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Assessment 3 Context Economic Decision Making As part of economic decision making, all health care leaders are expected to conduct a basic cost-benefit analysis (CBA). If you have not yet had the opportunity to conduct a CBA in the workplace, it is important to become familiar with this highly relevant tool for economic decision making. You may also find that this tool is helpful in your daily life. There are many factors to consider in making a sound economic decision. You must consider the major risk categories associated with the alternative, the time value of money, and the strategic fit over a long-term planning horizon. Some of the questions you need to consider are: • Does the recommended alternative break even at year two, and become more profitable thereafter? What is the relative value of the income from the investment if one considers the time value of money? What about the organizational context? • Will the organization’s focus and strategy change? • Will sufficient funds be available to support the project past the breakeven point in year two? Will the chosen alternative be at risk for obsolescence? The Role of Health Care Executives Economic decision making has many facets: legal issues, industry standards, risks, financial components, strategic alignment, and dynamic external environmental factors. Similarly, health care executives have many professional roles, responsibilities, and conduct expectations. Legal standards represent the bare minimum standard that is expected of health care professionals. Health care executives are sometimes held to higher standards than business people in other industries, as they are charged with protecting human lives and assuring patient safety. They are also expected to act in the best interests of others, and to serve as moral agents. Health care executives have fiduciary obligations, and an explicit code of conduct from the American College of Healthcare Executives (ACHE).

• Create a detailed implementation plan for an economic initiative.

As a master’s-level health care practitioner you may be expected to create budget and implementation plans to ensure that economic opportunities for the organization are rolled out successfully and can be sustained over multiple years. Additionally, it is important to be able to envision how an economic initiative could be used for different contexts and purposes to keep the investment a viable and positive asset to your organization or care setting.

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Note: Complete the assessments in this course in the order in which they are presented.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Competency 1: Analyze the effects of financial and economic factors (such as cost-benefit, supply and demand, return on investment, and risks) in a health care system on patient care, services offered, and organizational structures and operation.
  • Create a budget for relevant expected costs and earnings or benefits over the first five years of a proposed economic initiative.
  • Analyze how a proposed initiative, once implemented, may impact aspects of a care setting and ways in which negative impacts could be mitigated.
• Competency 2: Develop ethical and culturally equitable solutions to economic problems within a health care organization in an effort to improve the quality of care and services offered.
  • Propose a plan to roll out an economic initiative that will enable a care setting to successfully implement it in an ethical and culturally equitable way that will ensure the initiative achieves quality or service improvements.
• Competency 3: Justify the qualitative and quantitative information used to guide economic decision making to stakeholders and colleagues.
  • Justify the relevance and value of the quantitative and qualitative economic, financial, and scholarly evidence used to support recommendations throughout a plan.
• Competency 4: Develop ethical and culturally equitable economic strategies to address dynamic environmental forces and ensure the future security of an organization’s resources and its ability to provide quality care.
  • Explain strategies that have been integrated into a proposed economic initiative that will ensure it can remain a viable asset to a care setting in the face of dynamic environmental forces.
• Competency 5: Apply various communication methods in order to clearly, effectively, and efficiently relate information to stakeholders and colleagues related to economic data, findings, and strategies.
  • Communicate a business and implementation plan in a logically structured and concise manner, writing content clearly with correct use of grammar, punctuation, and spelling.
  • Effectively support a plan and recommendations with relevant economic data and scholarly sources, correctly formatting citations and references using current APA style.

Competency Map

CHECK YOUR PROGRESSUse this online tool to track your performance and progress through your course.

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Context

To support your work on this assessment, take time to read the contents of Assessment 3 Context [PDF].

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Questions to Consider

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

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• Do you think that cost shifting is a fair practice, or that it should it be legally banned?
• Why would a change in a hospital’s variable costs change the hospital’s profit-maximizing price?
• How do ethics and economic decision making come together when addressing health care issues?
• What is the highest-impact facet of health care economics that relates to your current or desired leadership role? What action steps and resources might you use to assure objective and ethical economic decision making in that role?

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Resources

Assessment Example

• Assessment 3 Example [PDF].

Suggested Resources

The resources provided here are optional and support the assessment. They provide helpful information about the topics. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The NHS-FP6008: Economics and Decision Making in Health Care Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the navigation menu in your courseroom, provide additional resources to help support you.

Assessment Context

Review the following:

• Assessment 3 Context [PDF].

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Budget Development

These articles may be helpful in helping you to create a budget:

• Mukherjee, T., Al Rahahleh, N., Lane, W., & Dunn, J. (2016). The capital budgeting process of healthcare organizations: A review of surveys. Journal of Healthcare Management, 61(1), 58–77.
• Danna, D. (2016). Learning and mastering the operating budget. Retrieved from http://www.strategiesfornursemanagers.com/ce_detail/213520.cfm#
• Pritchard, G. (n.d.). How to develop an operating budget for a nursing unit. Retrieved from http://smallbusiness.chron.com/develop-operating-budget-nursing-unit-79824.html

Budget Templates

Review the following:

• Missouri Department of Health & Senior Services. (n.d.). Budget preparation worksheet[PDF]. Retrieved from http://health.mo.gov/data/interventionmica/BudgetPreparationWorksheet.pdf
• (n.d.). Budget template [XLSX]. Retrieved from https://www.parklandhospital.com/Uploads/Public/Documents/Research/Budget%20Template_Multi-Year_FY2017.xlsx
• (n.d.). Developing a budget. Retrieved from https://www.parklandhospital.com/phhs/developing-a-budget.aspx

Strategy Development and Implementation

This document is designed to give you questions to consider and additional guidance to help you successfully complete the Implementation Plan for a New Economic Opportunity assessment:

• Guiding Questions: Implementation Plan for a New Economic Opportunity [DOC].

This is an example of an implementation plan for a strategy to expedite the care of a subset of the population:

• Agency for Healthcare Quality and Research. (n.d.). Improving patient flow and reducing emergency department crowding: A guide for hospitals – Appendix C: Example implementation plan. Retrieved from https://www.ahrq.gov/research/findings/final-reports/ptflow/appendix-c.html

Economic Evaluation and Justification of Evidence

This resource provides an overview of effective methods and other aspects of economic evaluation of public health services interventions:

• The Community Guide. (n.d.). Understanding and using the economic evidence[PDF]. Retrieved from https://www.thecommunityguide.org/sites/default/files/publications/Ch11-Economics.pdf

This web page provides a step-by-step guide to conducting and economic reviews of interventions:

• The Community Guide. (n.d.). Economic reviews. Retrieved from https://www.thecommunityguide.org/about/economicreviews

This is a systematic review of nursing-related studies assessed for quality of economic evaluation methodological criteria:

• Cook, W. A., Morrison, M. L., Eaton, L. H., Theodore, B. R., & Doorenboz, A. Z. (2017). Quantity and quality of economic evaluations in U.S. nursing research, 1997–2015: A systematic review. Nursing Research, 66(1), 28–39.

This is a review of the quality of and specific challenges related the economic evaluation of medical devices:

• Kirisits, A., & Redekop, W. K. (2013). The economic evaluation of medical devices: Challenges ahead. Applied Health Economics and Health Policy, 11(1), 15–26.

This is a systematic review of interventions, revealing there is economically advantageous opioid use disorder therapy, and more economic evaluations are needed to assess the relative value of existing opioid use disorder interventions:

• Murphy, S. M., & Polsky, D. (2016). Economic evaluations of opioid use disorder interventions. PharmacoEconomics, 34(9), 863–887.

This resource discusses variations in the intrinsic costs of dialysis modalities as well as other factors, such as variation by country, available health care infrastructures, the timing of dialysis initiation, and renal transplantation:

• Klarenbach, S. W., Tonelli, M., Chui, B., & Manns, B. J. (2014). Economic evaluation of dialysis therapies [PDF]. Nature Reviews. Nephrology, 10(11), 644–652.

Quantifying Costs, Risks, Benefits, and Impact of Health Care Initiatives

This study analyzes nationally representative data in the United States regarding how people prioritize health programs for children versus older adults:

• Eisenberg, D., Freed, G. L., Davis, M. M., Singer, D., & Prosser, L. A. (2011). Valuing health at different ages. Applied Health Economics and Health Policy, 9(3), 149–156.

This resource addresses the cost and benefits of medical interventions:

• Hauber, A. B., Fairchild, A. O., & Johnson, F. R. (2013). Quantifying benefit-risk preferences for medical interventions: An overview of a growing empirical literature. Applied Health Economics and Health Policy, 11(4), 319–329.

·         Assessment Instructions

In this assessment, you will plan for all pertinent details involved in implementing a new initiative.

Scenario

The senior management members have sent you their thanks and notes on your feasibility study for your proposed economic initiative. They have determined that your proposal has the potential to benefit the organization in both the short and long term. The last step in this process is to complete a thorough implementation plan for your proposed initiative. This plan will need to include a budget of relevant expected material, staffing, and capital costs over the first five years of the initiative (see the Resources for some examples and guides about budget planning), as well as projected earnings from the initiative for the care setting. You must also include a plan and timeline for rolling the initiative out, an analysis of how it may impact other aspects of the care setting, an explanation how it can remain viable in the face of environmental changes, and sufficient relevant supporting evidence.

Directions

In your 6–10-page plan, you have been asked to be sure to address the following. Note: The bullet points below correspond to grading criteria in the scoring guide. Be sure your work is, at minimum, addressing each of the bullets below. You may also want to read the scoring guide and the Guiding Questions: Implementation Plan for a New Economic Opportunity document, linked in the Resources, to better understand the performance levels that relate to each grading criterion:

• Create a budget for relevant expected costs and earnings or benefits over the first five years of a proposed economic initiative.
• Propose a plan to roll out your economic initiative that will enable your care setting to successfully implement it in an ethical and culturally equitable way that will ensure achievement of quality or service improvements.
• Analyze how your proposed initiative, once implemented, may impact other aspects of your care setting and ways in which negative impacts could be mitigated.
• Explain strategies you have integrated into your proposed economic initiative that will ensure it can remain a viable asset to your care setting in the face of dynamic environmental forces.
• Justify the relevance and value of the quantitative and qualitative economic, financial, and scholarly evidence you used to support your recommendations throughout your plan.
• Communicate your business and implementation plan in a logically structured and concise manner, writing content clearly with correct use of grammar, punctuation, and spelling.
• Effectively support your plan and recommendations with relevant economic data and scholarly sources, correctly formatting citations and references using current APA style.

Example Assessment: You may use the assessment example, linked in the Assessment Example section of the Resources, to give you an idea of what a Proficient or higher rating on the scoring guide would look like.

Additional Requirements

Your assessment should meet the following requirements:

• Length: 6–10 double-spaced, typed pages (not including title page and reference list). Your paper should be succinct yet substantive.
  • Be sure to include a separate title page and reference list.
  • Your completed budget plan should be included as an appendix within your final submission.
• APA format: Resources and citations are formatted according to current APA style.
• Resources: Cite 3–5 authoritative and scholarly resources. Be sure to include specific economic data and support as part of your cited resources.

ASSESSMENT 3 EXAMPLE

IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 2 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Implementation Plan for a New Economic Opportunity The economic initiative proposed to the senior management of Whilborne Medical Center (WMC) is setting up an urgent care center (UCC) on WMC’s premises. A UCC is a health care facility that offers immediate care for injuries and illnesses that are not lifethreatening (Yee, Lechner, & Boukus, 2013). The UCC at WMC will aim to deliver safe, timely, patient-centered, efficient, and effective health care to the community as well as attempt to address health inequalities in the community. An economic and environmental analysis was conducted to determine the feasibility of setting up the UCC, and a business plan was presented to the senior management of WMC. The management believes that this initiative has the potential to benefit the organization in the short and long term. With this in view, an implementation plan for setting up the UCC has been prepared. The implementation plan includes a 5-year budget for the UCC, a timeline for rolling out the UCC, an analysis of how the UCC might impact WMC, and an explanation of how WMC should deal with dynamic environmental forces. Budget for the Proposed Urgent Care Center A budget has been prepared to show the projected revenue and the expenses that the UCC expects to incur over a 5-year period following the completion of its construction. The budget has been created based on the assumption that construction of the UCC will be completed by the end of 2018. Therefore, the budget plan contains revenue and expenditure details for the first 5 years of operation, from 2019 to 2023. Revenue per annum over a 5-year period has been calculated by multiplying the expected patient volume by average consultation charges. It is estimated that around 357 patients will visit IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 3 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. the UCC per week and around $156 will be charged per patient per visit (AMN Healthcare, 2015; Yakobi, 2017). Thus, the revenue generated during the first year of operation is expected to be around $2,730,000. The UCC’s revenue is expected to increase by 5.3% annually (“Urgent Care Center Market,” 2018). Operating expenses for the UCC will comprise staff salaries, basic utilities, insurance, and other operating expenses (such as administrative and marketing costs). Staff salaries for the first three years include the salaries of a full-time physician ($232,000), a nurse practitioner ($112,000), a medical assistant ($35,000), and a medical receptionist ($32,000) (U.S. Bureau of Labor Statistics, 2017). However, in years four and five, new staff will be recruited to manage the increased number of patients. The new staff will comprise a full-time nurse practitioner and a full-time physician, whose salaries will be calculated taking into consideration the 2.7% per annum estimated actual growth rate of employees’ salaries (Economic Policy Institute, 2018). Expenditure on basic utilities is assumed to increase by 5% each year. Insurance expenses are assumed to increase in the fourth and fifth years of operation owing to recruitment of two staff members. Other operating expenses are assumed to be 12% of annual revenue based on trends observed in WMC’s financial statements. The total expected capital cost for the project is $350,000. One half of this cost will be funded through WMC’s reserves, and a bank loan will be arranged to fund the other half. Therefore, WMC will need to take a loan of $175,000 to fund this economic initiative. Assuming that the loan tenure is 5 years and the interest rate is 7% per annum, the loan repayment is expected to be $41,580 per annum. As per the budget, the UCC will earn a cash surplus during the first 5 years. The cash surplus generated in the fourth and fifth years of operation may be lower than the third year owing to recruitment of staff members in these years. The total cash surplus in the first 5 years is Comment [A1]: Great job thinking ahead! IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 4 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. estimated at $7,783,369.30 (see Appendix for more information on the 5-year budget for the proposed economic initiative). Rolling out the Economic Initiative The first step in the implementation plan is to set a timeline to roll out the UCC to the public. It is assumed that it will take around 2 months for WMC senior management to approve the project and for a bank to approve the loan. Considering that construction of the UCC will take around 7 months, the process is scheduled to begin in June 2018 and is expected to be completed by December 2018. After discussing with WMC’s senior management, the plan is to have the UCC fully operational from the first month of 2019. Active engagement and participation by stakeholders can ensure better clinical outcomes and patient experience in an urgent care setting. The board of directors of WMC and the senior management, the physicians, the nurses, and other staff members of WMC are some of the relevant internal stakeholders of this economic initiative. For successful implementation of the plan, it is crucial to collaborate with all internal stakeholders to obtain their inputs during the initial stages of implementation and decision-making. Meetings will be held with the stakeholders on a regular basis to discuss the progress of the UCC and devise ways to improve its health care services. WMC has always strived to focus on the six areas of health care quality stated by the Institute of Medicine (IOM), namely timeliness, safety, patient-centeredness, efficiency, equity, and effectiveness (Agency for Healthcare Research and Quality, 2015). It will be communicated to all internal stakeholders that the UCC will also focus on these six areas and that setting up the UCC will take WMC a step forward toward accomplishing its vision of serving the community. IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 5 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. In order to make this initiative sustainable, the staff working at the UCC will be encouraged to keep WMC’s vision in mind while trying to meet their short- and long-term goals. Patients are the key external stakeholders in the health care business. If patients receive quick and timely care from excellent service providers, they will be encouraged to visit again and refer new patients to the UCC. Being compassionate with patients, dealing with them in an ethical and culturally sensitive manner, and communicating medical information effectively will encourage patient loyalty while also ensuring that they adhere to their treatment plan (“Helping patients make informed decisions,” 2014). The resultant increase in patient flow and goodwill will help the UCC become a successful and sustainable venture. To ensure that the rollout of the center is done in an ethical and culturally sensitive manner, the UCC will follow the principles of the American Academy of Urgent Care Medicine, which includes not discriminating against patients on the basis of gender, age, color, religion, culture, disability, or other characteristics (Agency for Healthcare Research and Quality, 2015). The UCC will have a diverse workforce that can identify and relate to cultural differences; familiarize themselves with health care delivery relevant to patients’ unique socioeconomic, linguistic, and cultural requirements; and provide unbiased care. Hence, by delivering ethically and culturally sensitive health care services, physicians will enhance patient experience and medical outcomes (Cigna, n.d.). With all the stakeholders engaged in the process and focused on achieving the center’s vision, the rollout of the UCC will be a success and it will help WMC to sustain itself within the health care business. However, the implementation plan has some areas of uncertainty. The successful rollout of the UCC is highly dependent on the timely disbursement of the loan required for the construction of the UCC. If the loan does not get disbursed on time, then the IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 6 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. rollout will have to be set for a different timeline when the loan amount becomes available, and this will delay the implementation plan. Also, it is uncertain whether the actual number of patient visits at the UCC will match the estimated patient volume. This is because people in the community may not be aware of the benefits of availing care at the UCC due to lack of sufficient information, misinformation, or misunderstanding. The center will then have to bear the operating losses arising from low patient turnout. Further, an aging population suggests that the number of people who will need health care is set to increase in the coming years (Yakobi, 2017). This will overburden all health care practitioners at WMC. WMC must thus be ready to facilitate a larger number of patients than it may have anticipated. This negative impact can be mitigated by expanding WMC over the next few years by using the revenue generated by the UCC. WMC’s capacity and workforce could be expanded through the construction of additional departments or centers, addition of facilities and equipment, and hiring of new staff. Strategies to Deal With Dynamic Environmental Forces Various environmental forces, such as the presence of a retail health clinic in the center’s vicinity and the possibility of new UCCs being set up in the vicinity, could affect the urgent care services offered at WMC. The retail health clinic and the UCC have some common key characteristics such as easy accessibility, extended hours, convenience, and health care at affordable costs (Chang et al., 2015). This makes both clinics viable options for patients. However, UCCs are particularly beneficial to patients who wish to avail immediate health care services from physicians for conditions that are not life-threatening. UCCs, often staffed with emergency medicine physicians and equipped with more testing facilities than a retail clinic, are capable of providing care with high acuity (Chang et al., 2015). Therefore, by virtue of the IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 7 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. convenient and quality health care it provides, the UCC is an economically viable asset for WMC. Another factor that could affect the UCC at WMC is possible competition from upcoming UCCs and primary health clinics in the vicinity. Patients will choose the UCC over other clinics in the neighborhood once they have complete trust in it. Staff at the UCC will send out frequent health reminders to regular patients to ensure that the patients do not miss their regular checkups. This will help the patients to not miss their regular checkups. Also, the staff will analyze patients’ views on health care and customize care to improve patient outcomes and experience.This will not only help increase patient visits but also improve patients’ level of trust in the UCC (“Helping patients make informed decisions,” 2014). With all these measures in place, the UCC will be able to beat the competition from upcoming UCCs, making it a viable asset to WMC in the face of unpredictable environmental situations. Conclusion The budget for the UCC shows that it will be economically viable for WMC. With the active commitment and cooperation of all the key stakeholders at WMC and the strategies planned to face dynamic environmental forces, the team endeavors to implement the initiative successfully. It is believed that the UCC will serve not only as an additional revenue stream but also as a viable asset that provides quality community health care services. IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 8 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. References Agency for Healthcare Research and Quality. (2015). The six domains of health care quality. Retrieved from https://ahrq.gov/professionals/quality-patientsafety/talkingquality/create/sixdomains.html AMN Healthcare. (2015). Convenient care: Growth and staffing trends in urgent care and retail medicine. Retrieved from https:// amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Indust ry_Research/AMN%2015%20W001_Convenient%20Care%20Whitepaper(1).pdf Chang, J. E., Brundage, S. C., & Chokshi, D. A. (2015). Convenient ambulatory care—promise, pitfalls, and policy. The New England Journal of Medicine, 373(4), 382–388. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocvie w%2F1698429950%3Fac Cigna. (n.d.). Cultural competency in health care: Delivering quality care to an increasingly diverse population. Retrieved from https://cigna.com/assets/docs/about-cigna/thn-whitepapers/cultural-competency-in-health-care-final.pdf Economic Policy Institute. (2018, April 6). Nominal wage tracker. Retrieved from https://epi.org/nominal-wage-tracker/ Helping patients make informed decisions. (2014, April). Retrieved from https://cmpaacpm.ca/en/advice-publications/browse-articles/2014/helping-patients-make-informeddecisions IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 9 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Qin, H., Prybutok, G. L., Prybutok, V. R., & Wang, B. (2015). Quantitative comparisons of urgent care service providers. International Journal of Health Care Quality Assurance, 28(6), 574–594. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocvie w%2F1694933787%3Facco Urgent Care Center Market by Service (Acute Illness Treatment, Trauma/Injury Treatment, Physical Examination, Immunization & Vaccination), Ownership (Corporate Owned, Physician Owned, Hospital Owned), and Region – Global Forecast to 2023. (2018, March). Retrieved from https://marketsandmarkets.com/Market-Reports/urgent-carecenter-market-197843477.html U.S. Bureau of Labor Statistics. (2017). Occupational employment statistics. Retrieved from https://www.bls.gov/oes/current/naics4_621400.htm Yakobi, R. (2017). Impact of urgent care centers on emergency department visits. Health Care Current Reviews, 5(3). http://dx.doi.org/10.4172/2375-4273.1000204 Yee, T., Lechner, A. E., & Boukus, E. R. (2013). The surge in urgent care centers: Emergency department alternative or costly convenience? Research Briefs. Retrieved from https://researchgate.net/profile/Tracy_Yee/publication/257202014_The_surge_in_urgent _care_centers_emergency_department_alternative_or_costly_convenience/links/5750682 008aed9fa2bd2d531 Comment [A2]: ‘www.’ has to be included in the link for it to work. IMPLEMENTATION PLAN FOR A NEW ECONOMIC OPPORTUNITY 10 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Appendix 5-Year Budget for Proposed Economic Initiative FY 2019 FY 2020 FY 2021 FY 2022 FY 2023 Year 1 Year 2 Year 3 Year 4 Year 5 Total ($) ($) ($) ($) ($) ($) Opening Cash Balance 0.00 1,465,820.00 3,024,260.00 4,680,446.00 6,312,389.73 0.00 Fund Received 175,000.00 Loan 175,000.00 Operating Receipts Patient Service Receipts (UCC) 2,730,000.00 2,866,500.00 3,009,825.00 3,160,316.25 3,318,332.06 15,084,973.31 Total Receipts 2,730,000.00 2,866,500.00 3,009,825.00 3,160,316.25 3,318,332.06 15,084,973.31 Operating Payments Staff Salaries 825,000.00 849,750.00 875,242.50 1,023,885.20 1,315,719.80 4,889,597.50 Basic Utilities 55,000.00 57,750.00 60,637.50 63,669.38 66,852.84 303,909.72 Insurance 15,000.00 15,000.00 15,000.00 20,000.00 25,000.00 90,000.00 Other Operating Payments 327,600.00 343,980.00 361,179.00 379,237.95 398,199.85 1,810,196.80 Total Operating Payments 1,222,600.00 1,266,480.00 1,312,059.00 1,486,792.52 1,805,772.49 7,093,704.01 Operating Surplus/Deficit 1,507,400.00 1,600,020.00 1,697,766.00 1,673,523.73 1,512,559.57 7,991,269.30 Nonoperating Payments Annual Loan Repayment (41,580.00) (41,580.00) (41,580.00) (41,580.00) (41,580.00) (207,900.00) Total Nonoperating Expenses (41,580.00) (41,580.00) (41,580.00) (41,580.00) (41,580.00) (207,900.00) Investments Construction, Furniture, and Equipment (350,000.00) – – – – Cash Surplus/Deficit 1,465,820.00 1,558,440.00 1,656,186.00 1,631,943.73 1,470,979.57 7,783,369.30 Closing Cash Balance 1,465,820.00 3,024,260.00 4,680,446.00 6,312,389.73 7,783,369.30 7,783,369.30