on may 1 , 2018 , we completed the acquisition of all of the issued and outstanding stock of ambercare for approximately $ 39.6 million plus the amount of excess cash held by ambercare at closing ( approximately $ 12.0 million ) . with the purchase of ambercare , we expanded our personal care operations and acquired hospice and home health operations in the state of new mexico . we funded this acquisition through the delayed draw term loan portion of our credit facility . effective october 31 , 2018 , we entered into a definitive agreement to acquire the assets of vip health care services for approximately $ 28.0 million . with the purchase of vip health care services , we will expand our personal care operations in the state of new york and into the new york city metropolitan area . we expect to complete this transaction in the second quarter of 2019 , 35 contingent on the timing of certain regulatory approvals . we expect to fund this acquisition through a delayed draw term loan under our credit facility and available cash on hand . revenue by payor our payor clients are principally federal , state and local governmental agencies and , increasingly , managed care organizations . the federal , state and local programs under which the agencies operate are subject to legislative , budgetary and other risks that can influence reimbursement rates . we are experiencing a transition of business from government payors to managed care organizations , which we believe aligns with our emphasis on coordinated care and the reduction of the need for acute care . for the years ended december 31 , 2018 , 2017 and 2016 , our payor revenue was : replace_table_token_10_th with the acquisition of ambercare completed during the second quarter of 2018 , we began to report our business with two additional segments , hospice and home health . for the year ended december 31 , 2018 , our hospice and home health revenue was : replace_table_token_11_th we derive a significant amount of our net service revenues in illinois , which represented 47.5 % , 52.6 % and 53.6 % of our total net service revenues for the years ended december 31 , 2018 , 2017 and 2016 , respectively . a significant amount of our net service revenues are derived from one payor client , the illinois department on aging , which accounted for 31.0 % , 36.5 % and 42.1 % of our total net service revenues for the years ended december 31 , 2018 , 2017 and 2016 , respectively . the illinois department on aging 's payments for non-medicaid consumers have been delayed in the past and may continue to be delayed in the future due to budget disputes . the state of illinois did not adopt comprehensive budgets for fiscal years 2016 or 2017 , ending june 30 , 2016 and june 30 , 2017 , respectively . on july 6 , 2017 , the state of illinois passed a budget for the state fiscal year 2018 , which began on july 1 , 2017 , authorizing the illinois department on aging to pay for our services rendered to non-medicaid consumers provided in prior fiscal years . as of december 31 , 2018 , we have received substantially all such payments . on june 4 , 2018 , the state of illinois passed a budget for state fiscal year 2019 , which began in july 1 , 2018. in december 2014 , the chicago city council passed an ordinance that will raise the minimum wage for chicago workers to $ 13 per hour by july of 2019 , with increases up to $ 1 per hour effective on july 1 of each year . the rate is $ 12 per hour effective july 1 , 2018. the wage increase in 2016 did not have a material impact on our financial results because of our existing wage scale . the 2017 36 wage increase was offset by a reimbursement rate increase . in the budget process for the 2019 fiscal year , a similar provision was proposed but was not included in the f inal budget . we believe that there is legislative support for a reimbursement rate increase and anticipate that an increase to offset the wage increase could be passed in the first half of 2019. our financial performance will be impacted in qu arters for wh ich a reimbursement rate increase is not in effect . impact of changes in medicare and medicaid reimbursement in april of 2018 , the centers for medicare and medicaid services ( “ cms ” ) issued a final rule , which beginning january 1 , 2019 , will allow medicare advantage insurers to offer beneficiaries more options and new benefits . through this new rule , cms has redefined health-related supplemental benefits to include services that increase health and improve quality of life , including coverage of non-skilled in-homecare . this policy change , emphasizing improving quality and reducing costs , aligns with our overall approach to care , and we believe the increased demand for personal care from the medicare advantage population represents a significant upside opportunity over the next three to five years . components of our statements of income net service revenues we generate net service revenues by providing our services directly to consumers and primarily on an hourly basis . we receive payment for providing such services from our payor clients , including federal , state and local governmental agencies , managed care organizations , commercial insurers and private consumers . net service revenues are principally provided based on authorized hours , determined by the relevant agency , at an hourly rate which is either contractual or fixed by legislation and are recognized at the time services are rendered . story_separator_special_tag gross profit , expressed as a percentage of net service revenues , decreased from 27.2 % for the year ended december 31 , 2017 to 25.8 % for the year ended december 31 , 2018. the decrease was primarily due to our adoption of asc 606 , as described above , which resulted in a $ 9.7 million decrease in net service revenues for the year ended december 31 , 2018. provision for doubtful accounts decreased by approximately $ 8.1 million to $ 0.3 million for the year ended december 31 , 2018 compared to $ 8.4 million for the year ended december 31 , 2017. the decrease was primarily due to our adoption of asc 606 which resulted in a $ 8.0 million decrease in the provision for doubtful accounts for the year ended december 31 , 2017 , as the majority of what historically was classified as provision for doubtful accounts under operating expenses is now treated as an implicit price concession factored into net service revenues . general and administrative expenses increased by approximately $ 8.8 million for the year ended december 31 , 2018. the increase in general and administrative expenses was primarily due to acquisitions that resulted in a $ 6.4 million increase in administrative employee wages , taxes and benefit costs , a $ 1.2 million increase in commissions , and a $ 0.7 million increase in rent expenses for the year ended december 31 , 2018. hospice segment replace_table_token_15_th 42 in the second quarter of 2018 , with the completion of the acquisition of ambercare , we began operating a hospice segment . hospice generates net service revenues by providing care to patients with a life expectancy of six months or less and their families . net service revenues from medicare and managed care organizations accounted for 93.6 % and 5.6 % for the year ending december 31 , 2018 , respectively . gross profit , expressed as a percentage of net service revenues was 46.9 % for the year ending december 31 , 2018. general and administrative expenses , expressed as a percentage of net service revenues was 19.9 % for the year ending december 31 , 2018. the hospice segment 's general and administrative expenses primarily consist of administrative employee wages , taxes and benefit costs , rent , information technology and office expenses . the hospice segment 's operating income was $ 5.1 million for the year ending december 31 , 2018. home health segment replace_table_token_16_th on may 1 , 2018 , with the acquisition of ambercare , we began operating a home health segment . home health generates net service revenues by providing home health services on a short-term , intermittent or episodic basis to individuals , generally to treat an illness or injury . net service revenues from medicare and managed care organizations accounted for 88.0 % and 11.0 % for the year ending december 31 , 2018 , respectively . gross profit , expressed as a percentage of net service revenues was 33.4 % for the year ending december 31 , 2018. general and administrative expenses , expressed as a percentage of net service revenues was 22.6 % for the year ending december 31 , 2018. the home health segment 's general and administrative expenses consist of administrative employee wages , taxes and benefit costs , rent , information technology and office expenses . the home health segment 's operating income was $ 0.7 million for the year ending december 31 , 2018 . 43 results of operations year ended december 31 , 2017 compared to year ended december 31 , 2016 the following table sets forth , for the periods indicated , our consolidated results of operations . replace_table_token_17_th ( 1 ) average billable census is the number of unique clients receiving a billable service during the year . ( 2 ) billable hours is the total number of hours served to clients during a year . ( 3 ) for the years ended december 31 , 2017 and 2016 , revenue , gross profit , provision for doubtful accounts , operating expenses , operating income from continuing operations , income tax expense , net income from continuing operations and net income have been updated to reflect the correction , as discussed in note 2 to the notes to consolidated financial statements for additional information . net service revenues from state , local and other governmental programs accounted for 64.2 % and 70.5 % of net service revenues for 2017 and 2016 , respectively . managed care organizations accounted for 33.1 % and 26.0 % of net service revenues in 2017 and 2016 respectively , with private and commercial payors accounting for the remainder of net service revenues . a significant amount of our net service revenues in 2017 and 2016 were derived from one payor client , illinois department on aging , which accounted for 36.5 % and 42.1 % respectively , of our total net service revenues . net service revenues increased $ 25.1 million , or 6.3 % , to $ 426.0 million for 2017 compared to $ 400.9 million for 2016. the increase was primarily due to a 4.1 % increase in average billable census and a 2.9 % increase in revenues per billable hour . gross profit , expressed as a percentage of net service revenues , increased to 27.2 % for 2017 , from 26.5 % in 2016. this increase was primarily due to a $ 3.7 million reduction in direct service costs associated with benefits , travel mileage and unemployment taxes , and our exit from the lower margin adult day services centers . 44 general and administrative expenses , expressed as a percentage of net service revenues decreased to 18.1 % for 2017 , from 19.2 % in 2016. the decrease in general and administrative expenses was primarily du e to a decrease in severance and restructuring costs of $ 6.4 million and a decrease in costs for

cash flows the following table summarizes historical changes in our cash flows for the years ended december 31 , 2018 , 2017 and 2016 : replace_table_token_19_th year ended december 31 , 2018 compared to year ended december 31 , 2017 net cash provided by operating activities was $ 33.2 million for the year ended december 31 , 2018 , compared to $ 52.8 million for the same period in 2017. for the year ended december 31 , 2017 , the state of illinois passed a budget on july 6 , 2017 , which resulted in significant receipts on accounts receivable for services previously provided . during the year ended december 31 , 2018 , we received timely payments on receivables from the state of illinois . net cash used in investing activities was $ 67.8 million for the year ended december 31 , 2018 , compared to $ 24.3 million for the year ended december 31 , 2017. our investing activities for the year ended december 31 , 2018 consisted of $ 39.6 million for the acquisition of ambercare , net of cash acquired of $ 12.0 million , $ 18.9 million for the acquisition of arcadia , $ 3.3 million for the acquisition of lifestyle and $ 3.4 million in purchases of property and equipment primarily related to investments in our technology infrastructure . our investing activities for the year ended december 31 , 2017 consisted of $ 2.6 million in proceeds from the sale of three adult day services centers , $ 1.1 million in proceeds from the sale of investments in joint ventures , $ 22.4 million for the acquisition of options home care , net of cash acquired , $ 1.9 million for the acquisition of sun cities , net of cash acquired , and $ 3.6 million in purchases of property and equipment primarily related to new office space and investments in our technology infrastructure .


 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.
     ```cash flows the following table summarizes historical changes in our cash flows for the years ended december 31 , 2018 , 2017 and 2016 : replace_table_token_19_th year ended december 31 , 2018 compared to year ended december 31 , 2017 net cash provided by operating activities was $ 33.2 million for the year ended december 31 , 2018 , compared to $ 52.8 million for the same period in 2017. for the year ended december 31 , 2017 , the state of illinois passed a budget on july 6 , 2017 , which resulted in significant receipts on accounts receivable for services previously provided . during the year ended december 31 , 2018 , we received timely payments on receivables from the state of illinois . net cash used in investing activities was $ 67.8 million for the year ended december 31 , 2018 , compared to $ 24.3 million for the year ended december 31 , 2017. our investing activities for the year ended december 31 , 2018 consisted of $ 39.6 million for the acquisition of ambercare , net of cash acquired of $ 12.0 million , $ 18.9 million for the acquisition of arcadia , $ 3.3 million for the acquisition of lifestyle and $ 3.4 million in purchases of property and equipment primarily related to investments in our technology infrastructure . our investing activities for the year ended december 31 , 2017 consisted of $ 2.6 million in proceeds from the sale of three adult day services centers , $ 1.1 million in proceeds from the sale of investments in joint ventures , $ 22.4 million for the acquisition of options home care , net of cash acquired , $ 1.9 million for the acquisition of sun cities , net of cash acquired , and $ 3.6 million in purchases of property and equipment primarily related to new office space and investments in our technology infrastructure .
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 Suspicious Activity Report : on may 1 , 2018 , we completed the acquisition of all of the issued and outstanding stock of ambercare for approximately $ 39.6 million plus the amount of excess cash held by ambercare at closing ( approximately $ 12.0 million ) . with the purchase of ambercare , we expanded our personal care operations and acquired hospice and home health operations in the state of new mexico . we funded this acquisition through the delayed draw term loan portion of our credit facility . effective october 31 , 2018 , we entered into a definitive agreement to acquire the assets of vip health care services for approximately $ 28.0 million . with the purchase of vip health care services , we will expand our personal care operations in the state of new york and into the new york city metropolitan area . we expect to complete this transaction in the second quarter of 2019 , 35 contingent on the timing of certain regulatory approvals . we expect to fund this acquisition through a delayed draw term loan under our credit facility and available cash on hand . revenue by payor our payor clients are principally federal , state and local governmental agencies and , increasingly , managed care organizations . the federal , state and local programs under which the agencies operate are subject to legislative , budgetary and other risks that can influence reimbursement rates . we are experiencing a transition of business from government payors to managed care organizations , which we believe aligns with our emphasis on coordinated care and the reduction of the need for acute care . for the years ended december 31 , 2018 , 2017 and 2016 , our payor revenue was : replace_table_token_10_th with the acquisition of ambercare completed during the second quarter of 2018 , we began to report our business with two additional segments , hospice and home health . for the year ended december 31 , 2018 , our hospice and home health revenue was : replace_table_token_11_th we derive a significant amount of our net service revenues in illinois , which represented 47.5 % , 52.6 % and 53.6 % of our total net service revenues for the years ended december 31 , 2018 , 2017 and 2016 , respectively . a significant amount of our net service revenues are derived from one payor client , the illinois department on aging , which accounted for 31.0 % , 36.5 % and 42.1 % of our total net service revenues for the years ended december 31 , 2018 , 2017 and 2016 , respectively . the illinois department on aging 's payments for non-medicaid consumers have been delayed in the past and may continue to be delayed in the future due to budget disputes . the state of illinois did not adopt comprehensive budgets for fiscal years 2016 or 2017 , ending june 30 , 2016 and june 30 , 2017 , respectively . on july 6 , 2017 , the state of illinois passed a budget for the state fiscal year 2018 , which began on july 1 , 2017 , authorizing the illinois department on aging to pay for our services rendered to non-medicaid consumers provided in prior fiscal years . as of december 31 , 2018 , we have received substantially all such payments . on june 4 , 2018 , the state of illinois passed a budget for state fiscal year 2019 , which began in july 1 , 2018. in december 2014 , the chicago city council passed an ordinance that will raise the minimum wage for chicago workers to $ 13 per hour by july of 2019 , with increases up to $ 1 per hour effective on july 1 of each year . the rate is $ 12 per hour effective july 1 , 2018. the wage increase in 2016 did not have a material impact on our financial results because of our existing wage scale . the 2017 36 wage increase was offset by a reimbursement rate increase . in the budget process for the 2019 fiscal year , a similar provision was proposed but was not included in the f inal budget . we believe that there is legislative support for a reimbursement rate increase and anticipate that an increase to offset the wage increase could be passed in the first half of 2019. our financial performance will be impacted in qu arters for wh ich a reimbursement rate increase is not in effect . impact of changes in medicare and medicaid reimbursement in april of 2018 , the centers for medicare and medicaid services ( “ cms ” ) issued a final rule , which beginning january 1 , 2019 , will allow medicare advantage insurers to offer beneficiaries more options and new benefits . through this new rule , cms has redefined health-related supplemental benefits to include services that increase health and improve quality of life , including coverage of non-skilled in-homecare . this policy change , emphasizing improving quality and reducing costs , aligns with our overall approach to care , and we believe the increased demand for personal care from the medicare advantage population represents a significant upside opportunity over the next three to five years . components of our statements of income net service revenues we generate net service revenues by providing our services directly to consumers and primarily on an hourly basis . we receive payment for providing such services from our payor clients , including federal , state and local governmental agencies , managed care organizations , commercial insurers and private consumers . net service revenues are principally provided based on authorized hours , determined by the relevant agency , at an hourly rate which is either contractual or fixed by legislation and are recognized at the time services are rendered . story_separator_special_tag gross profit , expressed as a percentage of net service revenues , decreased from 27.2 % for the year ended december 31 , 2017 to 25.8 % for the year ended december 31 , 2018. the decrease was primarily due to our adoption of asc 606 , as described above , which resulted in a $ 9.7 million decrease in net service revenues for the year ended december 31 , 2018. provision for doubtful accounts decreased by approximately $ 8.1 million to $ 0.3 million for the year ended december 31 , 2018 compared to $ 8.4 million for the year ended december 31 , 2017. the decrease was primarily due to our adoption of asc 606 which resulted in a $ 8.0 million decrease in the provision for doubtful accounts for the year ended december 31 , 2017 , as the majority of what historically was classified as provision for doubtful accounts under operating expenses is now treated as an implicit price concession factored into net service revenues . general and administrative expenses increased by approximately $ 8.8 million for the year ended december 31 , 2018. the increase in general and administrative expenses was primarily due to acquisitions that resulted in a $ 6.4 million increase in administrative employee wages , taxes and benefit costs , a $ 1.2 million increase in commissions , and a $ 0.7 million increase in rent expenses for the year ended december 31 , 2018. hospice segment replace_table_token_15_th 42 in the second quarter of 2018 , with the completion of the acquisition of ambercare , we began operating a hospice segment . hospice generates net service revenues by providing care to patients with a life expectancy of six months or less and their families . net service revenues from medicare and managed care organizations accounted for 93.6 % and 5.6 % for the year ending december 31 , 2018 , respectively . gross profit , expressed as a percentage of net service revenues was 46.9 % for the year ending december 31 , 2018. general and administrative expenses , expressed as a percentage of net service revenues was 19.9 % for the year ending december 31 , 2018. the hospice segment 's general and administrative expenses primarily consist of administrative employee wages , taxes and benefit costs , rent , information technology and office expenses . the hospice segment 's operating income was $ 5.1 million for the year ending december 31 , 2018. home health segment replace_table_token_16_th on may 1 , 2018 , with the acquisition of ambercare , we began operating a home health segment . home health generates net service revenues by providing home health services on a short-term , intermittent or episodic basis to individuals , generally to treat an illness or injury . net service revenues from medicare and managed care organizations accounted for 88.0 % and 11.0 % for the year ending december 31 , 2018 , respectively . gross profit , expressed as a percentage of net service revenues was 33.4 % for the year ending december 31 , 2018. general and administrative expenses , expressed as a percentage of net service revenues was 22.6 % for the year ending december 31 , 2018. the home health segment 's general and administrative expenses consist of administrative employee wages , taxes and benefit costs , rent , information technology and office expenses . the home health segment 's operating income was $ 0.7 million for the year ending december 31 , 2018 . 43 results of operations year ended december 31 , 2017 compared to year ended december 31 , 2016 the following table sets forth , for the periods indicated , our consolidated results of operations . replace_table_token_17_th ( 1 ) average billable census is the number of unique clients receiving a billable service during the year . ( 2 ) billable hours is the total number of hours served to clients during a year . ( 3 ) for the years ended december 31 , 2017 and 2016 , revenue , gross profit , provision for doubtful accounts , operating expenses , operating income from continuing operations , income tax expense , net income from continuing operations and net income have been updated to reflect the correction , as discussed in note 2 to the notes to consolidated financial statements for additional information . net service revenues from state , local and other governmental programs accounted for 64.2 % and 70.5 % of net service revenues for 2017 and 2016 , respectively . managed care organizations accounted for 33.1 % and 26.0 % of net service revenues in 2017 and 2016 respectively , with private and commercial payors accounting for the remainder of net service revenues . a significant amount of our net service revenues in 2017 and 2016 were derived from one payor client , illinois department on aging , which accounted for 36.5 % and 42.1 % respectively , of our total net service revenues . net service revenues increased $ 25.1 million , or 6.3 % , to $ 426.0 million for 2017 compared to $ 400.9 million for 2016. the increase was primarily due to a 4.1 % increase in average billable census and a 2.9 % increase in revenues per billable hour . gross profit , expressed as a percentage of net service revenues , increased to 27.2 % for 2017 , from 26.5 % in 2016. this increase was primarily due to a $ 3.7 million reduction in direct service costs associated with benefits , travel mileage and unemployment taxes , and our exit from the lower margin adult day services centers . 44 general and administrative expenses , expressed as a percentage of net service revenues decreased to 18.1 % for 2017 , from 19.2 % in 2016. the decrease in general and administrative expenses was primarily du e to a decrease in severance and restructuring costs of $ 6.4 million and a decrease in costs for

