2023-05-12T13:01:31-05:00 2022-06-30 861065772 Deloitte Tax LLP 111 MONUMENT CIRCLE Suite 4200 INDIANAPOLIS IN 462045108 990 2021-07-01 420680391 Mercy Hospital Iowa City Iowa MERC 3193390300 500 East Market Street Iowa City IA 52245 Tom Clancy CEO 3193390300 2023-05-12 1 Tom Clancy 999009999 Shawna M Jansons P01222873 3174648600 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z Tom Clancy 500 East Market Street Iowa City IA 52245 233545515 0 0928 X www.mercyiowacity.org X 1873 IA To heal and comfort the sick and improve the health of the community in the spirit of Jesus Christ. 17 13 1362 114 5178746 0 1679077 3075832 176260217 168749231 4731889 4158235 10609055 1035307 193280238 177018605 0 14665 0 0 69704817 70453482 0 0 0 113123973 123367437 182828790 193835584 10451448 -16816979 261026318 209423313 164155664 153616891 96870654 55806422 Mercy Iowa City ("Mercy") heals and comforts the sick and works to improve the health of the community in the spirit of Jesus Christ and the Catholic tradition of the Sisters of Mercy. 0 0 121624627 14665 170152149 Hospital Services. In keeping with our mission of healing and comforting the sick, providing hospital medical services is at the heart of what we do. These services are provided in inpatient and outpatient settings, in situations that may be emergent, acute or chronic. Services include a 24 hour emergency unit, intensive and cardiovascular care. We also service a maternity unit and newborn nursery along with other surgical services, cardiac cath lab, cancer care, digestive care, telemetry monitored care, medical care, stroke care. 340049 282544 Education. The ongoing education of Mercy staff is critical in the fast changing field of health care and it necessary to meet regulations and certifications. Mercy hosts a number of professional continuing education classes each year, which is attended by it's own staff and staff from other institutions. Mercy provides a setting for students who are considering a career in health care including a class of insight to possible careers and preparation for CNA exam. 11524279 Community Benefit. Mercy's community benefits take many forms, beginning with the traditional charity care of ($1.0 million) and the unpaid cost of Medicaid ($6.2 million). Other examples include cash donations to community non-for-profits such as the Free Medical Clinic, leadership time and skills that further the work of the non-for-profits, first aid booth provided at public events including the Johnson Co Fair. These efforts are detailed in Mercy's community health benefit report. As a trusted, longtime member of the community, Mercy plays an important role not only in further community health but the general community good. 133488955 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 40 0 1 1362 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 17 13 1 1 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Tom Clancy 3193393540 500 East Market Street Iowa City IA 52245 Dawna Miller Treasurer 40.00 2.00 X X 346293 0 45192 Scott Alderman VP - Information and Technology 40.00 0.00 X X 231048 0 23146 Kim Volk VP - Nursing 40.00 0.00 X X 215130 0 24513 Mike Trachta CEO & Administrator (Beg 10/21) 1.00 41.00 X X 0 0 0 Sean Williams CEO & Administrator (End 9/21) 40.00 2.00 X X 0 0 0 Tom Clancy Vice Chair/Secretary 1.00 0.00 X X 0 0 0 Bob Ritz Board Member 1.00 1.00 X 0 0 0 Dave Vellinga Board Member 1.00 1.00 X 0 0 0 Dr Chris Scott Board Member 1.00 0.00 X 0 0 0 Jack Dusenbery Board Member 1.00 0.00 X 0 0 0 Karin Franklin Board Member 1.00 0.00 X 0 0 0 Madeline Windauer Board Member 1.00 1.00 X 0 0 0 Mary Westbrook Board Member 1.00 0.00 X 0 0 0 SR Helen Marie Burns Board Member 1.00 0.00 X 0 0 0 SR Linda Bretchen Board Member 1.00 0.00 X 0 0 0 SR Rita Specht Board Member 1.00 0.00 X 0 0 0 Steven Anderson Board Member 1.00 0.00 X 0 0 0 Tom McLaughlin Chair 1.00 1.00 X X 0 0 0 Kimberley Rossiter Assistant Treasurer 40.00 2.00 X 141766 0 24885 James Nielsen Physician 40.00 0.00 X 605725 0 36071 Andrew Ashby Physician 40.00 0.00 X 536364 0 34539 Luke Brunkhorst Physician 40.00 0.00 X 525513 0 30735 Michael Hoffman Physician 40.00 0.00 X 465724 0 41395 Rhys Kavanagh Physician 40.00 0.00 X 469180 0 40818 Martin Izakovic Former VP/Physician 40.00 0.00 X 238363 0 36818 3775106 0 338112 96 1 1 0 Medefis Consolidated PO Box 5068 New York NY 100875068 Contract Nursing Labor 8431850 Allscripts Healthcare 24630 Network Place Chicago IL 60631 EHR/Help Desk Services 3800179 The Chartis Group LLC 220 W Kinzie St Chicago IL 60654 EHR Implementation Consulting 3510185 Vaya Workforce Solutions LLC Dept CH18001 Palantine IL 600558001 Contract Clinical Labor 3101980 MercyOne PO Box 74008768 Chicago IL 606748768 Management Services 2885332 71 1329000 1746832 3075832 Patient Serv. Revenue 621400 87269874 87269874 Medicare/Medicaid 621400 70643705 70643705 Lab Outreach 621511 5178746 5178746 ASC/DIC Income 900099 3596095 3596095 2060811 2060811 168749231 1340923 1340923 1188393 1001679 186714 186714 186714 58342543 55525231 2817312 2817312 2817312 Cafeteria Income 722310 468790 468790 Emerson Point Meal Svc 722320 130046 130046 Telephone 517700 64585 64585 185172 185172 848593 177018605 163950288 5178746 4813739 X 13550 13550 1115 1115 993739 258486 735253 156513 156513 57713070 40220238 17492832 1553177 1082409 470768 5912054 4120110 1791944 4124929 2874663 1250266 2136708 2136708 498118 498118 132061 132061 26508 26508 32255183 21791494 10463689 529744 529744 11894459 7531350 4363109 8165218 280077 7885141 2492937 107179 2385758 137408 52742 84666 4135993 1615624 2520369 9811444 7731449 2079995 2327052 2327052 Medical Supplies 17670154 17658660 11494 Pharmacy Supplies 12645180 12372477 272703 Bad Debt Expense 11023219 11023219 Food Expense 1221357 1221357 6264694 3532756 2731938 193835584 133488955 60346629 0 22087082 5790517 1593041 133521 24230682 31243280 4404135 3579601 3167584 2610445 258746537 196366096 54919612 62380441 100105986 52778600 -78490419 -91318072 129008615 142224980 261026318 209423313 41950660 35705862 64516446 70127406 1819756 2316111 55868802 45467512 164155664 153616891 X 96870654 55806422 96870654 55806422 261026318 209423313 X -16816979 -11464513 -12782740 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 1 0 1 0 1 26508 26508 0 Part II-B, Line 1: Mercy Hospital, Iowa City, Iowa is a member of the Iowa Hospital Association (IHA) and American Hospital Association (AHA). A percentage of membership dues paid to IHA and AHA relate to Lobbying activities. 20513591 37504 -2858763 1274658 16417674 16457386 47025 5088018 1078838 20513591 17144539 140115 -233781 593487 16457386 17286002 14493 377510 533466 17144539 16775239 456231 744957 690425 17286002 0.83300 0.16700 0 1 1 4165665 4165665 142408307 112143676 30264631 110892507 83597282 27295225 1280058 625138 654920 62380441 Beneficial Interest-Foundation 16538204 Due From Affiliates 116452921 2011/2018 Bond Fund 4093477 ROU Assets 5140378 142224980 Pension Benefit Liability 39474959 Other Long-Term Liabilities 4382256 Professional Liability Claims 1610297 45467512 Part V, Line 4: All Restricted Endowed Funds are used for the benefit of Mercy Hospital Iowa City - capital equipment, employee grants, scholarships, etc. 1 1 X 1 X 1 X 1 1 1 0 1 1 1341169 1341169 0.00730 21089826 10906716 10183110 0.05570 22430995 10906716 11524279 0.06300 229149 229149 0.00130 617158 492985 124173 0.00070 846307 492985 353322 0.00200 23277302 11399701 11877601 0.06500 3999 3999 0.00000 3999 3999 0.00000 0 3028078 0 42421649 53783350 -11361701 X 1 1 1 Iowa City Ambulatory Surgery Center LLC Outpatient Surgery Center 0.40000 0.60000 2 Corridor Radiology LLC Outpatient Radiology Services 0.51000 0.49000 3 Eastern Iowa Rehabilitation Hospital LLC Rehabilitation Services 0.51000 0.49000 1 1 Mercy Hospital 500 East Market Street Iowa City IA 52245 www.mercyiowacity.org 520074H X X X X Lab Outreach Mercy Hospital Iowa City Iowa 1 0 0 1 X X X X X X X X X 21 1 0 0 1 X See Part V, Section C X 1 21 1 See Part V, Section C 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X 1 X See Part V, Section C X See Part V, Section C X See Part V, Section C X X X X X X 1 X 0 X X X X 1 X 0 0 Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 5: To solicit input from community stakeholders (key informants), those individuals who have a broad interest in the health of the community, an Online Key Informant Survey also was implemented as part of this process. A list of recommended participants was compiled by Mercy Iowa City; this list included names and contact information for physicians, public health representatives, other health professionals, social service providers, and a variety of other community leaders. Potential participants were chosen because of their ability to identify primary concerns of the populations with whom they work, as well as of the community overall. Final participation included representatives of the organizations outlined below.- Coralville Fire Department- Iowa City- Iowa City Area Development- Iowa City Crisis Center- Iowa City Fire Department- Johnson County- Johnson County Public Health Representative- Kinze Manufacturing- Lone Tree School District- Mercy Hospital Emergency Physicians- Mercy Services- NAMI of Johnson County- Oaknoll Retirement Community- Rural Health and Safety of Eastern Iowa (RHSEI)- UI College of Public Health - United Way- University Police- Washington County Hospital and ClinicsThrough this process, input was gathered from several individuals whose organizations work with low income, minority, or other medically underserved populations. Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 7a:https://www.mercyiowacity.org/upload/docs/About%20Mercy/2021%20PRC%20CHNA%20Report%20-%20Mercy%20Iowa%20City.pdf Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 10a:https://www.mercyiowacity.org/upload/docs/About%20Mercy/2021%20CHNA%20Implementation%20Plan.pdf Mercy Hospital, Iowa City, Iowa: Part V, Section B, Line 11:The 2021 CHNA summarized 11 areas of opportunity identified through Public Health, Vital Statistics, and Benchmark Data and 6 areas of need identified by Key Informants considered to be major needs. Mercy Hospital is addressing these needs as follows:Mental Health - Access to providers and facilities:In 2022, we hired a full-time physician psychiatrist specialist to both extend our psychiatric visits on our hospital campus and also to lead an effort to evaluate the options for developing a closed psychiatric unit. In the outpatient setting, we also have hired a second therapist to increase our therapy visits. We also intend to maintain mental health related links such as "Guild to Mental Health Resources" as well as "Stress and Coping" on our website for quick and convenient educational information available to the public.Nutrition, Physical Activity & Weight - Cultural headwinds and lack of insurance covered programs for children: In 2022, we expanded our bariatric surgery program by hiring a second physician and a second dietician. Bariatric surgery is an effective treatment option especially when it is supported by a robust support program that features dieticians. We intend to maintain our posts of healthy recipes with video instruction on the Mercy website and to provide a walk-in Wellness Program which aims to increase physical activity and increase healthy eating in our community.Substance Abuse - Alcohol, meth, opioid treatment options limited: Maintain a nurse navigator service that provides callbacks to patients as well as assisting these patients and their families in obtaining counseling services, transportation, or primary care referrals. Reopen meeting rooms so the local AA chapter can resume in-person meetings once our rooms become available, provided COVID status safety concerns are met.Diabetes - Limited access to dieticians and poor insurance coverage: Continue to offer a free pre-diabetes class taught by a registered dietician. This is offered as a virtual class in order to improve access to anyone interested. Continue to provide diabetic education to hospital based nurses so they can more directly convey the importance of managing this disease to patients. We also offer individualized diabetic education which covers nutrition management, the role of physical activity, psychosocial adjustment and healthy coping, glucose monitoring and insulin administration.Corona Virus/COVID-19 - Vaccination rate disparities: We began offering vaccinations in select clinics in 2021 and intend to continue offering those as long as the need persists. We also continue to offer tele visits which provide improved access to our providers for those in more rural settings where travel may be more difficult.Dementia/Alzheimer's - Lack of geriatric care units, adult daycare, and outpatient services focused on memory disorders: Maintain a nurse navigator service to arrange therapies and to assist in obtaining home health and/or respite care for the patients' caregivers. Primary Care Access - Cedar and Muscatine: Maintain a primary care presence in these two counties. Lung Cancer - Cedar and Muscatine:Maintain our low-dose CT screening program for long term smokers. Continue to offer smoking cessation counseling.Heart Disease - Iowa: Maintain our Primary Stroke Center designation through The Joint Commission and our recognition as a Blue Distinction Center for heart care. Maintain our Emergency Care protocols and training that have helped us achieve interventions "faster than the national average".Births to Adolescents - Muscatine and Washington: Maintain our primary care clinic in Muscatine and continue to provide support by linking prospective mothers to our OBGYN affiliates, our pediatric outpatient clinic, our breastfeeding support classes, and to provide access to our financial counselors. Maintain our website support including a free pregnancy tracker app. STI - Johnson: Continue to staff the infectious disease position. This person will monitor chlamydia incidence and maintain relationships with the public health departments at the county and state levels. Mercy Hospital, Iowa City, Iowa Part V, line 16a, FAP website:https://www.mercyiowacity.org/upload/docs/Patients%20and%20Visitors/Financial%20Assistance%20Docs/MercyIC%20Financial%20Assistance%20Policy_2021.pdf Mercy Hospital, Iowa City, Iowa Part V, line 16b, FAP Application website:https://www.mercyiowacity.org/upload/docs/Patients%20and%20Visitors/Financial%20Assistance%20Docs/Financial%20Assistance%20App_2021.pdf Mercy Hospital, Iowa City, Iowa Part V, line 16c, FAP Plain Language Summary Website:https://www.mercyiowacity.org/upload/docs/Patients%20and%20Visitors/Financial%20Assistance%20Docs/MercyIC%20Plain%20Language%20Summary_2021.pdf 1 1 - Mercy Home Health Care 500 East Market Street Iowa City IA 52245 Home Health and Private Duty Nursing Part I, Line 3c: Mercy Hospital also uses asset level, medical indigency, insurance status, and underinsurance status as factors in determining eligibility for free and discounted care. Part I, Line 7: Amounts in the table were derived using a cost accounting system that addresses all patient segments. A cost to charge ratio derived from completing IRS worksheet 2 was used to determine the amounts in Part I, Line 7a, 7b, 7c. and 7g. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 11,023,218. Part III, Line 2: The amount of bad debt expense reported on line 2 was derived from taking actual bad debt write-offs and applying the cost to charge ratio of .2747 to that amount. Part III, Line 3: Mercy Hospital works with those qualifying for charity care along every step of the process. Every effort is made to work with the patient to provide financial assistance when appropriate. While there are people who do not cooperate with Mercy Hospital regarding payment plans, financial assistance or with those trying to get help from Government programs. For individuals not providing necessary information, it is impossible to know the reason for not cooperating and therefore know whether they will qualify for charity care. Mercy Hospital is unable to reasonably determine whether any amount of bad debt could have been classified as charity care if the individuals do not provide the necessary information to evaluate their situation to determine qualifications with the charity care policy. Part II, Community Building Activities: Community Support:Mercy is proud to continue our dedicated annual support that we provide to our community.Mercy has provided support to the following community organizations in financial support, promotional collaboration and/or colleague volunteer time:Through the Iowa City Free Medical Clinic, Mercy provided mammograms and radiology exams at no charge to community members. Mercy holds a high emphasis for the importance of preventative care and wants to ensure access to mammograms for all community members, regardless of financial means. Mercy Iowa City is pleased to continue our partnership with Iowa City Hospice; often accepting patients for acute care and/or respite care. Mercy accommodates subsidies for Hospice patients as needed and is proud to continue to promote the value Iowa City Hospice in our community. Continued collaboration with Team Breast Friends, Breast Cancer Awareness Association through promotional materials offered in cancer care bags provided to Mercy cancer patients purchased by the Mercy Guild. The Mercy Hospital Foundation works with Team Breast Friends to offer in annual support to women in need who were unable to pay for mammography services at the hospital.Mercy Hospital is a partner in the community-wide initiative called Honoring Your Wishes. Mercy helps community members talk about long-term health care wishes and desires. Mercy offers to create a written plan of those wishes and desires referred to as Advanced Directives. This service is highly educational to community members and is provided at no charge through the Mercy Pastoral Care Department. Mercy's Pastoral Care Department provides clothing to discharged patients who lack appropriate attire, often because what they had worn when they were admitted was cut off in the Emergency Room to provide immediate care. Transportation is also provided via paid taxi for discharged patients and/or their family members as needed due to lack of financial means for required transportation.Mercy's 24-hour Mercy On-Call service provides medical triage and health information, scheduling of provider appointments, and refers callers to local supporting services as appropriate at no charge to the community member. This is a valued service and often complimented by community members such as new mothers seeking guidance on potential medical needs for their newborn or community members who are new to our community and unsure of existing resources. SHIIP (Senior Health Insurance Information Program) Volunteers assist seniors navigate through Medicare insurance enrollment with emphasis on the annual Medicare Open Enrollment Period for Part D coverage. 478 community members realized savings during Open Enrollment for Part D in FY 22' for our community members served through Mercy Iowa City. NAMI (National Association for Mental Illness) Mercy supports the annual NAMI walk in efforts to bring awareness and assistance for mental illness.AHA (American Heart Association) Mercy Iowa City supports the AHA Go Red For Women Luncheon to help bring awareness, early detection for heart disease to women.Mercy continues to be a donation site for the Toys-for-Tots annual toy drive, providing toys over the holiday season for children in need. Toys delivered to Mercy Iowa City are then delivered to the designated drop off area for final collection by Toys-for-Tots through Mercy colleague volunteered time. Environmental Improvements:Mercy has been a good neighbor by maintaining its buildings and landscaping at a quality level. Mercy also continues to pursue extensive recycling (including newspapers, office paper, magazines, plastic, batteries, cooking oil, construction materials and more) and pursues equipment that reduce energy consumption as equipment requires replacement.Coalition Building:Mercy is involved in many ways with local citizens and groups that are working to afford all members of our community a good quality of life and to improve overall quality of life. Part III, Line 4: Mercy Hospital's Audited Financial Statements includes a footnote for the Provision of Uncollectible Accounts on page 12 of the Audited Financial Statements. Part III, Line 8: Total revenue was determined using charges per the CMS Provider Statistical Reimbursement System reports for Fee Reimbursed Services for the fiscal year ended 6/30/22. Costs calculated using the Cost to Charge Ratio for the appropriate services from the submitted Medicare Cost Report Form 2552-96 for the fiscal year ended 06/30/22. Part III, Line 9b: Mercy Hospital has two policies related to debt collection. The Financial Assistance Policy provides guidelines for forgiving all or part of a patient's financial responsibility for healthcare services received at Mercy Hospitals. Patient may be given a financial assistance application at the time of service, be offered financial assistance during the normal collection process or learn of the option on the Hospital website. All patients with no insurance are offered financial assistance via billing statements & follow-up telephone calls. Any patient that is known to qualify for financial assistance is provided assistance. The payment plan policy enables those who qualify for patient financial assistance to establish payment plans of the remaining balance of their bill. Part VI, Line 2: The most recent community health needs assessment was conducted in December 2021. The organization engaged Professional Research Consultants to conduct the assessment. The community health survey is a systematic, data-driven approach to determining the health status, behaviors, and needs of residents in the communities the organization serves. The survey instrument used for the assessment is based largely on the Centers for Disease Control (CDC), Behavioral Risk Factor Surveillance System (BRFS), as well as various other public health surveys and customized questions addressing gaps in indicator data, relative to nation health promotion and disease prevention objectives and other recognized health issues. Part VI, Line 3: If a patient is deemed to not have insurance coverage (self-pay) or is under-insured, a referral is made to our third-party vendor to screen the patient for Medicaid eligibility. They can also assist with marketplace products and social security applications. If they are not eligible for Medicaid/Emergency Medicaid, our third-party eligibility vendor notifies the patient of the financial counselors and places a referral to the financial counselor to assist the patient. In order to be eligible for financial assistance the patients must complete the Medicaid, Medicare, and/or insurance exchange review process. The level of assistance is based on where the patient falls on the federal poverty level. The financial counselors provide/assist the patient with completion of the financial aid application and noting the account according to the outcome. Part VI, Line 4: Mercy Hospital is located in the community of Iowa City, Iowa, in Johnson County along the east central part of the state. The county's population in 2021 was approximately 154,748. Mercy Hospital services 10 counties in southeast Iowa, with the primary service area being Johnson County. The secondary service areas includes: Cedar, Iowa, Muscatine and Washington counties. The tertiary service area includes Henry, Jefferson, Keokuk, Lee and Louisa counties. The population of the service area is approximately 340,200.Iowa City is home to the University of Iowa, which has an enrollment of approximately 31,317 for the 2022-2023 academic year. Johnson County is well-educated, of individuals 25 and older, 95.3 percent are high school graduates and 54 percent hold a bachelors degree or higher. The University of Iowa also provides the foundation for an economy that has particular strengths in education, health care, services, technology, agribusiness and manufacturing. According to the U.S. Census Bureau, 14.7 percent of the Johnson County population lived below the poverty line between 2017 and 2021, compared to 11.1 percent for the entire state. Part VI, Line 5: Mercy Iowa City is faith-based institution that provides services based on the ethical and religious directives of the Catholic Church. An important part of Mercy's mission is to improve the health of the community. Mercy does so by: Ensuring that the medical staff is open to all qualified physicians; ensuring that the hospital is accredited and in good standing with the Joint Commission; ensuring that the board of directors is comprised of diverse, independent individuals, not employees of the hospital, representing the community and also providing necessary expertise; establishing and carrying out a conflict of interest policy; providing a site for clinical experience for a variety of health care professionals; providing charity care and financial assistance with medical bills as needed to community members; participating in such programs as Medicare, Medicaid, and Hawk-i, an insurance program for needy Iowa children; absorbing unreimbursed costs for such government programs; ensuring that account collections are carried out in compliance with state and federal guidelines; providing emergency room services and working with local and state officials in community preparedness issues; treating emergency patients according to EMTALA guidelines and service all patients regardless of their ability to pay; investing surplus funds in services, technology, and personnel that will further the benefit of the community. Part VI, Line 7, Reports Filed With States IA 1 Iowa City Area Development Group Inc 136 S Dubuque Street Iowa City IA 52240 421234837 501(c)(6) 12000 0 General Support 0 1 Part I, Line 2: All organizations Mercy provides assistance to are local organizations. Therefore, Mercy is in frequent contact with the organizations and is generally aware of their use of Mercy's assistance. However, there is no formal mechanism in place to track specific uses of the assistance. Mercy Hospital offers a Temporary Assistance Program (TAP) for emergency financial needs that employees may have. This confidential program offers crisis assistance and health benefit assistance. X X X X X 0 0 0 0 0 0 0 1 0 James Nielsen Physician 579459 0 0 0 26266 0 11313 0 24758 0 641796 0 0 0 Andrew Ashby Physician 517989 0 0 0 18375 0 6824 0 27715 0 570903 0 0 0 Luke Brunkhorst Physician 486017 0 39011 0 485 0 4874 0 25861 0 556248 0 0 0 Rhys Kavanagh Physician 420101 0 48839 0 240 0 10150 0 30668 0 509998 0 0 0 Michael Hoffman Physician 444614 0 10810 0 10300 0 10150 0 31245 0 507119 0 0 0 Dawna Miller Treasurer 290553 0 54250 0 1490 0 11721 0 33471 0 391485 0 0 0 Martin Izakovic Former VP/Physician 204804 0 18932 0 14627 0 6825 0 29993 0 275181 0 0 0 Scott Alderman VP - Information and Technology 208048 0 11500 0 11500 0 4812 0 18334 0 254194 0 0 0 Kim Volk VP - Nursing 203947 0 10725 0 458 0 5055 0 19458 0 239643 0 0 0 Kimberley Rossiter Assistant Treasurer 134678 0 6721 0 367 0 5095 0 19790 0 166651 0 0 0 Part I, Line 7 Non-fixed payments were provided to administrators and physicians who met stated criteria that included meeting certain RVU (Relative Value Unit), productivity levels, specified CMS/JACHO performance core indicators and certain patient satisfaction and/or nursing satisfaction survey scores. A City of Hills Iowa 420920947 000000000 2018-05-10 40501771 Refund Bonds issued 04/29/08 0 0 0 B City of Hills Iowa 420920947 431669AW0 2011-11-30 44742571 Build and Equip Facility; Refund Bonds issued 7/16/1998 0 0 0 A 2920000 40501771 4050177 2131594 34320000 2018 1 0 1 1 B 18100000 44743882 589874 20002570 24151438 2012 1 0 1 1 A 0 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 B 0 0 0 1 0 0 0 1 1 A 1 B 1 Schedule K, Part II, Line 3: Differences between the issue price (Part I) and total proceeds (Part II, line 3) are due to investment earnings. Schedule K, Part IV, Line 2c, Column B: Rebate calculation was performed 5/21/14. Schedule K, Part IV, Line 6, Column B: Such amounts were appropriately yield restricted. Form 990, Part VI, Section A, line 2 Sister Helen Marie Burns, board member; Sister Rita Specht, board member; and Sister Linda Bretchen, Board Member are members of the Sister of Mercy of the Americas West Midwest Community, Inc. Dawna Miller and Kimberley Rossiter have a business relationship as all three simultaneously serve together on the Mercy Services Iowa City, Iowa board. Form 990, Part VI, Section A, line 3 MercyOne provides certain management oversight and personnel services pursuant to a strategic management affiliation agreement. Sean Williams, Chief Executive Officer (ending 09/21) of Mercy Hospital, Iowa City, Iowa is not an employee of the hospital, but rather an employee of MercyOne, a management company. For his role as Chief Executive Officer of Mercy Hospital Iowa City, Sean Williams is compensated $972,326 by MercyOne. Mike Trachta, Chief Executive Officer (beginning 10/21) of Mercy Hospital, Iowa City, Iowa is not an employee of the hospital, but rather an employee of MercyOne, a management company. For his role as Chief Executive Officer of Mercy Hospital Iowa City, Mike Trachta is compensated $90,649 by MercyOne. Form 990, Part VI, Section A, line 6 Mercy's sole member is the Sisters of Mercy of the Americas West Midwest Community, Inc. Form 990, Part VI, Section A, line 7b Mercy's sole member, Sisters of Mercy of the Americas West Midwest Community, Inc., maintains a number of "reserved powers" including but not limited to approval of annual budgets, approval of amendments to the articles of incorporation and bylaws, approval of real property transactions and approval of long term borrowing. Form 990, Part VI, Section B, line 11b The Form 990 is prepared and reviewed by Mercy Hospital management and is also reviewed by Deloitte Tax LLP. In addition, a board resolution was established that provides that each board member be (i) provided a copy of the Form 990 as it is intended to be filed, and (ii) given a reasonable opportunity before filing to provide to the Audit Committee any comments, corrections, concerns or other inputs on the proposed Form. The Audit Committee's review process shall be intended to reasonably verify that the Form 990 has been fully and accurately completed, including but not limited to, all inquiries therein relating to corporate governance. After completing its review, the Audit Committee, on the Board's behalf, shall have the authority to authorize the filing of the annual Form 990. Form 990, Part VI, Section B, line 12c A conflict of interest statement is signed at the beginning of Board members term and on an annual basis there after. Any abstention from a vote is recorded in Board minutes. After the fiscal year end a "look back" questionnaire is distributed to all Board members to disclose any conflicts of interest that may have taken place in the previous year. Form 990, Part VI, Section B, line 15 Compensation for all executives and other key employees is determined based on national or regional market data for comparable positions at comparatively sized hospitals. The Executive Committee of the Board of Directors uses this market-based information to set the President and CEO's compensation. In turn, the CEO uses this same information to set compensation for officers and key employees, which is also approved by the board. Form 990, Part VI, Section C, line 19 The organization will provide any documents open to public inspection upon request. Form 990, Part IX, line 11g Outside Services: Program service expenses 21,791,494. Management and general expenses 10,463,689. Fundraising expenses 0. Total expenses 32,255,183. Form 990, Part XI, line 9: Change in Unrecognized Pension Actuarial Gain 667,732. Change in Beneficial Interest in Foundation -4,181,975. Change in Beneficial Interest of Services -12,830,776. Pension Income 3,373,072. Transfer to Self-Insured Trust -1,000,000. Other 1,189,207. Mercy Foundation 500 East Market Street Iowa City IA 52245 237040506 Foundation/Fundraising IA 501(c)(3) 12A, I Mercy Hospital 1 Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust 500 East Market Street Iowa City IA 52245 426591803 Self Insurance IA 501(c)(3) 12A, I Mercy Hospital 1 Sisters of Mercy of the Americas West Midwest Community Inc 7262 Mercy Road Omaha NE 68124 262400800 Religious Order NE 501(c)(3) Religious Order N/A 0 Mercy Hospital Guild 500 East Market Street Iowa City IA 52245 426099912 Fundraising IA 501(c)(3) 12C, III-FI N/A 0 Iowa City Ambulatory Surgical Center LLC 2963 Northgate Drive Iowa City IA 52245 208503424 Outpatient Surgery IA Mercy Hospital Related 3589831 1368442 0 1 0.51000 Corridor Radiology LLC 2769 Heartland Drive Suite 307 Coralville IA 52241 430635070 Radiology Services IA Mercy Hospital Related 383727 96664 0 0 0.51000 Eastern Iowa Rehabilitation Hospital LLC 680 S 4th Street Louisville KY 40202 831589139 Inpatient Rehabilitation Care IA Mercy Hospital Related -542590 -2725000 0 0 0.51000 Mercy Services Iowa City Inc 500 East Market Street Iowa City IA 52245 421241044 Medical Clinic Services IA Mercy Hospital C 25455747 7108725 1.00000 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 Mercy Foundation C 1329000 Cost Mercy Services Iowa City Inc A 670990 Cost Mercy Services Iowa City Inc R 5950000 Cost Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust R 1000000 Cost Mercy Services Iowa City Inc Q 2971697 Cost Mercy Services Iowa City Inc O 6843610 Cost