing didn't come through. Ireally stopped accepting letters from banks.That's what that refers to. Also, with the case of Alden, they haveexperience, as I tried to point out here, goingback at least 5 -- for longer than that now, over10 years they've been able to finance all theprojects they've proposed to the Board that you'veapproved, and the long-term care rules allow us tolook at that and that's what we've done. CHAIRWOMAN OLSON: Other questions orcomments? (No response.) CHAIRWOMAN OLSON: Seeing none, I wouldask for a roll call vote. MR. ROATE: Thank you, Madam Chair. Senator Burzynski. MEMBER BURZYNSKI: I would vote yes. Itappears to me that the applicant has answered the



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issues relative to the noncompliance, so I'm goingto vote yes. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I vote yes, as well, basedon testimony here today. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes becausethey appear to meet most of the criteria. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: I vote yes, based on thedata and the fact we have an aging population we'dlike to see continue. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: I vote yes, based onsubstantial compliance with State Board standardsand the explanation of the noncompliance. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote yes based onprevious comments.



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MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I vote yes, as well. Ithink we've already essentially approved theproject; we're just adding beds and the applicanthas explained any findings. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: Motion passes. MS. SCHULLO: Thank you. And I just wantto wish you all the best. I know this is yourlast meeting, and we appreciate your commitment tothe long-term care industry and to Alden over theyears. Good luck to you. CHAIRWOMAN OLSON: Thank you. Iappreciate that. Next we have Project 18-010, BlessingHospital medical office building. I need a motion to approve 18-010,Blessing Hospital to establish a two-store medicaloffice building in Quincy. A motion please. MEMBER MURPHY: Moved. CHAIRWOMAN OLSON: And a second. MR. MC GLASSON: Second.



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MEMBER SEWELL: Second. CHAIRWOMAN OLSON: The applicant will besworn in. (Whereupon, the witnesses were thereuponduly sworn.) CHAIRWOMAN OLSON: Your report,Mr. Constantino. MR. CONSTANTINO: Thank you, Madam Chair. The applicant proposed to construct anapproximately 81,000-gross-square-foot two-storymedical office building on the east side of Quincy,Illinois. The cost of the project is approximately$39.6 million dollars. The two-story buildingwould contain physician offices, laboratory,radiology, physical therapy, a coffee shop, andspace for medical supplies. The anticipatedcompletion date is December 31st, 2020. We received no comments regarding thisproject. There was no public hearing. We had onefinding related to the cost of the project. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you,Mr. Constantino. Please introduce yourself.



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MS. KAHN: Good morning and thank you forhaving us here, and thanks to the Board and thestaff for the review of our application. I'mMaureen Kahn, K-a-h-n, and I'm the president andCEO of the Blessing Health System in Quincy,Illinois. To my far right is Betty Kasparie;she's our vice president of compliance, and she isour CON expert. Immediately to my right isScott Koelliker; he's the executive VP of ourphysician practice group. And then to my left isPatrick Gerveler, and he is the CFO for the healthsystem. So this is our team here today. Just to give you a little geography,Blessing is located about four hours south andwest of where we are right now. We sit on theIllinois Missouri border, and we also sit on theIowa border. So we get to take care of patientsthat come in from all three statesin our region. We've been around now for 140-plus years.We're a not-for-profit center, and we're thelargest facility -- we're 307 beds but we're thelargest for about 100 miles in any direction. Wesupport probably about eight critical access



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hospitals out in our region for their tertiarywork, for trauma care, heart care, that type ofthing. So we sit in rural America. We are looking to construct a medical officebuilding on the east end of town for our facility,and we have chosen some farmland which has broughtto us some additional expenses, which as the teamreviewed our application we'll talk a little bitabout so that you can understand. Our facility is not just a hospital. Wehave a college of nursing and a school of alliedhealth there. So we have a school of respiratorytherapy; we also have a school of OR technology.And we continue to grow a workforce for ourregion, but nursing has been a big school for us,and we have a residency program with SIU comingout of the Springfield marketplace. So today we want to talk about thetwo negative findings while relative to the cost.The cost of the building we had some questions on,and we answered the questions to the team aboutwhat did we do differently in this building thatmay have added some additional cost. And it startedwith trying to understand some of the concerns



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from our consumers when we designed this newfacility. So we did things in our return air, ourHVAC system. Instead of open plenum, we now haveclosed. What that gives us is better heating andcooling in our building, as well as it allows toimprove the privacy in the exam rooms where wedon't have the open air and our walls will go upto the top deck. We also were using a new building materialon the exterior of our building in looking at howdo we avoid a lot of maintenance cost to theexterior of our building and build something thatwill have more durability, and so we're using anew material on the outside of the building. We also have a lot of X-ray andlaboratory. Our consumers don't want to come inand deal with hospital-based services. We arelooking to develop services that are consumer-friendly and out in areas where they can get inand out and not be in a provider-based environment. The land has given us some opportunity --because it was farmland and there are no utilitiesthere to develop it, we've done a lot of the



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excavating on the ground to make sure there wasn'tanything in the earth that we had to be concernedabout, as it has been farmland for many, many years. But it is an area of our town where wehave traffic that is growing, but it has publicaccess so we have buses that go out there. Wealso have all of our new housing starts that arehappening in that region. We are located near ourschools, so we will be close to our schools, andour orthopedic group is looking to be in thatbuilding. So we will be within a block from wherethey're playing a lot of their sports and activityand looking at how we can be very supportive. Thebuilding will also have some physical therapy in it. I think those were two of the findings inthe area was total cost of the building. I wouldlike to tell you we did put the building out tobid over the last two weeks. We have four bidsminimum in every trade, and our project right nowis coming in within $100,000 of the pricing thatwe listed here. The one bid that I will tell youis very short time dated for us is the bid forsteel, and so as much as we got the bid in, theygave us the bid for 15 days it is good for. So



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that is a big variability in our building. So, Pat, I don't know if anything that Ileft from a finance -- or if anybody has anyquestions. CHAIRWOMAN OLSON: Questions? MEMBER SEWELL: She said doctor first.You may ask my question. MEMBER MC NEIL: We never know. How many patients do you have headed overto Iowa, Peoria, leaving the area because ofcurrent -- you don't know if it's currentfacilities, but the expectation of the nicelobbies, all of the things you've talked about? MS. KAHN: I would tell you that thebiggest area that we have identified outmigrationis in orthopedics, and we are watching 750 andabove cases leaving the marketplace due to access,due to service availability, as well as makingsure that the services are all wrapped together.So you don't have to go here for this piece, thendrive another a couple blocks to go here for thispiece. That's what we're looking to do to packageour services that move, but ortho is our number



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one outmigration area. Pat, would you say anything else. MR. GERVELER: WE do look at the marketfor our outpatient services. We see about 20 to30 million -- not on cases but we look at a dollaramount -- that migrate out of the region. And toMaureen's point, probably a large majority of thatis in the orthopedic area. MEMBER MC NEIL: Where do they go? MR. GERVELER: We see in orthopedicsthey'll go, a lot of them over to University ofMissouri, Columbia, Missouri, town St. Louis,also, to that market. As Maureen said, we're alittle over 100 miles from Columbia, Missouri,Springfield, or St. Louis, and Iowa would beIowa City. MEMBER MC NEIL: While we talk aboutdollars, let's understand from a patient'sstandpoint they're driving 100, 200 miles, fourhours, six hours round trip. So that's the otherside of the issue just in human capital spent. MS. KAHN: Correct, convenience. CHAIRWOMAN OLSON: Other questions orcomments, Mr. Sewell?



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MEMBER SEWELL: As part of my ignorance ofconstruction costs, that's why I'm not botheredlike I should be, of this reasonableness ofproject costs. Because, you know, in addition tothe reasons you've listed here, you mentioned inyour testimony that you have a college of nursingand schools of allied health and you're doingresidency. So I guess I don't think of that kindof stuff as normally on-site with a medical officebuilding. And then you've got some underage -- CHAIRWOMAN OLSON: I don't think it'son-site. MS. KAHN: It's not on-site. It's justpart of who we are. It's on our main campus. MEMBER SEWELL: You've got some underagehere that is in excess of one of your overages onthe site survey but then that's a percentage. So should I -- I guess I should ask Mike.Should I be more bothered by these costs? MR. CONSTANTINO: RSMeans -- andMs. Kasparie told me what I could do with RSMeansafter I -- we're required to use RSMeans, Mr. Sewell.And if you like, George is the one that handles



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this for us. I don't want to blame -- I'm notblaming George. Ms. Avery would only allow us toget one license. MR. ROATE: The RSMeans data determinationsystem takes into account total gross squarefootage of the building, the actual geographicallocation, and the scores. So, for instance, with your medical officebuilding being a two-story. And what we found isaccording to RSMeans -- we've recently switchedfrom a data disk that we -- just a stationary diskto an actual prescription of the online service.It was smaller the gross square footage, the moreincrease in cost. Whereas, I want to say I guessit would reflect on the -- I don't know what theword is, scale, economies of scale come into playsignificantly. This has -- the cost per gross square footof this facility in Quincy did come up. What wehad determined low on the low end, but we ran thenumbers repeatedly and came up with the numbersthat we have in accordance with RSMeans. CHAIRWOMAN OLSON: Other questions orcomments?



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(No response.) CHAIRWOMAN OLSON: Seeing none, I wouldask for a roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by Murphy, seconded by McNeil. Senator Burzynski. MEMBER BURZYNSKI: I would support thisproject. I would vote yes based on the fact thatthey meet most State standards, and I believethey've addressed the reasons for noncompliance. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I vote yes due tosubstantial compliance with the standards. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes because ofsubstantial meeting of the standards. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: I vote yes. And I dounderstand the issue with steel. Canada is upset,Europe is upset. So the 15-day window isnecessary. So yes, based on the data.



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MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: I vote yes based on thetestimony and the substantial compliance withstandards. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote yes based on thesubstantial compliance. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I vote yes based on thefact I feel the applicant well explained their onenegative finding. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: At this point we willpause for one hour for lunch and return promptlyat 1:00. (Recess taken, 12:03 p.m. to 1:04 p.m.) CHAIRWOMAN OLSON: We're back in session.Next we have Project 17-014 DaVita Rutgers ParkDialysis. These are applications consequent tointent to deny.



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May I have a motion to approve aProject 17-014, DaVita Rutgers Park Dialysis toestablish a 12-station ESRD facility in Woodridge. MEMBER SEWELL: So moved. CHAIRWOMAN OLSON: Second, please. MEMBER MURPHY: Second. MR. ROATE: Madam chair, could I have arepeat, who called the motion and who seconded it? MEMBER MURPHY: I seconded. MEMBER SEWELL: I called the motion. MR. ROATE: Thank you very much. Sorryabout that. CHAIRWOMAN OLSON: The applicant will besworn in, please. (Whereupon, the witnesses were thereuponduly sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair. The applicants propose to establish a12-station ESRD facility in approximately 6900 grosssquare feet of lease space in Woodridge, Illinois.The cost of the project is approximately$4.1 million, and the completion date is



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June 30th, 2019. This application was given an intent todeny at the December 2017 State Board meeting. Atthat time no additional information was submitted. In April of 2018 the applicants notifiedthe Board staff that there was an error in theoriginal application for permit that affected thepopulation size of the 30-minute service area.The applicant submitted this information onApril 30th, 2018, and provided responses toquestions from the staff as well as revised zipcode and population information that increased thepopulation of the 30-minute service area, and thuseliminating the one finding we had -- or the onefinding we had related to surplus of stations inthat planning area, in that 30-minute service area. There was no public hearing. We didreceive opposition and support letters regardingthis project. Thank you, Madam Chair. CHAIRWOMAN OLSON: Thank you, Mike. Comments for the Board. MR. BHATTACHARYYA: I'm GauravBhattacharyya, good afternoon. With me today is



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Dr. Mat Philip, and our counsel, Kara Friedman andAnne Cooper. Despite being a fully positive Board staffreport, we did want to make a few comments herejust given a lot of commentary from our competitorsand wanted to make sure we addressed them on therecord. CHAIRWOMAN OLSON: Please. MR. BHATTACHARYYA: So as you know, theState Board report for this proposal is fullypositive and meets all the 21 criteria applicableto it, which includes both Part 1110, the needcriteria, as well as 1120, the financial viabilityand economic feasibility criteria. I'd like to just start by providing a fewacknowledgements for the support of this project.First, I'd like to thank the Board staff for thethorough review of this planned clinic and thefully positive reports. This project alsoreceived overwhelming community support, and I'dlike to thank our supporters, which includedSenator Dick Durbin, State Senators Curran andCullerton, Access DuPage, which is the largestfree clinic in the county, Edward Elmhurst Health,



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RML Specialty Hospital, and numerous organizationsand individuals from the Woodridge community whotook the time to submit letters of support and toshow up today to voice their support. I'd also like to thank the favorable votesof Chair Olson and Board members Demuzio, McGlasson,and Murphy who voted in favor of this project lastfall before the chair inventory was updated. When this clinic's proposal was originallyconsidered in the fall, there was a small excessof stations, and after consideration this Boardwas updated of service need determinations basedon updated use rates and demographic data, andbased on that, as Mr. Constantino said, it is nowa fully positive staff report. I would like to just address the oppositioncomments you heard today from both NANI and FMC,as I do believe some of them were incorrect or atbest case misleading. There's been a good deal ofcommotion from our competitors around this proposaland a lot of false and misleading statements.Nothing about their comments changes the fact thatit received a fully positive report, but I wouldlike to provide some context to what they said.



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First, as you all know, DaVita operatesclinics across the city, across the state, acrossthe country. Yet we have no facilities in DuPageCounty; this will be our first. The opponents,Fresenius and NANI, are joint owners of 80 percentof the clinics in this county. Again, we have nopresence, they have 80 percent, and yet they areunabashedly and falsely framing our entrance intothe market as a corporate takeover. Meeting all of the Board's need andfinancial criteria as evidenced by the fullypositive Board report, this proposal was a resultof careful planning and is designed to serve aspecific population that needs better access tocare. Fresenius is the world's largestmanufacturer of dialysis products and the world'slargest dialysis provider. The owner of theseclinics is NANI, which is the second largestnephrology group in the country and the largest inIllinois. And contrary to their statementsattempting to obstruct our entry into this market,as documented in the Board staff report, there'ssubstantial need for dialysis services in southernDuPage County for these planned clinics are



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proposed. We feel like the opposition has manipulatedthis process, inserting itself with a deluge ofpublic commentary aimed at intentionally disruptingthe process and intentionally misleadinginformation. The efforts of our competitors are drivenby a simple desire to control DuPage County marketwithout consideration for appropriate access tocare for patients and other health planningconsiderations. I think it's important to reflectthat this is not about NANI or DMG; this is aboutpatients and the access that they have to theirlife-saving care. The opposition claims that DaVita/DMGsubmitted the same referral letter for multipleapplications. While we used a standardized formletter to make sure we complied with all the Boardrequirements, each letter is substantially differentin that it addresses a different geographic areaand distinct issues for each application andputting up a map here that shows the CKD patientsthat were used specifically for this Woodridgeapplication.



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Per the Board's rules, the practicephysician referral letter must include the totalnumber of patients who have received dialysis careat existing facilities in the area and the numberof new patients referred to dialysis. GivenDuPage Medical Group is supporting more projects,this historical data must be the same for both buthas no bearing on the sufficiency of CKD patientreferral data for this project, and as I've said,there's no duplication of pre-ESRD patients foreither application. Despite FMC and NANI's objections to thefindings that the proposed clinics complied withPart 1110 criteria, our competitor has used thesame justification for their own clinics. Thefact is that in densely populated communities withgrowing senior populations like those in DuPageCounty we're going to see the type of growth thatwe've shown in our application. And while it's not the Board's job toprotect market share, the impact of this clinic onmarket share nonetheless is negligible. Thisplanned clinic only affects market share by about1.7 percent within a 30-minute service area, and



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Anne is putting up another chart to reflect that.The facts show that this is measured, incrementalgrowth, hardly a corporate takeover. And evenconsidering the additional stations that we wouldlike to place in the county, DaVita would stilltrail far behind FKC and NANI in their market share. Finally, DaVita's initial partner for ourclinic, DuPage Medical Group employs about10 nephrologists in the entire city of Chicago,and this group of specialists is dwarfed by thesize of the two opposing groups which combinedemploy about 545 nephrologists. So really in closing, I think DaVita'spresence in DuPage County will provide somemeasure of patient choice even though NANI willcontinue to dominate. We appreciate your timetoday and respectfully ask you to approve theplanned Rutgers Park clinic in Woodridge inaccordance with the fully positive Board staffreport. And with that I'd like to hand it off toDr. Philip. DR. PHILIP: Chairman Olson, illustriousmembers of the committee, Board members, thank you



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for the incredible privilege it is to be here withyou today. I was especially excited when I heard fromDr. McNeil and Dr. Goyal about the importance ofdecreasing costs in our health care system. That'ssomething I'm passionate about. I'm a physicianwith DuPage Medical Group, and we're the largestmember of Illinois Health Partners, which is thefifth largest ACO in the country. What we know is that it's easy to decreasecosts if you don't care about quality, and it'seasy to have great quality if you don't care aboutcosts, but doing both is the challenge. AndIllinois Health Partners is in the top 15 percentin quality in the country while being in thebottom 28 percent of cost. Part of that is one of the clinics that Ispearhead, which is our complex care clinics.What we notice is that 5 percent of patientsaccount for 50 percent of health care costs in ourcountry. This is based on data from theDepartment Health and Human Services. And westarted creating clinics that really focused onthose high-need patients to see, can we move the



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needle, can we help them, the patients most atrisk to decrease their hospitalization admissionsand readmission rates. And what we found is in 2017 that we hadgreater than 50 percent decrease in hospitalizations,emergency room visits, and hospital readmissionrates. But more importantly, people's qualityimproved. Their quality of life improved. They'reable to spend time with their grandchildren andtheir families be at home instead of in a nursinghome. And while we were doing that we were in thetop 1 percent of patient satisfaction both for ourregion as well as for the nation. Now, what we know is that those 5 percentof patients, a large portion of them are dialysispatients, and our goal to expand into the dialysisarea through partnership. We're a multispecialtygroup and we realize that it takes a villageworking together to actually help patients getbetter, that the whole burden is not on thenephrologist. There's several times patients come to meand say, "My nephrologist asked me to do this.What do you think about that?" And you say,



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"Well, I disagree with this but maybe this wouldbe the right thing," and we work on it together.Because that relationship, that physician-patientrelationship is key. And all of us have patientshere, and if we don't entrust our physicians, itputs us at a huge disadvantage, but if the primarycare provider is working together with thecardiologist and communicating back and forth tofigure out the best way of moving forward and totreat the root cause of what's going on, we noticethat quality improves while cost drasticallydecreases. So we're excited about the opportunity oftaking on cost production strategies whilemaintaining quality and expanding into dialysisbecause both our state and the country desperatelyneed this. So thank you for your time. MS. FRIEDMAN: Thank you. CHAIRWOMAN OLSON: Questions or comments? Yes, Doctor. MEMBER MC NEIL: Simple question. Youmentioned and I cited it had this morning the costof dialysis itself, and we could debate $97,500. What you brought up is a cost that is very



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different. That is if a patient doesn't complywith the dialysis, then they end up in the hospital,and that's not included in what I talked aboutthis morning. Is that a valid statement? DR. PHILIP: That's 100 percent correct,Dr. McNeil. What we noticed is that -- so I wasinvited five weeks ago to present before theU.S. Congressional ways and means committee onhealth care about health care innovation to sharewhat we're talking about because we've noticed ahuge decrease in costs and that's exactly my point. While dialysis care is expensive and weneed to focus on decreasing costs, missingdialysis, two days in the hospital is $150,000.We were just talking about one of my patients. Hewas there for 36 hours, and it was a $140,000 bill. One of my patients in particular who livesin DuPage County in this area we're talking about,she's a single woman in her early 70s, and she'safraid to be in the late shift. But for a yearwe've been asking to shift her into a differenttime, and we've called her local dialysis inDuPage County multiple times, but because there'sno relationship there she's just in the line



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waiting to move shifts. And she's missed herdialysis several times because she's scared to bein the parking lot by herself in the middle of theevening, and she's gotten hospitalized because it. Just simple things through a relationshipwith teams working together can drastically decreasethe cost of care while, more importantly, improvingher quality of life. And we have -- and thattrusting relationship is key. MEMBER MC NEIL: While we talk aboutmoney, it's really quality of life, longevity, andthose kinds of things, and that's where you'redoing the referrals is why the dialysis for manyin an OCC, outpatient care center, for many -- andas we talked about lunch; over lunch this is agreat topic to discuss -- but the in-home isn'tfor everyone because they just -- it's great ifthey can do it. CHAIRWOMAN OLSON: I have a couplecomments, clarifications. So from the time that this application wasfirst denied in September of '17 we've gone from atwo-station excess to a 49-station need? MS. FRIEDMAN: Correct.



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CHAIRWOMAN OLSON: And Mike and I talkedabout this extensively in our preconference becauseI still get stuck on the fact that there's23 facilities not at target utilization in thisHSA or within your travel distance. But I'm toldthat the reason that was found positive now isbecause of the high increase in patient populationand because of the error in the zip codes that youused; there should have been more zip codesincluded in the original application. MS. FRIEDMAN: That's right. That'spretty straightforward about the zip codes. Andthen what we discovered by doing the data miningof the data of your Board's report is that you seethe four-year CAGR, the compound annual growthrate, increasing much faster than it hadhistorically and also specifically within thisplanning area. So if you apply that growth rate, then yousee that these facilities are going to beoperating about 88 percent in 2020 when thisfacility is going to be online. And the reason that's important fromhealth planning is that, you know, there's a need



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for stations that then kind of pairs up withwhat's the correct locations to place these in,and it's the location where the facility use rateis rising rapidly. And what the documentationprovided you showed is that within this 30-minutearea that the utilization is rapidly increasingfaster than it is in other parts of the planningarea, so it's one of the most appropriate placesto place those services. CHAIRWOMAN OLSON: Just for the record,I'm not 100 percent on board with how you foundthat criteria to be met but it is met. MS. FRIEDMAN: And if I could just add,this is consistent with in the April meeting therewas a Fresenius project that was reviewed wherethe same analysis was applied, and it was a fullypositive State Board report despite the fact thatthere were some underutilized facilities inthe area. CHAIRWOMAN OLSON: Just to address --because this has been an application, as youmentioned, full of a lot of mudslinging. You'resaying under oath that the patient letters thatyou submitted were not duplicative; they were



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different for each one of the facilities that youput the letters in for? MS. FRIEDMAN: That is correct. And Ihave -- do you have the zip code data in frontof you? CHAIRWOMAN OLSON: She showed us on thechart I think. MS. COOPER: We've got the individual zipcodes, as well. MS. FRIEDMAN: Right. So it's differentzip codes between the letters. CHAIRWOMAN OLSON: And then the wholeissue surrounding the accusations aboutIlliniCare? MS. FRIEDMAN: Sure. What the issue thereis that this discussion occurred in September of2017. At that time it was a true statement thatFresenius did not participate in IlliniCare.Effective January 2018 they began participating.So we did not make a false statement about that atthe time that the statement was made. CHAIRWOMAN OLSON: And then the issuessurrounding the EMR, the lack of being able tocommunicate, that was not -- not having access to



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patient information? MS. FRIEDMAN: It's a timeliness issue.There are patient approvals, necessary writtenapprovals to get data and that sort of thing.But, Mat, maybe you can talk about that a littlebit more. DR. PHILIP: Yes. I mean, I have patientswho see both NANI as well as our own nephrologists.And we try to respect those relationships, butthere is a gap in terms of what actual labs areordered in dialysis. I don't see everythingthat's there, and sometimes patients request itfrom the dialysis center, and they bring it to meand we review it together, but there is aduplication of services. Now, there is some in between in terms ofEPIC. So I can see some results but not all ofthe results. But we try to communicate as much aspossible, but the more gaps you have is moreopportunities for miscommunication. CHAIRWOMAN OLSON: Thank you. Any otherquestions? (No response.) CHAIRWOMAN OLSON: Seeing none, I would



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ask for a roll call. MR. ROATE: Thank you, Madam Chair.Motion made by Sewell, seconded by Murphy. Senator Burzynski. MEMBER BURZYNSKI: I'm going to vote ayebased on the staff report. I do agree with theChairwoman, though, that there's been a lot ofmudslinging during this process, and I will tellyou from my perspective that doesn't go very far,and it does nothing to help or ensure patientsuccess. So I would hope that we can get pastthat and move on and provide the services that arenecessary for the health of our patients. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: Yes, because they have metall 21 criteria based on the staff reports. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, for exactly thesame reason. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Yes. And I encourage



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you -- I realize a technician can't can be used,but there are professionals that can that I havechecked on in the noontime. There are things wecan do for the in-home service as well as themajority are still going to do in the outpatientcare center. But, yes, based on the data. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on the updatedinformation and the complete staff report. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: Yes, based on the Stateagency report. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, based on the newState agency report. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: Motion passes. Next we have 17-016, DaVita Salt CreekDialysis. May have a motion to approveProject 17-106, DaVita Salt Creek Dialysis to



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establish a 12-station ESRD facility in Villa Park. MEMBER MURPHY: So moved. MEMBER SEWELL: Second. CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair. The applicants propose to establish a12-station ESRD facility in approximately6300 gross square feet of lease space in Villa Park,Illinois. The cost of the project is approximately$3.8 million, and the completion date isJune 30th, 2019. There is a need for 49 stations in thisHSA planning area. There was no public hearing.We did receive support and opposition commentsregarding this project, and we did receive commentson the State Board staff report that have beenincluded in the project file and sent -- emailedto the Board members. This project received an intent to deny inSeptember of 2017. Thank you, Madam Chair. CHAIRWOMAN OLSON: Comments. MS. FRIEDMAN: I just want to clarify that



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the reason State agency report was fully positiveis because, again, there was an excess of twostations, the data was reconsidered, and nowthere's need for 49 stations. CHAIRWOMAN OLSON: Thank you. Otherquestions? (No response.) CHAIRWOMAN OLSON: I actually do have aquestion. I was going to ask you this on the lastone. On both of these projects, if they shouldboth pass, are you still planning on June 30th of2019 completion date? MS. FRIEDMAN: What we would expect isthat it will be built by that time, and then we'regoing to have to see how far ahead of that date wehave submitted the Medicare certificationdocumentation. We expect it might take a few moremonths than that, and we can come back for a renewal. CHAIRWOMAN OLSON: Well, that's good becausethat's way less than the usual time frame. MS. FRIEDMAN: A lot of it is based on theuncertainty of Medicare certification, also. Ithink the facility will be about constructed andready for service.



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CHAIRWOMAN OLSON: Okay. Any other questionsor comments? (No response.) CHAIRWOMAN OLSON: Seeing none, I'd askfor a roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by Murphy, seconded by Sewell. Senator Burzynski. MEMBER BURZYNSKI: Yes, based on the Statestaff report. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: Yes, based on the staffreport. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: Yes, based on thecriteria being met. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Yes, based on the reportby the staff and the testimony. MR. ROATE: Thank you. Ms. Murphy.



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MEMBER MURPHY: Yes, based on thecompleted report. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: Yes, based on the Stateagency report. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: Yes, based on thepositive State Board staff report. MR. ROATE: Thank you. That's 7 votes in the affirmative. CHAIRWOMAN OLSON: Motion passes. MS. FRIEDMAN: Thank you very much. CHAIRWOMAN OLSON: Next we haveProject 17-045, Proctor Hemodialysis. May I have a motion to approveProject 17-045, Proctor Hemodialysis Center toestablish a 14-station ESRD facility in Peoria. MEMBER MURPHY: Motion. CHAIRWOMAN OLSON: May I have a second,please. MEMBER MC NEIL: Second. CHAIRWOMAN OLSON: Thank you.



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The applicant will be sworn in. (Witnesses sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair. The applicant has proposed to establish a14-station ESRD facility in approximately 5800 grosssquare feet of lease space in Peoria, Illinois.The cost of the project is $4.3 million, and thecompletion date is the December 31st, 2019. This project received an intent to deny atthe April 2018 State Board meeting. No additionalinformation was provided. CHAIRWOMAN OLSON: Thank you. Comments for the Board. MS. SIMON: Thank you and good afternoon.My name is Debbie Simon. I'm the CEO of MethodistHealth Service Corporation, which is the parent ofProctor Hospital. On my right is Keith Knepp, whois the president of the hospital and president ofour physician group. On my left is Terry Waters,who is our vice president of strategy anddevelopment. We are here today representing Proctor,



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who is a not-for-profit community-based hospitalin their application to open a dialysis unit.We're seeking this approval to try to bring anaffordable option to our community, particularlyour employer community where we have number ofself-funded health plans who are working hard tocontinue to provide affordable coverage to theiremployees. Terry is going to outline the basis of ourapplication, why we feel it's really important tothis community, and then both Keith and I andcertainly Terry are available for questions. So thank you for your consideration ofthis today, and I'll turn this over to Terry. MR. WATERS: Thank you, Debbie. I'd like to focus my comments this afternoonon two areas, excess capacity and the need forconsumer choice in order to lower the cost ofdialysis. The State agency report is largely positiveon our project. The State staff agrees that ourdialysis will fill within two years. They agreethat the size of the unit is appropriate and thatthe cost of constructing is more than reasonable.



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The principal concern raised in the State agencyreport is the fact that there's 16 excess dialysisstations in our service area. We do not disputethis fact. However, just to be clear, the issueof excess capacity is owned by Fresenius. Within our service area we have 12 renaldialysis centers with a combined capacity of175 stations. Fresenius owns 11 of those 12 unitsand controls more than 95 percent of the capacity.Fresenius could address the capacity issue simplyby right-sizing their dialysis operations. So youmust ask yourself, why does Fresenius not operatethe number of stations that are needed? One significant advantage of excess capacityis it creates a barrier to entry into the marketunder the certificate of need program. Allowingnew providers to enter the market may not be inFresenius' best interests. The second issue I want to address is thecost of dialysis in our service area. This issuefirst came to our attention several years ago whenwe had a dialysis patient that was covered underour health plan. At that time we were surprisedand frankly shocked by Fresenius' pricing structure.



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They were charging $4500 per treatment. When wecalled to try to negotiate a more reasonable rate,Fresenius simply refused. As the only provider inthe market, they did not have to negotiate withus; they could charge whatever they wanted tocharge, and we were forced to pay it. Currently, Fresenius appears to becharging $8500 per treatment. A sample bill wasincluded in our application. To put this chargein perspective, the current Medicare compositerate is $240 per treatment. Think a little bitabout those two numbers. Fresenius is charging inour market 35 times the Medicare composite rate. Commercial insurance is responsible forpaying for dialysis for the first 30 months oftreatment. The typical patient receives156 treatments per year. At a charge of $8500 pertreatment, that totals 1.3 million per patientper year. The cost of dialysis care in our market ison the radar of every payer. We've includedletters in our application from a variety ofpayers, including Caterpillar Tractor Company,including letters from insurance carriers and



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third-party administrators. Each of the payersare expressing a need for an alternative. Withouta viable option, payers and consumers will continueto pay an excessive amount for a relativelyinexpensive treatment. In our application we've committed to apricing structure which is 75 percent below theprevailing rate. If we are allowed to open acenter, consumers and payers can choose the bestoption to meet their needs. In our view, there islittle benefit to maintaining the status quo wherepatients and payers are forced to use a providerregardless of the service, regardless of thequality, and regardless of the price. The status quo benefits no one with theexception of Fresenius. Whether it is in excessof 16 stations or there's a need for 16 stations,it will not alter Fresenius' pricing structure.Only through choice will pricing be lower than ourmarket. That concludes my comments. I'd like tothank you for your consideration, and we'd answerany questions you might bring forward. CHAIRWOMAN OLSON: Thank you.



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Questions? MEMBER MC NEIL: What is your cost peryear for a dialysis patient? I didn't multiply156 times X. MR. WATERS: I actually calculated it. MEMBER MC NEIL: 97,500? MR. WATERS: What Medicare pays a year is$37,000. MEMBER MC NEIL: And that would be thecost through Medicare. MR. WATERS: That's roughly what our costis going to be. MEMBER MC NEIL: Medicaid is a little bitbelow that? Private payers like Caterpillar, Cityof Peoria? MS. SIMON: That's the concern we'retrying to address with the opening of this centeris being able to offer a different pricingstructure than they currently face in the market.Similar to what Terry has described, we faced inour one employee and subsequent employees who havehad dialysis, that's what they face for that30-month window, the charge that the employersbeing charged for those procedures.



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MEMBER MC NEIL: Your cost per patient peryear, do you break even at 37,000? MS. SIMON: We believe that we can sustainthis at the 75 percent reduction in pricingstructure from the current prevailing rate. Yes,we feel we can sustain ourselves with that. MEMBER MC NEIL: And you're going to dothat at the Methodist location. MS. SIMON: At the Proctor CommunityHospital location because it's a very accessiblelocation. MR. WATERS: We've ran dialysis in thepast. We sold our company -- it was a jointventure company with OSF. MEMBER MC NEIL: St. Francis. MR. WATERS: St. Francis, correct. Atthat time our charging structure was approximatelythree times the Medicare rate. To put it inperspective, Fresenius' charges are 35 times. MEMBER MC NEIL: Okay. In terms ofvetting patients for a kidney transplant, theU of I has a Rush Medical School there. Are youlooking to push patients toward -- because that isthe solution to the issue beyond dialysis.



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MR. WATERS: Absolutely. MS. SIMON: And our physicians, who areassociated -- they are not employed; they are anindependent in the community are very active inattempting to not only sign everyone up that meetsthe criteria, but then also to look for alternativeswith dialysis such as home dialysis, and we areseeking to continue to support the practice of renalphysicians who have patients who are seeking thattype of dialysis. So they're a group that islooking to look for options that patients can seekthat will help them. MEMBER MC NEIL: We've heard testimonytoday that home dialysis is much more effectivebecause it's six times a week rather than three,whole different system, but not many patients wantto do it. Do you have a way of working with thephysicians so they do the home, if possible? MS. SIMON: Yes. And Renal Care, that'sthe group that we work with, they're active ineducation, support as they partner with thehospitals, both hospitals to help provide thatemotional support, educational support in thehome. They are a group that supports those options.



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MEMBER MC NEIL: Thank you. MEMBER GOYAL: Madam Chair, this isArvind Goyal. I represent Medicaid on thisagency, but I have a question especially since youemphasis your billed charges versus Medicareallowed charges. The question is, Medicareallowed charges, are those global or are yourphysicians able to bill Part B separately, you'reable to bill medication separately, and you'reable to bill supplies and vascular access chargesseparately? MR. WATERS: The Medicare composite ratecovers all services. MEMBER GOYAL: So it's global, is thatwhat you're saying? MR. WATERS: It does not cover physicianservices I don't believe, but labs, all that isincluded. MEMBER GOYAL: Thank you. CHAIRWOMAN OLSON: So if I'm a Caterpillaremployee and I need dialysis, I'm going to pay mydeductible, and then 20 percent of whatever those35 times Medicare charges were as a privatelyinsured patient, which is what you're trying to



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address. MS. SIMON: That's what we're trying toaddress. CHAIRWOMAN OLSON: Privately employedpatients, the cost to the employer and employee isexorbitant? MR. WATERS: There's typically anout-of-pocket maximum that the patient will payuntil they hit the maximum. CHAIRWOMAN OLSON: Other questions? (No response.) CHAIRWOMAN OLSON: Seeing none, I wouldask for a roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by Murphy, seconded by McNeil. Senator Burzynski. MEMBER BURZYNSKI: I will vote yes basedon the majority of the staff report and also onthe testimony we've heard here today relativeto cost. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I'm going to vote yes, aswell. Again, substantial compliance with the



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standards, but I would also encourage you to findways to keep reducing costs down. MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes fortwo reasons. One, that we have to encourageinnovation if we hope to solve the problems ofhealth care, and second, that the reportessentially met the criteria. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: Yes, based on what yousaid, what you're trying to do, and the staffreport. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: Yes, based on substantialcompliance with the staff report. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote no. There's excesscapacity in the area. MR. ROATE: Thank you. Madam Chair.



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CHAIRWOMAN OLSON: I was actually fullyprepared to vote no on this application, but Ibelieve this is an access issue, and access is oneof the criteria that we are allowed to vote on,and I believe that you will open access. I mean,as a privately insured person myself, I understandhow exorbitant the costs can become if you're noton Medicare or Medicaid and were in a situationwhere you needed dialysis. So I'm changing my vote to yes based onthe fact that I think we'll improve access topatients in the area. MR. ROATE: Thank you. That's 6 votes in the affirmative, 1 votein the negative. CHAIRWOMAN OLSON: The motion passes. MR. WATERS: Thank you very much. MS. SIMON: Thank you very much. Weappreciate it. CHAIRWOMAN OLSON: Good luck. Next we have -- I guess Project 17-060 hasdeferred. So next we have Project 17-061, DialysisCare Center of Elgin.



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May have a motion to approve Project 17-061,Dialysis Care Center Elgin to establish a14-station ESRD in Elgin. MEMBER MC GLASSON: So moved. MEMBER MC NEIL: Second. (Whereupon, the witnesses were thereuponduly sworn.) CHAIRWOMAN OLSON: Mr. Constantino, yourreport. MR. CONSTANTINO: Thank you, Madam Chair. The applicant has proposed to establish a14-station ESRD facility in approximately 6500 grosssquare feet of lease space at a cost of approximately$1.5 million. The expected completion date isOctober 30th, 2019. This project received an intent to deny atthe April 2018 State Board meeting. There is anexcess of 24 stations in this planning area.There was no public hearing, and no additionalinformation was submitted. We did receive supportletters regarding this project. Thank you, Madam Chair. CHAIRWOMAN OLSON: Would you introduce whois at the table, please.



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DR. SALAKO: Yes. Good afternoon, Board.My name is Dr. Salako. I am the CEO of DialysisCare center. To my left is Dr. Farhan Bangash.He is the practicing nephrologist in the Elginarea. To his left is Mr. Asim Shazzad; he's thechief operating officer of the Dialysis CareCenter. And to his left is Ms. Melissa Smith; sheis my area manager, clinical area manager in theElgin market. And, finally, at the table isMs. Kristen Paoletti, who is my director ofclinical operations; she's also an RN. CHAIRWOMAN OLSON: Thank you. Commentsfor the Board. DR. SALAKO: Thank you. I'm going to makea brief statement and then ask members of my teamto chime in. We're here again to talk about our projectin Elgin, and I think the big elephant in the roomis that there's an excess capacity of 24 stationsin the region. However, as we said -- as we wantto clearly state to the Board, at our company, ourDNA, we're a home-therapy company at our core. Asof today, we are the largest independent hometherapy provider in the State of Illinois. We



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have more PD stations than U.S. Renal in theChicago area, across the whole state of Illinois,in fact, but we have a very unique problem. In the Elgin area alone, we have about80 PD patients. PD patients typically need respite,typically may have their PD catheters pulled out --oh, by the way, we also have about 40 independenthome PD patients in that northwest corridor. Ourpatients have a unique challenge today. When theyneed respite care, if for whatever reason theirPD catheters fail, they need to go into anin-center. When they go to a Fresenius, DaVita,or any other LDLs, they stay in-center patients. This is a huge problem for us becausethese patients want to be home therapy patients,but when they go into a traditional dialysisclinic, they end up staying there, and they say,"Just come every day. You don't need to be onhome care; This is more convenient for you." So we need a process, we need an environmentwhereby we can continue to provide some kind oftransient in-center dialysis care for our patients.If they, for instance, have a PD catheter pulled,they can go to in-center dialysis for four weeks,



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or five weeks, or six weeks, and they can go backto PD. We've done this very well in other statesin the country where we're present, but we havethis huge challenge, it's a huge roadblock infront of us in the Illinois market where ourpatients get PD or they need to have their PDcatheters revisited, or their caregiver goes onvacation, they need to have respite care for aweek, two weeks, three weeks, four weeks. They gointo an in-center clinic and they stay there;they're no longer home therapy patients. So it's a tool for us really to continuethe care of our patients. It's a very uniquerequest that we have, but this is the uniquesituation that we're faced with, and we reallywant the Board to look at this for us and grantour request favorably. I'll let the rest of my team give you thedetails of what goes on, but this is a top-levelview of why we really want this center. Dr. Bangash. DR. BANGASH: Thank you. So I've been here a couple times, and wehave discussed this project back in April, but



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I'll just start from scratch and kind of presentit from the bottom up here. So my name is Farhan Bangash. I'm a board-certified nephrologist. I am born actually inElgin, still live in the area; I have family inthe area. I started the practice six years ago,and we have grown tremendously. We now currentlyhave four physicians, a nurse practitioner, andwe'll be adding another physician in the nextcouple months. I have worked very closely withthe home dialysis services, and we have -- in thesix years I've been in practice, we now have thelargest home program in the area. Just like what Dr. Salako was bringing up,there is a major issue when it comes to our homepatients. So home dialysis is done either viaperitoneal dialysis, which is done nightlysix times, six to seven -- every night, and thenhome hemodialysis is done at home five, six times aweek. What -- and it works great. These patientsusually are active; they're independent, andinstead of, you know, missing work. They can dothe dialysis at home; they do well with it; theydo great during the day; they still contribute to



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society. The problem with home dialysis patients isthey can't stay on it forever, and sometimesthere's interruptions in their care. So eitherour home patients will go on to transplant --which is a great outcome and that that's what wepush for. We actually refer 100 percent of ourpatients to transplant centers. Over half of themusually make it to the appointments and then getthe process going. The other patients either forwhatever reason, access issues, or other healthissues, infections, have to go onto hemodialysisin-center, and this is really where we see theissues. So our patients know us very well. Theyhave my cell phone number; they have Missy, ourclinical manager's cell phone; they have our nurse'scell phone number. They call us with any issues;they text us. We see them two to three times amonth. One visit a month we do a multidisciplinarymeeting with them, the dietician, social worker,I'm there, the nurses are there. We know themvery well, and we try to keep them on the homeprogram.



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The surrounding dialyses in the area, ARA,Fresenius, DaVita, when our patients go to these,what happens is they get told they are never allowedor they cannot go back to home dialysis, which isjust not true. Rarely that can happen, but whathappens is these patients get sent out, fistulasare being placed; this is an invasive procedure;it's a cost to the whole health system. And it'sunnecessary really because they can stay onhemodialysis with a catheter for about three tofour weeks, get treated, and then go back to theirhome therapy. We've seen this multiple times, and theproblem honestly with the other units is they'rejust an algorithm. The patients get in there, andit's a one-size-fits-all model. We know withdialysis that men dialyze different than women;older individuals dialyze different than youngerindividuals; body mass has a lot to do with it.So they don't treat the patients for each specificpatient; they kind of treat them one-size-fits-all-type model. So in Elgin, which is the seventh largestcity in Illinois, we have a need for a unit that



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would be open to our home dialysis patients. Ifthere's a dialysis team that we have control over,we can send our home patients there; they can thencome back to their home therapies. On top ofthat, Elgin, either 50 percent of the populationis either Hispanic or African-American. We knowthat Hispanic and African-American population ismore prone to go onto dialysis. The two units in Elgin right now, one is101 capacity; the other is 91 percent capacity,and earlier today one of those units got approvedfor five extra stations. I have -- and I'm justgoing to go on a tangent here for a second. Ihave hemodialysis patients in those clinics; Ihave a lot of patients in those clinics that haveno options on when they can go to the clinic.They're either given 5:00 a.m. to 9:00 a.m. shiftsor 4:30 to 8:30 p.m. shifts. There's one patient in particular that comesto mind who misses at least two to three sessionsa month because she just can't get up at 4:30 inthe morning, get to the clinic by 5:30, and dodialysis. She's in the hospital every other month,and I think in the previous presentation we went



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over the cost of that. That is up to $150,000 forone to two nights. So a dialysis unit in Elgin would reallyhelp us in two ways. One, it would open up slotsfor current hemodialysis patients. It would givethem better options on when they could do dialysis,and two, it would already help the alreadyabundant home population in the area. With that I'll kind of wrap up here.Thanks for having us. Again, any questions we'llbe happy to answer. MS. SMITH: My name is Melissa Smith.Again, I'm the area manager for the northernregion. I've actually been with Dr. Bangash andhelped grow the home therapies program for thelast four years. As you can hear, we are very, very, verystrongly supportive of the home therapy programs,and we're very connected with our patients. Andin regards to patients that have been there forfour years or more, as Dr. Bangash was saying,they can't be on home therapy forever. So we takeour patients we -- for lack of a better word,we're like their family, and now we have many



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patients that are coming to the end of theirtimeline for home therapies, and they need somewherethey can go for that continuity of care. So theyneed to be in a center where they have a familiarcare team and the same things that we've beencovering as far as goals and commitment to themwould continue. CHAIRWOMAN OLSON: Thank you. Questions from Board members. MEMBER MC NEIL: This is déjà vu all overagain. How many patients go in for transplants?You said you had 100 percent referral, 50 percentactually go the next step, but how many actuallyget the transplant? DR. SALAKO: We looked at our numbers from2016. I don't have the 2017 numbers, but we runat about 8 to 10 percent of the ones that wereaccepted into the program who are transplanted.And we go to Loyola; we do Christ; we doNorthwestern; we do other transplant centers inthe community. MR. BANGASH: Actually, in my area also Ido send them to Madison where the wait time is a



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little less. So they have access to University ofWisconsin and Froedtert in Milwaukee. MEMBER MC NEIL: So that's part of the10 percent, though? DR. SALAKO: Yes. MEMBER MC NEIL: And then costwise -- Ithink we went over this last time -- we know theoutcome of in-home is -- seems to be better; we'veheard testimony today and last time on it. So thein-home, what's the average life span compared tothe outpatient care centers like we're talking about?Is there a difference? DR. BANGASH: So there -- no studies haveshown that there's a mortality difference betweenin center or home. Unfortunately -- we've beenwaiting for a study to show that. If that was thecase, then I think we would have to pick hometherapies for everyone. But they have shown improvement in qualityof life, improvement in the mass of the heart.The left ventricular mass, better improvement intheir phosphorus control, which all improve theirpatients' health in general. But that specific to -- there is no



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difference in mortality. MEMBER MC NEIL: But there is a differencein cost because they're hospitalized less; isthat true? DR. BANGASH: Definitely. DR. SALAKO: There's a definite differencein cost but really it's a lifestyle. I have apatient who is a bass musician. He's still ableto travel across the country and play bass. If hehas to come to dialysis three times a week, he'snot going to. He got infected recently. He wasable to -- he's a very headstrong guy -- go into aclinic say, "I need to go back onto PD because Ineed to be a bass musician." Most of thosepatients, we'd lose those patients, and that's ahuge problem. MEMBER MC NEIL: So you look on your centeras being transitional to take them out of the homebecause of a need and then put them back in as soonas possible? Some will never go back to home. DR. SALAKO: Absolutely. It's almost likea transitional clinic, but that's absolutely whatwe need. CHAIRWOMAN OLSON: Other questions or



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comments? I actually have a question. I'm justcurious. So we have seen a lot of otherESRD facilities proposed today, and they allapproximately cost between 3- and $4.5 million,and yet the cost of yours is $1.5 million. Howcan you do this so much cheaper for the same --I'm just curious. We don't have a criteria forcost is too low; we have one for too high. Butit's just kind of curious to me. MR. SHAZZAD: So since we're nottraditionally an in-center facility, we're almostlike a transitional facility. We have home unitsactually nearby with a lot of our administrationareas in there. So our in-centers do not havelarge staff rooms, large offices, large manageroffices. We only focus on patient care. It'sstrictly a transitional facility, and the space isall allocated mainly for the patients in thosefacilities. CHAIRWOMAN OLSON: So is this going to bea brand-new building or part of an existingbuilding?



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MR. SHAZZAD: In Elgin it's part of theexisting building; it's not a brand-new building. CHAIRWOMAN OLSON: So you're not having todo new construction? DR. SHAZZAD: There's no new constructioninvolved. CHAIRWOMAN OLSON: Other questions orcomments? (No response.) CHAIRWOMAN OLSON: Seeing none, I ask fora roll call vote. MR. ROATE: Thank you, Madam Chair.Motion made by Burzynski, seconded by McNeil. Senator Burzynski. MEMBER BURZYNSKI: I'm going to vote yesbased on the testimony that we've heard here todayrelative to cost benefits and just health benefitsto the patient. MR. ROATE: Thank you. Ms. Hemme. MEMBER HEMME: I'm going to vote yes. Ithink substantially they met the criterion, and Ithink that the commentary here today addressedsome of my concerns.



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MR. ROATE: Thank you. Mr. McGlasson. MEMBER MC GLASSON: I vote yes because themajority of the criteria were met. MR. ROATE: Thank you. Dr. McNeil. MEMBER MC NEIL: I vote yes, again, basedon the criteria, based on what you are doing notas an experiment but as a transition. So it'sbased on the report plus what you've said. Itwill be interesting to see the outcomes. MR. ROATE: Thank you. Ms. Murphy. MEMBER MURPHY: I vote yes based onsubstantial compliance and the unique nature ofthe project. MR. ROATE: Thank you. Mr. Sewell. MEMBER SEWELL: I vote no. State agencyreport showed excess capacity in the planningarea. MR. ROATE: Thank you. Madam Chair. CHAIRWOMAN OLSON: I really applaud what



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you're doing, but I'm bothered by the excesscapacity in the HSA. So I'm going to vote no, butwith five votes in the affirmative the motionpasses. MR. ROATE: Thank you, Madam Chair. That's 5 votes in the affirmative, 2 inthe negative. CHAIRWOMAN OLSON: Congratulations. Next we have rules development. MS. GUILD: As you will remember, effectivein March we adopted rules for Part 1110, and whatthose rules primarily did was to change one of theneed metrics from normal travel time to distance.In doing that, two categories of service got leftout. One was open heart and the other wasfreestanding emergency centers. So these ruleamendments correct that oversight. In addition, the Emergency Medical ServicesSystems Act had been amended since these ruleswere amended, so we updated the rules to beconsistent with what is in that act. CHAIRWOMAN OLSON: Questions from Boardmembers. (No response.)



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CHAIRWOMAN OLSON: We need a motion toapprove the amendments to Part 1110. MEMBER MC NEIL: So moved. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Opposed. (No response.) CHAIRWOMAN OLSON: Motion passes. We have no unfinished business. Other Business. We have a legislativeupdate. MS. GUILD: You have a summary of all ofthe legislation that we were following. For thoseof you who were not aware, our legislation HouseBill 4645 which extends the sunset of the PlanningAct for 10 years did pass both houses, has notbeen yet sent to the Governor but it will it be. House Bill 4892, which was a bill thatdeleted the requirement that a Planning Boardmember or Review Board member attend publichearings, that passed. There are also a number oftechnical changes in that bill, and that will be



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sent to the Governor. And the only other one I'm going to highlightis House Bill 5069. We had a friendly amendmentto that bill to correct some drafting errors thataffected us negatively, and that bill as amendedalso passed both houses. And you have a summary of all the others;I don't really need to address them. If anyonehas any questions, I'd be happy to answer them. MEMBER SEWELL: I have a question. CHAIRWOMAN OLSON: Yes, Mr. Sewell. MEMBER SEWELL: On House Bill 5069, ifthis becomes legislation, does it mean that wewould not review end-stage renal disease? MS. GUILD: No. The Department of PublicHealth, this was their initiative, and they had --what they're going to do is rely on Medicarecertification rather than the State licensingrequirement for that, and the way it's drafted nowit does not affect us at all. We still willcontinue to review these projects. MEMBER SEWELL: But it says that -- it lookslike it says -- you see me change that? It lookslike it says if they're not health care facilities.



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MS. GUILD: Oh, that was our amendment tofix that. MEMBER SEWELL: We fixed that? MS. GUILD: We fixed that. MEMBER SEWELL: Okay. I'm done. CHAIRWOMAN OLSON: Okay. Bed changes? MR. CONSTANTINO: No bed changes. CHAIRWOMAN OLSON: You have your updatedchanges in the employee handbook, Jeannie? MS. MITCHELL: You received the summaryand detailed explanation of the changes proposedin the personnel handbook. One of these changes is because of achange in Public Act 100-554 dealing with sexualharassment policies, so we needed to becomecompliant with that law, so that was a changeproposed there. There's some cleanup but most of the otherchanges are just to make -- give clearer guidelinesto employees as far as what's permitted and what'snot permitted and how things are supposed to happen. So you have a summary of those changes.I'd just like approval to update the handbook. CHAIRWOMAN OLSON: May I have a motion to



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update the handbook. MEMBER MC NEIL: I move. CHAIRWOMAN OLSON: So moved. Second, please. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Opposed like sign. (No response.) CHAIRWOMAN OLSON: Motion passes. Questionnaire revisions. MR. CONSTANTINO: Yes. That's the resultof the affiliation between Edward Hospital andElmhurst Hospital. They corrected their revenueestimates -- revenue information that they sent tous as part of the 2016. CHAIRWOMAN OLSON: Do you need a motion toapprove those? MR. CONSTANTINO: Yes, please. CHAIRWOMAN OLSON: May we have a motion toapprove the requested revision. MEMBER BURZYNSKI: So moved. CHAIRWOMAN OLSON: And a second, please. MEMBER MC NEIL: Second.



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CHAIRWOMAN OLSON: All those in favorsay aye. (Ayes heard.) CHAIRWOMAN OLSON: Like sign. (No response.) CHAIRWOMAN OLSON: Motion passes. And you have the IntergovernmentalAgreement review? MS. MITCHELL: So we enter into anintergovernmental agreement with IDPH annually,and that's because they perform a lot of functionsfor us such as accounting, HR, fiscal, and otherthings. So we need to sign a new IGA. It'smaterially the same as it was last year, differentdates, and a couple of other grammatical things. So I would need a motion to approve theIGA for fiscal year 2019. CHAIRWOMAN OLSON: May I have a motion. MEMBER MC NEIL: So moved. MEMBER BURZYNSKI: Second. CHAIRWOMAN OLSON: All in favor. MEMBER SEWELL: Discussion. CHAIRWOMAN OLSON: Oh, discussion, sir. MEMBER SEWELL: Who from here, I guess I'd



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use the word negotiates this with IDPH from thisBoard? MS. MITCHELL: As far as Board members orBoard staff? MEMBER SEWELL: Just whoever does it. MS. MITCHELL: It would be myself withinput from Courtney, of course, and anyone whoever has input. But I will tell you that we are --in attempts to make changes in the past theyhaven't been so willing to make changes. MEMBER SEWELL: My concern about this isthat aren't you all -- are you all employees of IDPH? MS. MITCHELL: No. MEMBER SEWELL: You're not? MS. MITCHELL: We're employees of theBoard. We are employees of Health FacilitiesReview Board. MEMBER SEWELL: Okay. Well, then Itrust you. MS. MITCHELL: Okay. Did you hear that,Mike and George? He only trusts Board employees. CHAIRWOMAN OLSON: So I have a motion anda second. All those in favor of approving the IAGsay aye.



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(Ayes heard.) CHAIRWOMAN OLSON: Opposed, like sign. (No response.) CHAIRWOMAN OLSON: Motion passes. Okay. May I have a motion to adjourn?Next meeting is July 24th, same time. MS. MITCHELL: 9:00 a.m. CHAIRWOMAN OLSON: 9:00 a.m. MEMBER MC NEIL: So moved. CHAIRWOMAN OLSON: All right. And asecond. No second? MEMBER SEWELL: I'll second that. CHAIRWOMAN OLSON: Oh, we are cancelingthe September meeting? MS. AVERY: Yes. CHAIRWOMAN OLSON: So there's a July meeting. And for the last time, adjourned. (Off the record at 2:09 p.m.)



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CERTIFICATE OF SHORTHAND REPORTER

I, Paula M. Quetsch, Certified ShorthandReporter No. 084-003733, CSR, RPR, and a NotaryPublic in and for the County of Kane, State ofIllinois, the officer before whom the foregoingproceedings were taken, do certify that the foregoingtranscript is a true and correct record of theproceedings, that said proceedings were taken byme stenographically and thereafter reduced totypewriting under my supervision, and that I amneither counsel for, related to, nor employed byany of the parties to this case and have nointerest, financial or otherwise, in its outcome.

IN WITNESS WHEREOF, I have hereunto set myhand and affixed my notarial seal this 15th day ofJune, 2018.

My commission expires: October 16, 2021

_____________________________Notary Public in and for theState of Illinois



Aability72:9able16:12, 16:16,16:23, 16:24,17:1, 17:2,29:12, 30:20,30:21, 48:15,67:15, 97:17,109:12, 132:9,138:23, 151:18,154:8, 154:9,154:10, 169:8,169:12about9:4, 16:8,19:15, 19:19,19:22, 21:24,22:21, 29:2,32:17, 55:4,60:21, 61:6,63:9, 63:13,66:12, 67:11,70:20, 71:1,71:2, 71:10,71:14, 72:16,72:18, 73:4,73:8, 73:14,73:23, 74:1,74:5, 74:12,76:14, 78:14,78:16, 79:11,79:15, 80:12,81:8, 82:4,87:5, 97:14,98:6, 113:14,113:23, 113:24,114:9, 114:18,114:21, 116:3,117:13, 118:4,118:17, 123:12,126:22, 128:12,129:23, 130:8,130:12, 131:4,131:6, 131:11,131:12, 132:24,

133:13, 134:3,134:9, 134:10,134:15, 134:18,135:10, 135:15,136:2, 136:12,136:21, 138:13,138:20, 139:5,143:23, 149:12,159:17, 160:4,160:7, 164:10,167:18, 168:11,179:11above28:6, 58:1,79:21, 117:17absent6:5, 6:6, 6:9,6:12, 80:16absolute71:15absolutely75:7, 79:1,153:1, 169:21,169:22abundant166:8accepted11:12, 167:19accepting109:7access15:8, 19:19,21:21, 22:15,27:11, 30:1,33:1, 35:2,35:8, 35:9,35:14, 35:17,36:6, 36:18,37:13, 37:24,38:6, 38:8,38:20, 55:20,60:4, 60:7,61:3, 61:15,63:23, 64:2,64:9, 65:23,68:24, 70:16,75:1, 81:1,83:22, 113:24,

116:6, 117:17,125:23, 127:14,128:9, 128:13,138:24, 154:10,157:3, 157:5,157:11, 163:11,168:1accessibility42:22, 55:22,64:7accessible152:10accessing68:1, 68:4,68:16accommodate98:9accomplish16:12accordance120:22, 130:19according68:6, 120:10account57:10, 120:5,131:20accountants81:14accounting178:12accusations138:13achieve104:13achieved66:14acknowledgements125:16aco16:14, 131:9across71:23, 72:19,127:2, 160:2,169:9act4:9, 7:1, 50:1,56:19, 173:19,173:21, 174:18,

176:14action4:2, 32:13,43:16actions7:14, 7:16active153:4, 153:20,162:21activity116:12actual45:24, 120:6,120:12, 139:10actually29:16, 47:20,58:1, 67:11,67:21, 81:1,108:2, 132:19,143:8, 151:5,157:1, 162:4,163:7, 166:14,167:14, 167:23,170:2, 170:15acute59:4, 62:3add19:3, 28:5,31:18, 81:3,90:8, 90:17,94:23, 96:23,104:11, 107:1,137:13added31:11, 83:5,114:23adding13:4, 111:5,162:9addition27:15, 28:2,56:18, 96:4,98:4, 103:4,106:8, 107:2,119:4, 173:18additional10:20, 14:21,16:17, 23:23,



25:3, 25:19,26:23, 30:10,30:23, 41:5,57:11, 75:1,85:18, 104:4,104:9, 105:13,106:13, 106:23,114:7, 114:23,124:4, 130:4,146:12, 158:19additionally40:24address11:3, 101:14,107:8, 126:16,137:20, 148:10,148:19, 151:17,155:1, 155:3,175:8addressed81:17, 105:3,121:10, 125:6,171:23addresses128:20adds27:13adequate13:9, 32:15,63:24adjacent27:10, 102:22,105:20adjourn180:5adjourned7:9, 180:17adjournment5:17administration170:15administrative36:21administrator2:7, 95:16,95:18, 97:12administrators150:1

admissions132:2admits14:22admitted10:6, 15:10,22:14adopt69:21adopted104:3, 173:11advantage22:20, 148:14adverse12:1, 12:2affect175:20affected124:7, 175:5affecting26:12affects129:23affiliates39:23affiliation177:13affirmative49:21, 53:1,86:3, 90:1,93:22, 100:7,111:8, 122:16,141:20, 145:12,157:14, 173:3,173:6affixed181:17affluent60:15afford17:1, 60:16affordable107:6, 147:4,147:7affront11:5afraid16:20, 72:14,

134:20african-american165:6, 165:7after22:13, 35:17,44:6, 47:13,78:12, 83:5,119:23, 126:11afternoon124:24, 146:16,147:16, 159:1again9:13, 14:18,15:12, 15:16,16:4, 16:7,31:10, 76:1,88:8, 88:11,105:18, 127:6,143:2, 155:24,159:17, 166:10,166:13, 167:11,172:7against21:13age66:16, 67:2age-appropriate31:17agency52:19, 66:11,100:1, 107:22,141:14, 141:18,143:1, 145:6,147:20, 148:1,154:4, 172:19agenda3:9, 8:7, 8:14,37:15, 58:16,81:22aging110:14ago29:10, 67:11,79:15, 79:20,97:14, 102:14,134:7, 148:21,162:6agree30:17, 79:7,

92:3, 140:6,147:22agreement5:16, 44:20,46:3, 48:9,178:8, 178:10agrees73:10, 147:21ahead22:9, 143:15aid78:10aimed128:4air115:3, 115:8alden3:18, 3:20,4:19, 27:6,28:9, 28:12,30:7, 31:5,31:11, 31:18,33:18, 50:8,100:12, 100:14,101:4, 101:5,102:6, 103:24,105:9, 109:9,111:13alden's27:8, 107:15algorithm164:15all6:2, 7:5, 8:3,8:11, 8:20,11:6, 11:7,11:23, 14:24,17:7, 21:14,21:23, 22:4,23:3, 31:9,35:12, 36:4,45:9, 48:17,54:8, 55:2,63:5, 67:14,71:16, 73:23,74:23, 75:13,76:21, 77:1,77:6, 77:11,



77:12, 78:2,78:15, 80:22,81:12, 83:4,85:4, 89:18,91:24, 92:9,92:20, 93:15,96:7, 98:5,98:15, 99:2,101:7, 101:19,105:5, 105:17,107:16, 109:12,111:11, 113:18,116:7, 117:13,117:19, 125:11,127:1, 127:10,128:18, 133:4,139:17, 140:17,154:13, 154:17,167:10, 168:22,170:5, 170:20,174:5, 174:14,175:7, 175:20,177:5, 178:1,178:21, 179:12,179:23, 180:10alliance33:22allied114:11, 119:7allocated170:20allow31:18, 85:15,109:14, 120:2allowed11:14, 11:19,150:8, 154:6,154:7, 157:4,164:3allowing148:16allows59:22, 75:23,115:6almost24:1, 76:12,169:21, 170:13alone24:10, 26:11,

160:4along14:24, 62:16already10:14, 14:10,21:18, 21:21,23:21, 25:17,28:6, 31:21,40:6, 42:2,71:5, 81:10,104:12, 111:4,166:7already-approved102:20also2:5, 19:21,31:12, 34:23,41:18, 42:3,43:2, 55:9,55:17, 56:5,56:10, 56:16,58:12, 60:1,60:13, 62:20,63:1, 63:17,74:2, 85:24,91:22, 92:7,103:13, 103:16,107:2, 109:9,113:16, 114:13,115:10, 115:16,116:7, 116:14,118:13, 125:19,126:5, 136:17,143:22, 153:6,155:18, 156:1,159:11, 160:7,167:23, 174:23,175:6alter150:18alteration4:6, 43:18,104:14, 104:15altering36:12alternative16:14, 62:19,150:2

alternatives153:6always13:2, 13:18,25:22, 78:20,102:11alzheimer's101:6amended173:19, 173:20,175:5amendment175:3, 176:1amendments5:9, 173:17,174:2amenities28:3, 28:14america114:3ami34:14amount31:9, 45:18,108:23, 118:6,150:4analysis137:16ancillary27:12ann2:9, 33:11anne54:18, 57:24,125:2, 130:1annual64:23, 136:15annually178:10another11:11, 13:4,23:16, 24:9,25:14, 27:13,30:7, 48:12,74:6, 81:21,91:18, 105:24,117:21, 130:1,162:9

answer10:9, 25:15,45:22, 51:12,66:6, 76:16,80:21, 92:9,96:9, 150:22,166:11, 175:9answered109:24, 114:21anticipated94:20, 101:2,112:16antioch12:12, 12:18any10:2, 10:7,20:1, 25:23,44:6, 45:22,51:12, 54:6,66:1, 66:6,79:24, 80:1,91:15, 91:16,91:17, 92:10,92:12, 96:9,106:6, 106:7,106:9, 107:8,111:6, 113:23,117:3, 139:21,144:1, 150:23,160:13, 163:18,166:10, 175:9,181:13anybody91:17, 117:3anyone26:17, 35:19,57:2, 67:1,78:12, 175:8,179:7anything12:24, 78:18,116:2, 117:2,118:2anytime68:15, 76:18anyway83:14, 99:1anywhere97:9



apart30:19, 87:21apologize9:17, 16:3,75:11apparently62:18appear107:23, 110:10appeared18:6, 18:14,21:9appears109:24, 149:7applaud172:24applicable96:8, 125:11applicant14:11, 14:20,15:5, 15:7,15:17, 20:10,85:16, 94:17,109:24, 111:5,112:2, 112:9,122:13, 123:13,124:9, 146:1,146:6, 158:11applicant's11:3applicants10:5, 10:19,11:14, 14:24,19:14, 21:12,50:17, 53:17,87:18, 90:17,94:10, 98:3,100:23, 101:11,101:14, 101:22,123:20, 124:5,142:7application10:8, 29:6,40:2, 41:22,58:22, 63:3,66:12, 81:22,86:7, 97:7,103:20, 104:23,

106:9, 106:18,113:3, 114:8,124:2, 124:7,128:21, 128:24,129:11, 129:19,135:21, 136:10,137:21, 147:2,147:10, 149:9,149:22, 150:6,157:2applications4:12, 5:2,9:23, 11:7,12:4, 14:13,14:19, 15:1,15:17, 19:4,19:10, 19:22,19:24, 21:15,22:20, 50:4,92:4, 122:23,128:17applied63:4, 103:22,137:16apply136:19appointment36:10appointments36:7, 61:17,77:21, 163:9appreciate24:15, 32:18,59:10, 61:24,95:11, 111:12,111:16, 130:16,157:19appreciated95:9approach20:4, 36:19,36:24appropriate32:13, 60:12,62:19, 128:9,137:8, 147:23approval3:9, 3:10,

8:16, 35:13,37:19, 41:10,43:11, 45:19,58:11, 66:6,103:22, 104:5,106:24, 107:1,147:3, 176:23approvals139:3, 139:4approve8:7, 39:16,50:8, 53:6,69:13, 86:20,90:6, 94:4,100:13, 101:20,109:3, 111:19,123:1, 130:17,141:23, 145:17,158:1, 174:2,177:18, 177:21,178:16approved3:23, 8:14,8:24, 12:16,28:6, 33:7,33:14, 33:16,44:7, 101:11,102:14, 102:17,104:12, 105:3,105:4, 109:14,111:4, 165:11approves44:19approving11:24, 20:6,92:4, 104:14,179:23approximately7:8, 23:18,50:18, 50:20,53:18, 53:19,87:20, 87:22,90:19, 94:19,101:2, 105:23,112:10, 112:12,123:21, 123:23,142:8, 142:10,146:7, 152:17,

158:12, 158:13,170:6april8:17, 21:9,53:21, 124:5,124:10, 137:14,146:12, 158:17,161:24ara164:1architect108:15area10:10, 10:21,11:21, 12:20,12:22, 13:7,13:8, 13:11,13:16, 14:1,19:4, 23:1,25:4, 25:15,26:24, 31:17,35:3, 41:21,42:24, 50:24,51:2, 53:24,55:11, 55:19,57:12, 58:9,58:16, 59:6,59:18, 62:14,63:8, 63:12,64:4, 64:5,64:17, 64:20,65:9, 67:24,69:9, 69:11,74:20, 81:24,83:20, 84:2,84:17, 85:1,88:1, 88:2,88:3, 96:21,96:24, 98:24,103:21, 104:10,106:1, 116:4,116:16, 117:10,117:15, 118:1,118:8, 124:8,124:13, 124:16,128:20, 129:4,129:24, 132:17,134:18, 136:18,



137:6, 137:8,137:19, 142:14,148:3, 148:6,148:20, 156:22,157:12, 158:18,159:5, 159:8,160:2, 160:4,162:5, 162:6,162:13, 164:1,166:8, 166:13,167:23, 172:21area's11:24areas58:6, 58:7,68:3, 115:20,147:17, 170:16aren't17:21, 19:22,179:12arnstein45:12arose104:22around17:24, 56:6,56:10, 65:20,68:4, 70:11,96:14, 113:20,126:20arrangement97:20arrangements3:6arranging60:10arrived7:11arterial40:19, 42:19arvind2:3, 75:8,154:3aside56:8asim159:5ask12:4, 23:9,

45:14, 45:19,46:4, 47:8,48:3, 51:18,66:5, 82:24,88:18, 92:3,92:14, 98:18,107:1, 109:20,117:7, 119:19,121:3, 130:17,140:1, 143:9,144:4, 148:12,155:13, 159:15,171:10asked18:20, 47:20,48:18, 76:7,91:17, 132:23asking25:12, 69:13,108:8, 134:21asks10:8assistance31:18associated55:2, 153:3associates34:3, 95:14association80:14assume58:21assuming82:7assumption77:4asymptomatic60:19attempt58:19attempting127:21, 153:5attempts179:9attend174:22attendance6:20

attention38:4, 39:3,148:21attest12:14, 26:8,37:21attorney45:12attract69:6auburn4:14, 50:7august44:22, 45:2,46:4, 46:5,46:9, 47:10,48:4, 48:10,48:14, 48:16authorized91:16availability71:15, 107:21,117:18available26:16, 41:5,61:17, 147:12avenue40:17, 42:15average39:10, 54:1,57:21, 65:3,76:11, 94:21,98:10, 168:10avery2:7, 32:23,33:2, 33:4,33:10, 120:2,180:15avoid115:12aware174:16away21:11, 31:11,62:17, 96:2axel95:6, 95:13,95:14, 98:7,

98:12, 100:10aye8:4, 8:12,8:21, 51:22,140:5, 174:6,177:6, 178:2,179:24ayes7:6, 8:5, 8:13,8:22, 174:7,177:7, 178:3,180:1

Bback7:13, 16:20,48:5, 71:12,85:17, 98:15,109:11, 122:21,133:8, 143:18,161:1, 161:24,164:4, 164:11,165:4, 169:13,169:19, 169:20backers18:24, 22:23balance21:20bangash159:3, 161:21,161:22, 162:3,166:14, 166:21,167:23, 168:13,169:5bank109:5banks109:7barbara1:15barrier148:15barriers61:9bart95:16, 98:7bartlett33:18



based38:1, 51:22,52:2, 52:6,52:10, 52:14,52:18, 52:22,57:19, 58:14,58:20, 63:6,63:22, 70:1,80:2, 83:19,85:5, 85:9,88:23, 89:3,89:14, 89:22,92:23, 93:7,93:11, 93:19,99:8, 99:16,99:20, 100:4,108:1, 110:5,110:13, 110:18,110:23, 121:8,121:24, 122:3,122:8, 122:12,126:12, 126:14,131:21, 140:6,140:17, 141:6,141:9, 141:13,141:17, 143:21,144:9, 144:13,144:17, 144:21,145:1, 145:5,145:9, 155:17,156:12, 156:17,157:10, 171:16,172:7, 172:8,172:10, 172:14basically46:20, 66:22basis37:19, 77:19,78:3, 147:9bass169:8, 169:9,169:14bearing129:8because11:15, 21:17,24:14, 24:18,26:2, 29:9,

29:13, 36:20,38:13, 43:11,46:5, 47:20,48:3, 58:22,60:15, 61:11,61:15, 64:12,65:6, 66:14,67:7, 67:9,68:17, 69:1,69:10, 69:14,69:24, 70:20,71:9, 71:14,72:15, 73:17,75:4, 76:11,77:17, 78:16,81:24, 82:1,93:3, 99:1,99:12, 104:17,109:3, 110:9,115:23, 117:10,119:4, 121:17,133:3, 133:16,134:10, 134:23,135:2, 135:4,135:17, 136:2,136:7, 136:8,137:21, 140:16,143:2, 143:19,152:10, 152:23,153:15, 160:14,164:9, 165:21,169:3, 169:13,169:19, 172:3,176:13, 178:11becker95:16, 97:3,98:8become157:7, 176:15becomes175:13bed5:13, 28:6,30:8, 34:14,94:18, 95:1,100:15, 101:12,101:15, 101:23,102:15, 102:19,

103:21, 104:1,104:2, 104:3,104:7, 106:8,106:12, 106:24,176:6, 176:7beds28:5, 28:7,30:10, 31:18,94:23, 96:3,96:4, 96:23,98:8, 101:4,101:5, 101:7,101:16, 101:17,101:24, 103:4,103:22, 103:23,104:5, 104:7,104:10, 104:12,104:18, 106:13,107:2, 107:16,108:14, 111:5,113:22been11:10, 11:22,12:17, 13:6,13:18, 14:24,15:14, 16:12,17:18, 18:11,18:19, 18:20,25:22, 30:22,36:24, 37:2,38:17, 39:23,40:5, 40:7,41:19, 42:1,42:3, 46:16,55:10, 58:18,65:14, 74:16,75:18, 81:17,83:5, 83:14,84:12, 95:7,95:14, 97:17,106:7, 106:15,109:4, 109:12,113:20, 114:15,116:3, 126:19,134:21, 136:9,137:21, 140:7,142:17, 161:23,162:12, 166:14,

166:20, 167:5,168:15, 173:19,174:19, 179:10before15:6, 15:13,18:7, 18:14,19:15, 20:14,21:9, 22:19,65:12, 71:13,78:7, 95:7,105:10, 126:8,134:7, 181:6began38:10, 138:19beginning9:9, 21:4,32:5, 65:14,79:16behalf30:7, 32:1,35:9behind76:6, 130:6being12:18, 12:19,21:13, 21:24,28:12, 82:16,120:9, 125:3,131:15, 138:23,144:18, 151:18,151:24, 164:7,169:18believe16:10, 24:18,39:4, 58:23,67:7, 78:11,79:19, 83:22,121:9, 126:18,152:3, 154:17,157:3, 157:5below103:17, 150:7,151:14benefit9:10, 9:13,18:21, 28:12,38:3, 41:7,43:6, 80:5,



150:11benefits150:15, 171:17best13:2, 13:6,13:13, 19:13,24:12, 24:15,78:4, 92:1,96:20, 97:1,111:11, 126:19,133:9, 148:18,150:9better30:22, 56:12,73:2, 73:3,75:5, 81:6,84:6, 99:9,106:10, 115:5,127:14, 132:20,166:6, 166:23,168:8, 168:21betty113:6between12:18, 31:14,80:15, 82:11,138:11, 139:16,168:14, 170:6,177:13beyond32:22, 58:10,68:20, 152:24bhattacharyya54:13, 54:14,71:17, 71:22,72:17, 74:12,75:7, 76:17,77:8, 77:13,79:1, 79:7,79:13, 79:18,80:4, 80:23,82:12, 88:14,124:23, 124:24,125:9bid116:18, 116:21,116:22, 116:23,116:24

bids116:18big81:5, 95:10,114:15, 117:1,159:18biggest78:23, 117:15bill2:2, 9:19,14:4, 134:16,149:8, 154:8,154:9, 154:10,174:17, 174:20,174:24, 175:3,175:4, 175:5,175:12billed154:5bit16:8, 76:8,114:8, 139:6,149:11, 151:13black97:10blame120:1blaming120:2blessing4:20, 111:17,111:20, 113:5,113:14blinded17:3block116:11blocks36:22, 117:21board's10:7, 10:19,10:24, 11:5,35:12, 37:20,41:10, 43:11,46:7, 58:4,101:15, 104:1,104:22, 106:11,107:1, 127:10,

129:1, 129:20,136:14boards22:10bob102:8, 103:5body164:19bolingbrook1:6bond97:19border113:16, 113:17born162:4both27:19, 29:22,30:15, 56:2,57:24, 58:17,73:5, 125:12,126:17, 129:7,131:13, 132:12,133:16, 139:8,143:10, 143:11,147:11, 153:22,174:18, 175:6bothered119:2, 119:20,173:1bottom23:4, 131:16,162:2boughton42:14, 42:16,42:19brad1:14, 6:5brand-new170:23, 171:2break33:4, 152:2brennan9:19, 14:4,14:5brian9:19, 15:24,56:13

bridgeview7:22brief44:1, 159:15briefly45:21bright96:19bring139:13, 147:3,150:23bringing86:8, 86:12,106:21, 162:14broader72:19broadly55:5brought10:13, 19:14,114:6, 133:24brush21:12build20:3, 102:18,115:13build-out44:24, 45:4building27:10, 28:3,31:12, 32:8,32:11, 44:16,44:18, 46:12,98:5, 108:14,111:18, 111:21,112:11, 112:13,114:5, 114:20,114:22, 115:6,115:10, 115:11,115:13, 115:15,116:11, 116:14,116:16, 116:17,117:1, 119:10,120:6, 120:9,170:23, 170:24,171:2built12:17, 12:19,



143:14bundled103:7burden72:23, 79:5,132:20burned109:4burzynski1:14, 6:5,7:10, 48:24,49:1, 51:21,51:22, 83:2,83:3, 83:4,83:9, 83:14,88:22, 88:23,92:18, 92:19,98:21, 98:22,109:22, 109:23,121:6, 121:7,140:4, 140:5,144:8, 144:9,155:16, 155:17,171:13, 171:14,171:15, 174:4,177:4, 177:22,178:20buses116:6business4:7, 5:10,5:11, 6:22, 9:1,27:3, 43:21,51:9, 59:9,70:14, 174:11,174:12busy42:18butchering9:17buy19:1, 44:16buzz21:23, 22:3

Ccagr136:15

calculate85:15calculated26:10, 50:23,63:6, 101:15,101:23, 106:12,151:5calculation104:1calculations68:6calendar17:19, 67:12call3:3, 3:4, 6:2,6:3, 48:21,50:6, 51:18,82:24, 88:19,92:15, 98:18,109:20, 121:3,140:1, 144:5,155:13, 163:18,171:11called9:3, 9:5, 9:7,76:20, 123:8,123:10, 134:22,149:2came79:19, 120:21,148:21campus27:22, 28:12,101:1, 119:15can9:14, 11:23,12:14, 14:15,16:7, 20:3,23:2, 23:22,24:15, 25:18,26:8, 29:14,32:13, 33:7,36:10, 37:21,44:5, 44:20,45:4, 45:22,46:14, 47:16,55:14, 58:21,66:6, 67:1,

67:22, 70:9,70:13, 73:8,74:23, 76:8,76:18, 77:17,78:21, 85:17,86:6, 86:10,97:1, 114:9,115:20, 116:13,131:24, 132:1,135:6, 135:18,139:5, 139:17,140:11, 141:1,141:2, 141:4,143:18, 150:9,152:3, 152:6,153:11, 157:7,160:21, 160:24,161:1, 162:22,164:5, 164:9,165:3, 165:16,166:17, 167:3,170:8can't46:6, 80:18,98:3, 141:1,163:3, 165:21,166:22canada121:22canceling180:13cancer72:2cannot10:22, 11:11,11:12, 26:12,35:7, 60:16,84:24, 164:4capacity11:24, 12:15,55:3, 66:1,68:6, 69:14,98:6, 147:17,148:5, 148:7,148:9, 148:10,148:14, 156:22,159:19, 165:10,172:20, 173:2

capital84:7, 118:21card51:9cardiologist133:8cardiovascular34:5, 35:21careful127:13carefully35:11, 105:11caregiver161:7caregiver's68:18caregivers66:4caretakers43:6caring21:11, 24:21carle34:13carriers149:24carthage34:16carve-outs17:8carved75:17case66:18, 88:13,109:9, 126:19,168:17, 181:13cases24:12, 117:17,118:5cash108:22catch61:19categories173:14caterpillar149:23, 151:14,154:20



catheter160:23, 164:10catheters160:6, 160:11,161:7cause77:22, 133:10causes56:3causing103:8cell163:16, 163:17,163:18censure20:10census57:10, 64:21centegra34:7, 34:9,34:11center4:8, 4:16,4:18, 5:5, 5:7,7:18, 7:19,7:22, 16:15,30:18, 34:5,34:18, 43:23,44:3, 45:11,86:19, 86:21,94:3, 94:6,95:24, 101:1,113:21, 135:14,139:13, 141:6,145:18, 150:9,151:17, 157:24,158:2, 159:3,159:7, 161:20,167:4, 168:15,169:17centered17:24centers39:24, 41:20,42:23, 59:5,148:7, 163:8,167:21, 168:11,173:16

ceo102:8, 103:5,113:5, 146:17,159:2ceo's70:13certainly13:8, 83:21,147:12certificate95:15, 148:16,181:1certification143:16, 143:22,175:18certified59:16, 101:8,107:16, 162:4,181:3certify181:7cetera72:2cfo113:11chair6:4, 9:20,15:23, 33:15,33:16, 34:20,45:7, 48:23,49:18, 50:16,51:3, 51:19,52:21, 53:16,54:3, 83:1,85:21, 86:2,87:17, 88:6,88:20, 89:21,90:16, 91:4,92:16, 93:18,94:16, 95:3,95:6, 98:19,100:3, 100:22,102:1, 102:5,109:21, 111:2,112:8, 112:21,121:4, 122:11,123:7, 123:19,124:20, 126:6,

126:8, 140:2,141:16, 142:6,142:22, 144:6,145:8, 146:5,154:2, 155:14,156:24, 158:10,158:22, 171:12,172:23, 173:5chairman1:13, 95:8,130:23chairs12:20, 13:11challenge131:13, 160:9,161:4challenges36:22, 63:14challenging35:19chance77:5, 78:4change34:3, 34:8,34:10, 34:12,34:16, 67:6,85:18, 104:13,173:12, 175:23,176:14, 176:16changed14:16changes5:13, 103:6,126:22, 174:24,176:6, 176:7,176:9, 176:11,176:13, 176:19,176:22, 179:9,179:10changing27:19, 157:10charge70:19, 149:5,149:6, 149:9,149:17, 151:23charged151:24charges152:19, 154:5,

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113:18, 115:17,120:16, 120:19,132:22, 143:18,160:18, 165:4,169:10comes22:15, 85:24,162:15, 165:19coming114:16, 116:20,167:1commend96:22comment10:13, 56:5,58:12, 79:11,80:11, 87:5,91:13, 96:12,107:17commentary125:5, 128:4,171:23comments13:22, 24:24,26:20, 40:9,42:6, 45:6,47:6, 51:14,54:11, 75:11,80:10, 82:20,88:10, 88:16,91:6, 91:15,91:16, 91:17,91:18, 91:20,96:11, 98:18,107:14, 107:21,109:17, 110:24,112:18, 118:24,120:24, 124:22,125:4, 126:17,126:22, 133:19,135:20, 142:15,142:16, 142:23,144:2, 146:15,147:16, 150:21,159:12, 170:1,171:8commercial149:14



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106:22, 107:4,107:7, 125:20,126:2, 147:4,147:5, 147:11,152:9, 153:4,167:22community-based147:1company149:23, 152:13,152:14, 159:21,159:22comparable106:4compared168:10comparison72:7compelling84:18competent79:24competing79:2, 79:8competition21:13, 23:7,70:18, 80:15,80:21, 80:24competitive21:19, 70:17,70:20, 72:9,74:24competitor56:6, 68:13,129:14competitors79:17, 80:2,81:12, 92:1,125:5, 126:20,128:7complement43:2complete108:12, 141:10completed145:2completely79:7

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64:19, 77:18,78:2, 89:19,92:9, 92:20,93:4, 93:16,96:8, 99:13,105:6, 110:10,125:11, 125:13,125:14, 127:11,129:14, 137:12,140:17, 144:18,153:6, 156:9,157:4, 170:9,172:4, 172:8criterion77:12, 107:21,171:22critical37:22, 113:24cross27:4, 27:6,28:10, 30:12,30:18, 100:24,102:22, 103:14,105:20, 106:17cruise6:6csr1:24, 181:4cullerton40:11, 125:23culture13:17, 25:21cunningham59:8curious170:3, 170:9,170:11curran40:11, 125:22current10:4, 13:9,23:16, 57:16,70:7, 88:5,91:2, 94:21,104:6, 106:8,117:11, 149:10,152:5, 166:5currently12:17, 13:14,

18:15, 19:20,20:1, 86:13,104:4, 106:22,107:3, 108:12,149:7, 151:19,162:7cycles83:10

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21:10, 24:21,24:22, 32:2,43:23, 44:3,76:3, 76:19,85:2, 98:15,121:23, 160:18,162:24, 181:17days98:10, 116:24,134:14deadline48:14, 48:16deal76:6, 115:18,126:19dealing74:6, 74:20,176:14debate133:23debbie146:17, 147:15debt97:17december57:10, 90:21,112:17, 124:3,146:10decisions29:21deck115:9declaratory4:7, 43:20decrease131:10, 132:2,132:5, 134:11,135:6decreases133:12decreasing10:23, 131:5,134:13dedicated21:18, 25:23,82:8, 101:4,101:6dedication39:5

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21:23, 22:13,22:17, 22:21,23:4, 36:3,36:7, 36:16,38:3, 38:17,128:12, 128:15dmg's15:9, 36:1,36:18, 36:24,38:24, 39:5dna159:22docs28:23doctor14:2, 66:9,117:6, 133:20doctors26:7, 77:21documentation137:4, 143:17documented57:9, 63:15,127:22does15:5, 15:7,19:5, 22:17,70:16, 72:16,77:10, 90:24,92:8, 140:10,148:12, 154:16,175:13, 175:20,179:5doesn't25:24, 32:12,73:17, 74:6,107:23, 134:1,140:9doing17:16, 33:6,46:19, 58:18,81:12, 97:8,119:7, 131:13,132:11, 135:13,136:13, 172:8,173:1, 173:14dollar38:13, 118:5

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73:11, 82:1,86:14, 99:9,130:3, 130:15,152:2evening135:4ever105:10, 179:8every14:10, 15:13,20:5, 38:13,38:22, 73:13,77:4, 87:7,98:3, 98:5,105:10, 116:19,149:21, 160:18,162:18, 165:23everybody19:2, 74:15,83:12, 102:4everyone10:8, 30:16,135:17, 153:5,168:18everything9:14, 48:10,48:11, 139:11evidenced127:11evidently83:4ewing45:12ex2:1exact29:7exactly29:17, 58:8,58:17, 68:13,78:21, 134:11,140:20exam115:7example73:15exams16:24, 17:2

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165:12extraordinarily42:18eye16:24

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28:6, 31:7,31:10, 32:16,34:19, 41:3,45:15, 47:24,50:18, 50:24,53:8, 53:18,54:16, 62:19,65:20, 68:12,68:13, 78:22,82:8, 82:14,83:16, 84:3,85:24, 86:22,87:19, 87:20,90:9, 90:18,91:3, 91:11,94:7, 94:18,95:17, 95:24,96:2, 96:6,97:9, 97:13,97:17, 99:4,99:9, 100:15,100:24, 101:13,102:15, 102:19,102:21, 102:24,103:19, 106:3,106:10, 106:20,106:23, 107:1,113:22, 114:5,114:10, 115:2,120:19, 123:3,123:21, 136:22,137:3, 142:1,142:8, 143:23,145:19, 146:7,158:12, 170:13,170:14, 170:19facility's94:21facing60:4fact10:12, 11:1,11:23, 19:5,22:10, 83:17,84:17, 87:14,110:14, 121:8,122:13, 126:22,129:16, 136:3,



137:17, 148:2,148:4, 157:11,160:3factor66:17, 81:13,92:3factors73:19, 74:3,76:21facts22:19, 26:18,130:2fail160:11failed18:17, 86:5failure11:3, 38:3,56:3, 60:20fall75:21, 126:8,126:10false58:24, 126:21,138:20falsely127:8familiar81:24, 98:22,167:4families37:24, 60:6,132:10family59:5, 66:3,76:2, 162:5,166:24fantastic17:24far16:12, 22:7,30:23, 55:8,55:14, 66:2,71:16, 81:23,95:21, 113:6,130:6, 140:9,143:15, 167:6,176:20, 179:3

far-off30:18farhan159:3, 162:3farmland114:6, 115:23,116:3fascinating84:13fast75:24faster64:24, 136:16,137:7favor7:5, 8:3, 8:11,8:20, 126:7,174:5, 177:5,178:1, 178:21,179:23favorable65:8, 126:5favorably161:17feasibility47:19, 125:14february50:21federal64:1feel13:8, 58:7,122:13, 128:2,147:10, 152:6feet50:19, 53:19,123:22, 142:9,146:8, 158:13fellow25:13fellowship59:19few28:18, 31:10,60:21, 95:5,125:4, 125:15,143:17fewer60:6

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68:17, 73:10,84:16, 156:1finding54:22, 63:6,65:8, 83:17,105:7, 112:20,122:14, 124:14,124:15findings24:6, 26:8,51:5, 51:23,52:3, 52:7,52:11, 52:15,88:24, 89:4,89:15, 94:24,105:2, 105:18,111:6, 114:19,116:15, 129:13fine47:14finish48:9finished97:18firm95:21first9:16, 12:23,13:2, 13:3,13:13, 13:20,16:19, 27:9,36:8, 36:10,54:24, 55:7,57:3, 73:11,75:13, 76:3,76:19, 83:4,84:13, 91:13,102:11, 103:19,117:6, 125:17,127:1, 127:4,135:22, 148:21,149:15firsthand35:16firstly84:11fiscal178:12, 178:17



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37:20, 40:7,98:17, 105:14,106:1furthermore10:19

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124:2, 125:5,129:5, 165:17gives27:22, 115:5giving28:18, 75:1,96:20glasson1:16, 6:11,7:4, 8:8, 48:20,49:7, 50:9,52:6, 53:9,84:11, 89:7,93:3, 97:6,97:23, 99:12,110:9, 111:24,121:17, 140:20,144:17, 156:5,158:4, 172:3global154:7, 154:14go6:23, 66:9,74:5, 74:17,75:4, 76:20,77:20, 78:7,96:13, 105:13,115:8, 116:6,117:20, 117:21,118:9, 118:11,140:9, 160:11,160:12, 160:16,160:24, 161:1,161:9, 163:5,163:12, 164:2,164:4, 164:11,165:8, 165:13,165:16, 167:3,167:12, 167:14,167:20, 169:12,169:13, 169:20goal56:11, 132:16goals167:6goes161:7, 161:19going16:20, 17:23,



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116:10, 127:19,129:6, 130:8,130:10, 131:7,132:18, 146:21,153:10, 153:20,153:24group's40:2groups9:4, 130:11grow65:1, 114:14,166:15growing27:21, 30:24,96:24, 106:22,116:5, 129:17grown104:2, 162:7grows31:1growth11:22, 64:23,106:2, 129:18,130:3, 136:15,136:19guess82:12, 119:8,119:19, 120:14,157:21, 178:24guidelines176:19guild2:9, 33:9,33:11, 173:10,174:14, 175:15,176:1, 176:4guy29:8, 169:12

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81:18, 94:24,96:15, 103:11,103:16, 105:2,112:19, 114:20,116:2, 120:20,124:14, 124:15,132:4, 133:22,136:16, 148:22,151:22, 167:13,173:19, 175:3,175:16half79:15, 163:8hand59:12, 130:21,181:17handbook5:14, 176:9,176:12, 176:23,177:1handles119:24handwritten9:11hanson95:18, 97:11,97:12hanson's95:19hanus39:21, 39:22,41:13, 41:14,43:5, 43:8happen29:18, 32:12,164:5, 176:21happening116:8happens76:3, 164:3,164:6happy51:12, 87:9,92:9, 96:9,166:11, 175:9harassment176:15hard28:24, 63:10,



77:23, 97:4,147:6hardly130:3hardship66:2harm16:11has11:6, 11:21,11:22, 12:17,13:18, 14:8,14:10, 14:11,14:16, 14:19,14:20, 17:11,17:15, 18:16,18:17, 21:19,24:8, 24:9,25:22, 26:11,26:13, 28:8,31:3, 31:5,36:24, 37:2,38:17, 39:10,40:5, 40:6,40:14, 42:1,42:2, 46:16,48:9, 55:10,59:13, 61:6,63:8, 63:18,64:3, 70:11,71:5, 71:6,71:20, 79:10,82:17, 83:14,89:8, 91:15,95:9, 95:10,104:2, 104:23,105:9, 106:7,106:15, 106:22,109:4, 109:24,111:6, 114:6,114:15, 115:22,116:3, 116:5,117:3, 120:18,128:2, 129:8,129:14, 137:21,146:6, 151:20,152:22, 157:21,158:11, 164:19,

169:10, 174:18,175:9, 179:8haven't179:10having13:6, 16:3,27:21, 61:14,81:15, 84:21,113:2, 138:24,166:10, 171:3he'll74:17he's75:15, 113:9,159:5, 169:8,169:10, 169:12headed117:9headstrong169:12health1:1, 1:2, 4:9,7:22, 21:17,27:18, 35:15,35:18, 36:11,36:18, 37:12,37:21, 37:23,38:8, 38:12,41:3, 42:8,50:1, 51:1,55:11, 55:18,55:19, 58:5,59:3, 59:6,60:1, 60:4,60:7, 60:14,61:10, 62:2,63:11, 63:19,63:22, 63:24,64:2, 64:5,64:10, 80:13,80:16, 84:8,85:3, 88:2,95:19, 101:8,113:5, 113:11,114:12, 119:7,125:24, 128:10,131:5, 131:8,131:14, 131:20,

131:22, 134:9,136:24, 140:13,146:18, 147:6,148:23, 156:8,163:11, 164:8,168:23, 171:17,175:16, 175:24,179:16healthy17:17, 29:12,59:5hear16:7, 24:20,29:2, 29:14,78:9, 92:1,107:20, 166:17,179:20heard7:6, 8:5, 8:13,8:22, 46:11,103:13, 103:16,105:22, 106:16,126:17, 131:3,153:13, 155:19,168:9, 171:16,174:7, 177:7,178:3, 180:1hearing50:22, 53:22,88:4, 90:21,103:9, 112:19,124:17, 142:14,158:19hearings174:23heart114:2, 168:20,173:15heating115:5heavily40:18heights33:23hello14:4help35:14, 40:21,

57:5, 62:6,74:5, 75:4,76:21, 85:2,98:8, 132:1,132:19, 140:10,153:12, 153:22,166:4, 166:7helped38:10, 166:15helpful56:9helps28:4hemme1:15, 6:7, 6:8,49:3, 49:4,52:1, 52:2,84:1, 84:2,86:23, 88:21,89:2, 89:3,92:22, 92:23,94:8, 96:12,98:20, 99:7,99:8, 110:4,110:5, 121:12,121:13, 140:15,140:16, 144:12,144:13, 155:22,155:23, 171:20,171:21hemodialysis5:5, 145:16,145:18, 162:19,163:12, 164:10,165:14, 166:5her91:11, 103:12,134:19, 134:21,134:22, 135:1,135:8here6:14, 6:16,6:19, 9:22,12:10, 14:5,16:22, 23:6,23:14, 23:23,25:10, 26:17,27:5, 28:20,



29:18, 30:7,32:8, 35:10,37:13, 44:1,44:2, 45:13,45:21, 54:15,54:24, 55:12,56:23, 59:14,63:12, 72:22,80:13, 80:24,81:18, 81:22,83:5, 87:10,91:24, 109:10,110:6, 113:2,113:12, 116:21,117:20, 117:21,119:5, 119:17,125:4, 128:22,131:1, 133:5,146:24, 155:19,159:17, 161:23,162:2, 165:13,166:9, 171:16,171:23, 178:24hereunto181:16herring56:5herself135:3hi32:6, 91:7high41:16, 65:7,69:1, 136:7,170:10high-need131:24high-quality38:4, 38:11higher55:13, 63:20,72:21, 79:6highest39:10, 56:14,72:3, 72:4,106:2highlight175:2

highly55:1, 58:9hills23:17, 24:12him17:6, 32:10,32:15, 73:16,74:17hip30:16hired14:20his17:4, 17:5,32:9, 32:14,48:15, 51:9,51:10, 59:14,73:17, 95:20,159:5, 159:7hispanic165:6, 165:7historical129:7historically103:24, 136:17hit155:9hmos16:20holding57:24home7:22, 31:2,62:7, 71:3,72:11, 72:13,72:24, 73:3,73:8, 73:10,73:12, 73:20,74:3, 74:22,75:4, 81:4,84:6, 84:23,86:8, 86:13,86:15, 96:16,98:23, 132:10,132:11, 153:7,153:14, 153:18,153:24, 159:23,160:8, 160:15,

160:19, 161:11,162:11, 162:13,162:15, 162:16,162:19, 162:23,163:2, 163:5,163:23, 164:4,164:12, 165:1,165:3, 165:4,166:8, 166:15,166:18, 166:22,167:2, 168:15,168:17, 169:18,169:20, 170:14home-therapy159:22homes74:5, 96:14honestly164:14honesty99:2hope24:15, 84:15,140:11, 156:7hopefully46:14, 105:3hospital4:20, 7:21,27:4, 27:6,27:16, 27:20,28:1, 28:2,28:4, 28:8,28:11, 28:15,30:12, 30:21,33:22, 34:1,34:7, 34:9,34:11, 34:14,34:15, 37:3,59:4, 61:19,62:3, 78:3,101:1, 102:22,103:2, 103:6,103:14, 105:21,106:17, 111:18,111:20, 114:10,126:1, 132:6,134:2, 134:14,146:19, 146:20,

147:1, 152:10,165:23, 177:13,177:14hospital-based115:18hospitalization132:2hospitalizations132:5hospitalized135:4, 169:3hospitals27:19, 103:8,103:13, 114:1,153:22hour122:18hours60:23, 113:14,118:20, 134:16house174:16, 174:20,175:3, 175:12houses174:18, 175:6housing31:3, 116:7how11:4, 14:14,15:5, 33:8,46:16, 62:7,68:13, 71:8,71:19, 76:10,81:14, 81:23,84:3, 97:7,98:6, 98:11,103:6, 103:12,103:14, 115:11,116:13, 117:9,137:11, 143:15,157:7, 167:12,167:14, 170:7,176:21however10:1, 32:10,57:17, 78:20,148:4, 159:20hr178:12



hsa23:22, 136:5,142:14, 173:2hub27:14, 40:21,42:18hud105:12, 108:2,108:4, 108:16,108:23huge71:10, 133:6,134:11, 160:14,161:4, 169:16huma20:18, 21:7human118:21, 131:22hunched96:18hundreds38:18huntley34:12hurting61:15hurts61:20hvac115:4hypertension35:22, 56:1,64:11hypothesis82:15

Ii'll44:9, 48:21,66:9, 71:3,71:12, 84:15,97:11, 147:14,161:18, 162:1,166:9, 180:12i've18:11, 18:19,18:20, 21:8,24:2, 39:6,

74:16, 81:10,81:17, 81:18,83:5, 84:12,84:14, 95:6,95:14, 96:21,97:2, 109:3,129:9, 161:23,162:12, 166:14iag179:23idea16:18identified117:15idph2:2, 2:8, 2:10,44:20, 44:22,45:2, 45:17,46:3, 48:9,48:12, 178:10,179:1, 179:12idph's48:13iga178:13, 178:17ignorance119:1ihfs2:3ill-fed96:18illinicare15:12, 138:14,138:18illinois1:1, 1:6,75:23, 87:21,90:19, 91:23,94:7, 101:8,112:12, 113:6,113:16, 123:22,127:20, 131:8,131:14, 142:10,146:8, 159:24,160:2, 161:5,164:24, 181:6,181:24illustrates11:4

illustrious130:23imagine77:17immediate42:24, 67:24,84:16, 95:17immediately102:21, 104:6,105:20, 113:8imminent60:20impact12:1, 12:2,16:9, 57:3,65:10, 86:1,129:21implore20:9imply79:24importance22:1, 131:4important12:21, 13:12,21:9, 22:12,27:13, 29:9,30:11, 64:6,92:3, 106:5,128:11, 136:23,147:10importantly57:23, 132:7,135:7impressed39:8impresses39:14impression27:23improve115:7, 157:11,168:22improved61:2, 132:8improvement72:3, 168:19,168:20, 168:21

improves133:11improving25:23, 37:23,60:3, 135:7in-center160:12, 160:13,160:22, 160:24,161:10, 163:13,170:13in-centers170:16in-home73:4, 135:16,141:4, 168:8,168:10inaccurate14:22incentive39:10, 56:17inception38:17, 75:18incidence55:13, 63:20,64:11include11:9, 129:2included107:17, 125:21,134:3, 136:10,142:18, 149:9,149:21, 154:18includes125:12including40:10, 42:7,57:1, 59:3,59:7, 149:23,149:24income61:8incongruous58:17incorrect14:22, 15:2,126:18increase22:24, 35:20,



43:12, 98:6,101:16, 104:15,104:16, 104:18,120:14, 136:7increased10:20, 41:6,61:6, 64:23,124:12increasing58:7, 61:9,136:16, 137:6incredible65:17, 131:1incremental80:5, 130:2independent12:3, 31:6,31:15, 69:7,107:6, 153:4,159:23, 160:7,162:21independently97:15indicate55:20, 62:21,68:10, 76:8indicated57:23, 89:8indicates26:9indicators55:2, 63:18,63:23individual138:8individuals35:17, 40:9,40:12, 42:5,42:10, 126:2,164:18, 164:19inducement17:9industry72:19, 79:22,111:13inevitably22:24inexpensive150:5

infected169:11infections163:12information10:20, 14:21,14:23, 20:14,22:5, 22:15,22:16, 32:19,78:14, 87:7,87:9, 103:11,124:4, 124:9,124:12, 128:6,139:1, 141:10,146:13, 158:20,177:15initial4:12, 50:5,98:8, 108:10,130:7initially45:1initiative57:3, 175:16initiatives39:13, 56:23,73:4innovation15:9, 16:16,39:6, 134:9,156:7innovative22:1, 22:7,22:9, 39:14,56:24, 106:21inpatient72:16input59:10, 179:7,179:8inserting128:3inspection44:23inspections48:10installation47:1, 47:4

instance120:8, 160:23instead115:4, 132:10,162:22instituted16:15instruction84:6insurance17:5, 60:15,149:14, 149:24insured154:24, 157:6integrated56:20intent5:2, 86:16,106:11, 122:24,124:2, 142:20,146:11, 158:16intentional20:11intentionally128:4, 128:5interest181:14interested31:9interesting83:15, 87:12,172:11interests13:3, 13:6,24:12, 82:16,148:18interfere73:19intergovernmental5:16, 178:7,178:10internal47:1, 59:17internationally70:12interruptions163:4intersection42:14, 42:15,

43:1into6:23, 7:9,16:11, 19:1,40:15, 48:4,61:1, 75:4,86:8, 86:12,105:13, 120:5,120:16, 127:8,127:21, 132:16,133:15, 134:21,148:15, 160:11,160:16, 161:10,167:19, 169:12,178:9introduce18:8, 51:6,102:4, 112:24,158:23introduction96:8invasive164:7inventory104:4, 126:8investment22:22investor15:18invited134:7involved171:6involves96:4iowa113:17, 117:10,118:15, 118:16irony19:16isn't19:19, 66:16,67:16, 135:16issue22:17, 58:20,66:16, 67:17,74:9, 75:14,78:9, 81:2,



83:22, 86:7,97:19, 104:22,105:6, 108:22,118:21, 121:22,138:13, 138:15,139:2, 148:4,148:10, 148:19,148:20, 152:24,157:3, 162:15issued31:3issues3:6, 18:22,29:20, 36:18,47:2, 55:20,60:4, 61:15,68:16, 70:17,77:22, 105:4,110:1, 128:21,138:22, 163:11,163:12, 163:14,163:18it'll29:1it's12:24, 13:19,16:14, 17:24,22:3, 28:24,30:13, 40:7,42:3, 47:3,55:17, 56:16,62:20, 63:17,64:14, 65:14,68:12, 69:6,69:8, 69:10,70:1, 72:8,73:6, 73:9,74:12, 81:1,81:6, 81:10,81:15, 82:4,82:12, 83:9,84:6, 84:13,85:1, 92:3,96:20, 96:24,97:20, 98:23,108:18, 108:20,108:22, 117:11,119:12, 119:14,

119:15, 128:11,129:20, 131:10,131:11, 135:11,135:17, 137:3,137:8, 138:10,139:2, 147:10,152:10, 153:15,154:14, 161:4,161:12, 161:13,164:8, 164:16,169:7, 169:21,170:11, 170:18,171:1, 171:2,172:9, 175:19,178:13items3:23, 4:2,33:7, 33:14,33:16, 43:16its15:10, 18:6,18:14, 18:24,22:22, 26:11,27:9, 45:15,90:8, 94:7,96:1, 106:24,181:14itself128:3, 133:23ivelisse35:1

Jjack95:13james33:22january138:19jeannie2:6, 43:21,45:8, 45:13,45:16, 176:9jeff95:21jim91:11job1:22, 17:11,

96:13, 129:20jobs60:9joe45:11, 102:10john1:16, 32:2,102:9john's34:4johnson6:9, 11:2joined53:11joining83:8joint82:16, 127:5,152:13jonathan39:21, 39:22judgment82:18july46:21, 180:6,180:16june1:7, 46:18,46:23, 87:24,124:1, 142:12,143:11, 181:18just16:8, 29:8,33:7, 47:13,62:7, 62:11,67:17, 69:16,69:21, 77:10,77:14, 80:1,83:9, 84:7,85:23, 86:6,87:4, 87:14,88:8, 88:10,91:13, 91:21,97:18, 111:5,111:10, 113:13,114:10, 118:21,119:14, 120:11,125:5, 125:15,

126:16, 134:15,134:24, 135:5,135:17, 137:10,137:13, 137:20,142:24, 148:4,160:18, 162:1,162:14, 164:5,164:15, 165:12,165:21, 170:2,170:9, 170:11,171:17, 176:19,176:23, 179:5justification129:15justify15:3, 18:22,19:6

Kk-a-h-n113:4k-a-r-a37:10, 51:8kahn113:1, 113:4,117:14, 118:22,119:14kamradt9:18, 18:5,18:10, 18:13,20:9, 20:13kane63:8, 96:14,181:5kara37:9, 37:11,51:7, 54:17,88:12, 125:1kasparie113:6, 119:22kathy1:12keep16:6, 156:2,163:23keith146:19, 147:11kept29:12



key133:4, 135:9kidney4:16, 26:5,29:11, 29:13,35:21, 36:13,38:3, 39:13,56:3, 57:1,57:6, 60:18,60:20, 61:4,63:20, 64:12,71:11, 74:11,74:18, 76:10,76:13, 86:19,86:21, 91:14,152:21kids67:14kind16:5, 27:9,81:13, 119:8,137:1, 160:21,162:1, 164:21,166:9, 170:11kinds135:12klein95:20knepp146:19kniery102:9, 108:1,108:18, 109:1know14:7, 19:22,21:5, 30:13,30:14, 35:15,38:2, 38:24,39:1, 47:21,55:23, 66:17,68:13, 69:15,71:16, 81:14,81:17, 81:21,98:5, 99:3,107:3, 111:11,117:2, 117:8,117:11, 119:4,120:15, 125:9,

127:1, 131:10,132:14, 136:24,162:22, 163:15,163:22, 164:16,165:6, 168:7knowing78:21, 84:2,99:8knowledge38:1, 67:10known39:7, 40:4,41:24knows12:16, 21:23,30:10koelliker113:9kristen159:10

Ll-e-o-n23:13laboratory112:14, 115:17labs139:10, 154:17lack10:5, 58:14,60:15, 64:9,96:3, 138:23,166:23lacks11:8ladies28:17lake23:17, 24:11,33:20, 55:9,57:14, 59:23,59:24, 62:14,63:7, 63:17land115:22landlord32:7, 46:12landscape27:18

language61:8large118:7, 132:15,170:17largely147:20larger41:4, 43:13,56:21, 64:11,64:20largest55:8, 63:18,113:22, 113:23,125:23, 127:15,127:17, 127:18,127:19, 131:7,131:9, 159:23,162:13, 164:23last14:7, 14:18,32:1, 46:18,58:19, 59:18,60:21, 61:7,71:7, 72:3,73:15, 78:5,79:14, 81:9,87:5, 97:18,111:12, 116:18,126:7, 143:9,166:16, 168:7,168:9, 178:14,180:17lastly20:9late64:14, 69:24,134:20later29:7, 31:7,58:16, 60:19laughter98:1law67:4, 75:23,95:21, 176:16ldls160:13

lead36:22, 47:23,74:22leader39:9leaders59:10leading36:3, 38:18,56:3, 56:18,59:5learn36:13, 39:8,84:15learned19:9, 84:14learning36:11lease50:19, 53:19,123:22, 142:9,146:8, 158:13least35:23, 97:10,109:11, 165:20leave9:12, 65:19leaving19:11, 117:10,117:17left91:9, 91:11,95:17, 95:19,95:20, 95:21,113:10, 117:3,146:21, 159:3,159:5, 159:7,168:21, 173:14legal3:8, 7:17,54:17, 74:8legislation174:15, 174:16,175:13legislative5:12, 174:12lehr45:12



lenders109:3lending105:12length75:11, 98:10lenox3:18, 3:20,4:19, 27:4,27:7, 27:10,27:15, 30:6,30:24, 31:3,31:6, 31:8,31:17, 100:12,100:14, 100:16,102:16, 102:21,103:18, 103:20,105:20, 105:22,106:17, 107:4leon20:19, 23:13less60:7, 79:4,79:24, 80:1,143:20, 168:1,169:3let15:17, 20:3,24:10, 29:24,44:9, 107:3,161:18let's33:4, 66:8,70:16, 71:13,118:18letter11:6, 11:7,86:17, 106:11,108:2, 108:10,108:20, 128:16,128:18, 128:19,129:2letters10:6, 11:12,40:9, 42:6,54:7, 109:5,109:7, 124:18,126:3, 137:23,

138:2, 138:11,149:22, 149:24,158:21level63:24, 68:14,70:10, 70:14levels41:8liability104:23license44:21, 48:15,120:3licensed101:7licensing175:18licensure45:17, 47:3life25:24, 36:12,47:1, 61:3,76:12, 76:23,132:8, 135:8,135:11, 168:10,168:20life-saving128:14lifestyle60:8, 169:7lifetime76:4like16:6, 16:20,17:22, 18:19,19:2, 22:11,23:20, 24:20,26:5, 32:15,35:6, 38:15,44:15, 45:2,46:4, 54:19,54:23, 56:5,58:12, 59:1,59:12, 63:10,65:17, 66:11,68:15, 73:11,73:23, 73:24,79:5, 81:11,

84:5, 86:14,87:4, 87:11,96:12, 102:11,102:20, 107:12,110:15, 116:17,119:3, 119:24,125:15, 125:17,125:21, 126:5,126:16, 126:24,128:2, 129:17,130:5, 130:21,147:16, 150:21,151:14, 162:14,166:24, 168:11,169:21, 170:14,175:23, 175:24,176:23, 177:8,178:4, 180:2likelihood77:24likely55:24, 56:1,61:2, 61:16,106:9limitation22:14, 61:17limitations21:24limited9:7, 56:23,68:24line23:4, 39:5,134:24lines48:1lisle15:12list32:22, 57:6,76:24, 77:5,77:16, 77:17,77:22listed76:9, 76:11,77:6, 77:12,116:21, 119:5listening62:11

listing77:7little16:8, 62:20,76:8, 83:9,113:13, 114:8,118:14, 139:5,149:11, 150:11,151:13, 168:1live19:21, 71:10,73:2, 162:5lives134:17living31:6, 31:15,35:18, 35:20,55:23, 107:6loan108:4, 108:6lobbies117:13local11:23, 41:2,41:7, 134:22locally37:23locate41:3located23:18, 25:9,27:22, 42:23,44:17, 51:1,58:1, 62:16,88:1, 105:19,106:4, 113:14,116:8locating58:9location26:11, 29:16,41:1, 43:1,57:21, 68:3,101:13, 106:1,120:7, 137:3,152:8, 152:10,152:11locations47:24, 137:2



lock48:3long36:9, 46:16,95:7, 97:2,98:11, 105:9long-term27:20, 40:14,42:11, 61:21,94:7, 100:15,101:12, 101:15,101:17, 101:24,106:10, 109:14,111:13long-time14:5longer45:3, 73:2,109:11, 161:11longevity135:11longstanding38:2look10:3, 70:9,70:15, 71:23,71:24, 79:18,91:23, 109:15,118:3, 118:5,153:6, 153:11,161:16, 169:17looked79:14, 81:10,84:21, 167:16looking63:11, 67:10,67:13, 114:4,115:11, 115:19,116:10, 116:13,117:23, 152:23,153:11looks17:22, 28:9,66:11, 175:22,175:23lori91:7lose19:16, 169:15

lost80:6, 81:9lot28:23, 73:3,73:4, 73:19,74:21, 81:11,84:14, 84:15,98:24, 115:12,115:16, 115:24,116:12, 118:11,125:5, 126:21,135:3, 137:22,140:7, 143:21,164:19, 165:15,170:4, 170:15,178:11lots22:3, 77:18louder35:5louis118:12, 118:15love72:20low120:20, 170:10low-income37:24, 38:9,64:12low-level36:2lower17:15, 56:12,84:7, 147:18,150:19lowering80:15lowest106:3loyola167:20luck111:14, 157:20lunch122:18, 135:15

Mm-u-r-p-h-y37:10

ma'am46:14macchione32:3, 32:6machine73:18macro70:10, 70:14madam6:4, 9:20,15:23, 33:15,34:20, 45:7,48:23, 49:18,50:16, 51:3,51:19, 52:21,53:16, 54:3,83:1, 85:21,86:2, 87:17,88:6, 88:20,89:21, 90:16,91:4, 92:16,93:18, 94:16,95:3, 95:6,98:19, 100:3,100:22, 102:1,102:5, 109:21,111:2, 112:8,112:21, 121:4,122:11, 123:7,123:19, 124:20,140:2, 141:16,142:6, 142:22,144:6, 145:8,146:5, 154:2,155:14, 156:24,158:10, 158:22,171:12, 172:23,173:5made15:6, 38:12,40:14, 48:17,51:20, 56:6,65:8, 76:4,79:11, 83:2,88:21, 92:17,98:20, 107:15,121:5, 138:21,140:3, 144:7,

155:15, 171:13madison167:24mail17:4, 17:6main119:15mainly170:20maintain96:6maintained21:19maintaining133:15, 150:11maintenance115:12major40:14, 40:21,42:17, 72:1,162:15majority35:22, 84:24,118:7, 141:5,155:18, 172:4make9:14, 40:21,43:8, 54:23,75:11, 77:15,77:18, 77:23,78:3, 80:11,80:20, 86:6,87:4, 91:13,96:12, 116:1,125:4, 125:6,128:18, 138:20,159:14, 163:9,176:19, 179:9,179:10makes10:17, 15:15,27:16making17:17, 42:11,78:1, 117:18managed59:22management102:7



manager2:9, 159:8,166:13, 170:17manager's163:17managing68:14manipulate14:15manipulated128:2manteno7:18manual97:24manufacturer127:16many21:1, 26:6,27:21, 29:15,33:8, 35:17,36:6, 39:14,41:21, 42:9,55:23, 60:8,60:23, 76:10,76:11, 116:3,117:9, 135:13,135:14, 153:16,166:24, 167:12,167:14map55:12, 128:22march94:20, 101:3,101:10, 173:11margin81:8, 81:13marianne1:18mariel27:3, 31:21market91:12, 118:3,118:13, 127:9,127:21, 128:8,129:21, 129:22,129:23, 130:6,148:15, 148:17,

149:4, 149:13,149:20, 150:20,151:19, 159:9,161:5marketplace19:1, 114:17,117:17mary's7:20mass164:19, 168:20,168:21mat125:1, 139:5match28:14matched38:14mate's99:2material20:14, 115:10,115:15materialize46:6materially178:14materials63:15, 67:13,67:21math92:6matter26:1, 43:22,45:16maureen113:4, 118:13maureen's118:7maximize31:19maximum155:8, 155:9may6:3, 6:23,7:15, 7:23, 8:7,8:16, 16:24,17:1, 25:12,

36:12, 36:14,45:23, 48:8,50:7, 53:6,77:3, 79:6,86:20, 90:6,90:11, 94:4,97:23, 100:13,107:9, 114:23,117:7, 123:1,141:23, 145:17,145:21, 148:17,158:1, 160:6,176:24, 177:20,178:18, 180:5maybe72:15, 91:22,92:3, 92:4,133:1, 139:5mayfield59:8mayor59:8mc1:16, 1:17,6:11, 7:4, 7:24,8:8, 8:10, 8:18,47:11, 47:15,48:20, 49:7,49:10, 50:9,52:6, 52:10,53:9, 70:9,70:24, 71:8,71:19, 72:8,74:4, 74:14,81:3, 84:11,84:21, 89:7,89:11, 90:12,93:3, 93:7,94:9, 97:6,97:23, 98:2,98:14, 99:12,99:16, 100:17,110:9, 110:13,111:24, 117:8,118:9, 118:17,121:17, 121:21,133:21, 135:10,140:20, 140:24,

144:17, 144:21,145:23, 151:2,151:6, 151:9,151:13, 152:1,152:7, 152:15,152:20, 153:13,154:1, 156:5,156:12, 158:4,158:5, 167:10,168:3, 168:6,169:2, 169:17,172:3, 172:7,174:3, 177:2,177:24, 178:19,180:9mccormack32:2mcglasson6:10, 49:6,51:20, 52:5,84:10, 89:6,93:2, 97:5,99:11, 110:8,121:16, 126:6,140:19, 144:16,156:4, 172:2mchenry34:8, 63:7mcneil6:12, 7:10,49:9, 52:9,80:12, 84:20,89:10, 92:17,93:6, 98:20,99:15, 110:12,121:5, 121:20,131:4, 134:6,140:23, 144:20,155:15, 156:11,171:13, 172:6md74:7meals60:11mean66:20, 77:11,79:24, 139:7,157:5, 175:13



meaningful22:4, 66:1means134:8measure130:15measured130:2median76:11, 76:14medicaid75:9, 75:20,78:8, 78:24,96:2, 101:9,107:16, 151:13,154:3, 157:8medical4:17, 7:19,12:12, 23:16,25:8, 25:12,25:17, 27:14,34:17, 35:7,36:8, 37:5,37:22, 38:16,38:19, 38:23,40:2, 41:20,43:3, 45:10,54:16, 59:13,62:1, 62:21,73:5, 75:3,82:14, 90:4,90:7, 91:9,101:1, 111:18,111:20, 112:11,112:16, 114:4,119:9, 120:8,129:6, 130:8,131:7, 152:22,173:18medically39:1, 51:2,55:1, 55:10,55:17, 58:6,64:3, 69:9,73:11, 88:2medicare16:17, 17:23,19:20, 23:1,

66:14, 66:21,67:1, 75:17,75:19, 78:8,78:23, 98:9,101:9, 143:16,143:22, 149:10,149:13, 151:7,151:10, 152:18,154:5, 154:6,154:12, 154:23,157:8, 175:17medication154:9medicine59:17meet10:6, 12:22,13:9, 13:15,15:18, 27:24,35:12, 47:2,48:16, 77:11,78:2, 92:9,110:10, 121:9,150:10meeting6:3, 8:17,10:12, 111:12,121:18, 124:3,127:10, 137:14,146:12, 158:17,163:21, 180:6,180:14, 180:16meetings7:1, 11:2meets22:6, 89:18,92:20, 93:4,93:15, 99:13,106:11, 125:11,153:5melissa159:7, 166:12members1:11, 2:1,7:10, 9:21,11:1, 15:24,18:22, 21:6,22:7, 36:2,

43:24, 45:7,51:15, 82:21,87:10, 88:16,92:12, 96:11,102:5, 107:11,126:6, 130:24,142:19, 159:15,167:9, 173:23,179:3memorial34:13, 34:15,34:17memory30:23, 31:15,102:23men164:17mentioned56:13, 58:13,62:14, 72:21,77:2, 77:14,97:21, 119:5,133:22, 137:22mentioning21:2mere12:13messaging58:17met63:5, 137:12,140:16, 144:18,156:9, 171:22,172:4method69:16, 86:12methodist146:17, 152:8methodology57:15, 69:21,70:8metrics173:13michael2:8middle65:19, 135:3might30:21, 33:3,

86:11, 86:14,92:10, 95:5,143:17, 150:23migrate118:6mike33:13, 34:21,69:23, 91:5,104:9, 119:19,124:21, 136:1,179:21mile57:20miles12:13, 23:18,25:9, 82:4,113:23, 118:14,118:19million17:20, 17:23,50:20, 53:20,63:9, 87:23,94:19, 95:5,101:2, 112:13,118:5, 123:24,142:11, 146:9,149:18, 158:14,170:6, 170:7milwaukee168:2mind97:11, 165:20minimum116:19mining136:13minute71:3, 124:8,124:13, 124:16,129:24, 137:5minutes7:8, 8:24, 9:8,20:8, 23:5,28:18, 37:1,39:15, 43:4,54:2, 62:15,62:17, 64:22,65:24, 68:23,



87:20mirrors28:3miscommunication139:20misconception78:17misleading126:19, 126:21,128:5misrepresent78:17misrepresentation20:13, 26:18misrepresentatio-ns15:6misrepresented15:6misrepresenting22:19miss77:20missed135:1misses165:20missing17:4, 134:13,162:22mission35:7, 97:14missouri113:16, 118:12,118:14missy163:16mistake107:15mistakes15:2, 15:4mitchell2:6, 7:15, 9:3,20:17, 31:21,31:24, 43:22,44:14, 48:8,86:16, 176:10,178:9, 179:3,

179:6, 179:13,179:15, 179:20,180:7modalities73:12, 73:14,73:23modality73:9, 73:20,73:21model16:15, 164:16,164:22modernization94:6, 94:18,98:4modify76:8molitor102:8moment54:22money16:18, 16:21,74:22, 81:11,135:11month31:8, 79:19,107:5, 151:23,163:20, 165:21,165:23months14:7, 14:18,22:13, 29:7,46:24, 47:20,58:19, 143:18,149:15, 162:10more12:23, 13:11,31:11, 38:10,38:14, 40:22,55:3, 55:24,56:15, 57:16,60:15, 60:21,60:23, 61:2,61:16, 61:18,61:21, 62:17,63:13, 65:24,67:9, 69:1,

69:16, 69:22,70:18, 74:22,75:3, 76:22,80:15, 84:15,86:14, 87:9,92:2, 96:23,104:16, 109:4,115:14, 119:20,120:13, 129:6,132:7, 135:7,136:9, 139:6,139:19, 143:17,147:24, 148:9,149:2, 153:14,160:1, 160:19,165:8, 166:21moreover11:12morning9:20, 12:8,15:23, 21:6,23:12, 25:6,27:2, 28:17,28:19, 30:4,37:9, 39:21,41:13, 59:15,65:20, 83:15,85:4, 113:1,133:22, 134:4,165:22mortality168:14, 169:1most12:21, 13:12,40:18, 57:4,59:20, 64:19,67:9, 79:19,106:5, 110:10,121:9, 132:1,137:8, 169:14,176:18mother30:15mother-in-law30:15motion6:23, 7:16,7:23, 8:7, 8:17,

8:23, 47:9,48:18, 49:22,50:7, 51:20,53:2, 53:6,83:2, 86:5,86:20, 88:21,90:6, 90:9,92:17, 93:23,94:4, 98:20,100:8, 100:13,111:9, 111:19,111:21, 121:5,123:1, 123:8,123:10, 140:3,141:21, 141:23,144:7, 145:13,145:17, 145:20,155:15, 157:16,158:1, 171:13,173:3, 174:1,174:10, 176:24,177:10, 177:17,177:20, 178:6,178:16, 178:18,179:22, 180:4,180:5motivated19:24move117:24, 131:24,135:1, 140:12,177:2moved7:2, 7:24, 8:8,8:18, 47:11,50:9, 53:9,86:23, 90:10,94:8, 100:17,111:22, 123:4,142:2, 158:4,174:3, 177:3,177:22, 178:19,180:9moving30:17, 133:9much14:14, 16:6,30:2, 41:11,



43:13, 53:3,56:21, 61:2,71:8, 71:19,93:24, 96:5,97:3, 116:23,123:11, 136:16,139:18, 145:14,153:14, 157:17,157:18, 170:8mudslinging137:22, 140:8muldoon91:9multidisciplinary163:20multiple43:9, 74:3,75:10, 128:16,134:23, 164:13multiply151:3multispecialty36:19, 132:17multitudes42:21municipal41:9murphy1:18, 6:13,6:14, 37:9,37:11, 39:16,49:12, 49:13,52:13, 52:14,53:10, 83:2,85:8, 85:9,89:13, 89:14,93:10, 93:11,99:19, 99:20,100:19, 110:17,110:18, 111:22,121:5, 122:2,122:3, 123:6,123:9, 126:7,140:3, 141:8,141:9, 142:2,144:7, 144:24,145:1, 145:20,155:15, 156:16,

156:17, 172:13,172:14musician169:8, 169:14must44:6, 65:1,104:19, 129:2,129:7, 148:12mutually43:5myself24:20, 157:6,179:6

Nname9:4, 9:10,9:18, 9:21,12:8, 14:4,15:24, 20:24,21:7, 23:12,25:6, 27:2,28:19, 32:4,32:6, 34:23,35:1, 37:11,41:13, 51:10,54:13, 75:8,91:7, 95:13,146:17, 159:2,162:3, 166:12names88:8nancy20:22, 30:4,107:4nani12:9, 12:23,13:17, 14:5,15:16, 18:6,18:11, 18:14,18:19, 19:8,19:17, 21:8,23:14, 24:4,25:7, 25:21,26:6, 56:7,58:13, 58:18,82:9, 82:11,126:17, 127:5,

127:18, 128:12,130:6, 130:15,139:8nani's129:12nation132:13national26:5, 39:22,41:18, 42:17nature172:15naveen9:16, 9:21near41:3, 42:14,116:8nearby106:4, 170:15nearly42:4necessarily85:3necessary28:1, 96:24,121:24, 139:3,140:13need10:2, 12:19,13:11, 14:1,20:12, 22:10,23:23, 25:3,25:17, 25:19,26:10, 26:23,30:10, 31:1,31:14, 31:19,36:21, 39:3,46:7, 46:24,50:23, 57:8,57:11, 57:15,57:19, 58:2,58:14, 58:23,62:22, 64:18,65:23, 69:18,70:15, 71:10,71:15, 73:24,81:20, 83:19,85:2, 85:18,

87:24, 91:1,95:1, 95:15,99:4, 101:15,101:23, 103:21,104:1, 104:2,104:4, 104:9,106:12, 106:19,111:19, 125:12,126:12, 127:10,127:23, 133:17,134:13, 135:23,136:24, 142:13,143:4, 147:17,148:16, 150:2,150:17, 154:21,160:5, 160:10,160:11, 160:18,160:20, 161:6,161:8, 164:24,167:2, 167:4,169:13, 169:14,169:19, 169:23,173:13, 174:1,175:8, 177:17,178:13, 178:16needed57:14, 98:4,148:13, 157:9,176:15needle132:1needs12:22, 13:10,13:15, 35:16,55:3, 57:16,63:9, 80:17,127:14, 150:10needy64:1negative16:9, 54:22,65:10, 86:4,114:19, 122:14,157:15, 173:7negatively175:5negligible129:22



negotiate149:2, 149:4negotiates179:1negotiations32:10neighbors38:11neil1:17, 7:24,8:10, 8:18,47:11, 47:15,49:10, 52:10,70:9, 70:24,71:8, 71:19,72:8, 74:4,74:14, 81:3,84:21, 89:11,90:12, 93:7,94:9, 98:2,98:14, 99:16,100:17, 110:13,117:8, 118:9,118:17, 121:21,133:21, 135:10,140:24, 144:21,145:23, 151:2,151:6, 151:9,151:13, 152:1,152:7, 152:15,152:20, 153:13,154:1, 156:12,158:5, 167:10,168:3, 168:6,169:2, 169:17,172:7, 174:3,177:2, 177:24,178:19, 180:9neither181:12nephrologist9:22, 10:15,12:9, 21:8,23:14, 24:4,25:7, 36:14,132:21, 132:23,159:4, 162:4nephrologists19:9, 60:21,

62:13, 130:9,130:12, 139:8nephrology17:13, 19:6,19:16, 19:17,59:17, 127:19net37:21never76:13, 81:18,117:8, 164:3,169:20new3:18, 3:20,4:19, 14:20,19:3, 26:16,27:4, 27:7,27:10, 27:15,28:7, 30:6,30:24, 31:3,31:6, 31:8,31:17, 43:1,76:19, 78:22,81:3, 85:15,98:4, 100:12,100:14, 100:16,102:16, 102:21,103:18, 103:20,104:19, 105:20,105:22, 106:10,106:17, 106:21,107:4, 115:1,115:10, 115:15,116:7, 129:5,141:17, 148:17,171:4, 171:5,178:13newest18:21next6:22, 9:1,12:7, 14:3,15:22, 18:4,20:17, 32:11,37:8, 39:20,43:16, 46:15,50:4, 53:4,78:7, 79:10,

86:17, 86:18,90:4, 94:1,100:11, 108:9,108:10, 108:17,111:17, 122:22,141:22, 145:15,157:21, 157:23,162:9, 167:14,173:9, 180:6nexus42:20nice117:12night65:19, 74:17,85:4, 162:18nightly162:17nights166:2nine14:18noncompliance36:23, 110:1,110:20, 121:10noncompliant17:7none47:8, 51:17,82:23, 88:18,92:14, 103:18,109:19, 121:2,139:24, 144:4,155:12, 171:10nonetheless129:22noontime141:3nor181:12normal72:16, 76:13,173:13normally70:24, 71:10,119:9north3:13, 3:17,

3:19, 4:15,12:11, 13:24,23:15, 23:19,25:2, 25:11,26:22, 28:21,40:17, 53:5,53:7, 64:22,82:5northern166:13northwest160:8northwestern59:19, 167:21not-for-profit113:21, 147:1notarial181:17notary181:4, 181:23note56:9, 62:12,86:6, 106:5noted61:12, 107:13notes105:8nothing14:16, 22:4,49:24, 50:2,126:22, 140:10notice95:4, 131:19,133:10noticed46:22, 134:6,134:10notified124:5notify32:12now7:7, 19:11,31:7, 31:9,44:15, 56:19,60:22, 67:13,71:21, 79:11,85:19, 101:21,



108:6, 109:11,113:15, 113:20,115:4, 116:19,126:14, 132:14,136:6, 139:16,143:3, 162:7,162:12, 165:9,166:24, 175:19number66:15, 70:10,101:17, 117:24,129:3, 129:4,147:5, 148:13,163:16, 163:18,174:23numbers71:23, 72:6,81:14, 91:24,92:2, 92:5,120:21, 149:12,167:16, 167:17numerous40:12, 59:9,126:1nurse74:7, 162:8nurse's163:17nurses163:22nursing4:18, 27:8,94:2, 94:5,95:24, 96:14,96:16, 100:24,102:24, 103:19,105:21, 106:23,114:11, 114:15,119:6, 132:10nutritious60:11

Oo'dea9:19, 15:23,15:24oath15:5, 15:9,

15:12, 137:23obesity35:22objections129:12obstruct127:21obvious99:4obviously60:7, 98:23,99:13occ71:1, 135:14occasions18:6, 18:13occupancy69:1occurred67:9, 71:5,138:16october29:5, 158:15,181:20off21:12, 33:14,60:17, 77:3,77:22, 83:11,91:13, 92:5,97:17, 130:21,180:18offer72:10, 73:22,151:18offered73:13office60:23, 111:18,111:21, 112:11,114:4, 119:9,120:8officer159:6, 181:6offices27:12, 112:14,170:17, 170:18officials40:8, 42:5

officio2:1often35:16, 36:10,36:22, 64:14,77:20oh160:7, 176:1,178:23, 180:13okay31:24, 32:20,49:24, 53:11,54:11, 70:9,87:16, 98:16,144:1, 152:20,176:5, 176:6,179:18, 179:20,180:5old30:12, 69:15,69:23, 98:5older64:24, 164:18olympia33:22omaima9:17, 12:9on-site119:9, 119:13,119:14once85:24, 109:5one9:24, 14:10,17:3, 18:16,26:14, 29:1,29:2, 29:8,29:16, 35:23,38:21, 40:17,43:22, 62:14,63:9, 63:16,63:17, 64:3,65:17, 66:18,68:8, 74:4,74:8, 74:18,76:2, 77:4,79:19, 83:17,86:6, 87:5,

96:20, 112:19,116:21, 118:1,119:17, 119:24,120:3, 122:13,122:18, 124:14,131:17, 134:15,134:17, 137:8,138:1, 143:10,148:14, 150:15,151:21, 156:6,157:3, 163:20,165:9, 165:11,165:19, 166:2,166:4, 170:10,173:12, 173:15,175:2, 176:13one-size-fits-all164:16, 164:21ones167:18ongoing77:19online57:13, 85:24,120:12, 136:22only9:8, 11:16,15:9, 15:11,23:2, 24:5,26:3, 29:23,58:21, 59:4,62:3, 68:7,68:20, 74:14,75:21, 82:15,97:16, 104:12,104:22, 105:6,120:2, 129:23,149:3, 150:19,153:5, 170:18,175:2, 179:21onto83:11, 163:12,165:8, 169:13open1:4, 7:1, 7:11,21:19, 57:2,81:23, 82:1,82:6, 115:4,



115:8, 147:2,150:8, 157:5,165:1, 166:4,173:15opening31:7, 31:11,107:5, 151:17opens65:4, 84:4operate20:1, 68:11,97:15, 148:12operated26:1operates59:4, 127:1operating26:14, 58:1,62:23, 62:24,63:1, 65:13,65:14, 68:8,68:9, 68:12,97:9, 104:24,105:17, 136:21,159:6operational26:15operations148:11, 159:11opinion85:17opponents127:4opportunities84:15, 139:20opportunity24:19, 30:20,95:9, 96:15,115:22, 133:13oppose9:22, 14:6,18:15, 23:14,25:13, 58:13,82:13opposed174:8, 177:8,180:2opposing21:14, 21:16,

130:11opposite20:4opposition12:10, 21:13,25:10, 28:21,50:22, 51:5,53:23, 54:4,54:7, 54:9,88:4, 88:10,90:22, 94:24,106:6, 106:7,106:13, 124:18,126:16, 128:2,128:15, 142:15optimize77:24option73:16, 147:4,150:3, 150:10options61:22, 153:11,153:24, 165:16,166:6order3:3, 6:3, 6:22,9:1, 9:6, 66:23,101:14, 147:18ordered139:11ordering47:23orders3:7organ74:15organization13:17, 16:2,25:21, 38:6organizational40:12organizations26:5, 40:8,42:5, 42:9,126:1original102:18, 103:5,103:10, 105:4,

105:8, 105:18,106:6, 106:14,124:7, 136:10originally19:10, 105:2,126:9originator's108:4, 108:6ortho117:24orthopedic34:3, 116:10,118:8orthopedics117:16, 118:10osf152:14other4:7, 5:11,10:10, 10:24,15:18, 23:21,24:13, 26:12,29:20, 36:16,36:22, 39:14,41:2, 42:9,43:2, 43:20,47:6, 62:3,62:5, 62:16,64:4, 65:9,65:10, 65:21,66:3, 67:23,68:12, 68:21,72:1, 77:21,80:9, 82:20,97:21, 99:1,105:21, 109:16,118:20, 118:23,120:23, 128:10,137:7, 139:21,143:5, 144:1,155:10, 160:13,161:2, 163:10,163:11, 164:14,165:10, 165:23,167:21, 169:24,170:4, 171:7,173:15, 174:12,175:2, 176:18,

178:12, 178:15others175:7otherwise26:17, 181:14ours69:23, 91:20ourselves23:7, 51:6,152:6ourth45:7, 45:11,46:3, 46:10,49:23, 102:10out7:14, 9:14,17:22, 24:22,29:1, 33:5,33:13, 45:16,60:12, 63:11,74:14, 75:17,79:12, 79:19,80:19, 85:16,98:15, 107:13,109:10, 114:1,114:17, 115:20,115:21, 116:6,116:17, 118:6,133:9, 160:6,164:6, 169:18,173:15out-of-pocket155:8outcome163:6, 168:8,181:14outcomes38:5, 56:12,56:22, 73:1,75:5, 81:6,84:6, 172:11outdated57:18outline147:9outmigration117:15, 118:1outpatient118:4, 135:14,



141:5, 168:11outreach35:2, 36:3outside60:9, 115:15over14:18, 17:20,28:5, 28:9,40:1, 51:9,56:1, 58:18,59:12, 61:6,64:21, 64:23,65:4, 65:22,68:15, 71:7,72:2, 82:1,94:22, 96:1,96:3, 96:18,97:18, 109:11,111:13, 116:18,117:9, 118:11,118:14, 135:15,147:14, 163:8,165:2, 166:1,167:10, 168:7overages119:17overburden73:18overcome36:18overlapping10:21overridden82:17overriding84:8oversees91:10oversight173:17overwhelming125:20own15:1, 41:16,58:22, 61:5,91:20, 129:15,139:8owned148:5

owner127:17owners127:5ownership34:3, 34:8,34:10, 34:12,34:16owns148:8

Ppackage117:23pad23:4page3:2, 66:11,75:14, 78:16,107:13pages1:23pairs137:1palos34:1panel36:5paoletti159:10parent146:18parents65:18park3:12, 3:15,3:22, 4:14, 5:3,5:6, 35:10,37:15, 39:17,40:3, 40:13,40:16, 41:24,50:7, 50:8,122:22, 123:2,130:18, 142:1,142:9parking135:3parse63:10

part5:9, 12:23,26:4, 61:4,64:19, 65:8,96:13, 101:11,104:5, 107:3,119:1, 119:15,125:12, 129:14,131:17, 154:8,168:3, 170:23,171:1, 173:11,174:2, 177:16part-time96:13participate36:5, 59:21,138:18participates56:10participating138:19participation3:11, 9:2particular86:7, 96:21,134:17, 165:19particularly18:21, 103:1,103:7, 147:4parties181:13partner10:16, 27:24,28:13, 31:6,38:18, 82:17,130:7, 153:21partners131:8, 131:14partnership36:1, 38:2,77:14, 132:17parts47:23, 137:7pass51:9, 143:11,174:18passed56:20, 67:4,

174:23, 175:6passes8:23, 49:22,53:2, 90:2,93:23, 100:8,111:9, 141:21,145:13, 157:16,173:4, 174:10,177:10, 178:6,180:4passionate131:6past17:16, 31:2,64:21, 140:11,152:13, 179:9pat117:2, 118:2patient10:13, 11:10,12:2, 13:13,13:18, 15:8,15:15, 15:19,16:2, 17:3,21:20, 22:2,22:16, 24:5,25:22, 26:2,29:19, 29:21,38:5, 56:19,57:10, 61:5,64:13, 70:16,71:1, 71:15,72:22, 73:10,73:14, 73:15,73:20, 76:19,81:1, 96:3,96:17, 129:8,130:15, 132:12,134:1, 136:7,137:23, 139:1,139:3, 140:10,148:22, 149:16,149:18, 151:3,152:1, 154:24,155:8, 164:21,165:19, 169:8,170:18, 171:18patient's73:6, 118:18



patrick113:11paula1:24, 181:3pause122:18pay97:17, 149:6,150:4, 154:21,155:8payer78:14, 149:21payers78:23, 149:23,150:1, 150:3,150:9, 150:12,151:14paying149:15payment16:15pays151:7pd74:2, 160:1,160:5, 160:6,160:8, 160:11,160:23, 161:2,161:6, 169:13penalties103:7pending63:3people55:23, 63:9,67:24, 68:16,70:10, 74:21,75:19, 75:21,75:22, 75:24,76:1, 79:4,83:21, 85:2,96:14people's132:7peoria117:10, 145:19,146:8, 151:15per70:19, 71:1,

120:18, 129:1,149:1, 149:8,149:11, 149:17,149:18, 149:19,151:2, 152:1percent54:2, 55:24,57:22, 58:2,58:10, 61:6,62:23, 63:1,64:23, 64:24,65:4, 65:13,65:22, 68:9,68:12, 68:14,68:16, 72:18,79:20, 79:21,81:9, 82:1,82:15, 88:5,91:3, 96:1,104:16, 104:17,104:18, 108:12,127:5, 127:7,129:24, 131:14,131:16, 131:19,131:20, 132:5,132:12, 132:14,134:5, 136:21,137:11, 148:9,150:7, 152:4,154:22, 163:7,165:5, 165:10,167:13, 167:18,168:4percentage56:14, 72:10,72:14, 72:20,74:10, 76:9,76:18, 78:22,119:18perfect87:16perfectly73:16perform178:11performance95:20performing56:16

period45:3peritoneal162:17permissible86:15permit4:3, 33:21,43:17, 101:12,101:18, 101:22,102:16, 102:18,104:13, 124:7permits4:11, 31:4,50:3permitted86:13, 176:20,176:21perplexed82:3person76:13, 157:6personal29:10personally26:8, 37:21,38:24personnel176:12perspective64:2, 73:1,140:9, 149:10,152:19pertinence94:22phase108:17philip125:1, 130:22,130:23, 134:5,139:7philosophy16:22phone163:16, 163:17,163:18phosphorus168:22

physical112:15, 116:14physician11:9, 27:12,38:23, 61:3,69:8, 112:14,113:10, 129:2,131:6, 146:21,154:16, 162:9physician's91:19physician-patient133:3physicians18:6, 18:14,19:8, 24:16,24:20, 27:16,36:4, 36:7,36:16, 38:19,59:9, 62:17,69:7, 133:5,153:2, 153:9,153:18, 154:8,162:8pick168:17picture57:16piece117:20, 117:22pink96:19place130:5, 137:2,137:9placed164:7places66:2, 137:8plan24:18, 59:22,148:23planned11:4, 14:14,54:16, 54:20,59:13, 125:18,127:24, 129:23,130:18



planning11:5, 50:24,53:24, 57:12,63:11, 64:20,88:1, 103:21,104:10, 106:1,124:16, 127:13,128:10, 136:18,136:24, 137:7,142:14, 143:11,158:18, 172:20,174:17, 174:21plans108:11, 108:12,108:16, 147:6play81:14, 120:16,169:9played14:11playing74:3, 116:12plays37:22plazas39:23, 41:19please6:3, 7:3, 7:15,8:1, 8:9, 8:17,9:5, 9:9, 18:9,20:23, 21:3,23:8, 31:18,32:3, 33:13,34:22, 35:5,37:4, 43:7,43:14, 44:10,50:10, 50:15,54:12, 77:9,86:24, 90:9,100:18, 111:21,112:24, 123:5,123:14, 125:8,145:22, 158:24,177:3, 177:19,177:23pleased30:6, 97:13,102:7, 107:8

plenum115:4plundering11:17, 23:2plus18:11, 70:11,105:24, 113:20,172:10point32:14, 42:22,44:6, 55:7,57:8, 76:5,77:7, 80:5,80:23, 107:12,109:10, 118:7,122:17, 134:11points54:24policies176:15polsinelli51:7poor67:24, 69:6,79:3poorest55:9, 63:16poorly11:4, 14:13populated129:16population10:18, 31:1,56:21, 61:6,63:8, 64:4,70:2, 79:3,106:2, 110:14,124:8, 124:12,124:13, 127:14,136:7, 165:5,165:7, 166:8populations129:17portion132:15positioned27:24positions47:24

positive37:18, 40:6,42:3, 52:23,54:21, 64:18,89:23, 92:8,92:24, 93:20,99:20, 100:5,125:3, 125:11,125:19, 126:15,126:23, 127:12,130:19, 136:6,137:17, 143:1,145:10, 147:20possible38:13, 73:24,139:19, 153:18,169:20postacute27:23, 28:2,102:9, 103:10postpermit101:19potentially40:21, 41:5poverty55:13, 55:19,55:24, 68:3,69:1practice13:7, 36:19,59:17, 60:3,62:2, 73:11,113:10, 129:1,153:8, 162:6,162:12practices35:6practicing95:7, 159:4practitioner12:21, 74:7,162:8prairie34:4pre-esrd129:10preclude104:14

preconference136:2predicted65:1preferred103:23prep47:23prepared105:13, 157:2prescription120:12presence7:19, 7:20,40:24, 127:7,130:14present1:11, 2:1, 2:5,6:8, 134:7,161:3, 162:1presentation165:24presented8:15, 40:5,42:1, 93:8,99:17president37:12, 39:22,41:18, 51:10,54:14, 91:10,102:6, 113:4,113:7, 146:20,146:22pretty67:10, 82:2,136:12prevailing150:8, 152:5preventive60:14, 61:10previous10:12, 11:2,110:24, 165:24previously14:23, 41:14price71:14, 71:20,150:14



pricing116:20, 148:24,150:7, 150:18,150:19, 151:18,152:4pride97:22primarily98:12, 173:12primary36:3, 36:5,36:15, 38:21,64:5, 64:10,69:5, 133:6principal148:1printed67:21priori80:20privacy115:7private18:24, 22:22,41:9, 61:22,151:14privately154:23, 155:4,157:6privilege131:1privileged95:14probably16:4, 113:24,118:7problem22:18, 22:23,85:1, 160:3,160:14, 163:2,164:14, 169:16problems36:12, 156:7procedure164:7procedures151:24proceed102:18

proceedings7:11, 181:7,181:9process11:5, 14:15,24:18, 46:12,59:11, 60:1,87:15, 108:11,108:17, 128:3,128:5, 140:8,160:20, 163:10proctor5:5, 145:16,145:18, 146:19,146:24, 152:9producing22:21production133:14products127:16professional51:1, 55:11,55:18, 58:6,64:5, 88:2professionals141:2professor75:13profit81:8profitably97:10profits22:9prognosis61:21program17:24, 18:2,23:1, 37:13,38:10, 38:12,39:10, 56:10,56:15, 56:17,57:1, 57:3,57:7, 67:14,76:20, 76:24,78:14, 114:16,148:16, 162:13,

163:24, 166:15,167:19program's75:18programs39:14, 56:24,166:18progression64:15project's85:10projections65:2projects10:10, 10:17,11:4, 11:8,11:20, 12:1,14:6, 14:8,14:11, 14:14,14:17, 15:3,15:14, 18:15,18:16, 18:23,20:6, 21:1,21:16, 28:23,39:5, 91:18,109:13, 129:6,143:10, 175:21prolonging61:3prominent40:20promoting73:4promptly122:18prone165:8proof19:13proper62:20, 68:20properly9:15properties41:19property41:7, 97:15proposal27:8, 56:8,

58:8, 59:2,62:7, 63:5,90:23, 94:22,125:10, 126:9,126:20, 127:12proposals19:11, 35:12,37:18propose50:17, 53:17,87:18, 90:17,100:23, 105:19,123:20, 142:7proposed12:11, 12:13,16:19, 18:15,23:19, 25:9,25:11, 35:10,37:14, 39:4,40:5, 42:2,55:5, 55:16,57:21, 101:16,106:20, 107:24,109:13, 112:9,128:1, 129:13,146:6, 158:11,170:5, 176:11,176:17proposes94:17proposing19:3, 29:3,102:21, 104:18prospective40:22prospectively41:8protect23:6, 129:21proved31:5provide17:2, 38:7,38:14, 41:6,41:8, 42:12,44:1, 55:22,56:20, 59:23,62:3, 69:8,



74:23, 80:1,97:1, 126:24,130:14, 140:12,147:7, 153:22,160:21provided10:20, 28:3,103:11, 124:10,137:5, 146:13provider15:11, 25:23,27:23, 56:14,56:16, 59:6,86:10, 106:6,127:17, 133:7,149:3, 150:12,159:24provider-based115:21providers10:11, 11:18,11:24, 12:3,19:13, 21:19,23:3, 27:20,35:4, 35:15,36:5, 38:15,39:11, 41:3,43:3, 65:11,148:17provides57:15providing35:8, 38:20,40:15, 58:4,80:6, 81:1,108:23, 125:15proximity27:15, 30:11,42:16, 106:2public1:1, 3:11, 9:1,32:20, 41:15,41:17, 50:22,53:22, 54:5,57:2, 58:12,88:4, 90:21,91:15, 91:16,91:17, 101:8,

112:19, 116:5,124:17, 128:4,142:14, 158:19,174:22, 175:15,176:14, 181:5,181:23pull91:22, 92:5pulled160:6, 160:23purchase44:17, 46:12,46:15pursuant6:24push152:23, 163:7put12:23, 13:2,13:13, 13:20,76:5, 80:2,116:17, 138:2,149:9, 152:18,169:19puts133:6putting22:8, 128:22,130:1

Qqualified80:1qualify66:15, 66:21,67:1, 75:19,77:7qualities72:4quality19:16, 19:20,21:22, 25:24,27:24, 39:8,39:9, 56:17,56:22, 76:23,99:3, 131:11,131:12, 131:15,132:7, 132:8,

133:11, 133:15,135:8, 135:11,150:14, 168:19quarters66:15, 67:3,67:12question48:3, 67:23,71:18, 71:19,76:7, 78:6,78:8, 79:10,81:16, 82:13,97:6, 98:2,108:9, 117:7,133:21, 143:9,154:4, 154:6,170:2, 175:10questionnaire5:15, 177:11questions19:24, 45:22,47:6, 51:12,51:14, 66:6,66:8, 80:9,82:20, 88:16,92:10, 92:12,96:9, 96:11,105:14, 107:8,107:11, 107:19,109:16, 114:20,114:21, 117:4,117:5, 118:23,120:23, 124:11,133:19, 139:22,143:6, 144:1,147:12, 150:23,151:1, 155:10,166:10, 167:9,169:24, 171:7,173:22, 175:9quetsch1:24, 181:3quickly65:7, 71:16quincy111:21, 112:11,113:5, 120:19quite78:9, 81:18,

84:14quo150:11, 150:15quote20:1, 66:12

Rr-o-h-a-i-l21:8radar149:21radiology112:15raised11:1, 75:14,148:1ran120:20, 152:12randi102:6rapidly137:4, 137:6rarely164:5rate64:24, 71:5,84:5, 136:16,136:19, 137:3,149:2, 149:11,149:13, 150:8,152:5, 152:18,154:12rated95:24rates10:23, 57:9,58:7, 85:16,126:13, 132:3,132:7rather19:1, 21:3,70:17, 153:15,175:18rating39:11ratings79:15, 79:16,80:3



ratio105:7ratios104:24, 105:15reach60:13reactivation47:3read17:4, 17:6,33:7, 33:14readmission103:8, 132:3,132:6ready143:24real104:22realize132:18, 141:1really29:18, 47:3,56:11, 58:19,59:10, 61:24,65:16, 67:16,68:15, 70:15,84:22, 85:2,97:4, 97:7,109:7, 130:13,131:23, 135:11,147:10, 161:12,161:15, 161:20,163:13, 164:9,166:3, 169:7,172:24, 175:8reason18:18, 26:3,29:18, 30:2,46:6, 56:8,63:21, 75:16,75:20, 81:5,136:6, 136:23,140:21, 143:1,160:10, 163:11reasonable147:24, 149:2reasonableness119:3

reasons14:9, 85:23,119:5, 121:10,156:6recall101:10receive19:20, 36:21,38:11, 39:2,54:6, 86:16,108:3, 124:18,142:15, 142:16,158:20received40:6, 42:2,43:24, 59:2,103:22, 109:5,112:18, 125:20,126:23, 129:3,142:20, 146:11,158:16, 176:10receives149:16receiving10:14, 13:15recent67:9, 67:10,67:11, 69:16,69:22, 79:19recently19:8, 57:4,96:15, 120:10,169:11recess122:20recognize46:6, 76:6recognizes105:16recommend74:15recommendation85:6recommendations51:23reconsidered143:3record46:13, 67:18,

88:9, 91:14,91:21, 105:9,107:17, 125:7,137:10, 180:18,181:8red56:5reddy9:16, 9:20,9:21reduce37:2, 84:4reduced181:10reducing156:2reduction72:4, 152:4reestablish32:16, 86:22refer7:16, 24:14,38:22, 72:11,76:1, 163:7reference80:12referencing67:8referral10:6, 11:7,128:16, 129:2,129:9, 167:13referrals3:8, 10:4,11:10, 135:13referred8:6, 36:6,129:5referring21:5, 70:22,70:23refers109:8reflect120:15, 128:11,130:1reflects57:18

refused73:17, 149:3regard63:22regarding87:5, 105:14,109:5, 112:18,124:18, 142:16,158:21regardless12:24, 14:14,67:2, 150:13,150:14regards166:20region39:24, 40:20,113:19, 114:1,114:15, 116:8,118:6, 132:13,159:20, 166:14regional91:10registered32:21regulations98:16rehab4:18, 30:11,31:15, 94:2,94:5, 98:13rehabilitation30:18, 95:23reimbursement71:6, 103:6reinhart95:21reinvested81:11related45:16, 97:7,101:6, 112:20,124:15, 181:12relating108:19relationship24:2, 28:8,28:10, 82:11,



133:3, 133:4,134:24, 135:5,135:9relationships139:9relative72:5, 79:21,83:18, 110:1,114:19, 155:19,171:17relatively150:4relatives31:2relevant67:16relinquish101:22, 104:6relinquishment33:21, 33:24reluctant109:3rely22:3, 175:17remainder96:5remains102:16remarks9:9, 9:12, 32:5remember20:23, 32:4,173:10renal26:2, 64:9,73:3, 148:6,153:8, 153:19,160:1, 175:14renew44:21, 47:13renewal4:3, 43:17,143:18renovation96:5reopen44:20, 45:5repeat77:9, 123:8

repeated15:8repeatedly10:5, 14:12,120:21replace104:7report20:5, 22:6,24:7, 26:9,40:7, 42:3,50:15, 52:19,52:23, 53:15,54:21, 54:22,57:18, 61:12,66:11, 87:3,89:23, 90:15,93:12, 93:20,94:15, 99:21,100:1, 100:5,101:18, 102:13,104:20, 105:8,105:16, 107:14,112:6, 123:18,125:4, 125:10,126:15, 126:23,127:12, 127:22,130:20, 136:14,137:17, 140:6,141:10, 141:14,141:18, 142:5,142:17, 143:1,144:10, 144:14,144:21, 145:2,145:6, 145:10,146:4, 147:20,148:2, 155:18,156:8, 156:14,156:18, 158:9,172:10, 172:20reported1:24, 40:7,42:4reporter9:11, 9:13,20:24, 181:1,181:4reporting57:18, 69:24

reports4:10, 37:17,50:2, 92:24,125:19, 140:17represent28:21, 75:9,154:3representative59:7, 106:18representatives56:7representing32:7, 91:8,146:24represents55:13request13:23, 25:1,26:21, 28:5,43:10, 46:8,139:12, 161:14,161:17requested45:3, 50:23,53:22, 177:21requesting44:8, 45:1,103:3, 104:8requests4:3, 4:4, 4:5,4:6, 43:17,43:18, 43:19require64:16required10:18, 44:24,47:4, 70:6,119:23requirement11:8, 174:21,175:19requirements101:20, 105:12,128:19requires56:4, 65:19requisite66:14

residency114:16, 119:8residential31:3residents27:11, 35:8,38:9, 42:21,60:4, 61:9,96:1, 98:9,105:24resources60:6, 60:16,61:10respect69:3, 69:4,78:8, 104:1,139:9respectfully13:23, 23:10,25:1, 26:21,43:10, 75:15,130:17respectively41:2respiratory114:12respite160:5, 160:10,161:8response19:23, 47:7,51:16, 82:22,88:17, 92:13,109:18, 121:1,139:23, 143:7,144:3, 155:11,171:9, 173:24,174:9, 177:9,178:5, 180:3responses124:10responsible149:14rest68:19, 79:21,161:18restrictions86:9



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Ss16:21s-c-h-i-f-f-n-e-r28:20s-u-j-a-t-a23:13safe75:10safely73:12safety37:21, 47:1said13:12, 18:19,19:23, 33:10,44:15, 45:13,45:16, 46:1,57:13, 57:23,65:12, 75:5,77:10, 80:13,80:17, 81:15,84:14, 117:6,118:13, 126:14,126:24, 129:9,156:13, 159:20,167:13, 172:10,181:9salako159:1, 159:2,159:14, 162:14,167:16, 168:5,169:6, 169:21salary70:13salima20:20, 25:7



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81:20, 92:1,95:5, 96:20,118:2, 120:14,132:23, 132:24,160:17, 169:13,174:6, 177:6,178:2, 179:24saying14:24, 30:12,55:17, 67:18,78:10, 107:22,137:23, 154:15,166:21says175:22, 175:23,175:24scale120:16scared135:2schedule65:16, 68:18scheduled15:14scheduling61:14schiffner20:20, 28:17,28:19school41:16, 114:11,114:12, 114:13,114:15, 152:22schools41:7, 116:9,119:7schullo102:5, 102:6,108:8, 108:24,111:10scores42:17, 120:7scott20:20, 28:19,113:9scottish7:22scratch162:1

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118:4, 118:10,129:18, 131:24,136:14, 136:20,139:8, 139:11,139:17, 143:15,163:13, 163:19,172:11, 175:23seeing16:5, 47:8,51:17, 82:23,88:18, 92:14,98:17, 109:19,121:2, 139:24,144:4, 155:12,171:10seek153:11seeking31:17, 40:16,42:13, 147:3,153:8, 153:9seems69:13, 87:11,168:8seen36:14, 96:21,97:2, 164:13,170:4segment56:21self-funded147:6self-referral4:9, 50:1sell32:10senator6:5, 6:6,40:10, 42:8,48:24, 51:21,83:3, 84:14,88:22, 92:18,98:21, 106:19,109:22, 121:6,125:22, 140:4,144:8, 155:16,171:14senators40:11, 125:22



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148:3, 148:6,148:20, 150:13,173:14services1:2, 11:16,27:22, 28:14,31:15, 38:15,39:2, 40:16,40:22, 41:9,44:4, 44:5,44:15, 46:17,55:3, 58:9,61:5, 63:24,65:6, 65:10,65:24, 66:13,68:1, 68:5,68:17, 69:5,69:8, 71:6,72:10, 75:17,80:1, 102:7,102:9, 103:11,115:18, 115:19,117:19, 117:24,118:4, 127:23,131:22, 137:9,139:15, 140:12,154:13, 154:17,162:11, 173:18serving79:8session1:4, 3:5, 6:23,6:24, 7:8, 7:10,7:11, 7:13,7:14, 122:21sessions61:16, 165:20set56:8, 91:14,108:16, 181:16setting29:22, 74:24settlement3:6seven162:18seventh164:23

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42:17, 42:23shorewood107:15short25:9, 116:22short-term103:3shortage51:1, 55:11,55:19, 58:6,64:5, 88:3shorter-term98:13shorthand181:1, 181:3should11:18, 11:19,15:19, 22:17,58:8, 58:15,62:6, 68:11,101:20, 119:3,119:19, 119:20,136:9, 143:10show16:4, 24:7,65:2, 85:3,126:4, 130:2,168:16showed20:5, 68:2,72:3, 137:5,138:6, 172:20showing104:4shown36:24, 37:2,129:19, 168:14,168:19shows128:22sick16:5side70:14, 112:11,118:21sign74:15, 153:5,177:8, 178:4,

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48:16, 90:21,94:20, 101:3,112:17, 118:12,118:15, 146:10,152:15, 152:16staff2:8, 2:10,19:23, 20:5,22:5, 24:7,26:9, 37:17,51:22, 52:2,52:7, 52:10,52:23, 54:19,65:8, 85:5,88:24, 89:3,89:8, 89:23,91:22, 92:4,92:7, 92:24,93:12, 93:20,99:21, 100:5,107:14, 113:3,124:6, 124:11,125:3, 125:17,126:15, 127:22,130:19, 140:6,140:17, 141:10,142:17, 144:10,144:13, 144:22,145:10, 147:21,155:18, 156:13,156:18, 170:17,179:4staff's52:14stage61:10stages60:19, 64:14staging108:21stakeholders55:6, 62:6standardized128:17standards10:7, 22:6,47:2, 68:10,85:11, 96:6,

110:19, 121:9,121:14, 121:18,122:5, 156:1standpoint74:8, 118:19star39:10, 79:15,80:3stars56:15, 79:11,79:20start9:23, 34:22,66:8, 76:20,76:24, 77:2,125:15, 162:1started114:23, 131:23,162:6starts76:19, 116:7state4:2, 9:10,20:23, 21:4,23:22, 24:6,25:18, 26:9,26:17, 32:4,34:22, 40:6,40:11, 42:3,43:16, 52:18,52:23, 54:21,59:7, 66:10,67:14, 83:12,85:10, 88:8,89:23, 90:24,99:21, 99:24,100:5, 101:11,101:14, 101:20,102:13, 104:20,105:8, 105:16,106:18, 106:19,107:14, 107:22,110:19, 121:9,124:3, 125:10,125:22, 127:2,133:16, 137:17,141:13, 141:18,142:17, 143:1,



144:9, 145:5,145:10, 146:12,147:20, 147:21,148:1, 158:17,159:21, 159:24,160:2, 172:19,175:18, 181:5,181:24stated10:14, 13:20,15:1, 63:2,69:17, 85:23,104:9, 107:4statement56:6, 75:14,134:4, 138:17,138:20, 138:21,159:15statements58:24, 126:21,127:20states71:24, 72:1,72:5, 113:18,161:2stating86:17, 106:19station40:3, 40:17,41:23, 42:13,50:18, 53:8,53:17, 86:22,87:19, 87:20,90:8, 90:18,91:1, 123:3,123:21, 135:23,142:1, 142:8,145:19, 146:7,158:3, 158:12stationary120:11stations9:24, 11:22,14:1, 14:9,19:3, 23:2,23:24, 24:8,25:3, 25:19,26:10, 26:16,

26:23, 29:3,29:6, 50:24,53:24, 57:11,57:14, 63:7,69:18, 70:3,83:18, 85:18,87:24, 90:8,90:17, 90:24,124:15, 126:11,130:4, 137:1,142:13, 143:3,143:4, 148:3,148:8, 148:13,150:17, 158:18,159:19, 160:1,165:12status4:10, 45:22,47:21, 50:2,69:2, 150:11,150:15stay77:16, 98:10,103:3, 160:13,161:10, 163:3,164:9staying160:17steel116:23, 121:22stenographically181:10stent72:13step95:10, 108:9,108:10, 167:14steps86:17still66:18, 104:8,130:5, 136:3,141:5, 143:11,162:5, 162:24,169:8, 175:20stop64:15stoplight83:10

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sworn44:11, 44:13,50:13, 53:13,90:13, 94:11,94:13, 100:20,112:3, 112:5,123:14, 123:16,146:1, 146:2,158:7synergistically41:1system21:18, 27:18,28:15, 47:22,59:3, 72:5,84:8, 113:5,113:12, 115:4,120:5, 131:5,153:16, 164:8systems27:20, 173:19

Ttable9:5, 9:12,50:6, 53:12,158:24, 159:9take17:13, 17:14,21:10, 32:13,33:4, 54:23,60:16, 72:23,74:1, 74:7,74:8, 97:11,108:15, 113:17,143:17, 166:22,169:18taken17:15, 42:6,59:14, 83:6,122:20, 181:7,181:9takeover127:9, 130:3takes17:21, 120:5,132:18taking45:8, 133:14

talk16:6, 16:8,21:24, 55:4,63:13, 71:13,73:13, 73:22,114:8, 114:18,118:17, 135:10,139:5, 159:17talked117:13, 134:3,135:15, 136:1talking70:20, 134:10,134:15, 134:18,168:11tangent165:13tara9:18, 18:10target58:10, 65:5,65:23, 103:18,105:1, 105:17,136:4tax97:15taxes41:7, 41:9team103:12, 113:12,114:7, 114:21,159:15, 161:18,165:2, 167:5team-based36:19teams135:6technical64:19, 174:24technician75:4, 84:22,86:8, 86:12,141:1technicians74:5technologies81:4technology57:5, 114:13



tell11:23, 70:13,76:18, 88:10,108:13, 116:17,116:21, 117:14,140:8, 179:8temporarily44:4, 44:5,44:14temporary44:6, 45:15,45:20, 46:22,47:9tenants42:18tend72:15tené102:8term101:17terms72:22, 139:10,139:16, 152:20terry146:21, 147:9,147:12, 147:14,151:20tertiary114:1testament31:8testified70:11testify12:10, 19:15,25:10testimony21:3, 45:9,58:13, 58:20,62:11, 99:2,110:6, 119:6,122:4, 144:22,153:13, 155:19,168:9, 171:16text163:19th8:17, 32:11,

42:15, 44:22,45:2, 46:4,46:15, 46:23,48:10, 48:14,50:21, 53:21,87:24, 124:1,124:10, 142:12,143:11, 158:15,180:6, 181:17than12:23, 17:15,19:2, 29:21,38:10, 38:14,62:17, 64:24,65:24, 69:1,69:16, 69:22,70:17, 87:9,104:16, 109:4,109:11, 132:5,136:16, 137:7,143:18, 143:20,147:24, 148:9,150:19, 151:19,153:15, 160:1,164:17, 164:18,175:18thanks113:2, 166:10that's6:17, 6:20,16:2, 24:14,28:20, 29:17,30:5, 32:17,48:2, 48:10,49:21, 51:8,53:1, 54:10,55:15, 57:2,63:8, 63:12,66:24, 69:4,69:20, 70:5,70:7, 70:13,70:24, 71:12,72:9, 72:18,74:6, 74:8,74:14, 75:6,79:12, 79:23,80:22, 81:4,82:6, 82:7,

86:3, 87:11,90:1, 93:22,100:7, 108:1,109:1, 109:8,109:15, 111:8,117:23, 118:20,119:2, 119:18,122:16, 131:5,134:3, 134:5,134:11, 135:12,136:11, 136:23,139:12, 141:20,143:19, 143:20,145:12, 151:11,151:16, 151:22,153:19, 155:2,157:14, 163:6,168:3, 169:15,169:22, 173:6,177:12, 178:11their9:23, 10:6,10:9, 11:6,13:2, 14:22,15:1, 19:1,19:12, 19:16,19:23, 22:4,22:20, 22:22,24:17, 27:17,27:22, 33:13,35:20, 36:4,36:5, 36:7,36:11, 36:15,38:19, 39:1,44:21, 54:19,58:20, 58:22,58:24, 59:10,60:9, 61:14,61:20, 62:4,63:1, 66:3,68:18, 68:24,69:1, 73:3,76:19, 76:22,76:24, 77:20,77:24, 81:12,82:16, 82:18,91:20, 102:12,105:24, 107:16,

114:1, 116:12,122:13, 126:4,126:22, 127:20,128:13, 129:15,130:6, 132:2,132:8, 132:9,132:10, 147:2,147:7, 148:11,150:10, 160:6,160:10, 161:6,161:7, 163:4,164:11, 165:4,166:24, 167:1,168:22, 175:16,177:14them9:12, 10:2,16:24, 17:1,17:2, 17:16,22:15, 24:15,25:16, 29:13,30:17, 30:22,33:5, 44:9,51:13, 60:22,61:19, 62:14,65:19, 67:15,68:8, 68:9,75:12, 76:1,76:10, 76:21,76:23, 77:2,77:22, 79:9,82:13, 91:19,108:16, 118:11,125:6, 126:18,132:1, 132:15,153:12, 163:8,163:19, 163:21,163:22, 163:23,164:21, 166:6,167:6, 167:24,169:18, 169:19,175:8, 175:9themselves19:2, 58:15,72:24, 74:23,91:24, 92:6then11:15, 14:20,



21:14, 29:7,45:3, 48:4,56:4, 61:19,64:15, 66:9,68:20, 88:9,98:15, 108:15,113:10, 117:20,119:11, 119:18,134:2, 136:13,136:19, 137:1,138:12, 138:22,143:14, 147:11,153:6, 154:22,159:15, 162:18,163:9, 164:11,165:3, 168:6,168:17, 169:19,179:18therapies165:4, 166:15,167:2, 168:18therapy112:15, 114:13,116:14, 159:24,160:15, 161:11,164:12, 166:18,166:22there7:14, 13:24,14:9, 17:3,25:19, 26:13,26:15, 46:16,47:15, 50:22,50:23, 53:22,53:23, 54:4,54:8, 55:14,57:20, 58:2,61:17, 61:22,62:12, 65:3,69:18, 71:23,72:12, 73:14,78:16, 81:13,81:20, 83:11,84:3, 85:4,86:9, 88:4,88:9, 90:21,96:19, 99:1,103:17, 103:21,

104:8, 105:21,106:3, 106:5,106:7, 106:13,106:15, 106:19,112:19, 114:12,115:23, 115:24,116:1, 116:6,124:6, 124:17,126:10, 134:16,134:24, 136:9,137:14, 137:18,138:15, 139:3,139:10, 139:12,139:14, 139:16,141:2, 141:3,142:13, 142:14,143:2, 150:10,152:22, 158:17,158:19, 160:17,161:10, 162:15,163:22, 164:15,165:3, 166:20,168:12, 168:13,168:24, 169:2,170:16, 174:23,176:17there's10:1, 12:19,13:10, 23:23,24:8, 25:3,26:10, 26:23,28:23, 29:18,30:1, 44:23,47:22, 51:5,53:23, 57:11,58:23, 62:22,64:10, 68:5,68:7, 68:20,70:18, 72:21,77:18, 81:21,87:24, 104:15,106:12, 126:19,127:22, 129:10,132:22, 134:23,136:3, 136:24,140:7, 143:4,148:2, 150:17,155:7, 156:21,

159:19, 163:4,165:2, 165:19,168:14, 169:6,171:5, 176:18,180:16thereabouts70:19thereafter181:10therefore38:24thereof10:5thereupon44:12, 50:12,94:12, 112:4,123:15, 158:6these10:10, 10:17,10:22, 11:3,11:4, 11:8,11:11, 11:19,12:1, 12:4,13:5, 14:11,14:13, 14:16,14:19, 15:4,15:13, 15:17,17:7, 17:13,17:14, 17:16,18:16, 18:23,19:10, 19:11,19:17, 19:19,19:22, 19:24,20:6, 24:21,30:9, 31:18,35:11, 35:23,37:18, 39:4,58:3, 60:4,60:13, 61:5,61:14, 62:4,63:14, 64:6,64:13, 71:10,85:5, 98:12,105:1, 119:20,122:23, 127:17,127:24, 136:20,137:2, 143:10,160:15, 162:20,

164:2, 164:6,173:16, 173:19,175:21, 176:13they'll85:18, 118:11they're15:11, 19:18,21:17, 29:2,33:12, 44:15,48:12, 58:21,58:23, 68:14,68:17, 75:20,82:14, 92:1,98:11, 116:12,118:19, 132:8,153:10, 153:20,161:11, 162:21,164:14, 165:17,169:3, 175:17,175:24they've66:14, 109:12,109:13, 121:10thing12:21, 13:12,29:8, 69:12,74:4, 81:12,108:15, 114:3,133:2, 139:4things17:7, 17:16,66:10, 74:22,85:5, 95:5,98:5, 99:1,115:3, 117:13,135:5, 135:12,141:3, 167:5,176:21, 178:13,178:15think17:11, 29:17,48:6, 55:23,56:9, 65:17,67:20, 69:17,74:4, 74:12,76:4, 76:7,76:21, 80:13,80:14, 80:18,



80:19, 80:23,82:4, 83:19,84:4, 85:14,85:24, 96:23,97:1, 111:4,116:15, 119:8,119:12, 128:11,130:13, 132:24,138:7, 143:23,149:11, 157:11,159:18, 165:24,168:7, 168:17,171:22, 171:23third-party150:1thomas32:2thorough125:18those7:5, 8:3, 8:6,8:11, 8:20,35:9, 35:16,35:19, 36:13,56:2, 57:14,57:22, 61:3,62:17, 64:16,67:21, 67:22,68:21, 72:5,72:6, 73:9,73:14, 74:22,75:19, 77:11,78:2, 78:4,79:8, 82:17,84:23, 85:15,98:14, 116:15,129:17, 131:24,132:14, 135:12,137:9, 139:9,148:8, 149:12,151:24, 153:24,154:7, 154:22,165:11, 165:14,165:15, 169:14,169:15, 170:20,173:12, 174:5,174:15, 176:22,177:5, 177:18,

178:1, 179:23though58:14, 68:5,86:14, 108:19,130:15, 140:7,168:4three19:9, 38:22,46:24, 47:20,54:24, 55:4,56:15, 61:7,68:11, 72:16,79:11, 79:12,79:20, 113:18,152:18, 153:15,161:9, 163:19,164:10, 165:20,169:10three-county63:12three-month48:6through28:10, 44:22,45:2, 45:14,45:18, 46:4,46:5, 47:10,60:2, 75:21,76:21, 109:6,132:17, 135:5,150:19, 151:10throughout99:3thus124:13tillary102:8time10:1, 12:19,13:21, 15:13,24:23, 26:19,28:19, 30:8,32:15, 36:8,36:9, 38:20,39:18, 40:9,42:6, 44:9,45:3, 45:18,47:4, 47:17,

47:23, 54:23,59:14, 60:17,62:8, 65:4,66:18, 68:22,75:22, 79:14,79:16, 91:24,95:7, 97:2,103:24, 116:22,124:4, 126:3,130:16, 132:9,133:17, 134:22,135:21, 138:17,138:21, 143:14,143:20, 148:23,152:17, 167:24,168:7, 168:9,173:13, 180:6,180:17timeline167:2timeliness139:2times72:15, 132:22,134:23, 135:2,149:13, 151:4,152:18, 152:19,153:15, 154:23,161:23, 162:18,162:19, 163:19,164:13, 169:10today9:22, 12:5,14:17, 21:15,23:23, 25:18,28:20, 28:24,29:1, 37:15,54:15, 54:24,56:6, 57:22,58:2, 58:13,58:16, 58:20,59:14, 63:12,81:22, 83:13,84:8, 91:15,102:8, 102:16,103:14, 104:8,104:11, 106:16,107:2, 110:6,

113:12, 114:18,124:24, 126:4,126:17, 130:17,131:2, 146:24,147:14, 153:14,155:19, 159:23,160:9, 165:11,168:9, 170:5,171:16, 171:23together117:19, 132:19,133:2, 133:7,135:6, 139:14told119:22, 136:5,164:3tom32:6too24:6, 29:15,60:11, 64:14,92:2, 170:10took40:9, 83:10,126:3tool161:12top56:16, 115:9,131:14, 132:12,165:4top-level161:19topic135:16torres35:1, 35:6,37:2, 37:5total19:4, 28:7,94:23, 116:16,120:5, 129:2totaling14:8totals149:18touch54:21



toward152:23town114:5, 116:4,118:12township55:15, 105:24tracey95:20track105:9tractor149:23tracy20:21trade116:19traditional160:16traditionally170:13traffic42:18, 116:5trafficked40:18trail130:6training74:1, 74:2transcript8:16, 181:8transcripts3:10transform96:17transient160:22transit40:21transition172:9transitional33:20, 169:18,169:22, 170:14,170:19transplant29:13, 39:13,57:6, 71:11,

74:18, 76:10,76:12, 76:23,77:5, 77:12,77:16, 77:17,78:1, 87:8,152:21, 163:5,163:8, 167:15,167:21transplanted167:19transplants59:22, 74:11,75:24, 87:6,167:12transportation17:2trauma114:2travel60:9, 65:24,68:22, 136:5,169:9, 173:13traveling66:2, 83:13treat133:10, 164:20,164:21treated38:23, 164:11treatment36:23, 56:4,58:3, 61:20,61:22, 65:16,77:20, 149:1,149:8, 149:11,149:16, 149:18,150:5treatments149:17tremendously162:7trend61:11, 65:1tried109:10tries103:24trip118:20

trips43:9true21:14, 66:16,67:1, 71:2,72:19, 75:6,138:17, 164:5,169:4, 181:8trust81:21, 179:19trusting135:9trusts179:21try14:14, 19:1,21:12, 97:4,139:9, 139:18,147:3, 149:2,163:23trying14:13, 36:17,44:16, 48:2,67:17, 68:17,78:17, 114:24,151:17, 154:24,155:2, 156:13tuesday1:7, 32:11,46:15turn147:14turned96:19turns96:2twice56:1twice-elected41:15two9:8, 14:6,20:8, 23:5,29:7, 29:24,32:1, 37:1,37:14, 37:18,39:15, 40:8,43:4, 46:24,

47:20, 55:2,56:3, 60:9,61:12, 62:12,64:3, 66:10,68:7, 68:21,73:12, 81:19,82:2, 87:20,102:14, 114:19,116:15, 116:18,130:11, 134:14,143:2, 147:17,147:22, 149:12,156:6, 161:9,163:19, 165:9,165:20, 166:2,166:4, 166:7,173:14two-stage108:3two-station135:23two-store111:20two-story112:10, 112:13,120:9two-year-old57:19type11:18, 79:3,114:2, 129:18,153:10, 164:22types9:14, 62:3typewriting181:11typical149:16typically155:7, 160:5,160:6

Uultimately73:6, 109:6unabashedly127:8unable10:18



unanimously102:14uncertainty143:22under10:3, 12:15,15:5, 15:9,15:12, 43:20,44:4, 46:6,50:1, 56:15,56:16, 64:6,64:8, 75:17,86:13, 101:7,102:18, 104:24,106:12, 137:23,148:16, 148:22,181:11underage119:11, 119:16undermine21:17undermines29:19underserved13:8, 51:2,55:1, 55:7,55:10, 55:18,58:6, 64:4,69:9, 74:20,84:17, 85:1understand11:13, 32:8,39:7, 72:12,114:9, 114:24,118:18, 121:22,157:6understanding37:17, 44:18,48:11understood47:5underutilized12:18, 29:17,29:24, 137:18underway31:7, 86:15undetectable64:13

undocumented75:22, 75:24undue66:2unfinished5:10, 174:11unfortunate15:2unfortunately15:4, 168:15uninsured37:24, 38:9unique10:17, 15:16,160:3, 160:9,161:13, 161:14,172:15unit12:16, 13:4,17:6, 17:10,31:6, 102:24,107:6, 147:2,147:23, 164:24,166:3units18:1, 31:9,31:12, 70:11,148:8, 164:14,165:9, 165:11,170:14university57:4, 59:19,77:15, 118:11,168:1unmanaged36:11unnecessarily20:7unnecessary11:16, 23:1,164:9unprecedented16:10, 19:7unserved88:2until60:19, 60:20,64:14, 108:4,

155:9update5:12, 174:13,176:23, 177:1updated126:8, 126:12,126:13, 141:9,173:20, 176:8upon12:2upset121:22, 121:23urge15:16, 39:16use57:9, 58:7,71:21, 85:15,119:23, 126:13,137:3, 150:12,179:1used11:6, 11:7,11:10, 15:3,69:15, 69:21,98:24, 128:17,128:23, 129:14,136:9, 141:1using115:10, 115:14usual143:20usually60:12, 104:13,162:21, 163:9utilities115:23utilization10:4, 10:23,12:14, 54:1,57:22, 62:24,63:2, 65:3,65:5, 65:6,65:13, 65:23,70:2, 82:1,88:5, 91:1,91:2, 94:22,103:17, 105:1,105:17, 136:4,

137:6utilized23:2, 58:10

Vvacation161:8valid102:16, 134:4valley34:2value27:21value-based56:20variability117:1variety149:22vascular154:10ventricular168:21venture82:17, 152:14verification11:9verify10:18vernon23:17, 24:11versus72:1, 76:14,154:5very29:9, 29:12,30:2, 30:19,36:8, 41:11,43:13, 53:3,60:3, 71:16,73:9, 76:5,77:23, 84:17,93:24, 97:3,97:13, 97:20,98:22, 103:19,105:1, 116:13,116:22, 123:11,133:24, 140:9,



145:14, 152:10,153:4, 157:17,157:18, 160:3,161:2, 161:13,162:10, 163:15,163:23, 166:17,166:19, 169:12vetting152:21via162:16viability125:13viable150:3vice1:13, 39:22,51:10, 54:14,91:10, 113:7,146:22view150:10, 161:20views28:1villa40:3, 40:13,40:16, 142:1,142:9village27:9, 30:6,30:9, 106:16,107:5, 107:7,108:13, 132:18violates10:24virtue26:11visit96:13, 96:16,163:20visits132:6vista59:3vital40:24voice126:4

volunteer35:15, 38:15,38:19vote13:22, 13:23,18:17, 24:24,25:1, 26:20,26:21, 48:22,51:18, 67:17,75:10, 82:24,83:16, 83:23,84:2, 84:18,85:5, 85:11,85:14, 85:19,85:22, 88:23,89:3, 89:7,89:11, 89:14,89:18, 89:22,92:15, 92:19,92:23, 93:3,93:11, 93:15,93:19, 98:18,99:5, 99:8,99:12, 99:24,109:20, 109:23,110:2, 110:5,110:9, 110:13,110:18, 110:23,111:3, 121:3,121:8, 121:13,121:17, 121:21,122:3, 122:8,122:12, 140:5,144:5, 155:13,155:17, 155:23,156:5, 156:21,157:2, 157:4,157:10, 157:14,171:11, 171:15,171:21, 172:3,172:7, 172:14,172:19, 173:2voted14:10, 14:19,126:7votes49:21, 53:1,86:3, 90:1,

93:22, 100:7,111:8, 122:16,126:5, 141:20,145:12, 157:14,173:3, 173:6vp113:9vu167:10

Wwait57:6, 167:24waiting84:12, 108:13,135:1, 168:16walls115:8want16:3, 16:8,34:22, 45:19,47:12, 48:3,72:13, 73:17,75:1, 75:15,78:11, 78:16,80:2, 80:6,80:11, 80:20,82:10, 88:8,91:13, 92:7,96:22, 102:4,107:2, 111:10,114:18, 115:17,120:1, 120:14,125:4, 142:24,148:19, 153:16,159:20, 160:15,161:16, 161:20wanted62:12, 76:5,91:21, 107:20,125:6, 149:5wanting19:15warrant37:19warrants58:11was10:14, 10:22,

11:1, 14:23,15:2, 15:12,16:15, 16:19,16:20, 17:3,17:4, 20:4,21:10, 21:20,29:10, 29:12,30:19, 32:16,39:8, 50:22,53:22, 54:4,54:9, 55:17,66:18, 67:4,67:10, 67:13,67:17, 69:17,73:16, 76:7,80:22, 83:6,88:4, 88:9,90:21, 96:16,96:18, 96:19,97:15, 103:21,105:18, 106:5,106:13, 107:13,112:19, 115:23,116:16, 120:13,124:2, 124:4,124:6, 124:17,126:8, 126:9,126:10, 126:12,127:12, 131:3,134:6, 134:16,135:21, 136:6,137:15, 137:16,138:17, 138:21,138:24, 142:14,143:1, 143:2,143:3, 143:9,146:13, 148:22,149:8, 152:13,152:17, 157:1,158:19, 158:20,162:14, 166:21,168:16, 169:11,173:12, 173:15,174:20, 175:16,176:1, 176:16,178:14washington17:22



wasn't116:1watched96:17watching117:16waters146:21, 147:15,151:5, 151:7,151:11, 152:12,152:16, 153:1,154:12, 154:16,155:7, 157:17waukegan5:6, 12:20,13:11, 23:24,24:10, 25:2,25:8, 25:18,25:20, 26:22,28:22, 29:4,29:6, 53:8,54:17, 54:24,55:3, 55:8,55:14, 55:15,55:20, 58:1,59:5, 59:7,59:8, 59:18,59:20, 60:2,60:5, 60:8,60:22, 60:23,61:9, 61:13,61:22, 61:23,62:1, 62:15,62:19, 62:21,63:10, 63:16,63:21, 64:1,64:2, 65:7,65:21, 68:4,68:8, 68:20,79:5, 81:20,81:22, 81:23,82:2way16:22, 19:1,56:22, 70:5,74:6, 74:14,133:9, 143:20,153:17, 160:7,

175:19ways15:18, 134:8,156:2, 166:4we'd32:15, 87:9,92:9, 96:9,110:14, 150:22,169:15we'll51:6, 54:21,55:4, 67:20,114:8, 157:11,162:9, 166:10we're16:16, 16:22,16:23, 17:1,17:12, 17:13,17:14, 17:22,51:12, 63:12,70:5, 74:20,74:24, 75:1,77:23, 78:15,78:17, 80:5,87:14, 108:14,111:5, 113:21,113:22, 115:14,117:23, 118:13,119:23, 122:21,129:18, 131:7,132:17, 133:13,134:10, 134:18,143:14, 147:3,151:16, 155:2,159:17, 159:22,161:3, 161:15,166:19, 166:24,168:11, 170:12,170:13, 179:15we've14:24, 15:13,16:11, 16:12,17:17, 38:10,91:15, 91:16,92:2, 105:3,109:15, 111:4,113:20, 115:24,120:10, 129:19,

134:10, 134:21,134:22, 135:22,138:8, 149:21,150:6, 152:12,153:13, 155:19,161:2, 164:13,167:5, 168:8,168:15, 171:16weak80:16website92:5week47:19, 67:11,72:15, 73:15,153:15, 161:9,162:20, 169:10weeks31:10, 74:2,116:18, 134:7,160:24, 161:1,161:9, 164:11welcome78:20welfare43:12well12:15, 27:23,44:2, 47:18,48:5, 54:17,59:9, 65:4,65:22, 66:3,71:4, 72:20,73:16, 84:23,85:22, 86:1,98:24, 99:4,110:5, 111:3,115:6, 117:18,122:13, 124:11,125:13, 132:13,133:1, 138:9,139:8, 141:4,143:19, 155:24,161:2, 162:23,163:15, 163:23,179:18well-being24:17

went165:24, 168:7were11:12, 11:13,21:14, 30:19,30:20, 33:16,44:12, 44:16,45:1, 45:9,46:22, 46:23,50:12, 62:12,62:18, 67:12,76:1, 78:10,79:17, 91:18,94:12, 103:17,103:18, 104:24,112:4, 115:10,116:15, 123:15,126:18, 128:23,132:11, 134:15,137:18, 137:24,148:23, 149:1,149:6, 154:23,157:8, 158:6,167:18, 172:4,173:20, 174:15,174:16, 181:7,181:9west40:19, 113:15what10:17, 14:24,15:15, 16:9,16:11, 16:12,16:16, 19:24,20:4, 22:10,30:13, 30:14,46:1, 47:21,58:17, 61:4,63:13, 67:8,70:15, 70:16,70:23, 71:9,72:10, 73:8,74:10, 76:6,76:9, 76:18,77:10, 78:22,80:12, 86:9,86:17, 109:2,109:8, 109:15,



114:22, 115:5,117:23, 119:22,120:9, 120:15,120:19, 126:24,131:10, 131:19,132:4, 132:14,132:24, 133:24,134:3, 134:6,134:10, 136:13,137:4, 138:15,139:10, 143:13,151:2, 151:7,151:11, 151:20,151:22, 154:15,154:24, 155:2,156:12, 156:13,161:19, 162:14,162:20, 163:6,164:3, 164:5,169:22, 172:8,172:10, 172:24,173:11, 173:21,175:17what's13:13, 24:14,29:17, 44:1,45:24, 71:17,133:10, 137:2,168:10, 176:20whatever74:7, 75:20,83:11, 149:5,154:22, 160:10,163:11whelan95:22when9:4, 14:16,16:19, 29:15,46:18, 46:21,47:18, 57:13,61:16, 63:11,64:14, 69:17,70:22, 71:24,73:20, 74:18,75:13, 84:4,97:14, 103:20,104:15, 105:4,

115:1, 126:9,131:3, 136:21,148:21, 149:1,160:9, 160:12,160:16, 162:15,164:2, 165:16,166:6where10:9, 13:14,16:21, 19:21,24:12, 44:16,44:20, 55:16,58:8, 62:17,68:3, 71:21,72:11, 74:23,76:14, 76:20,79:5, 81:19,106:2, 113:15,115:7, 115:20,116:4, 116:11,118:9, 135:12,137:3, 137:15,147:5, 150:11,157:9, 161:3,161:5, 163:13,167:4, 167:24whereas120:14whereby160:21whereof181:16whereupon44:12, 50:12,94:12, 112:4,123:15, 158:6whether12:24, 13:19,44:17, 44:18,47:22, 73:6,78:10, 150:16which9:6, 12:13,12:17, 13:5,15:15, 21:5,23:18, 24:7,26:9, 29:1,29:11, 30:8,

39:23, 41:6,42:19, 42:21,48:14, 56:3,56:19, 57:12,58:5, 59:4,60:18, 62:18,64:18, 64:24,65:16, 68:9,70:10, 74:1,105:2, 114:6,114:7, 125:12,125:21, 125:23,127:18, 130:11,131:8, 131:18,146:18, 150:7,154:24, 162:17,163:6, 164:4,164:23, 168:22,174:17, 174:20while17:21, 30:16,31:14, 33:6,33:12, 81:18,103:16, 104:13,114:19, 118:17,128:17, 129:20,131:15, 132:11,133:11, 133:14,134:12, 135:7,135:10who17:3, 21:21,24:20, 25:23,33:10, 36:13,36:14, 36:17,43:5, 43:8,45:10, 59:13,60:14, 61:1,62:13, 65:23,66:13, 73:10,73:15, 75:19,75:21, 76:13,77:11, 84:23,88:10, 91:10,96:16, 96:17,96:19, 103:1,119:15, 123:8,126:2, 126:7,

129:3, 134:17,139:8, 146:19,146:22, 147:1,147:6, 151:21,153:2, 153:9,158:23, 159:10,165:20, 167:19,169:8, 174:16,178:24, 179:7whoever95:9, 179:5whole16:22, 132:20,138:12, 153:16,160:2, 164:8wholeheartedly30:9wholly37:18whom181:6whose24:5, 96:18why11:11, 11:13,14:9, 25:12,26:4, 26:6,29:8, 44:9,47:19, 48:2,48:15, 62:20,63:12, 64:18,68:2, 82:3,82:13, 107:22,119:2, 135:13,147:10, 148:12,161:20widely73:13wife73:18will8:6, 9:3, 10:9,12:1, 13:1,20:6, 21:12,22:24, 25:22,27:11, 28:11,28:13, 29:23,31:1, 31:7,



32:12, 38:3,39:2, 40:21,41:1, 41:4,41:6, 41:7,43:2, 43:5,43:8, 43:12,44:22, 51:1,51:9, 57:13,61:11, 64:16,65:3, 65:9,70:18, 76:8,76:21, 77:12,78:13, 84:3,84:4, 84:18,84:23, 85:15,85:16, 86:1,88:1, 94:10,94:23, 98:6,98:8, 101:4,101:5, 101:7,101:10, 101:22,101:23, 102:17,102:23, 103:1,103:14, 103:19,104:8, 104:20,112:2, 115:8,115:14, 116:9,116:11, 116:14,116:21, 122:17,123:13, 127:4,130:14, 130:15,140:8, 143:14,143:23, 146:1,147:22, 150:3,150:18, 150:19,153:12, 155:8,155:17, 157:5,163:5, 169:20,172:11, 173:10,174:19, 174:24,175:20, 179:8willing21:10, 179:10willingness13:21, 24:23,26:19window121:23, 151:23

winschel95:19wisconsin168:2wish111:11withdraw58:22within14:7, 54:2,57:20, 62:15,64:22, 68:22,68:23, 116:11,116:20, 129:24,136:5, 136:17,137:5, 147:22,148:6without10:23, 17:7,24:19, 26:12,35:6, 35:18,36:21, 61:21,74:21, 78:21,97:15, 128:9,150:2witness53:13, 181:16witnesses44:12, 50:12,90:13, 94:12,100:20, 112:4,123:15, 146:2,158:6woman134:19women164:17won't47:13wonder16:5woodridge41:21, 41:24,42:2, 42:10,42:12, 123:3,123:22, 126:2,128:23, 130:18woodstock34:10

woodward42:15, 42:16word120:16, 166:23,179:1words15:1, 21:23,22:3work24:4, 24:11,25:15, 25:16,25:23, 60:3,60:9, 60:10,60:17, 66:23,91:19, 102:12,114:2, 133:2,153:20, 162:22worked24:1, 45:16,162:10worker4:9, 50:1,163:21workforce114:14working18:11, 18:19,23:21, 24:20,25:18, 44:15,60:1, 77:23,132:19, 133:7,135:6, 147:6,153:17works24:18, 35:3,36:15, 68:18,162:20world's127:15, 127:16would11:15, 13:4,16:11, 16:21,17:7, 17:8,18:8, 20:9,21:14, 23:9,24:19, 25:13,26:17, 28:7,29:8, 30:16,

31:12, 33:13,44:10, 46:4,46:7, 47:8,48:14, 50:6,51:17, 54:19,54:23, 56:9,56:20, 59:1,62:18, 62:21,67:8, 69:4,69:18, 71:8,72:20, 73:24,74:1, 74:5,77:3, 78:22,78:23, 80:14,80:24, 81:3,81:19, 82:13,82:15, 82:23,84:7, 86:15,87:12, 98:18,102:11, 103:23,104:6, 107:12,108:11, 109:19,109:23, 112:14,116:16, 117:14,118:2, 118:15,120:2, 120:15,121:2, 121:7,121:8, 126:16,126:23, 130:4,130:5, 133:1,139:24, 140:11,143:13, 151:9,155:12, 156:1,158:23, 165:1,166:3, 166:4,166:5, 166:7,167:7, 168:17,175:14, 178:16,179:6wouldn't48:15wrap166:9wrapped117:19wright91:7, 93:24write97:24



writing22:14written139:3

Xx-ray115:16

Yyear17:19, 44:5,46:18, 46:20,65:14, 70:19,71:1, 79:15,81:9, 81:10,85:16, 87:7,96:3, 98:3,134:20, 149:17,149:19, 151:3,151:7, 152:2,178:14, 178:17year-old65:18, 66:20years13:7, 18:11,18:20, 24:2,28:9, 29:10,30:19, 31:2,35:17, 40:1,41:21, 59:18,60:21, 61:7,64:21, 66:23,67:9, 71:7,71:11, 71:13,72:3, 76:15,97:14, 97:18,98:23, 102:14,109:12, 111:14,113:20, 116:3,147:22, 148:21,162:6, 162:12,166:16, 166:21,174:18yekich27:2, 27:3,31:21yep71:2

yet12:17, 17:21,26:15, 82:6,106:3, 127:3,127:7, 170:7,174:19you'd20:23you'll86:16you're16:4, 21:1,21:2, 21:5,29:2, 34:23,63:11, 67:8,67:18, 68:15,69:13, 70:20,70:22, 75:10,75:16, 79:2,83:21, 95:4,108:8, 119:7,135:12, 137:22,152:7, 154:8,154:9, 154:15,154:24, 156:13,157:7, 171:3,173:1, 179:14you've81:17, 83:19,105:22, 109:13,117:13, 119:5,119:11, 119:16,172:10younger164:18your9:4, 9:9, 9:10,9:17, 13:21,17:10, 20:24,21:2, 21:3,21:4, 22:6,24:6, 24:23,26:9, 26:19,28:19, 32:4,32:5, 34:23,37:17, 39:18,41:17, 43:15,46:11, 50:14,

53:14, 55:21,62:8, 64:6,64:8, 66:5,66:6, 66:12,68:10, 70:13,72:10, 72:16,74:10, 75:14,76:9, 78:22,79:17, 80:2,86:17, 87:2,88:8, 90:14,92:9, 94:14,95:8, 96:16,97:7, 97:9,104:14, 106:12,107:20, 111:11,111:12, 112:6,119:6, 119:17,120:8, 123:17,130:16, 133:17,136:5, 136:14,142:4, 146:3,147:13, 150:22,151:2, 152:1,154:5, 154:7,158:8, 169:17,176:8yours170:7yourself18:9, 25:12,112:24, 148:12

Zzion12:16, 12:18,81:23, 81:24,84:3, 85:24zip124:11, 136:8,136:9, 136:12,138:4, 138:8,138:11

$$1.5158:14, 170:7$1038:14

$100,000116:20$1117:20$140,000134:16$1517:23$150,000134:14, 166:1$1695:5$16.894:19$196,00090:20$240149:11$3.453:20$3.8142:11$37,000151:8$39.6101:2, 112:13$450:20$4.1123:24$4.3146:9$4.5170:6$4500149:1$8500149:8, 149:17$97,50070:19, 133:23

00065:20, 74:17,85:3, 85:4,122:19, 165:17,180:7, 180:800186:18, 86:21



003733181:400490:4, 90:700594:2, 94:500920:21, 30:8,100:12, 100:14,101:21010111:17, 111:1901233:190149:16, 122:22,123:201620:18, 141:2202034:202134:402234:702334:902434:1102534:1302634:1502734:170297:1903122:200317:2104122:20045145:16, 145:1804733:24051101:12, 101:19,

101:2205533:210633:18060157:21061157:23, 158:106250:6, 50:806620:19, 53:4,53:7084181:409101:21, 180:18

1165:20, 122:19,122:201,00031:31.3149:181.563:91.7129:241013:7, 23:18,44:22, 45:2,46:4, 48:10,48:14, 60:22,66:23, 67:12,72:3, 72:18,80:5, 109:12,130:9, 167:18,168:4, 174:181004:19, 82:15,113:23, 118:14,118:19, 134:5,137:11, 163:7,167:13, 176:14101165:10

10588:5106141:24117:1, 72:18,74:17, 148:81114:2011105:9, 64:19,65:8, 125:12,129:14, 173:11,174:21120125:13114101:4123:13, 14:7,29:3, 29:6,32:11, 40:3,40:17, 41:23,42:13, 46:15,50:18, 53:8,53:17, 122:20,123:3, 123:21,142:1, 142:8,148:6, 148:81225:313107:13143:14, 145:19,146:7, 158:3,158:1214028:6, 101:12,102:15, 102:19,103:23, 104:7,106:24, 108:14,113:201415:4, 103:22143065:81455:5

157:8, 66:20,101:12, 101:19,101:22, 116:24,121:23, 131:14,181:1715,000105:24156149:17, 151:41575:6, 5:7169:19, 33:18,33:19, 33:21,34:14, 87:19,148:2, 150:17,181:2016628:7, 30:8,100:15, 100:24,103:23, 104:7,108:141673231:22178:17, 9:16,9:19, 17:21,20:18, 20:19,33:24, 50:6,50:8, 53:4,53:7, 122:22,123:2, 135:22,141:22, 141:24,145:16, 145:18,157:21, 157:23,158:11735:91745:10, 5:12175148:81765:13, 5:141775:151785:16



183:15, 7:19,7:20, 7:21,20:21, 30:8,34:2, 34:4,34:7, 34:9,34:11, 34:13,34:15, 34:17,86:18, 86:21,90:4, 90:7,94:2, 94:5,94:23, 96:4,98:8, 100:12,100:14, 101:21,111:17, 111:191805:171811:2319104:1819094:181st46:21

22180:182(c)(7:12(c)(16:242(c)(56:242,00042:4207:8, 18:11,18:20, 59:18,90:8, 90:18,97:14, 97:18,98:10, 98:23,118:4, 154:22200118:19200138:10

201512:16, 69:22,70:2201617:19, 101:10,104:2, 167:17,177:16201729:5, 57:10,79:16, 87:15,124:3, 132:4,138:17, 142:21,167:1720181:7, 8:17,47:10, 90:21,124:5, 124:10,138:19, 146:12,158:17, 181:182019124:1, 142:12,143:12, 146:10,158:15, 178:17202101:24, 104:9202050:21, 53:21,57:12, 69:17,70:4, 87:24,94:20, 112:17,136:212021101:3, 181:2020894:23213:16, 7:1,63:4, 125:11,140:17228101:15, 104:4,106:13233:17, 136:423770:122424:8, 53:24,

70:3, 86:22,87:20, 158:18,159:19, 180:62512:13, 98:1025098:9250070:112628:5, 101:17,103:4, 104:12,106:8, 107:226,000105:23273:18281:8, 3:19, 7:9,131:162950:21

33170:63.171:123.671:13303:20, 7:20,46:23, 53:21,54:2, 57:20,62:15, 62:17,64:22, 64:23,65:24, 68:23,87:24, 98:15,118:5, 124:1,124:8, 124:10,124:13, 124:16,129:24, 137:5,142:12, 143:11,149:15, 151:23,158:15, 165:18,165:21, 165:22307113:22

3146:9, 47:10,48:4, 48:16,90:21, 94:20,101:3, 112:17,146:10323:21333:23, 57:14353:22, 149:13,152:19, 154:2335542:1936134:1637,000152:2

44165:18, 165:214040:1, 160:740096:3, 98:3421132:7434:3, 4:4, 4:5,4:6, 4:8, 50:24,87:244645174:174881:94892174:20494:9, 135:23,142:13, 143:4

55165:17, 165:22504:10, 4:14,



55:24, 61:6,96:1, 131:20,132:5, 165:5,167:1350,00038:115069175:3, 175:1252101:5534:15, 7:12,31:6, 31:9,107:6545130:125583:11554176:145800146:7

6685:36-station34:186.287:236.781:960,00071:2604901:66300142:96500158:126900123:21

77,00050:187057:11, 69:18,

85:18, 134:19710053:187267:4, 68:1675150:7, 152:4750117:1678,00070:12

8885:4, 165:188058:10, 65:18,65:22, 127:5,127:7, 160:581,000112:10849:24, 14:9,19:3, 54:2,57:228579:21, 108:12864:168742:1588136:21

991:8, 7:9, 7:12,165:17, 180:7,180:8904:17, 16:21,58:2, 65:4,65:22, 68:12,68:14, 82:1,94:2291165:1091.191:3

944:189579:20, 148:997,50070:23, 71:20,151:69862:23, 63:1,68:998,00071:209965:13



Transcript of Open Session Meeting - Illinois.gov

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