forward-looking statements include , among other things , the information concerning our possible future results of operations , business and growth strategies , financing plans , expectations that regulatory developments or other matters will not have a material adverse effect on our business or financial condition , our competitive position and the effects of competition , the projected growth of the industry in which we operate , and the benefits and synergies to be obtained from our completed and any future acquisitions , and statements of our goals and objectives , and other similar expressions concerning matters that are not historical facts . words such as “ may , ” “ will , ” “ should , ” “ could , ” “ would , ” “ predicts , ” “ potential , ” “ continue , ” “ expects , ” “ anticipates , ” “ future , ” “ intends , ” “ plans , ” “ believes , ” “ estimates , ” “ appears , ” “ projects ” and similar expressions , as well as statements in future tense , identify forward-looking statements . in evaluating those statements , you should specifically consider various factors , including the risks related to healthcare industry trends and those set forth herein in item 1a . risk factors . those factors may cause our actual results to differ materially from any of our forward-looking statements . 43 forward-looking statements should not be read as a guarantee of future performance or results , and will not necessarily be accurate indications of the times at , or by which , such performance or results will be achieved . forward-looking information is based on information available at the time and or our good faith belief with respect to future events , and is subject to risks and uncertainties that could cause actual performance or results to differ materially from those expressed in the statements . such factors include , among other things , the following : our ability to comply with the existing laws and government regulations , and or changes in laws and government regulations ; an increasing number of legislative initiatives have been passed into law that may result in major changes in the health care delivery system on a national or state level . legislation has already been enacted that has eliminated the penalty for failing to maintain health coverage that was part of the original patient protection and affordable care act ( the “ legislation ” ) . president trump has already taken executive actions : ( i ) requiring all federal agencies with authorities and responsibilities under the legislation to “ exercise all authority and discretion available to them to waiver , defer , grant exemptions from , or delay ” parts of the legislation that place “ unwarranted economic and regulatory burdens ” on states , individuals or health care providers ; ( ii ) the issuance of a final rule in june , 2018 by the department of labor to enable the formation of association health plans that would be exempt from certain legislation requirements such as the provision of essential health benefits ; ( iii ) the issuance of a final rule in august , 2018 by the department of labor , treasury , and health and human services to expand the availability of short-term , limited duration health insurance , ( iv ) eliminating cost-sharing reduction payments to insurers that would otherwise offset deductibles and other out-of-pocket expenses for health plan enrollees at or below 250 percent of the federal poverty level ; ( v ) relaxing requirements for state innovation waivers that could reduce enrollment in the individual and small group markets and lead to additional enrollment in short-term , limited duration insurance and association health plans ; ( vi ) the issuance of a final rule in june , 2019 by the departments of labor , treasury , and health and human services that would incentivize the use of health reimbursement arrangements by employers to permit employees to purchase health insurance in the individual market , and ; ( vii ) directing the issuance of federal rulemaking by executive agencies to increase transparency of healthcare price and quality information . the uncertainty resulting from these executive branch policies has led to reduced exchange enrollment in 2018 , 2019 and 2020 and is expected to further worsen the individual and small group market risk pools in future years . it is also anticipated that these and future policies may create additional cost and reimbursement pressures on hospitals , including ours . in addition , while attempts to repeal the entirety of the legislation have not been successful to date , a key provision of the legislation was repealed as part of the tax cuts and jobs act and on december 14 , 2018 , a federal u.s. district court judge in texas ruled the entire legislation is unconstitutional . that ruling was stayed and has been appealed . on december 18 , 2019 , the 5 th circuit court of appeals voted 2-1 to strike down the legislation individual mandate as unconstitutional and sent the case back to the u.s. district court in texas to determine which legislation provisions should be stricken with the mandate or whether the entire law is unconstitutional without the individual mandate . it is likely this matter will ultimately be appealed to the u.s. supreme court . we are unable to predict the final outcome of this matter which has caused greater uncertainty regarding the future status of the legislation . if all or any parts of the legislation are ultimately found to be unconstitutional , it could have a material adverse effect on our business , financial condition and results of operations . story_separator_special_tag in implementing the discount policy , we first attempt to qualify uninsured patients for governmental programs , charity care or any other discount program . if an uninsured patient does not qualify for these programs , the uninsured discount is applied . uncompensated care ( charity care and uninsured discounts ) : the following table shows the amounts recorded at our acute care hospitals for charity care and uninsured discounts , based on charges at established rates , for the years ended december 31 , 2019 , 2018 and 2017 : replace_table_token_5_th 47 the estimated cost of providing uncompensated care : the estimated cost of providing uncompensated care , as reflected below , were based on a calculation which multiplied the percentage of operating expenses for our acute care hospitals to gross charges for those hospitals by the above-mentioned total uncompensated care amounts . the percentage of cost to gross charges is calculated based on the total operating expenses for our acute care facilities divided by gross patient service revenue for those facilities . an increase in the level of uninsured patients to our facilities and the resulting adverse trends in the adjustments to net revenues and uncompensated care provided could have a material unfavorable impact on our future operating results . replace_table_token_6_th self-insured/other insurance risks : we provide for self-insured risks including general and professional liability claims , workers ' compensation claims and healthcare and dental claims . our estimated liability for self-insured professional and general liability claims is based on a number of factors including , among other things , the number of asserted claims and reported incidents , estimates of losses for these claims based on recent and historical settlement amounts , estimate of incurred but not reported claims based on historical experience , and estimates of amounts recoverable under our commercial insurance policies . all relevant information , including our own historical experience is used in estimating the expected amount of claims . while we continuously monitor these factors , our ultimate liability for professional and general liability claims could change materially from our current estimates due to inherent uncertainties involved in making this estimate . our estimated self-insured reserves are reviewed and changed , if necessary , at each reporting date and changes are recognized currently as additional expense or as a reduction of expense . in addition , we also : ( i ) own commercial health insurers headquartered in reno , nevada , and puerto rico and ; ( ii ) maintain self-insured employee benefits programs for employee healthcare and dental claims . the ultimate costs related to these programs/operations include expenses for claims incurred and paid in addition to an accrual for the estimated expenses incurred in connection with claims incurred but not yet reported . given our significant insurance-related exposure , there can be no assurance that a sharp increase in the number and or severity of claims asserted against us will not have a material adverse effect on our future results of operations . see note 8 to the consolidated financial statements-commitments and contingencies , for additional disclosure related to our professional and general liability , workers ' compensation liability and property insurance . long-lived assets : we review our long-lived assets for impairment whenever events or circumstances indicate that the carrying value of these assets may not be recoverable . the assessment of possible impairment is based on our ability to recover the carrying value of our asset based on our estimate of its undiscounted future cash flow . if the analysis indicates that the carrying value is not recoverable from future cash flows , the asset is written down to its estimated fair value and an impairment loss is recognized . fair values are determined based on estimated future cash flows using appropriate discount rates . goodwill and intangible assets : goodwill and indefinite-lived intangible assets are reviewed for impairment at the reporting unit level on an annual basis or sooner if the indicators of impairment arise . our judgments regarding the existence of impairment indicators are based on market conditions and operational performance of each reporting unit . we have designated october 1 st as our annual impairment assessment date for our goodwill and indefinite-lived intangible assets . we performed an impairment assessment as of october 1 , 2019 which indicated no impairment of goodwill . there were also no goodwill impairments during 2018 or 2017. our 2019 and 2018 financial results included aggregate pre-tax provisions for asset impairments of $ 98 million and $ 49 million , respectively , recorded in connection with foundations recovery network , l.l.c . ( “ foundations ” ) , which was acquired by us in 2015. these pre-tax provisions for asset impairments include : ( i ) a $ 124 million impairment provision to write-off the carrying value of the foundations ' tradename intangible asset ( $ 75 million recorded during 2019 and $ 49 million recorded during 2018 ) , and ; ( ii ) a $ 23 million impairment provision recorded during 2019 to reduce the carrying value of real property assets of certain foundations ' facilities . please see below in provision for asset impairment-foundations recovery network for additional information . future changes in the estimates used to conduct the impairment review , including profitability and market value projections , could indicate impairment in future periods potentially resulting in a write-off of a portion or all of our goodwill or indefinite-lived intangible assets . income taxes : deferred tax assets and liabilities are recognized for the amount of taxes payable or deductible in future years as a result of differences between the tax basis of assets and liabilities and their reported amounts in the financial statements . we 48 believe that future income will enable us to realize our deferred tax assets net of recorded valuation allowances relating to state and foreign net operating loss carry-forwards , foreign tax credits , and interest deduction limitations . on

net cash provided by operating activities net cash provided by operating activities was $ 1.275 billion during 2018 as compared to $ 1.248 billion during 2017. the net increase of $ 27 million was primarily attributable to the following : a favorable change of $ 91 million due to an increase in net income plus/minus depreciation and amortization expense , stock-based compensation , a net gain on sales of assets , and provision for intangible asset impairment ; an unfavorable change of $ 48 million in accrued and deferred income taxes ; a favorable change of $ 40 million in other working capital accounts resulting primarily from changes in accrued expenses and due to timing of disbursements ; an unfavorable change of $ 18 million in accounts receivable ; an unfavorable change of $ 7 million in accrued insurance expense , net of commercial premiums paid , and ; $ 30 million of other combined net unfavorable changes . net cash used in investing activities net cash used in investing activities was $ 747 million during 2018 and $ 685 million during 2017. the factors contributing to the $ 747 million of net cash used in investing activities during 2018 are detailed above . 2017 : the $ 685 million of net cash used in investing activities during 2017 consisted of : $ 557 million spent on capital expenditures including capital expenditures for equipment , renovations and new projects at various existing facilities ; $ 64 million spent in connection with net cash outflows from forward exchange contracts that hedge our investment in the u.k. against movements in exchange rates ; $ 29 million spent on the purchase and implementation of information technology applications ; $ 23 million spent to acquire businesses and property ; $ 8 million spent to fund construction costs of a new , jointly owned behavioral health care facility , and ; $ 3 million spent to increase the statutorily required capital reserves of our commercial insurance subsidiary . net cash used in financing activities net cash used in financing activities was $ 492 million during 2018 and $ 519 million during 2017. the factors contributing to the $ 492 million of net cash used in financing activities during 2018 are detailed above .


 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.
     ```net cash provided by operating activities net cash provided by operating activities was $ 1.275 billion during 2018 as compared to $ 1.248 billion during 2017. the net increase of $ 27 million was primarily attributable to the following : a favorable change of $ 91 million due to an increase in net income plus/minus depreciation and amortization expense , stock-based compensation , a net gain on sales of assets , and provision for intangible asset impairment ; an unfavorable change of $ 48 million in accrued and deferred income taxes ; a favorable change of $ 40 million in other working capital accounts resulting primarily from changes in accrued expenses and due to timing of disbursements ; an unfavorable change of $ 18 million in accounts receivable ; an unfavorable change of $ 7 million in accrued insurance expense , net of commercial premiums paid , and ; $ 30 million of other combined net unfavorable changes . net cash used in investing activities net cash used in investing activities was $ 747 million during 2018 and $ 685 million during 2017. the factors contributing to the $ 747 million of net cash used in investing activities during 2018 are detailed above . 2017 : the $ 685 million of net cash used in investing activities during 2017 consisted of : $ 557 million spent on capital expenditures including capital expenditures for equipment , renovations and new projects at various existing facilities ; $ 64 million spent in connection with net cash outflows from forward exchange contracts that hedge our investment in the u.k. against movements in exchange rates ; $ 29 million spent on the purchase and implementation of information technology applications ; $ 23 million spent to acquire businesses and property ; $ 8 million spent to fund construction costs of a new , jointly owned behavioral health care facility , and ; $ 3 million spent to increase the statutorily required capital reserves of our commercial insurance subsidiary . net cash used in financing activities net cash used in financing activities was $ 492 million during 2018 and $ 519 million during 2017. the factors contributing to the $ 492 million of net cash used in financing activities during 2018 are detailed above .
```    
 Suspicious Activity Report : forward-looking statements include , among other things , the information concerning our possible future results of operations , business and growth strategies , financing plans , expectations that regulatory developments or other matters will not have a material adverse effect on our business or financial condition , our competitive position and the effects of competition , the projected growth of the industry in which we operate , and the benefits and synergies to be obtained from our completed and any future acquisitions , and statements of our goals and objectives , and other similar expressions concerning matters that are not historical facts . words such as “ may , ” “ will , ” “ should , ” “ could , ” “ would , ” “ predicts , ” “ potential , ” “ continue , ” “ expects , ” “ anticipates , ” “ future , ” “ intends , ” “ plans , ” “ believes , ” “ estimates , ” “ appears , ” “ projects ” and similar expressions , as well as statements in future tense , identify forward-looking statements . in evaluating those statements , you should specifically consider various factors , including the risks related to healthcare industry trends and those set forth herein in item 1a . risk factors . those factors may cause our actual results to differ materially from any of our forward-looking statements . 43 forward-looking statements should not be read as a guarantee of future performance or results , and will not necessarily be accurate indications of the times at , or by which , such performance or results will be achieved . forward-looking information is based on information available at the time and or our good faith belief with respect to future events , and is subject to risks and uncertainties that could cause actual performance or results to differ materially from those expressed in the statements . such factors include , among other things , the following : our ability to comply with the existing laws and government regulations , and or changes in laws and government regulations ; an increasing number of legislative initiatives have been passed into law that may result in major changes in the health care delivery system on a national or state level . legislation has already been enacted that has eliminated the penalty for failing to maintain health coverage that was part of the original patient protection and affordable care act ( the “ legislation ” ) . president trump has already taken executive actions : ( i ) requiring all federal agencies with authorities and responsibilities under the legislation to “ exercise all authority and discretion available to them to waiver , defer , grant exemptions from , or delay ” parts of the legislation that place “ unwarranted economic and regulatory burdens ” on states , individuals or health care providers ; ( ii ) the issuance of a final rule in june , 2018 by the department of labor to enable the formation of association health plans that would be exempt from certain legislation requirements such as the provision of essential health benefits ; ( iii ) the issuance of a final rule in august , 2018 by the department of labor , treasury , and health and human services to expand the availability of short-term , limited duration health insurance , ( iv ) eliminating cost-sharing reduction payments to insurers that would otherwise offset deductibles and other out-of-pocket expenses for health plan enrollees at or below 250 percent of the federal poverty level ; ( v ) relaxing requirements for state innovation waivers that could reduce enrollment in the individual and small group markets and lead to additional enrollment in short-term , limited duration insurance and association health plans ; ( vi ) the issuance of a final rule in june , 2019 by the departments of labor , treasury , and health and human services that would incentivize the use of health reimbursement arrangements by employers to permit employees to purchase health insurance in the individual market , and ; ( vii ) directing the issuance of federal rulemaking by executive agencies to increase transparency of healthcare price and quality information . the uncertainty resulting from these executive branch policies has led to reduced exchange enrollment in 2018 , 2019 and 2020 and is expected to further worsen the individual and small group market risk pools in future years . it is also anticipated that these and future policies may create additional cost and reimbursement pressures on hospitals , including ours . in addition , while attempts to repeal the entirety of the legislation have not been successful to date , a key provision of the legislation was repealed as part of the tax cuts and jobs act and on december 14 , 2018 , a federal u.s. district court judge in texas ruled the entire legislation is unconstitutional . that ruling was stayed and has been appealed . on december 18 , 2019 , the 5 th circuit court of appeals voted 2-1 to strike down the legislation individual mandate as unconstitutional and sent the case back to the u.s. district court in texas to determine which legislation provisions should be stricken with the mandate or whether the entire law is unconstitutional without the individual mandate . it is likely this matter will ultimately be appealed to the u.s. supreme court . we are unable to predict the final outcome of this matter which has caused greater uncertainty regarding the future status of the legislation . if all or any parts of the legislation are ultimately found to be unconstitutional , it could have a material adverse effect on our business , financial condition and results of operations . story_separator_special_tag in implementing the discount policy , we first attempt to qualify uninsured patients for governmental programs , charity care or any other discount program . if an uninsured patient does not qualify for these programs , the uninsured discount is applied . uncompensated care ( charity care and uninsured discounts ) : the following table shows the amounts recorded at our acute care hospitals for charity care and uninsured discounts , based on charges at established rates , for the years ended december 31 , 2019 , 2018 and 2017 : replace_table_token_5_th 47 the estimated cost of providing uncompensated care : the estimated cost of providing uncompensated care , as reflected below , were based on a calculation which multiplied the percentage of operating expenses for our acute care hospitals to gross charges for those hospitals by the above-mentioned total uncompensated care amounts . the percentage of cost to gross charges is calculated based on the total operating expenses for our acute care facilities divided by gross patient service revenue for those facilities . an increase in the level of uninsured patients to our facilities and the resulting adverse trends in the adjustments to net revenues and uncompensated care provided could have a material unfavorable impact on our future operating results . replace_table_token_6_th self-insured/other insurance risks : we provide for self-insured risks including general and professional liability claims , workers ' compensation claims and healthcare and dental claims . our estimated liability for self-insured professional and general liability claims is based on a number of factors including , among other things , the number of asserted claims and reported incidents , estimates of losses for these claims based on recent and historical settlement amounts , estimate of incurred but not reported claims based on historical experience , and estimates of amounts recoverable under our commercial insurance policies . all relevant information , including our own historical experience is used in estimating the expected amount of claims . while we continuously monitor these factors , our ultimate liability for professional and general liability claims could change materially from our current estimates due to inherent uncertainties involved in making this estimate . our estimated self-insured reserves are reviewed and changed , if necessary , at each reporting date and changes are recognized currently as additional expense or as a reduction of expense . in addition , we also : ( i ) own commercial health insurers headquartered in reno , nevada , and puerto rico and ; ( ii ) maintain self-insured employee benefits programs for employee healthcare and dental claims . the ultimate costs related to these programs/operations include expenses for claims incurred and paid in addition to an accrual for the estimated expenses incurred in connection with claims incurred but not yet reported . given our significant insurance-related exposure , there can be no assurance that a sharp increase in the number and or severity of claims asserted against us will not have a material adverse effect on our future results of operations . see note 8 to the consolidated financial statements-commitments and contingencies , for additional disclosure related to our professional and general liability , workers ' compensation liability and property insurance . long-lived assets : we review our long-lived assets for impairment whenever events or circumstances indicate that the carrying value of these assets may not be recoverable . the assessment of possible impairment is based on our ability to recover the carrying value of our asset based on our estimate of its undiscounted future cash flow . if the analysis indicates that the carrying value is not recoverable from future cash flows , the asset is written down to its estimated fair value and an impairment loss is recognized . fair values are determined based on estimated future cash flows using appropriate discount rates . goodwill and intangible assets : goodwill and indefinite-lived intangible assets are reviewed for impairment at the reporting unit level on an annual basis or sooner if the indicators of impairment arise . our judgments regarding the existence of impairment indicators are based on market conditions and operational performance of each reporting unit . we have designated october 1 st as our annual impairment assessment date for our goodwill and indefinite-lived intangible assets . we performed an impairment assessment as of october 1 , 2019 which indicated no impairment of goodwill . there were also no goodwill impairments during 2018 or 2017. our 2019 and 2018 financial results included aggregate pre-tax provisions for asset impairments of $ 98 million and $ 49 million , respectively , recorded in connection with foundations recovery network , l.l.c . ( “ foundations ” ) , which was acquired by us in 2015. these pre-tax provisions for asset impairments include : ( i ) a $ 124 million impairment provision to write-off the carrying value of the foundations ' tradename intangible asset ( $ 75 million recorded during 2019 and $ 49 million recorded during 2018 ) , and ; ( ii ) a $ 23 million impairment provision recorded during 2019 to reduce the carrying value of real property assets of certain foundations ' facilities . please see below in provision for asset impairment-foundations recovery network for additional information . future changes in the estimates used to conduct the impairment review , including profitability and market value projections , could indicate impairment in future periods potentially resulting in a write-off of a portion or all of our goodwill or indefinite-lived intangible assets . income taxes : deferred tax assets and liabilities are recognized for the amount of taxes payable or deductible in future years as a result of differences between the tax basis of assets and liabilities and their reported amounts in the financial statements . we 48 believe that future income will enable us to realize our deferred tax assets net of recorded valuation allowances relating to state and foreign net operating loss carry-forwards , foreign tax credits , and interest deduction limitations . on

