2022-02-15T16:01:50-08:00 2021-03-31 990 2020-04-01 930386823 LEGACY EMANUEL HOSPITAL & HEALTH CENTER LEGA 5034155600 2801 N GANTENBEIN AVENUE PORTLAND OR 97227 ANNA L LOOMIS CFO & TREASURER 2022-02-15 ANNA L LOOMIS 999009999 2 AAL1 IAL1 FAL1 2020 2022-09-23 18:48:47Z KATHRYN CORREIA 2801 N GANTENBEIN AVENUE PORTLAND OR 97227 1001853056 false X WWW.LEGACYHEALTH.ORG X 1912 OR Legacy Emanuel Hospital & Health Center (LEHHC), established in 1912, provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC is part of Legacy Health. 17 13 0 246 19712110 10828722 11863367 960548891 981369284 6021386 8496438 13753 28651 977412752 1001757740 95070 67300 0 634376251 645691667 0 0 392142943 406446401 1026614264 1052205368 -49201512 -50447628 440911107 683060442 467951380 529687053 -27040273 153373389 X Legacy Emanuel Hospital & Health Center(LEHHC), established in 1912, provides acute and tertiary care in northeast Portland, with 554 licensed beds. LEHHC operates Randall Children's hospital, Level I Trauma Center, the Oregon Burn Center and high-risk obstetric services including a Level III NICU. LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC is part of Legacy Health (Legacy).Our mission:Our legacy is good health for our people, our patients, our communities, and our world. We will work as a team to demonstrate our values:Respect - Treat all people with respect and compassion Service - Put the needs of our patients and their families first Quality - Deliver outstanding clinical services within healing environments Excellence - Set high standards and achieve them Responsibility - Be good stewards of our resources, ensuring access to care for all Innovation - Be progressive in our thinking an false false 628259538 67300 743697775 LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC provides training for interns and residents through its nationally accredited graduate medical education program. LEHHC operates primary care teaching clinics at LEHHC and in St. Helens, located approximately 30 miles from the main LEHHC campus. In addition to its core hospital services, LEHHC provides related health services through the following programs:The Randall Children's Hospital; Legacy Research; Legacy Laboratory Services, LLC(Lab); Legacy Metro Lab; Unity Center for Behavioral HealthThe Randall Children's Hospital at Legacy Emanuel is a full-service children's hospital within LEHHC committed to providing care in an environment sensitive to the special needs of children and their families, including premature and critically ill newborns. The Randall Children's Hospital treats children from throughout Oregon, southwest Washington, Alaska and Idaho.Legacy Research is a full-service research facility that supports a wide range of research activity. Legacy Research collaborates with pharmaceutical, biotechnology and medical device companies. Legacy Research is located in northeast Portland (Holladay Park campus).LEHHC is one of four members of an emergency air transport service joint venture, Life Flight Network LLC, which serves Oregon and southwest Washington.In support of its mission, LEHHC voluntarily provides medically necessary patient care services that are discounted or free of charge to persons who have insufficient resources and/or who are uninsured. During fiscal year 2021, LEHHC provided financial assistance on approximately 13,809 patient accounts (of which about 2,159 accounts received discounts totaling 100% of costs) and resulted in LEHHC incurring roughly $16,561,600 in uncompensated costs associated with this program. In addition to charity care, LEHHC provides services under various states' Medicaid programs for financially needy patients, Medicare beneficiaries, and other government programs for which the cost of treating these patients exceeds the government payments received. During fiscal year 2021, LEHHC incurred approximately $158,246,560, $89,876,430 and $4,338,700 in uncompensated costs attributable to Medicaid, Medicare, and other government programs, respectively. LEHHC also provides a variety of other community benefit activities such as medical education, donations to other charitable entities, research, and other health improvement services which totaled roughly $16,692,700 during fiscal year 2021.LEHHC is part of Legacy, which collectively provided over $42 million, $258 million, $191 million, and $7 million in uncompensated care attributable to its financial assistance, Medicaid, Medicare, and other government programs, respectively, in fiscal year 2021. 161131932 117148378 LEHHC is the sole member of Legacy Clinics, LLC, an Oregon limited liability company, which operates over seventy primary care and specialty clinic sites across the Portland-Vancouver Metropolitan area as well as to the Mid-Willamette Valley since the affiliation of Silverton Health with Legacy. In addition, Legacy Clinics operates the hospitalist and intensivist programs at the four Legacy Health Oregon hospitals. 71512181 71344923 Unity Center for Behavioral Health is a 24 hour behavioral and mental health services center located on Legacy's Holladay Park campus. It is a partnership between Legacy Health, Adventist Health, Kaiser Permanente and OHSU that provides immediate psychiatric care. It has 85 adult beds, 22 adolecent beds, 50 short term spaces as well as calming and therapy rooms. 37606125 49178209 898509776 true true false true false false false false false true true false false false true false false true false false false false false false false false true true true true true false false false false false true true false false false false false true true true false false false true 0 0 false 0 true true false false false false false false 0 false false false false false false false X 17 13 false true false false true true true true true false false true true true true true true true true true true OR X X ANNA LOOMIS 5034155600 1919 NW LOVEJOY STREET PORTLAND OR 97209 MONICA C WEHBY MD PED NEUROSURGEON 40.00 0.00 3651520 0 181088 KATHRYN CORREIA President & CEO 0.00 40.00 X X 0 1828174 62132 JOHN P IGUIDBASHIAN MD CARDIO SURGEON 40.00 0.00 978252 0 153464 TRENT S GREEN SR VP 0.00 40.00 0 984100 78481 ANNA LOOMIS CFO & TREASURER 0.00 40.00 X X 0 945032 46582 NAVEEN SACHDEV MD CARDIOLOGIST 40.00 0.00 940035 0 42780 ARLAN H MINTZ MD MEDICAL DIRECTOR 40.00 0.00 824533 0 41610 BRYCE R HELGERSON SR VP 0.00 40.00 0 738723 104095 AMISH J DESAI MD CARDIOLOGIST 40.00 0.00 790829 0 33260 LEWIS L LOW MD SR VP 40.00 40.00 115189 631731 69163 JOHN J KENAGY SR VP 0.00 40.00 0 676875 88776 BRIAN P YOUNG MD VP 40.00 0.00 619692 0 107234 SONJA O STEVES SR VP 0.00 40.00 0 574772 127479 GRETCHEN M NICHOLS HOSPITAL PRESIDENT 40.00 0.00 632995 0 57166 MOLLY F BURCHELL MD VP 40.00 0.00 550468 0 136174 DUNCAN R NEILSON MD VP 40.00 0.00 583540 0 85527 BRONWYN J HOUSTON PRESIDENT CHILDREN'S HOSPITAL 40.00 0.00 537961 0 80278 MELINDA J MULLER MD SR VP INTERIM 0.00 40.00 0 507985 108917 ROBERT E DEWITT FORMER SR. VP & SECRETARY 0.00 0.00 504774 0 18636 CATHERINE J MARKIN VP 40.00 0.00 451307 0 59235 LORI FARRELL MD VP 40.00 0.00 415717 0 60131 ANITA N IYENGER SR VP 0.00 40.00 0 410454 60096 MAUREEN A BRADLEY SR VP 0.00 40.00 0 388955 73838 CAROL BRADLEY FORMER SR. VP 0.00 0.00 406321 0 31375 ANNE T GREER Secretary 0.00 40.00 X X 0 353676 60712 CYNTHIA HILL RN VP 40.00 0.00 340685 0 69162 MELISSA L ECKSTEIN UCBH PRESIDENT 40.00 0.00 342403 0 25968 JOSEPH FRASCELLA VP 40.00 0.00 327171 0 32978 JONATHAN HILL MD BOARD DIRECTOR 40.00 3.00 X 296477 0 37731 DONALD A TOUSSAINT VP 40.00 0.00 263596 0 55195 STACY L YOUNGS RN VP 40.00 40.00 107043 114098 52883 KARI M HOWARD RN VP 40.00 0.00 209048 0 31955 LESLIE ROOT MD BOARD DIRECTOR 40.00 3.00 X 201390 0 26242 IYDA M ANTONY VP 40.00 0.00 112358 0 7467 CHARLES WILHOITE Chairman 4.00 0.00 X X 0 22500 0 DAVID RAMUS VICE CHAIR 4.00 0.00 X X 0 17500 0 GAYLE GOSCHIE BOARD DIRECTOR 3.00 0.00 X 0 12500 0 NANCY R LOCKE BOARD DIRECTOR 3.00 0.00 X 0 12500 0 LYNN T GUST BOARD DIRECTOR 3.00 0.00 X 0 12500 0 JEFFREY BARBER BOARD DIRECTOR 3.00 0.00 X 0 7908 0 EDGAR NAVAS BOARD DIRECTOR 3.00 0.00 X 0 7500 0 JEFFREY D FULLMAN MD BOARD DIRECTOR 3.00 0.00 X 0 7500 0 PATRICK REITEN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 JERRY D PETTY BOARD DIRECTOR 3.00 0.00 X 0 7500 0 NANCY HORTON BOARD DIRECTOR 3.00 0.00 X 0 7500 0 LISA FREEDMAN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 SAMIR DESAI MD BOARD DIRECTOR 3.00 0.00 X 0 7500 0 JACK A FRIEDMAN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 BISHOP DIANA AKIYAMA BOARD DIRECTOR 3.00 0.00 X 0 0 0 BISHOP LAURIE LARSON CAESAR BOARD DIRECTOR 3.00 0.00 X 0 0 0 14203304 8299983 2307810 1427 true true false TRAUMA SPECIALISTS LLP 1620 SW TAYLOR PORTLAND OR 97205 MEDICAL SERVICES 7913697 BLOODWORKS NORTHWEST 921 TERRY AVE SEATTLE WA 98104 MEDICAL SERVICES 3642586 ASSOCIATED REGIONAL & UNIVERSITY PATHOLOGISTS 3181 SW SAM JACKSON PARK RD PORTLAND OR 97239 LABORATORY SERVICES 2761546 OREGON HEALTH & SCIENCE UNIVERSITY 3181 SW SAM JACKSON PARK RD PORTLAND OR 97239 MEDICAL SERVICES 2742207 NBBJ LP 310 SW 4TH AVE STE 900 PORTLAND OR 97204 ARCHITECTURE & DESIGN 1618583 57 5516815 6315315 31237 11863367 LAB, PHARMACY, ETC 49178209 29466099 19712110 PATIENT PROGRAM REV 713823267 713823267 PHYSICIANS 27604066 27604066 REVENUE CLINICS 117148378 117148378 UNITY 71013819 71013819 2601545 2601545 981369284 8573318 8573318 0 0 47087 18436 28651 28651 28651 76880 -76880 -76880 -76880 0 0 0 0 1001757740 959055629 19712110 11126634 24300 24300 43000 43000 0 0 6895905 6304566 591339 0 503353281 468552299 34800982 28043339 26263227 1780112 69866579 64022328 5844251 37532563 35055457 2477106 0 499233 439056 60177 0 0 0 0 22790632 22790632 0 146101411 143080061 3021350 0 0 9878204 9102677 775527 222309 216906 5403 0 0 8524895 7497306 1027589 0 30838004 27210275 3627729 12230272 11205833 1024439 ADMINISTRATIVE SERVICES FEES 105230668 7028080 98202588 PROVIDER TAX 40906322 40906322 BAD DEBTS 28181209 28181209 CONSULTING 1043242 586242 457000 0 1052205368 898509776 153695592 0 -2089448 -2433176 235000000 0 145808217 165166864 0 0 1475740 1203187 10822577 10388279 825229 846353 842798132 442937961 371358607 399860171 0 -126618122 -126971236 0 0 39328307 0 440911107 683060442 97900821 156550217 370050559 373136836 467951380 529687053 X -29985414 150387119 2945141 2986270 -27040273 153373389 440911107 683060442 X -50447628 230861290 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false X 26183 259692 26183 259692 924339988 1280790571 924366171 1281050263 1000000 1000000 250000 250000 false 2000000 2000000 2000000 2000000 8000000 12000000 296586 316588 402167 285875 1301216 500000 500000 500000 500000 2000000 3000000 8124357 2969206 296673 2690371 8699865 12842883 1324334 18177 6061037 8124357 11474882 2255825 108358 996178 12842887 11633427 833253 360479 1352282 11474877 12262567 1125971 314161 2069270 11633429 0.05000 0.07000 0.88000 false true true 4616051 4616051 444588322 233917973 210670349 9382091 4581263 4800828 248675225 204438725 44236500 135536443 135536443 399860171 CONTRACT PAYABLE 3852903 I/C AFFILIATE DEBT 366573084 NONCURRENT ENVIRONMENTAL OBLIGATION 1371785 NONCURRENT WORKERS' COMP LIABILITY 1339062 Rounding 2 373136836 956083000 956083000 45674740 45674740 1001757740 1007401000 1007401000 44804368 44804368 1052205368 Part V, Line 4: Intended uses of the endowment fund. Endowment funds disclosed in Part V are used to improve the healthcare of the community as designated by the donors. Legacy Health Foundation (LHF) and Randall Children's Hospital Foundation (RCHF) maintains all charitable gifts including endowment funds for the benefit of LEHHC and it's programs. Income from permanently restricted net assets is accounted for in accordance with the donors' instructions.Legacy follows the guidance in the Uniform Prudent Management of Institutional Funds Act (UPMIFA) in determining the net asset classification of all donor-restricted endowment funds. In accordance with UPMIFA and board policy, assets classified as permanent endowments in accordance with donor intent are only utilized for current period expenditures to the extent that earnings on the endowment exceed the original fair value of the donation. To the extent earnings on endowment funds exceed identified expenditures on which to apply those earnings, the earnings are classified as temporarily restricted net assets. Legacy has adopted investment and spending policies for endowment assets to provide a predictable stream of funding to programs supported by its endowment and to maintain the value of the endowment assets. Asset allocation is reviewed quarterly with respect to: i) Legacy's tolerance for risk based on its financial condition and need for cash from investments to support operations; ii) expected asset class return, risk and correlation characteristics; iii) changes in accounting guidance or tax law and iv) changes in bond covenants or other restrictions.Legacy's spending practices are intended to comply with donor's wishes and meet all applicable laws and regulations. Spending must be for a purpose that is consistent with the documented intent of the donor, and may not exceed the amounts annually determined by Legacy. Factors that are considered in addressing the annual spending allocation are: i) market value of the fund relative to the principal of the gift and ii) the level of spending in prior years.From time to time, the fair value of assets associated with individual donor-restricted endowment funds may fall below the level that the donor or UPMIFA requires Legacy to retain as a fund of perpetual duration. Deficiencies of this nature are reported as a reduction to unrestricted net assets and are excluded from the performance indicator. Part XI, Line 4b: Other revenue amounts included on 990 but not included in F/S REVENUE FROM RESEARCH $10642202 OTHER RECLASS OF REV/EXP FOR TAX PURPOSE $34486602 MEDICAL STAFF INCOME $545975 ROUNDING $-39 Part XII, Line 4b: Other revenue amounts included on 990 but not included in F/S EXPENSE FROM RESEARCH $10601075 OTHER RECLASS OF REV/EXP FOR TAX PURPOSE $34148852 MEDICAL STAFF EXPENSE $316989 ELIMINATE EQUIPMENT DONATIONS $-262320 ROUNDING $-228 true true X true X 300.000000000 true X true true true false true true 16561606 16561606 0.01570 335323338 177076780 158246558 0.15040 14432864 10094157 4338707 0.00410 366317808 187170937 179146871 0.17020 1210576 143575 1067001 0.00100 9519221 3990202 5529019 0.00530 8699682 8699682 0.00830 1397004 1397004 0.00130 20826483 4133777 16692706 0.01590 387144291 191304714 195839577 0.18610 false 28181209 20008658 68544090 85451761 -16907671 X true true 1 1 LEGACY EMANUEL HOSP & HEALTH 2801 N GANTENBEIN AVENUE PORTLAND OR 97229 www.legacyhealth.org 14-0056 X X X X X X X LEGACY EMANUEL HOSP & HEALTH 1 false false true X X X X X X X X X 20 true true true true X www.legacyhealth.org true 21 true www.legacyhealth.org false false true X 300.0000 400.0000 X X X X X true true X X X true X www.legacyhealth.org X www.legacyhealth.org X www.legacyhealth.org X X X X X X true X false X X X X true X false false Facility: LEGACY EMANUEL HOSP & HEALTH - Part V, Section B, Line 5 In 2020, Legacy Emanuel Medical Center participated with seven other hospital systems, four county health departments and one coordinated care organization in the four-county regional 2019 Healthy Columbia Willamette Collaborative (HCWC) Community Health Needs Assessment (CHNA) which was used as a base for the Legacy Emanuel Community Health Needs Assessment. The results of Legacys Community Needs Assessment can be found at www.legacyhealth.org.The HCWC CHNA is regional and developed to improve efficiency and effectiveness and also to help meet the requirements of the ACA and Public Health Accreditation. HCWC prioritized community input and lived experiences of priority populations and leaders from community-based organizations across the region. Volunteer participants shared their insights on the vision, strengths, challenges, and needs of their communities in town halls and listening sessions. Four town halls were conductedone in each countyand community-based organizations hosted 18 community listening sessions across the quad-county region, with more than 200 participants. In the 2019 CHNA, HCWC also reviewed population data (health-related behaviors, morbidity, mortality); medical data from local Coordinated Care Organizations (CCO) (most frequent conditions Medicaid-covered individuals sought care for); and hospital data (uninsured patients seen in the emergency department for conditions that could have been managed in primary or ambulatory care settings).Our work included the following community partners: Adelante MujeresAntFarmASACCascade AIDS Project Aging WellCentral City ConcernCommunity Partnership for Affordable HousingCity of Lake OswegoClackamas Behavioral Health DivisionClackamas County Aging Services Advisory CouncilClackamas County Community Action BoardClackamas County Disaster ManagementClackamas County Public Health DivisionClackamas County Social ServicesClackamas WorkforceClark County Community ServicesClark County Public HealthCoalition of Community Health ClinicsEstacada Community CenterFaith Organization in Multnomah CountyFriendly HouseIndividual Facilitators, Arabic CommunityIndividual Facilitator, FarmworkersIraqi Society of OregonLatino NetworkMicronesian Islander CommunityMomentum AllianceNAMI, Clackamas CountyNAYA Family CenterNorthwest Family ServicesOutside InOregon AIDS Education & Training CenterOregon Community Health Workers AssociationOregon Dairy and Nutrition CouncilOregon Food BankOregon Health Equity AllianceOregon Office on Disability and HealthOregon Oral Health CoalitionPacific Islander CoalitionPlanned ParenthoodProject Access NOWProvidence ElderPlaceQuest Center for Integrative HealthSW WA Accountable Community of HealthSociety of St. Vincent de PaulVeterans of Foreign WarsVibrant Future Coalition/NW Family ServicesYMCA of Columbia Willamette Facility: LEGACY EMANUEL HOSP & HEALTH - Part V, Section B, Line 6a In addition to Legacy Healths five hospitals which includes Legacy Emanuel Medical Center, the other seven hospital systems in the metro area that participated in the Healthy Columbia Willamette Collaborative Community Health Needs Assessment were: Adventist Health, Kaiser Permanente, Oregon Health & Science University, Peace Health Southwest Medical Center, Providence Health & Services and Tuality Health Care. Facility: LEGACY EMANUEL HOSP & HEALTH - Part V, Section B, Line 11 The FY2021 Legacy Emanuel CHNA identified health-related needs across the quad county region. Legacy Emanuel grouped the health needs identified in the 2019 Healthy Columbia Willamette Collaborative Community Health Assessment into two broad categories of need: Access to Health Care Chronic ConditionsIn addition to identified health-related needs across the quad county region, Legacy Emanuel Medical Center heard through community members that discrimination, racism and trauma impact the health and well-being of communities and should be addressed as part of all programming and projects (HCWC CHNA 2019). Legacy Emanuel Medical Centers Community Health Improvement Plan highlights the health equity strategies for this improvement plan cycle.The priority areas identified in the implementation plan will be addressed through health service delivery, health education and outreach, community partnerships, community investments, and funding for evidence-based health programs and services.No singular hospital facility can address all the issues present in the community. Through our partnerships in the Quad County, Legacy Emanuel Medical Center is confident these needs are being addressed by other community organizations. Legacy Emanuel Medical Centers top priority continues to be a focus on the issues which have the greatest impact on the health of the community and where we can affect the most changeDetails on the specific initiatives Legacy Emanuel Medical Center is undertaking to address these priority issues can be found in the Community Health Improvement Plan (CHIP), which can be found on the organizations website at www.legacyhealth.org Legacy Medical Clinics LLC 1919 NW Lovejoy Street Portland OR 97209 Physician Clinics Legacy Laboratory Services 1225 NE 2nd Ave Portland OR 97232 Diagnostic Laboratory Services Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense LEHHC uses many different approaches to inform and educate patients on the availability of financial assistance as is described later in Part VI of Schedule H. Still, many patients do not respond to requests for information or provide appropriate documentation to benefit from financial assistance. As a result, LEHHC must report these amounts as bad debt. A portion of bad debt expense should be considered as charity care, using reasonable methodologies to analyze the information. Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit The estimated amount of bad debt expenses attributable to charity care policy was calculated using the demographic profile of household income and average household size in the zip code areas around the hospital. 71% of households in the LEHHC service area would qualify for financial assistance with incomes under 400% of the Federal Poverty Guidelines using this methodology. Part III, Line 4 - Bad Debt Expense The footnote that describes the Legacy bad debt expense can be found on page 9 of the attached audited financial statements. Part III, Line 8 - Explanation Of Shortfall As Community Benefit The entire Medicare shortfall should be considered a community benefit. Medicare shortfalls must be absorbed by the hospital in order to continue treating the elderly in the community served by the hospital. The hospital provides care regardless of this shortfall and thereby relieves the federal government of the burden of paying the full cost for Medicare beneficiaries. The Medicare amounts listed in Part III Section B. on lines 5, 6, and 7 do not represent all of the organization's revenues and costs associated with its participation in Medicare programs. The methodology used in reporting in Part III Section B Medicare is inconsistent with the other sections in Schedule H, as the instructions limit Medicare revenues and allowable cost to those from only the Medicare Cost Report. Revenue and costs from Medicare Part C patients, Part B physician services billed by the organization, and clinical laboratory services weren't included. In addition, hospitals incur other costs to provide care that Medicare does not allow in the cost report, such as Physician Call pay to ensure adequate physician coverage for the ED.The total revenues and costs attributable to all Medicare services are $163,261,757 and $253,138,189 respectively. This results in a total Medicare shortfall of $89,876,432.Costing Methodology (Part III, Line 8).Medicare allowable costs were calculated using the costing methodologies in the Medicare Cost Report. The cost report arrives at total allowable hospital cost through a cost finding process that includes direct cost allocations and a step-down allocation of indirect or overhead costs. Inpatient operating costs are composed of general inpatient routine and ICU unit costs derived from cost per diems, as well as inpatient ancillary service costs that utilize cost to charge ratios to arrive at cost. Apportionment of cost applicable to hospital outpatient services is through the application of cost to charge ratios. This excludes other costs incurred to provide services of the hospital to the community that the cost report deems as unallowable costs, such as Physician on-call pay. Part III, Line 9b - Provisions On Collection Practices For Qualified Patients Legacy provides care without charge or at amounts less than its established rates to patients who meet certain criteria under its financial assistance policy. Since Legacy does not pursue collection of amounts determined to qualify as charity care, they are excluded from net patient service revenues. Part VI, Line 2 - Needs Assessment The described CHNA provides the primary source for assessing needs. Senior leadership, in conjunction with the Board of Directors, Community Benefit and Community Relations staff continually assess the needs of the communities it serves through a compilation of primary and secondary market research (qualitative and quantitative), medical staff input, reviewing national trends and practices, working with local foundations and funders regarding their assessments, and working with local community-based partners to understand their needs. The goal is to understand the needs and develop programs specific to the community. Involvement is both proactive and responsive - a leadership role in initiating programs as well as being readily available as a collaborative partner when the community asks. The outcome of these assessments is the development of both long-term and fiscal year plans that are supported by a yearly budget that is proposed by staff and approved by the Board of Directors. These are then aligned to the community health needs identified in the formal CHNA. The region served by LEHHC, along with most of Oregon, is experiencing significant challenges in population growth, economic development, education and health care. Recognizing that social and economic determinants impact health, LEHHC has been and will remain committed to addressing these issues to improve the health of all residents in the community, including equity among ethnically diverse populations. Part VI, Line 3 - Patient Education of Eligibility for Assistance LEHHC employs financial counselors and social workers that assist patients in obtaining coverage for their healthcare needs. This includes assistance with workers compensation, motor vehicle accident policies, COBRA, veterans assistance, Legacys financial assistance program, and public assistance programs, such as Medicaid. In support of its mission, Legacy Emanuel provides medically necessary patient care services that are discounted or free of charge to persons who have insufficient resources and/or who are uninsured. The criteria for charity care are determined based on eligibility for insurance coverage, household income, qualified assets, catastrophic medical events, or other information supporting a patients inability to pay for services provided. Specifically, Legacy Emanuel provides an uninsured discount of 35% to self-pay patients with no coverage. Additional discounts, on a sliding scale, are available to patients whose household income is less than 400% of the federal poverty level. For patients whose household income is at or below 300% of the federal poverty level, a full subsidy is available. In addition to the household income criteria, patients qualified assets (e.g. 25% of household assets) and other catastrophic or economic circumstances are considered in determining eligibility for charity care. In addition to financial counselors and social workers, Legacy Emanuel makes every effort to communicate its Financial Assistance Program to all patients. This includes signage in main admitting areas of the hospital and brochures explaining financial assistance in all patient care areas, translated for patients/individuals with limited English proficiency (LEP). Financial counselors are available to assist patients in understanding and applying for available resources, including the Legacy Emanuel Financial Assistance Program. Legacy Emanuels website also has information about the availability of financial assistance. Legacy Emanuel offers financial assistance customer service Monday through Friday, as well as the availability of voicemail so patients can leave confidential, detailed messages during non-business hours. Patients are encouraged to sign up for MyHealth, a secure online tool to access their medical record. Using their MyHealth account they can correspond with a financial counselor via email. Finally, all of Legacys billing statements include information regarding the availability of financial assistance. If Legacy Emanuel requires the use of a collection agency, those agencies are required to provide a telephone number that patients can call to request financial assistance.Annual education is provided to all billing and admitting staff, so they can be kept informed of and speak with knowledge about current financial assistance policies and options. Legacy Emanuel provides copies of the latest policies in main admitting areas, as well as with the hospital financial counselor, online via the website and through MyHealth.Since 2008, the four-county metro area health delivery systems (encompassing all hospitals in the area) and safety net clinics have partnered to establish a seamless, coordinated program (Project Access NOW) to provide care for the low income uninsured. This program enables low income uninsured patients to receive continuity of care in earlier stages of acuity due to the collaboration among nearly 3,000 providers and all health systems. Legacy Emanuel also contributes to Project Access NOWs Premium Assistance program, which pays the premiums for families in the region who cannot afford to make those payments on their own. Part VI, Line 4 - Community Information Legacy Emanuel Medical Center defines service area based on actual patient origin (ZIP codes) and geographic location. Legacy Emanuel is located in one of the oldest neighborhoods in Portland Inner North Portland across the Willamette River slightly north of downtown. The primary service area extends across 64 zip codes, from the Columbia River in the north to south of Highway 99E and from Walker Road and St. Helens in the west to N.E./S.E. 161st in the east. The inner primary service area includes the close-in Portland neighborhoods. Hospital service area neighborhoods and zip codes include 97005-97008 Beaverton, 97009 Boring, 97013 Canby, 97015 Clackamas, 97024 Fairview, 97030 Gresham, 97034-97035 Lake Oswego, 97045 Oregon City, 97051 Saint Helens, 97055 Sandy, 97056 Scappoose, 97060 Troutdale, 97062 Tualatin, 97068 West Linn, 97070 Wilsonville, 97080 Gresham, 97086 Happy Valley, 97103 Astoria, 97116 Forest Grove, 97123-97124 Hillsboro, 97132 Newberg, 97140 Sherwood. Portland address include 97201-97206, 97209-97220, 97222-97225, 97227, 97229-97230, 97232-97233, 97236, 97239, 97266-97267. The most recently available demographic data is from 2021 to 2026. When available, data at the primary service area level is used, followed by the county (Multnomah) and then the state (Oregon). County data is used most frequently because there is a lack of available data at the zip code level, particularly related to race and ethnicity.While ZIP codes across the metropolitan area are considered as part of Legacy Emanuels broader service area, the primary service area is within Multnomah County. The certified population estimate of the primary service area for Legacy Emanuel as of July 1, 2019, was 812,855.In 2019 the LEHHC primary service area was 69.1% non-Hispanic white, 12% Hispanic, 6% African American, 8.1% Asian, 1.4% Native American and Alaska Native, and 4.7% two or more races. The foreign-born population represents about 14.0% of total population in the area, an increase of nearly 20 percent since 2005.The African American/Black population continues to be most concentrated in the historical neighborhoods of North/Northeast Portland, but increased housing prices have resulted in the community moving increasingly to East Multnomah County. Multnomah County continues to have three to six times the percentage population of African Americans as the other three counties. Hispanics are moving into the service area at a higher rate than any other group. The Portland Native American community is the ninth largest urban Native American population in the US. With high child poverty and unemployment rates, the Native American community struggles across multiple indicators in contrast to the non-Hispanic white community. The immigrant and refugee population is increasing significantly. Recent immigrants and refugees are more likely to be culturally and linguistically isolated. A small but increasing African refugee population has settled primarily in North and NE Portland and is distinct from the African American/Black population. Available data suggests that the African population is generally poorer than other communities.Census numbers do not adequately represent the true and changing picture of the population. More than 100 languages are spoken in the Portland public schools. Schools near LEHHC are 40% - 70% children of color made up primarily of African-American and increasingly Hispanic students. Schools are experiencing a 50% English-as-a-Second-Language rate and a 50-80% reduced-cost or free lunch rates.Multnomah Countys median household income (MHI) from 2015-2019 was $69,176 with 12.0 percent of the population living below the federal poverty level. People of color represent 30% of the overall population of Multnomah County, but they represent 47% of the countys population in poverty. In Portland, Multnomah Countys largest city, groups experiencing the highest rate of poverty were Blacks (35%), Native Americans (30%), and Hispanics (28%).However, there is a much greater disparity of median per capita income between communities of color earning half the incomes of non-Hispanic whites in Multnomah County. In Multnomah County, while non-Hispanic white median per capita income was at $36,751, Native Hawaiin/Pacific Islander had the lowest median per capita income at $15,905 followed by American Indian/Alaska Native at $16,534, Hispanic/Latinosat $17,335 and African Americans at 17,805. In contrast, Asians median per capita income was $27,896. From 2015-2019 the overall high school graduation rate in Multnomah County was 91.5 percent. The Dignity Health and Truven Health Community Needs Index (CNI) is accepted as the national standard in identifying communities with health disparities and comparing relative need. CNI for the Legacy Emanuel primary service area shows highest need in proximity to Emanuel: 97203-St. Johns, 97216-Montavilla, 97218-Cully, 97220-Maywood Park, 97227-Boise-Elliott, and 97266-Lents.The LEHHC five mile primary service area includes four other tertiary hospitals. LEHHC operates a Level I trauma center and Randall Children's Hospital at Legacy Emanuel Medical Center. OHSU located on the southwest side of town operates a Level 1 trauma center, a children's hospital and has the only medical school in Portland. Providence Health operates one hospital about five miles west of LEHHC and the other three miles southeast. Kaiser Permanente formerly operated a hospital about a mile north of LEHHC; but continues to maintain a strong clinic presence in the area.LEHHCs primary service area includes two Medically Underserved Areas (MUA): St. Johns community and SE Portland. With the long-standing income disparities in the LEHHC area, safety net services have expanded in the last decade. Multnomah County Health Department operates FQHCs in many locations throughout Portland. Two blocks from Emanuel is the site of a NARA (Native American Rehabilitation Association) FQHC. Additionally, the North by Northeast Community Health Center provides primary care for the uninsured and Medicaid low-income residents, primarily African-American. Legacy Emanuels internal medicine residency program operates a teaching clinic and a midwifery clinic serving the low income and often uninsured.In FY 2021, LEHHC provided about $16.5 million in charity care which accounts for 6% of total unreimbursed costs of $269 million.Legacy Emanuels charity care policy includes patients with incomes up to 400 percent of Federal Poverty Level (FPL). Part VI, Line 5 - Promotion of Community Health Legacy Emanuel collaborates with other health care providers, community-based organizations, business and the public on projects to improve the health of the community. One example of clinically based partnerships includes, among others: CARES NW (Child Abuse Response and Evaluation Services), a collaboration among three health systems; Legacy Emanuel serves as the employer and donates the infrastructure. Additionally, the first collaborative medical initiative of its kind in the Pacific Northwest, Unity Center for Behavioral Health, is a joint effort between Adventist Health, Kaiser Permanente, Oregon Health & Science University and Legacy Health, providing psychiatric emergency services. Legacy has collaborated with more than a dozen community mental health partners in developing this new psychiatric center.Over 20 years ago, LEHHC recognized that nonprofit organizations spend valuable dollars on office space and infrastructure dollars better spent on meeting their missions. Since then LEHHC has provided free office space to some nonprofit partners, in-kind lab donations to safety net clinics in its service area and other infrastructure services to nonprofit organizations on its campus. Non-cash donations of resources include clinical and non-clinical services and items, e.g., screenings and support services, internships, information and referral services and health fairs. Legacys warehouse is open to nonprofit organizations to obtain surplus equipment and furniture. In addition, conference room space is made available to local nonprofits for Board and community meetings.As a hospital located in a high-density, inner-city neighborhood, LEHHC's security department patrols the neighborhoods as a service to those communities. Emanuel employees, local businesses and neighborhood associations collaborated to revitalize a neighboring park which was previously used for drug and other illegal activities. Since that time police incidents have decreased significantly.In 1986, nurses in Emanuel Hospitals Level I Trauma Center developed the Trauma Nurses Talk Tough (TNTT) program. The American Hospital Association awarded the TNTT program its NOVA Award. In FY21, TNTT went virtual offering all classes online to provide important safety education to all ages. On average every month TNTT offers 12 court ordered classes, two senior falls prevention classes, and multiple school, parent, and young driver safety education classes. Last year, Legacy Emanuel staff fit and distributed 900 low-cost helmets and safety gear to children, of which 70% were donated. Legacy staff members also provide new parents with training to reduce the incidences of shaken baby syndrome as well as an education and awareness program about window safety (to prevent children falling from upper stories). As a tertiary center, Legacy Emanuel provides several unique services to a four-state region (Alaska, Washington, Oregon and Idaho) such as its Level I trauma center, Randall Childrens Hospital, Oregon Burn Center, and high-risk obstetric services, including a Level III NICU. In addition, Legacy provided training for interns and residents through its nationally accredited graduate medical education program, totaling over 10,000 hours of training as a system; Legacy Emanuel provided over 15,000 of these hours. Health professions training ranged from nursing, occupational and physical therapy, and radiography to public health, lab assistant, emergency medical technician, and many others. Legacy also partners with schools to provide training and education for nursing and other health professionals.The COVID-19 pandemic continued surging across the U.S. in FY21. The pandemic presented unforeseen challenges within our communities and heightened the need for community benefit. The economic implications of COVID-19 have constrained the availability of resources and required Legacy to redirect funding and develop new strategies in response to emerging community needs. Legacy responded to the significant needs of our communities from setting up mass vaccines sites, to working with community-based organizations to repurposing grants to respond to the immediate impacts of the pandemic. Legacy joined our local health care partners to support the effort of providing safe, fast, and equitable vaccinations across our communities. Most vaccinations came through large clinics at mass vaccination sites as well as Legacy affiliate hospitals. The clinics were often run by our staff who contributed their time to support the effort. About 1,570 Legacy staff volunteered for about 8,300 shifts and contributed almost 50,000 hours across seven vaccination settings. Part VI, Line 6 - Affilated Health Care System Legacy Emanuel is a subsidiary of Legacy Health (Legacy). Legacy is an integrated health system based in Portland, Oregon and primarily operates six acute care hospitals and dedicated childrens care offered at Randall Childrens Hospital at Legacy Emanuel, and related services (e.g., physician practices, hospice, preferred provider network) in the four-county metro area of Portland and SW Washington, and Marion County. In addition, Legacy Health is a collaborative partner with Unity Center for Behavioral Health.The Legacy Health Board is comprised of community and business leaders as well as representatives of the medical staff. The Legacy Emanuel medical staff is open, with physicians submitting credentialing information reviewed according to Legacy Emanuel policies and standards. While there is investment in a variety of community-based activities and programs as a part of its non-profit status, an overwhelming majority of Legacy and LEHHC's community benefit comes in the form of providing uncompensated care. Legacy's policy of providing care regardless of the ability to pay makes it one of the region's largest providers of uncompensated care in the four-county metropolitan area.As the health needs of communities surrounding our hospitals is changing, Legacy continues to identify investments for underserved populations. In FY21,grants totaling $$1.08 million were provided to community-based organizations to strengthen organizational capacity and support programs and initiatives that address health equity, access to care, behavioral health, and COVID-19 education and outreach.Recognizing that education, employment, and income inequities exist for communities of color, and that health professions are lacking in diversity, Legacy established the Health Occupation Profession and Education program (HOPE, formerly Youth Employment in Summer). Each year between 5-15 students of ethnically diverse communities receive paid summer employment in departments where they work with health professionals. Students are paid between $13-17 per hour and may work up to 400 hours during the summer. HOPE students also receive college scholarships between $3,000 and $10,000 annually. Students remain in the program if they remain in school and pursue health careers. Some students remain in the program as long as seven years and graduate with a range of degrees from imaging tech, to bachelors in nursing, to medical residents. Most students are the first in their family to go to college. While not all the HOPE students were able to work due to supplemental employment pauses due to COVID-19, we were able to provide two limited internships and provide all the HOPE students with their education scholarships.In the fall of 2018, Legacy in collaboration with Kaiser Permanente NW, PeaceHealth and Providence Health & Services came together to create the Health Systems Access to Care Fund through the Oregon Community Foundation. The goal of this fund is to strengthen the capacity and infrastructure for community clinics that are expanding and/or adapting their current models to respond to the changing needs of patient populations due to ongoing healthcare reform, Medicaid transformation, and the increasing pressure on the safety net for access to care. In 2021, eleven clinics were invited to apply and were each awarded $50,000 in funding. Clinics received training and individual technical assistance in various areas of organizational development for community supported clinics.Legacy also provided cash donations to local health and human service, education, economic development and civic organizations. Donations focus on organizations with year-round relationships through programs and board representationspecifically focused on organizations addressing disparities. A few examples include Latino Network, Ronald McDonald Charities, Free Clinic of SW Washington, Silverton Area Community Aid, Trillium Family Services, National Alliance on Mental Illness Oregon, Native American Youth and Family Center, and Basic Rights Oregon. Part VI, Line 7 - States Filing of Community Benefit Report OR true MEDICAL TEAMS INTERNATIONAL 14150 SW MILTON CT TIGARD OR 97224 930878944 501(c)(3) 0 24300 COST EQUIPMENT & SUPPLIES FOR DISASTER ASSISTANCE 1 0 BURN/WOUND GARMENTS 200 38000 COMPRESSION GARMENTS DECREASE FALLS AT HOME 5000 DURABLE MEDICAL EQUIPMENT Grantmaker's Description of How Grants are Used Legacy reviews all organizations prior to donating cash or supplies to ensure their 501(c)(3) status. Legacy regularly donates supplies to Medical Teams International for disaster relief. Several Legacy medical staff members, volunteer for Medical Teams International. X true true true true false true true true true false true true AMISH J DESAI MD CARDIOLOGIST 587967 203776 -914 18525 14735 824089 ANITA N IYENGER SR VP 366611 48185 -4342 35919 24177 470550 ANNA LOOMIS CFO & TREASURER 698377 249915 -3260 14250 32332 991614 26293 ANNE T GREER Secretary 287532 64949 1195 39087 21625 414388 ARLAN H MINTZ MD MEDICAL DIRECTOR 797546 28562 -1575 15107 26503 866143 BRIAN P YOUNG MD VP 474535 88012 57145 76535 30699 726926 BRONWYN J HOUSTON PRESIDENT CHILDREN'S HOSPITAL 413844 120933 3184 45468 34810 618239 BRYCE R HELGERSON SR VP 566173 147785 24765 88143 15952 842818 13437 CAROL BRADLEY FORMER SR. VP 406321 31451 -76 437696 CATHERINE J MARKIN VP 401303 53015 -3011 22800 36435 510542 CYNTHIA HILL RN VP 275895 58391 6399 47446 21716 409847 DONALD A TOUSSAINT VP 171578 31752 60266 40771 14424 318791 DUNCAN R NEILSON MD VP 473137 63229 47174 17100 68427 669067 GRETCHEN M NICHOLS HOSPITAL PRESIDENT 512851 68743 51401 28111 29055 690161 JOHN J KENAGY SR VP 498198 134864 43813 51967 36809 765651 33935 JOHN P IGUIDBASHIAN MD CARDIO SURGEON 802571 20871 154810 119828 33636 1131716 JONATHAN HILL MD BOARD DIRECTOR 280000 12520 3957 11400 26331 334208 JOSEPH FRASCELLA VP 276742 43887 6542 14250 18728 360149 KARI M HOWARD RN VP 191393 18664 -1009 16849 15106 241003 KATHRYN CORREIA President & CEO 1354597 468527 5050 22730 39402 1890306 87021 LESLIE ROOT MD BOARD DIRECTOR 144244 57380 -234 22831 3411 227632 LEWIS L LOW MD SR VP 33826 442077 181297 81363 8357 45862 2918 20383 118107 697976 46391 LORI FARRELL MD VP 370209 46552 -1044 35112 25019 475848 MAUREEN A BRADLEY SR VP 317132 66752 5071 53547 20291 462793 MELINDA J MULLER MD SR VP INTERIM 407848 96755 3382 70510 38407 616902 MELISSA L ECKSTEIN UCBH PRESIDENT 295308 40448 6647 13847 12121 368371 MOLLY F BURCHELL MD VP 447151 94837 8480 115582 20592 686642 MONICA C WEHBY MD PED NEUROSURGEON 497254 24700 3129566 171551 9537 3832608 3000000 NAVEEN SACHDEV MD CARDIOLOGIST 765124 174103 808 14250 28530 982815 ROBERT E DEWITT FORMER SR. VP & SECRETARY 504774 18636 523410 SONJA O STEVES SR VP 452690 120822 1260 103312 24167 702251 30627 STACY L YOUNGS RN VP 109787 108134 11556 -2744 -5592 18378 13232 21273 138653 135371 TRENT S GREEN SR VP 780820 206375 -3095 40574 37907 1062581 18765 Part I, Line 1a: Relevant information in regards to selections on 1a. Legacy does periodically reimburse for some travel of companions. During 2020, some travel expenses for companions of Legacy Board Directors and executives were reimbursed. These transactions follow Legacys reimbursement policy requiring documentation and approval of the expenses, prior to reimbursement. These payments are taxable to the individuals and are reported on a W-2 for employees or a 1099 for Board Directors. Part I, Line 5b: Explanation of organization compensation based on revenues of related organization Physicians employed by Legacy affiliates are paid variable compensation based on quality, value, and production. Production is based upon the level of effort of services provided during the year measured by industry standard relative value units (RVU) and which generate revenue. Part I, Line 6b: Explanation of organization compensation contingent on net earnings from related or Legacy has an at-risk incentive compensation plan for management. The plan is based on meeting goals related to employee engagement, work processes, customer service, clinical quality, financial management, and certain key strategic tactics. In order to payout any at-risk incentive compensation, Legacy must exceed operating margin targets. Part I, Line 8: Amounts reported on 990 VII pursuant to initial contract exemption described in Regs Legacy enters into initial employment agreements with Executives that qualify under the initial contract exception. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee relies on comparable market data and all decisions are documented. Part III, Additional Information Sch J, Part 1, Question 3 Regarding Compensation PracticesDirectors for Legacy started receiving compensation for their services in August 2014. They also receive expense reimbursements related to their duties. Any expense reimbursements to board members are reviewed by the Director of Tax for determining 1099 tax reporting. In addition to the Board of Directors compensation, during 2020, Dr. Hill received compensation related to his duties as Medical Director while Dr. Root received compensation for medical services provided at Legacy Emanuel Hospital. There was no other reportable compensation received by any board member during 2020.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior leaders responsible for ensuring Legacy Health serves its mission and patients every day, and for ensuring a safe, inclusive and equitable workplace for all Legacy employees. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates, and are accountable for the effective day-to-day operation of the system.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market.The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for executive positions. The Committee oversees the system's governance procedures with respect to intermediate sanctions legislation and the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures.Sch J, Part II, Column Breakdown Of W-2 Or Misc-1099:Column B(i) - Base compensation consists of regular base pay including employee elected deferrals for retirement plans (403(b) and 457(b) plans).Column B(ii) - The incentive compensation program for Legacy is based on predetermined criteria and reviewed and approved by the Board. Bonuses are paid to key employees for interim duties outside their primary responsibilities (e.g. Acting in Capacity).Column B(iii) - Other compensation consists of deferred compensation amounts paid toexecutives during the current year and were reported on prior form 990 returns. These amounts include arrangements that contain elements of a substantial risk of forfeiture conditioned on continued employment, vesting and/or a noncompete provision upon termination of employment. Distributions from 457(b) plans, reported to the employee on a 1099-R, are also included as other compensation. In addition, imputed income for insurance, cell phone and other benefits is included in other compensation as well as any severance related payments. Column C - Deferred compensation includes contributions to defined contribution plans, amounts deferred under the 457(f) plan including earnings, earnings in the 457(b) plan, and the value of the pension restoration plan. Earnings on the 457(f) and 457(b) include gains and losses on the underlying investments. The defined contribution plan is available to all employees as they become qualified to participate. The pension restoration plan provides executive pension benefits in excess of IRS mandated limits on eligible compensation to key executives. The benefits are unfunded and subject to forfeiture. Executive pension benefits are intended to make the executive's retirement benefit, as a proportion of their final average salary, comparable to all other employees, and are treated as income when paid.The Legacy Health Board approved the goals and long-term objectives for the Executive Long-Term Incentive Plan effective April 1, 2017 for 3 years ending on March 31, 2020. The plan was discretionary and could be terminated at any time. The purpose of the Plan was to achieve market share growth in key areas identified in Legacy Healths strategic plan. Targets for operating margins and clinical quality were required over the three-year period and all goals were measured at March 31, 2020. The plan was funded and paid out in August 2020 after approval from the Legacy Health Compensation Committee and the Legacy Health Board. The final payout is included in the Executive compensation reported as deferred on the FY2018, FY2019 and FY2020 990.Column D - Nontaxable benefits include company paid health and welfare and long term care and disability benefits under group plans.Column F - Current year compensation reported as deferred in prior years. Amber Cox Employee 59872 Fam-Gretchen Nichols KE false Form 990, Part III, Line 4d: Other Program Services Description OTHER PROGRAM SERVICES 4: Unity Center for Behavioral Health is a 24 hour behavioral and mental health services center located on Legacy's Holladay Park campus. It is a partnership between Legacy Health, Adventist Health, Kaiser Permanente and OHSU that provides immediate psychiatric care. It has 85 adult beds, 22 adolecent beds, 50 short term spaces as well as calming and therapy rooms. Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company Legacy Health (Legacy) provides management services for all of its affiliated companies which includes, accounting, purchasing, contracting, legal, human resources, information technology, billing, facilities, budgeting, transcription, security, public relations, strategic planning, organization development.Cascade Pathology Services provides a Medical Director and pathologists who oversee the pathology laboratory services at LEMHHC. The amount paid for the year ended March 31, 2021 was $755,040. Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder Legacy Health is the sole member of Legacy Emanuel Hospital & Health Center. Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body The Board of Directors includes the following members: (a) The Bishop of the Oregon Synod of the Evangelical Lutheran Church inAmerica (the "Oregon Synod") or the Bishop's designee, who shall serve ex officio;(b) The Bishop of the Episcopal Diocese of Oregon (the "Episcopal Diocese")or the Bishop's designee, who shall serve ex officio;(c) One (1) person elected by the Legacy Health Board of Directors pursuant to the process set forth in the Bylaws; provided, however, that such person shall be an active member of a Lutheran congregation in the Oregon Synod ("Lutheran Director");(d) One (1) person elected by the Legacy Health Board of Directors pursuant to the process set forth in the Bylaws; provided, however, that such person shall be an active member of an Episcopal congregation in the Episcopal Diocese known to his/her parish priest, or alternatively a member of the clergy in the Episcopal Diocese ("Episcopal Director"). Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders The election of Lutheran Director is subject to the approval by the Bishop of the Oregon Synod, who may object to the newly-elected director for any reason by delivering written notice to the Legacy President or the Chair of the Board of Directors no later than one week after the election. If the Bishop timely objects to the election of the new Lutheran Director, the election will be ineffective and that person will not be a director; otherwise, if no timely objection is received, that person shall be conclusively presumed to be the Lutheran Director for his/her full term or the remainder of an unexpired term to which elected. The election of the Episcopal Director is subject to approval by the Bishop of the Episcopal Diocese, who may object to the newly elected director for any reason by delivering written notice to the Legacy President or Chair of the Board of Directors no later than one week after the election. The election of the Episcopal Director is also subject to approval by the Standing Committee of the Episcopal Diocese, who may object to the newly elected director only on the grounds that he/she is not an active member of an Episcopal congregation or a member of the Episcopal clergy in the Episcopal Diocese; such objection to be effected by delivering written notice to the Legacy President or Chair of the Board of Directors within five days after the next meeting of the Standing Committee or 45 days after the election, whichever is earlier. If the Bishop or Standing Committee timely object to the election of the new Episcopal Director, the election will be ineffective and that person will not be a director; otherwise, if no timely objection is received, that person shall be conclusively presumed to be the Episcopal Director for his/her full term or the remainder of an unexpired term to which elected. Form 990, Part VI, Line 11b: Form 990 Review Process The Legacy Board received a copy of the 990 return prior to filing. At the direction of the entire Board, the Board Compensation Committee reviewed the compensation disclosures and the Board Audit and Compliance Committee received a memorandum with a draft 990 return highlighting key areas and requesting feedback. Questions from the Board Audit and Compliance Committee are answered and changes made where appropriate. Any significant differences from the draft 990 to the final 990 return are provided to the Board Audit and Compliance Committee. Depending on the deadline for the 990 return filing and the Board Audit and Compliance Committee meeting this discussion may take place following the filing of the return. Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts The following is a summary of Legacy's policy and procedures for conflict of interest disclosure, monitoring and resolution.All Legacy employees and non-employees in leadership positions (e.g., Board members, Foundation Trustees, Medical Directors) are required to disclose potential conflicts of interest as the conflict arises. All employees are required to disclose any conflict of interest per the Standard of Conduct policy. Certain groups have annual formal disclosure requirements. Executives and non-employees in leadership positions complete the Conflict Disclosure Statement from the Standards of Conduct policy annually. Officers, Directors, Trustees, Key and Highly Compensated employees are also required to complete a questionnaire covering business relationships, business transactions with interested parties, loans and grants. Conflict Disclosure Statements and questionnaires are returned to Legacy Corporate Compliance or Tax Department for review of the disclosure. If a conflict is disclosed, or identified through any other means, Legacy Corporate Compliance ensures that management mitigates the risk (e.g.,discontinues relationship with vendor, segregates responsibilities, recuses Board member from voting in area of conflict) and that the conflict and mitigation steps are reported to the appropriate level (e.g. Audit and Compliance Committee of the Board). Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees The following describes the compensation practices of Legacy Health and its affiliates.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior leaders responsible for ensuring Legacy Health serves its mission and patients every day, and for ensuring a safe, inclusive and equitable workplace for all Legacy employees. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates, and are accountable for the effective day-to-day operation of the system.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee oversees the system's governance procedures with respect to the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures. Form 990, Part VI, Line 19: Other Organization Documents Publicly Available Legacy Health's audited and interim consolidated financial statements are publicly available on the Electronic Municipal Market Access(EMMA) (www.emma.msrb.org) and DAC Bond (www.dacbond.com) websites. Legacy's audited consolidated financial statements include consolidating schedules which highlights LEHHC's financial results.When changes are made to the LEHHC Articles or Bylaws, LEHHC discloses and attaches copies to the IRS Form 990, which are publicly available by request or on various public websites such as Guidestar(www.guidestar.org). Other governing documents are not available to the public. Other Changes In Net Assets Or Fund Balances - Other Increases CAPITAL CONTRIBUTION FROM RESEARCH = $262320 Other Changes In Net Assets Or Fund Balances - Other Increases DEFERRED REVENUE - UNITY = $600000 Other Changes In Net Assets Or Fund Balances - Other Decreases Gift Shop Operations Fund = -$1025 Other Changes In Net Assets Or Fund Balances - Other Decreases Reduction to commitment = -$5000000 Other Changes In Net Assets Or Fund Balances - Other Decreases ROUNDING = -$5 Other Changes In Net Assets Or Fund Balances - Other Increases TRANSFER FROM AFFILIATES = $235000000 Form 990, Part IV, question 12 Legacy has an audit of its consolidated financial statement which includes consolidating schedules highlighting LEHHC's financial results. Form 990, Part VI, question 2 Legacy Health System CPC, LLC (CPC) is a common pay agent for Legacy and its affiliates. The CPC files all required federal employment tax returns for Legacy and its affiliates. The number of employees reported on Form W-3 for LEHHC, the lab & clinics is 6,398. Form 990, Part X LEHHC participates in the Legacy investment pooled funds which include professionally managed equity and fixed income securities in both separately managed portfolios and commingled investment accounts. Investment returns are prorated according to each affiliate's share of the pool. Form 990, Schedule J Schedule J Reporting of Officers and Senior Management on Legacy Affilate Returns. The Legacy Officers, Senior Vice Presidents and other key employees may have responsibilities for the operations of the entire health system, including the affiliated entities. Their compensation is paid from and reported on the Legacy return(EIN 23-7426300). The compensation is reported again for informational purposes on related affiliated entity returns including, Legacy Emanuel Hospital & Health Center, Legacy Good Samaritan Hospital and Medical Center, Legacy Meridian Park Hospital, Legacy Mount Hood Medical Center, Legacy Salmon Creek Hospital, Silverton Health, Legacy Visiting Nurse Association, and Legacy Adventist Venture. 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