covid-19 will also continue to influence customer and consumer behavior , both during and after the pandemic , which could impact how care is delivered and the manner in which consumers wish to receive their prescription drugs or infusion services . the impact of covid-19 on our care provider and payer clients could impact the volume and types of services optum provides , as well as the pacing of potential new business opportunities . as a result of the dynamic situation and broad-reaching impact to the health system , the ultimate impact of covid-19 on our optum businesses is uncertain . 25 unitedhealthcare . during 2020 , we expanded benefit coverage in areas such as covid-19 care and testing , telemedicine , and pharmacy benefits ; provided customers assistance in the form of co-pay waivers and premium forgiveness ; offered additional enrollment opportunities to those who previously declined employer-sponsored offerings ; extended certain premium payment terms for customers experiencing financial hardship ; simplified administrative practices ; and accelerated payments to care providers , all with the aim of assisting our customers , care providers , members and communities in addressing the covid-19 crisis . temporary care deferrals significantly impacted unitedhealthcare 's results of operations for the year ended december 31 , 2020. the impact of temporary care deferrals was offset by covid-19 related care and testing , the significant financial assistance we provided our customers , rebate requirements and broader economic impacts . enrollment in our commercial products declined primarily due to employer actions in response to the pandemic . increased consumer demand for care , potentially even higher acuity care , along with continued covid-19 care and testing costs are expected to result in increased future medical costs . disrupted care patterns , as a result of the pandemic , may temporarily affect the ability to obtain complete member health status information , impacting future revenue in businesses utilizing risk adjustment methodologies . the ultimate overall impact is uncertain and dependent on the future pacing and intensity of the pandemic , the duration of policies and initiatives to address covid-19 , and general economic uncertainty . business trends our businesses participate in the united states , south america and certain other international health markets . in the united states , health care spending has grown consistently for many years and comprises 18 % of gross domestic product ( gdp ) . we expect overall spending on health care to continue to grow in the future , due to inflation , medical technology and pharmaceutical advancement , regulatory requirements , demographic trends in the population and national interest in health and well-being . the rate of market growth may be affected by a variety of factors , including macro-economic conditions , such as the economic impact of covid-19 , and regulatory changes , which could impact our results of operations , including our continued efforts to control health care costs . pricing trends . to price our health care benefit products , we start with our view of expected future costs , including any potential impacts from covid-19 . we frequently evaluate and adjust our approach in each of the local markets we serve , considering relevant factors , such as product positioning , price competitiveness and environmental , competitive , legislative and regulatory considerations , including minimum mlr thresholds . we will continue seeking to balance growth and profitability across all of these dimensions . the commercial risk market remains highly competitive in both the small group and large group segments . we expect broad-based competition to continue as the industry adapts to individual and employer needs . the aca had an annual , nondeductible insurance industry tax ( health insurance industry tax ) to be levied proportionally across the insurance industry for risk-based health insurance products . pricing for contracts covering some portion of calendar year 2021 reflected the permanent repeal of the health insurance industry tax . medicare advantage funding continues to be pressured , as discussed below in “ regulatory trends and uncertainties . ” we expect medicaid revenue growth due to anticipated changes in mix and increases in the number of people we serve ; we also believe the payment rate environment creates the risk of continued downward pressure on medicaid margin percentages . we continue to take a prudent , market-sustainable posture for both new business and maintenance of existing relationships . we continue to advocate for actuarially sound rates commensurate with our medical cost trends and we remain dedicated to partnering with those states who are committed to the long-term viability of their programs . medical cost trends . our medical cost trends primarily relate to changes in unit costs , health system utilization and prescription drug costs . covid-19 care and testing costs and certain of our customer assistance initiatives have also impacted medical cost trends in the current year and may continue in future years . we endeavor to mitigate those increases by engaging physicians and consumers with information and helping them make clinically sound choices , with the objective of helping them achieve high-quality , affordable care . the uncertain impact of covid-19 may impact our ability to estimate medical costs payable , which could result in increased variability to medical cost reserve development in future periods . delivery system and payment modernization . the health care market continues to change based on demographic shifts , new regulations , political forces and both payer and patient expectations . health plans and care providers are being called upon to work together to close gaps in care and improve overall care quality , improve the health of populations and reduce costs . we continue to see a greater number of people enrolled in plans with underlying performance-based care provider payment models rewarding high-quality , affordable care and foster collaboration . story_separator_special_tag for example , for the most recent two months , we estimate claim costs incurred by applying 33 observed medical cost trend factors to the average per member per month ( pmpm ) medical costs incurred in prior months for which more complete claim data is available , supplemented by a review of near-term completion factors . completion factors . a completion factor is an actuarial estimate , based upon historical experience and analysis of current trends , of the percentage of incurred claims during a given period adjudicated by us at the date of estimation . completion factors are the most significant factors we use in developing our medical costs payable estimates for periods prior to the most recent two months . completion factors include judgments in relation to claim submissions such as the time from date of service to claim receipt , claim levels and processing cycles , as well as other factors . our judgments also consider the impacts of covid-19 on these factors . if actual claims submission rates from providers ( which can be influenced by a number of factors , including provider mix and electronic versus manual submissions ) or our claim processing patterns are different than estimated , our reserve estimates may be significantly impacted . the following table illustrates the sensitivity of these factors and the estimated potential impact on our medical costs payable estimates for those periods as of december 31 , 2020 : replace_table_token_6_th medical cost per member per month trend factors . medical cost pmpm trend factors are significant factors we use in developing our medical costs payable estimates for the most recent two months . medical cost trend factors are developed through a comprehensive analysis of claims incurred in prior months , provider contracting and expected unit costs , benefit design and a review of a broad set of health care utilization indicators , which included consideration of covid-19 in 2020. these factors include but are not limited to pharmacy utilization trends , inpatient hospital authorization data and influenza incidence data from the national centers for disease control . we also consider macroeconomic variables such as gdp growth , employment and disposable income . a large number of factors can cause the medical cost trend to vary from our estimates , including : our ability and practices to manage medical and pharmaceutical costs , changes in level and mix of services utilized , mix of benefits offered , including the impact of co-pays and deductibles , changes in medical practices , catastrophes , epidemics and pandemics , such as covid-19 . the following table illustrates the sensitivity of these factors and the estimated potential impact on our medical costs payable estimates for the most recent two months as of december 31 , 2020 : replace_table_token_7_th the completion factors and medical costs pmpm trend factors analyses above include outcomes considered reasonably likely based on our historical experience estimating liabilities for incurred but not reported benefit claims . management believes the amount of medical costs payable is reasonable and adequate to cover our liability for unpaid claims as of december 31 , 2020 ; however , actual claim payments may differ from established estimates as discussed above . assuming a hypothetical 1 % difference between our december 31 , 2020 estimates of medical costs payable and actual medical costs payable , excluding aarp medicare supplement insurance and any potential offsetting impact from premium rebates , 2020 net earnings would have increased or decreased by approximately $ 157 million . for more detail related to our medical cost estimates , see note 2 of the notes to the consolidated financial statements included in part ii , item 8 , “ financial statements . ” 34 goodwill we evaluate goodwill for impairment annually or more frequently when an event occurs or circumstances change indicating the carrying value may not be recoverable . when testing goodwill for impairment , we may first assess qualitative factors to determine if it is more likely than not the carrying value of a reporting unit exceeds its estimated fair value . during a qualitative analysis , we consider the impact of changes , if any , to the following factors : macroeconomic , industry and market factors , cost factors , changes in overall financial performance , and any other relevant events and uncertainties impacting a reporting unit . if our qualitative assessment indicates a goodwill impairment is more likely than not , we perform additional quantitative analyses . we may also elect to skip the qualitative testing and proceed directly to the quantitative testing . for reporting units where a quantitative analysis is performed , we perform a test measuring the fair values of the reporting units and comparing them to their aggregate carrying values , including goodwill . if the fair value is less than the carrying value of the reporting unit , an impairment is recognized for the difference , up to the carrying amount of goodwill . we estimate the fair values of our reporting units using a discounted cash flow method or a weighted combination of discounted cash flows and a market-based method . the discounted cash flow method includes assumptions about a wide variety of internal and external factors . significant assumptions used in the discounted cash flow method include financial projections of free cash flow , including revenue trends , medical costs trends , operating productivity , income taxes and capital levels ; long-term growth rates for determining terminal value beyond the discretely forecasted periods ; and discount rates . financial projections and long-term growth rates used for our reporting units are consistent with , and use inputs from , our internal long-term business plan and strategies . discount rates are determined for each reporting unit and include consideration of the implied risk inherent in their forecasts . our most significant estimate in the discount rate determinations involves our adjustments to the peer company weighted average costs of capital reflecting

debt obligations . see note 8 of the notes to the consolidated financial statements included in part ii , i tem 8 , “ financial statements ” for further detail of our commercial paper and long-term debt and the timing of expected future payments . interest coupon payments are typically paid semi-annually . operating leases . see note 12 of the notes to the consolidated financial statements included in part ii , item 8 , “ financial statements ” for further detail of our obligations and the timing of expected future payments . purchase and other obligations . these include $ 5.3 billion , $ 2.0 billion of which is expected to be paid within the next twelve months , of fixed or minimum commitments under existing purchase obligations for goods and services , including agreements cancelable with the payment of an early termination penalty , and remaining capital commitments for venture capital funds and other funding commitments . these amounts exclude agreements cancelable without penalty and liabilities to the extent recorded in our consolidated balance sheets as of december 31 , 2020. other liabilities . these include other long-term liabilities reflected in our consolidated balance sheets as of december 31 , 2020 , including obligations associated with certain employee benefit programs , unrecognized tax benefits and various long-term liabilities , which have some inherent uncertainty in the timing of these payments . redeemable noncontrolling interests . see note 2 of the notes to the consolidated financial statements included in part ii , item 8 , “ financial statements ” for further detail .


 Write a concise suspicious activity report of the following text delimited by triple backquotes. Return your response as a formal report which covers the key points highlighting the location,dates,entity names and account holder information in chronological order of the text.
     ```debt obligations . see note 8 of the notes to the consolidated financial statements included in part ii , i tem 8 , “ financial statements ” for further detail of our commercial paper and long-term debt and the timing of expected future payments . interest coupon payments are typically paid semi-annually . operating leases . see note 12 of the notes to the consolidated financial statements included in part ii , item 8 , “ financial statements ” for further detail of our obligations and the timing of expected future payments . purchase and other obligations . these include $ 5.3 billion , $ 2.0 billion of which is expected to be paid within the next twelve months , of fixed or minimum commitments under existing purchase obligations for goods and services , including agreements cancelable with the payment of an early termination penalty , and remaining capital commitments for venture capital funds and other funding commitments . these amounts exclude agreements cancelable without penalty and liabilities to the extent recorded in our consolidated balance sheets as of december 31 , 2020. other liabilities . these include other long-term liabilities reflected in our consolidated balance sheets as of december 31 , 2020 , including obligations associated with certain employee benefit programs , unrecognized tax benefits and various long-term liabilities , which have some inherent uncertainty in the timing of these payments . redeemable noncontrolling interests . see note 2 of the notes to the consolidated financial statements included in part ii , item 8 , “ financial statements ” for further detail .
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 Suspicious Activity Report : covid-19 will also continue to influence customer and consumer behavior , both during and after the pandemic , which could impact how care is delivered and the manner in which consumers wish to receive their prescription drugs or infusion services . the impact of covid-19 on our care provider and payer clients could impact the volume and types of services optum provides , as well as the pacing of potential new business opportunities . as a result of the dynamic situation and broad-reaching impact to the health system , the ultimate impact of covid-19 on our optum businesses is uncertain . 25 unitedhealthcare . during 2020 , we expanded benefit coverage in areas such as covid-19 care and testing , telemedicine , and pharmacy benefits ; provided customers assistance in the form of co-pay waivers and premium forgiveness ; offered additional enrollment opportunities to those who previously declined employer-sponsored offerings ; extended certain premium payment terms for customers experiencing financial hardship ; simplified administrative practices ; and accelerated payments to care providers , all with the aim of assisting our customers , care providers , members and communities in addressing the covid-19 crisis . temporary care deferrals significantly impacted unitedhealthcare 's results of operations for the year ended december 31 , 2020. the impact of temporary care deferrals was offset by covid-19 related care and testing , the significant financial assistance we provided our customers , rebate requirements and broader economic impacts . enrollment in our commercial products declined primarily due to employer actions in response to the pandemic . increased consumer demand for care , potentially even higher acuity care , along with continued covid-19 care and testing costs are expected to result in increased future medical costs . disrupted care patterns , as a result of the pandemic , may temporarily affect the ability to obtain complete member health status information , impacting future revenue in businesses utilizing risk adjustment methodologies . the ultimate overall impact is uncertain and dependent on the future pacing and intensity of the pandemic , the duration of policies and initiatives to address covid-19 , and general economic uncertainty . business trends our businesses participate in the united states , south america and certain other international health markets . in the united states , health care spending has grown consistently for many years and comprises 18 % of gross domestic product ( gdp ) . we expect overall spending on health care to continue to grow in the future , due to inflation , medical technology and pharmaceutical advancement , regulatory requirements , demographic trends in the population and national interest in health and well-being . the rate of market growth may be affected by a variety of factors , including macro-economic conditions , such as the economic impact of covid-19 , and regulatory changes , which could impact our results of operations , including our continued efforts to control health care costs . pricing trends . to price our health care benefit products , we start with our view of expected future costs , including any potential impacts from covid-19 . we frequently evaluate and adjust our approach in each of the local markets we serve , considering relevant factors , such as product positioning , price competitiveness and environmental , competitive , legislative and regulatory considerations , including minimum mlr thresholds . we will continue seeking to balance growth and profitability across all of these dimensions . the commercial risk market remains highly competitive in both the small group and large group segments . we expect broad-based competition to continue as the industry adapts to individual and employer needs . the aca had an annual , nondeductible insurance industry tax ( health insurance industry tax ) to be levied proportionally across the insurance industry for risk-based health insurance products . pricing for contracts covering some portion of calendar year 2021 reflected the permanent repeal of the health insurance industry tax . medicare advantage funding continues to be pressured , as discussed below in “ regulatory trends and uncertainties . ” we expect medicaid revenue growth due to anticipated changes in mix and increases in the number of people we serve ; we also believe the payment rate environment creates the risk of continued downward pressure on medicaid margin percentages . we continue to take a prudent , market-sustainable posture for both new business and maintenance of existing relationships . we continue to advocate for actuarially sound rates commensurate with our medical cost trends and we remain dedicated to partnering with those states who are committed to the long-term viability of their programs . medical cost trends . our medical cost trends primarily relate to changes in unit costs , health system utilization and prescription drug costs . covid-19 care and testing costs and certain of our customer assistance initiatives have also impacted medical cost trends in the current year and may continue in future years . we endeavor to mitigate those increases by engaging physicians and consumers with information and helping them make clinically sound choices , with the objective of helping them achieve high-quality , affordable care . the uncertain impact of covid-19 may impact our ability to estimate medical costs payable , which could result in increased variability to medical cost reserve development in future periods . delivery system and payment modernization . the health care market continues to change based on demographic shifts , new regulations , political forces and both payer and patient expectations . health plans and care providers are being called upon to work together to close gaps in care and improve overall care quality , improve the health of populations and reduce costs . we continue to see a greater number of people enrolled in plans with underlying performance-based care provider payment models rewarding high-quality , affordable care and foster collaboration . story_separator_special_tag for example , for the most recent two months , we estimate claim costs incurred by applying 33 observed medical cost trend factors to the average per member per month ( pmpm ) medical costs incurred in prior months for which more complete claim data is available , supplemented by a review of near-term completion factors . completion factors . a completion factor is an actuarial estimate , based upon historical experience and analysis of current trends , of the percentage of incurred claims during a given period adjudicated by us at the date of estimation . completion factors are the most significant factors we use in developing our medical costs payable estimates for periods prior to the most recent two months . completion factors include judgments in relation to claim submissions such as the time from date of service to claim receipt , claim levels and processing cycles , as well as other factors . our judgments also consider the impacts of covid-19 on these factors . if actual claims submission rates from providers ( which can be influenced by a number of factors , including provider mix and electronic versus manual submissions ) or our claim processing patterns are different than estimated , our reserve estimates may be significantly impacted . the following table illustrates the sensitivity of these factors and the estimated potential impact on our medical costs payable estimates for those periods as of december 31 , 2020 : replace_table_token_6_th medical cost per member per month trend factors . medical cost pmpm trend factors are significant factors we use in developing our medical costs payable estimates for the most recent two months . medical cost trend factors are developed through a comprehensive analysis of claims incurred in prior months , provider contracting and expected unit costs , benefit design and a review of a broad set of health care utilization indicators , which included consideration of covid-19 in 2020. these factors include but are not limited to pharmacy utilization trends , inpatient hospital authorization data and influenza incidence data from the national centers for disease control . we also consider macroeconomic variables such as gdp growth , employment and disposable income . a large number of factors can cause the medical cost trend to vary from our estimates , including : our ability and practices to manage medical and pharmaceutical costs , changes in level and mix of services utilized , mix of benefits offered , including the impact of co-pays and deductibles , changes in medical practices , catastrophes , epidemics and pandemics , such as covid-19 . the following table illustrates the sensitivity of these factors and the estimated potential impact on our medical costs payable estimates for the most recent two months as of december 31 , 2020 : replace_table_token_7_th the completion factors and medical costs pmpm trend factors analyses above include outcomes considered reasonably likely based on our historical experience estimating liabilities for incurred but not reported benefit claims . management believes the amount of medical costs payable is reasonable and adequate to cover our liability for unpaid claims as of december 31 , 2020 ; however , actual claim payments may differ from established estimates as discussed above . assuming a hypothetical 1 % difference between our december 31 , 2020 estimates of medical costs payable and actual medical costs payable , excluding aarp medicare supplement insurance and any potential offsetting impact from premium rebates , 2020 net earnings would have increased or decreased by approximately $ 157 million . for more detail related to our medical cost estimates , see note 2 of the notes to the consolidated financial statements included in part ii , item 8 , “ financial statements . ” 34 goodwill we evaluate goodwill for impairment annually or more frequently when an event occurs or circumstances change indicating the carrying value may not be recoverable . when testing goodwill for impairment , we may first assess qualitative factors to determine if it is more likely than not the carrying value of a reporting unit exceeds its estimated fair value . during a qualitative analysis , we consider the impact of changes , if any , to the following factors : macroeconomic , industry and market factors , cost factors , changes in overall financial performance , and any other relevant events and uncertainties impacting a reporting unit . if our qualitative assessment indicates a goodwill impairment is more likely than not , we perform additional quantitative analyses . we may also elect to skip the qualitative testing and proceed directly to the quantitative testing . for reporting units where a quantitative analysis is performed , we perform a test measuring the fair values of the reporting units and comparing them to their aggregate carrying values , including goodwill . if the fair value is less than the carrying value of the reporting unit , an impairment is recognized for the difference , up to the carrying amount of goodwill . we estimate the fair values of our reporting units using a discounted cash flow method or a weighted combination of discounted cash flows and a market-based method . the discounted cash flow method includes assumptions about a wide variety of internal and external factors . significant assumptions used in the discounted cash flow method include financial projections of free cash flow , including revenue trends , medical costs trends , operating productivity , income taxes and capital levels ; long-term growth rates for determining terminal value beyond the discretely forecasted periods ; and discount rates . financial projections and long-term growth rates used for our reporting units are consistent with , and use inputs from , our internal long-term business plan and strategies . discount rates are determined for each reporting unit and include consideration of the implied risk inherent in their forecasts . our most significant estimate in the discount rate determinations involves our adjustments to the peer company weighted average costs of capital reflecting

