ensuring continuous compliance with these laws and regulations is an operating requirement for all healthcare providers . over the last several years , changes in regulations governing inpatient rehabilitation hospitals have created challenges for inpatient rehabilitation providers with many of these changes resulting in 30 limitations on , and in some cases reductions to , reimbursement from medicare , including reductions to the annual “ market basket update ” ( i.e . , annual adjustment to medicare payment rates ) . on august 7 , 2009 , the centers for medicare and medicaid services ( “ cms ” ) published in the federal register the fiscal year 2010 notice of final rulemaking ( the “ 2010 rule ” ) for irfs under the prospective payment system ( “ irf-pps ” ) . the 2010 rule contains medicare pricing changes as well as new documentation and coverage requirements , as described below . the pricing changes were effective for medicare discharges between october 1 , 2009 and september 30 , 2010 and included a 2.5 % market basket update , which was the first market basket update we had received in 18 months . however , as discussed below , on march 23 , 2010 , president obama signed the patient protection and affordable care act ( the “ ppaca ” ) into law . on march 30 , 2010 , president obama signed into law the health care and education reconciliation act of 2010 , which amended the ppaca ( together , the “ 2010 healthcare reform laws ” ) . these laws include a reduction in annual market basket updates to providers . starting on april 1 , 2010 , the market basket increase of 2.5 % we received on october 1 , 2009 was reduced to 2.25 % . similar reductions to our annual market basket updates are scheduled to occur each year through 2019 , although the amount of each year 's decrease will vary over time and will include to-be-determined productivity adjustments , as discussed below . the 2010 rule includes requirements , referred to as “ coverage requirements , ” for preadmission screening , post-admission evaluations , and individual treatment planning that all delineate the role of physicians in ordering and overseeing patient care . although these changes , that were effective january 1 , 2010 , have not resulted in material modifications to our clinical or business models , they have resulted in significantly increased procedural and documentation requirements for all irfs . in addition , due to the complexity of the changes within the 2010 rule , cms continues to clarify these revised coverage requirements . we have undertaken efforts to educate our employees and affiliated physicians on compliance with these new requirements , and we will continue to train our employees as these requirements are further clarified . in addition , on july 22 , 2010 , cms published in the federal register its irf-pps final rule for fiscal year 2011 ( the “ 2011 rule ” ) . the 2011 rule will be effective for medicare discharges between october 1 , 2010 and september 30 , 2011. the pricing changes in this rule include a 2.5 % market basket update that will be reduced to 2.25 % under the requirements of the 2010 healthcare reform laws discussed above , as well as other pricing changes that impact our hospital-by-hospital base rate for medicare reimbursement . based on our analysis which includes the acuity of our patients over the twelve–month period prior to the rule 's release and incorporates other adjustments of the 2011 rule , we believe the 2011 rule will increase our medicare-related net operating revenues for our irfs by approximately 2.1 % annually . beginning on october 1 , 2011 , the 2010 healthcare reform laws require for the first time a to-be-determined productivity adjustment ( reduction ) to the market basket update on an annual basis . our outpatient services are primarily reimbursed under medicare 's physician fee schedule . by statute , the physician fee schedule is subject to annual automatic adjustment by a sustainable growth rate formula that has resulted in reductions in reimbursement rates every year since 2002. however , in each case , congress has acted to suspend or postpone the effectiveness of these automatic reimbursement reductions . for example , congress passed , and on june 25 , 2010 president obama signed into law , a 2.2 % increase to medicare physician fee schedule payment rates from june 1 , 2010 through november 30 , 2010 , further postponing the statutory reduction of 21.3 % that briefly became effective on june 1 , 2010. subsequently , congress acted to postpone the statutory reduction through december 31 , 2010 and then again through december 31 , 2011. if congress does not extend this relief , as it has done since 2002 , or permanently modify the sustainable growth rate formula by january 1 , 2012 , payment levels for outpatient services under the physician fee schedule will be reduced at that point by more than 25 % . on november 2 , 2010 , cms released its notice of final rulemaking for the medicare physician fee schedule for calendar year 2011. congress further modified this final rule through the physician and therapy relief act of 2010. collectively , these changes would implement a 25 % rate reduction to the practice expense component for reimbursement of therapy expenses for additional procedures when 31 multiple therapy services are provided to the same patient on the same day in a hospital outpatient department . story_separator_special_tag this continued focus on the teamworks initiative , coupled with the dedication and hard work of our employees , allowed us to continue to generate discharge growth throughout 2009 , in spite of the difficult comparisons to 2008 's growth . this growth in discharges helped mitigate the negative impact of the pricing roll-back . decreased outpatient volumes in all periods presented resulted primarily from the closure of outpatient satellite clinics in prior periods . challenges in securing therapy staffing in certain markets and continued competition from physicians offering physical therapy services within their own offices also contributed to the decline . during 2010 , outpatient visit cancellations caused by the severe winter storms in some of our northeast and mid-atlantic markets in the first quarter of 2010 also contributed to the decreased volume . as of december 31 , 2010 , 2009 , and 2008 , we operated 32 , 40 , and 50 outpatient satellite clinics , respectively . as discussed above , the market basket increase of 2.5 % irfs received on october 1 , 2009 was reduced to 2.25 % effective april 1 , 2010. as also discussed above , irfs received a market basket update of 2.5 % under the 2011 rule effective october 1 , 2010. however , this market basket update was reduced to 2.25 % under the requirements of the 2010 healthcare reform laws . salaries and benefits salaries and benefits represent the most significant cost to us and represent an investment in our most important asset : our employees . salaries and benefits include all amounts paid to full- and part-time employees who directly participate in or support the operations of our hospitals , including all related costs of benefits provided to employees . it also includes amounts paid for contract labor . we actively manage the productive portion of our salaries and benefits utilizing certain metrics , including employees per occupied bed , or “ epob . ” this metric is determined by dividing the number of full-time equivalents , including an estimate of full-time equivalents from the utilization of contract labor , by the number of occupied beds during each period . the number of occupied beds is determined by multiplying the number of licensed beds by our occupancy percentage . for the years ended december 31 , 2010 , 2009 , and 2008 , our epob was 3.50 , 3.53 , and 3.62 , respectively , or a year-over-year improvement of 0.8 % and 2.5 % in 2010 and 2009 , respectively . salaries and benefits increased from 2009 to 2010 as a result of an approximate 2.3 % merit increase provided to employees on october 1 , 2009 , an increase in the number of full-time equivalents as a result of our development activities , as discussed above , and a change in the mix of licensed versus non-licensed employees . the process of standardizing our labor practices across all of our hospitals , which we began in 2009 with the roll-out of a new labor management system , and the implementation of the new coverage requirements that became effective january 1 , 2010 have decreased the use of non-licensed employees , which increased our average cost per full-time equivalent . salaries and benefits as a percent of net operating revenues in 2010 continued to be positively impacted by continued improvement in labor productivity , a reduction in self-insured workers ' compensation costs due to revised actuarial estimates , and the medicare pricing changes that became effective on october 1 , 2009. these positive impacts were offset by the decline in outpatient revenues , as discussed above , as well as an increase in the number of full-time equivalents at new or newly acquired hospitals who were ramping up operations during 2010. during late 2008 , we addressed our comprehensive benefits package and made refinements that allowed us , and continue to allow us , to remain competitive in this challenging staffing environment while also being consistent with our goal of being a high-quality , low-cost provider of inpatient rehabilitative services . such refinements included , but were not limited to , passing along a portion of the increased costs associated with medical plan benefits to our employees and reducing certain aspects of our paid-time-off program . also , as a result of our recruiting and retention efforts , costs associated with contract labor decreased in 2009. as a result , salaries and benefits as a percent of net operating revenues decreased from 2008 to 2009. as it is routine to provide merit increases to our employees on october 1 of each year , which normally coincides with our annual medicare pricing adjustment , we provided an approximate 2 % merit increase to our employees effective october 1 , 2010 . 37 other operating expenses other operating expenses include costs associated with managing and maintaining our hospitals . these expenses include such items as contract services , utilities , insurance , professional fees , and repairs and maintenance . other operating expenses in 2010 increased over 2009 due primarily to increased self-insurance costs associated with professional and general liability claims and investments we made in our core business in 2010 , including the investment in our case management function , as discussed above . as a result of the jury verdict discussed in note 22 , contingencies and other commitments , “ other litigation , ” to the accompanying consolidated financial statements , we recorded a $ 4.6 million charge to other operating expenses during the second quarter of 2010. in addition , we update our actuarial estimates surrounding our self-insurance reserves in june and december of each year . during 2010 , we recorded a $ 7.6 million increase in self-insurance costs associated with professional and general liability risks due to revised actuarial estimates that primarily resulted from an increase in expected losses on a subset of claims in our recent claims history . other operating

net cash provided by operating activities was $ 331.0 million and $ 406.1 million in 2010 and 2009 , respectively . net cash provided by operating activities in 2010 included $ 13.5 million of state income tax refunds associated with prior periods . net cash provided by operating activities in 2009 included $ 73.8 million in net cash proceeds related to the ubs settlement and the receipt of $ 63.7 million in federal and state income tax refunds for prior periods . see the “ results of operations ” and “ liquidity and capital resources ” sections of this item for additional information . in anticipation of the continuing capital market volatility throughout 2010 and the significant changes in the broader healthcare regulatory landscape , we focused our 2010 strategy on : further deleveraging our balance sheet , growing organically , providing high-quality , cost-effective care , pursuing acquisitions of inpatient rehabilitation facilities on a disciplined , opportunistic basis , and adapting to regulatory changes affecting our industry . while growth in adjusted ebitda was the focus of our 2010 deleveraging efforts , we also reduced our total debt outstanding by approximately $ 151 million . additionally , we improved our overall debt profile in october 2010 by refinancing our credit agreement . in that refinancing , we extended debt maturities and reduced floating interest rate exposure by replacing our term loans with later maturing fixed rate senior notes . we used cash on hand , a draw under our new revolving credit facility , and the net proceeds from the october 2010 issuance of $ 275.0 million of 7.25 % senior notes due 2018 and $ 250.0 million of 7.75 % senior notes due 2022 to repay all $ 743.1 million of our former term loans . we also improved the flexibility of our capital structure by amending other terms of our credit agreement to provide for a senior secured revolving credit facility of up to $ 500.0 million , including a $ 260.0 million letter of credit subfacility maturing in october 2015 , and to make other changes that are more consistent with our financial position .


 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 was $ 331.0 million and $ 406.1 million in 2010 and 2009 , respectively . net cash provided by operating activities in 2010 included $ 13.5 million of state income tax refunds associated with prior periods . net cash provided by operating activities in 2009 included $ 73.8 million in net cash proceeds related to the ubs settlement and the receipt of $ 63.7 million in federal and state income tax refunds for prior periods . see the “ results of operations ” and “ liquidity and capital resources ” sections of this item for additional information . in anticipation of the continuing capital market volatility throughout 2010 and the significant changes in the broader healthcare regulatory landscape , we focused our 2010 strategy on : further deleveraging our balance sheet , growing organically , providing high-quality , cost-effective care , pursuing acquisitions of inpatient rehabilitation facilities on a disciplined , opportunistic basis , and adapting to regulatory changes affecting our industry . while growth in adjusted ebitda was the focus of our 2010 deleveraging efforts , we also reduced our total debt outstanding by approximately $ 151 million . additionally , we improved our overall debt profile in october 2010 by refinancing our credit agreement . in that refinancing , we extended debt maturities and reduced floating interest rate exposure by replacing our term loans with later maturing fixed rate senior notes . we used cash on hand , a draw under our new revolving credit facility , and the net proceeds from the october 2010 issuance of $ 275.0 million of 7.25 % senior notes due 2018 and $ 250.0 million of 7.75 % senior notes due 2022 to repay all $ 743.1 million of our former term loans . we also improved the flexibility of our capital structure by amending other terms of our credit agreement to provide for a senior secured revolving credit facility of up to $ 500.0 million , including a $ 260.0 million letter of credit subfacility maturing in october 2015 , and to make other changes that are more consistent with our financial position .
```    
 Suspicious Activity Report : ensuring continuous compliance with these laws and regulations is an operating requirement for all healthcare providers . over the last several years , changes in regulations governing inpatient rehabilitation hospitals have created challenges for inpatient rehabilitation providers with many of these changes resulting in 30 limitations on , and in some cases reductions to , reimbursement from medicare , including reductions to the annual “ market basket update ” ( i.e . , annual adjustment to medicare payment rates ) . on august 7 , 2009 , the centers for medicare and medicaid services ( “ cms ” ) published in the federal register the fiscal year 2010 notice of final rulemaking ( the “ 2010 rule ” ) for irfs under the prospective payment system ( “ irf-pps ” ) . the 2010 rule contains medicare pricing changes as well as new documentation and coverage requirements , as described below . the pricing changes were effective for medicare discharges between october 1 , 2009 and september 30 , 2010 and included a 2.5 % market basket update , which was the first market basket update we had received in 18 months . however , as discussed below , on march 23 , 2010 , president obama signed the patient protection and affordable care act ( the “ ppaca ” ) into law . on march 30 , 2010 , president obama signed into law the health care and education reconciliation act of 2010 , which amended the ppaca ( together , the “ 2010 healthcare reform laws ” ) . these laws include a reduction in annual market basket updates to providers . starting on april 1 , 2010 , the market basket increase of 2.5 % we received on october 1 , 2009 was reduced to 2.25 % . similar reductions to our annual market basket updates are scheduled to occur each year through 2019 , although the amount of each year 's decrease will vary over time and will include to-be-determined productivity adjustments , as discussed below . the 2010 rule includes requirements , referred to as “ coverage requirements , ” for preadmission screening , post-admission evaluations , and individual treatment planning that all delineate the role of physicians in ordering and overseeing patient care . although these changes , that were effective january 1 , 2010 , have not resulted in material modifications to our clinical or business models , they have resulted in significantly increased procedural and documentation requirements for all irfs . in addition , due to the complexity of the changes within the 2010 rule , cms continues to clarify these revised coverage requirements . we have undertaken efforts to educate our employees and affiliated physicians on compliance with these new requirements , and we will continue to train our employees as these requirements are further clarified . in addition , on july 22 , 2010 , cms published in the federal register its irf-pps final rule for fiscal year 2011 ( the “ 2011 rule ” ) . the 2011 rule will be effective for medicare discharges between october 1 , 2010 and september 30 , 2011. the pricing changes in this rule include a 2.5 % market basket update that will be reduced to 2.25 % under the requirements of the 2010 healthcare reform laws discussed above , as well as other pricing changes that impact our hospital-by-hospital base rate for medicare reimbursement . based on our analysis which includes the acuity of our patients over the twelve–month period prior to the rule 's release and incorporates other adjustments of the 2011 rule , we believe the 2011 rule will increase our medicare-related net operating revenues for our irfs by approximately 2.1 % annually . beginning on october 1 , 2011 , the 2010 healthcare reform laws require for the first time a to-be-determined productivity adjustment ( reduction ) to the market basket update on an annual basis . our outpatient services are primarily reimbursed under medicare 's physician fee schedule . by statute , the physician fee schedule is subject to annual automatic adjustment by a sustainable growth rate formula that has resulted in reductions in reimbursement rates every year since 2002. however , in each case , congress has acted to suspend or postpone the effectiveness of these automatic reimbursement reductions . for example , congress passed , and on june 25 , 2010 president obama signed into law , a 2.2 % increase to medicare physician fee schedule payment rates from june 1 , 2010 through november 30 , 2010 , further postponing the statutory reduction of 21.3 % that briefly became effective on june 1 , 2010. subsequently , congress acted to postpone the statutory reduction through december 31 , 2010 and then again through december 31 , 2011. if congress does not extend this relief , as it has done since 2002 , or permanently modify the sustainable growth rate formula by january 1 , 2012 , payment levels for outpatient services under the physician fee schedule will be reduced at that point by more than 25 % . on november 2 , 2010 , cms released its notice of final rulemaking for the medicare physician fee schedule for calendar year 2011. congress further modified this final rule through the physician and therapy relief act of 2010. collectively , these changes would implement a 25 % rate reduction to the practice expense component for reimbursement of therapy expenses for additional procedures when 31 multiple therapy services are provided to the same patient on the same day in a hospital outpatient department . story_separator_special_tag this continued focus on the teamworks initiative , coupled with the dedication and hard work of our employees , allowed us to continue to generate discharge growth throughout 2009 , in spite of the difficult comparisons to 2008 's growth . this growth in discharges helped mitigate the negative impact of the pricing roll-back . decreased outpatient volumes in all periods presented resulted primarily from the closure of outpatient satellite clinics in prior periods . challenges in securing therapy staffing in certain markets and continued competition from physicians offering physical therapy services within their own offices also contributed to the decline . during 2010 , outpatient visit cancellations caused by the severe winter storms in some of our northeast and mid-atlantic markets in the first quarter of 2010 also contributed to the decreased volume . as of december 31 , 2010 , 2009 , and 2008 , we operated 32 , 40 , and 50 outpatient satellite clinics , respectively . as discussed above , the market basket increase of 2.5 % irfs received on october 1 , 2009 was reduced to 2.25 % effective april 1 , 2010. as also discussed above , irfs received a market basket update of 2.5 % under the 2011 rule effective october 1 , 2010. however , this market basket update was reduced to 2.25 % under the requirements of the 2010 healthcare reform laws . salaries and benefits salaries and benefits represent the most significant cost to us and represent an investment in our most important asset : our employees . salaries and benefits include all amounts paid to full- and part-time employees who directly participate in or support the operations of our hospitals , including all related costs of benefits provided to employees . it also includes amounts paid for contract labor . we actively manage the productive portion of our salaries and benefits utilizing certain metrics , including employees per occupied bed , or “ epob . ” this metric is determined by dividing the number of full-time equivalents , including an estimate of full-time equivalents from the utilization of contract labor , by the number of occupied beds during each period . the number of occupied beds is determined by multiplying the number of licensed beds by our occupancy percentage . for the years ended december 31 , 2010 , 2009 , and 2008 , our epob was 3.50 , 3.53 , and 3.62 , respectively , or a year-over-year improvement of 0.8 % and 2.5 % in 2010 and 2009 , respectively . salaries and benefits increased from 2009 to 2010 as a result of an approximate 2.3 % merit increase provided to employees on october 1 , 2009 , an increase in the number of full-time equivalents as a result of our development activities , as discussed above , and a change in the mix of licensed versus non-licensed employees . the process of standardizing our labor practices across all of our hospitals , which we began in 2009 with the roll-out of a new labor management system , and the implementation of the new coverage requirements that became effective january 1 , 2010 have decreased the use of non-licensed employees , which increased our average cost per full-time equivalent . salaries and benefits as a percent of net operating revenues in 2010 continued to be positively impacted by continued improvement in labor productivity , a reduction in self-insured workers ' compensation costs due to revised actuarial estimates , and the medicare pricing changes that became effective on october 1 , 2009. these positive impacts were offset by the decline in outpatient revenues , as discussed above , as well as an increase in the number of full-time equivalents at new or newly acquired hospitals who were ramping up operations during 2010. during late 2008 , we addressed our comprehensive benefits package and made refinements that allowed us , and continue to allow us , to remain competitive in this challenging staffing environment while also being consistent with our goal of being a high-quality , low-cost provider of inpatient rehabilitative services . such refinements included , but were not limited to , passing along a portion of the increased costs associated with medical plan benefits to our employees and reducing certain aspects of our paid-time-off program . also , as a result of our recruiting and retention efforts , costs associated with contract labor decreased in 2009. as a result , salaries and benefits as a percent of net operating revenues decreased from 2008 to 2009. as it is routine to provide merit increases to our employees on october 1 of each year , which normally coincides with our annual medicare pricing adjustment , we provided an approximate 2 % merit increase to our employees effective october 1 , 2010 . 37 other operating expenses other operating expenses include costs associated with managing and maintaining our hospitals . these expenses include such items as contract services , utilities , insurance , professional fees , and repairs and maintenance . other operating expenses in 2010 increased over 2009 due primarily to increased self-insurance costs associated with professional and general liability claims and investments we made in our core business in 2010 , including the investment in our case management function , as discussed above . as a result of the jury verdict discussed in note 22 , contingencies and other commitments , “ other litigation , ” to the accompanying consolidated financial statements , we recorded a $ 4.6 million charge to other operating expenses during the second quarter of 2010. in addition , we update our actuarial estimates surrounding our self-insurance reserves in june and december of each year . during 2010 , we recorded a $ 7.6 million increase in self-insurance costs associated with professional and general liability risks due to revised actuarial estimates that primarily resulted from an increase in expected losses on a subset of claims in our recent claims history . other operating

