2021-05-17T16:33:08-05:00 2020-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Suite 2800 Minneapolis MN 554021538 990 2019-07-01 420680391 Mercy Hospital Iowa City Iowa MERC 3193390300 500 East Market Street Iowa City IA 52245 Dawna Miller CFO 3193390300 2021-05-17 1 SHAWNA M JANSONS P01222873 6123974000 2019 2022-09-23 18:48:47Z Dawna Miller 500 East Market Street Iowa City IA 52245 196200525 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. 15 13 1540 239 5779197 -1105604 760710 761447 160757444 164750687 9050009 3185800 1359361 4677058 171927524 173374992 36419 26015 0 0 74122343 74419495 0 0 0 83087540 101594788 157246302 176040298 14681222 -2665306 263566195 259707250 170390276 200346271 93175919 59360979 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 116594231 168348305 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 and behavioral and hospice care. 315842 218854 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. 7352668 26015 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. 124262741 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 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 57 0 1 1540 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 13 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Kimberley Rossiter 3193393900 500 East Market Street Iowa City IA 52245 Tim Krumm Chair 1.00 1.00 X X 0 0 0 Tom McLaughlin Vice Chair 1.00 0.00 X 0 0 0 Tom Clancy Secretary 40.00 0.00 X 143440 0 0 Bob Ritz Board Member 1.00 1.00 X 0 0 0 Dave Vellinga Board Member 1.00 0.00 X 0 0 0 Dr Chris Scott Board Member(Beg 11/19) 1.00 0.00 X 0 0 0 Jack Dusenbery Board Member 1.00 0.00 X 0 0 0 Madeline Windauer Board Member 1.00 0.00 X 0 0 0 Mary Westbrook Board Member 1.00 0.00 X 0 0 0 Shari DeMaris Board Member 1.00 1.00 X 0 0 0 SR Helen Marie Burns Board Member 1.00 0.00 X 0 0 0 SR Linda Bretchen Board Member (Beg 10/19) 1.00 0.00 X 0 0 0 SR Patricia Murphy Board Member (End 10/19) 1.00 0.00 X 0 0 0 SR Rita Specht Board Member(End 10/19) 1.00 0.00 X 0 0 0 Steven Anderson Board Member 1.00 0.00 X 0 0 0 Sean Williams CEO & Administrator 40.00 2.00 X X 0 0 0 Dawna Miller CFO (Beg 5/20) 40.00 2.00 X X 0 0 0 Douglas Davenport CFO (End 2/20) 40.00 2.00 X X 0 0 0 Kimberley Rossiter Assistant Treasurer 40.00 2.00 X 136295 0 38029 Andrew Ashby Physician 40.00 0.00 X 594766 0 34460 Benjamin Green Physician 40.00 0.00 X 576915 0 41034 Joseph Truszowski Physician 40.00 0.00 X 626678 0 39879 Luke Brunkhorst Physician 40.00 0.00 X 589353 0 32527 Yonas Getachew Physician 40.00 0.00 X 609652 0 34511 Michael Heinrich Former Officer 0.00 0.00 X 226705 0 1005 Martin Izakovic Former Officer 40.00 0.00 X 514624 0 43686 4018428 0 265131 105 1 1 0 MercyOne PO Box 74008768 Chicago IL 606748768 Management Services 3095759 Philips Healthcare PO Box 100355 Atlanta GA 303840355 Medical Equipment Supplier 1463331 Progressive Rehabilitation Associates LL 2751 Northgate Dr NE Iowa City IA 52240 Rehabilitation Services 1412432 Allscripts HealthCare 8700 W Bryn Mawr Avenue 700N Chicago IL 60631 IT Services 1217551 Mccomas-Lacina Construction 1310 Highland Ct Iowa City IA 52240 Construction Services 1061318 57 761447 761447 Patient Serv. Revenue 621400 86651755 86651755 Medicare/Medicaid 621400 65852768 65852768 Lab Outreach 621511 5779197 5779197 ASC/DIC Income 900099 4207962 4207962 2259005 2259005 164750687 1734972 1734972 1404576 1296689 107887 107887 107887 22789423 190249 21460205 68639 1329218 121610 1450828 1450828 Cafeteria Income 722210 752699 752699 Telephone 517000 154097 154097 Access 517000 4071 4071 3658304 3658304 4569171 173374992 162787962 5779197 4046386 X 21950 21950 4065 4065 413672 211600 202072 214256 214256 60108024 43548264 16559760 2936607 2127572 809035 6623715 4798882 1824833 4123221 2987274 1135947 2074710 2074710 200728 200728 153493 153493 25273 25273 17928524 11861856 6066668 539175 4744 534431 13421637 8152588 5269049 6726412 281688 6444724 2674271 90713 2583558 177099 95954 81145 4354908 1751547 2603361 10030126 8470824 1559302 789821 789821 Medical Supplies 15495272 15371948 123324 Pharmacy Supplies 15453067 15422203 30864 Bad Debt Expense 6679240 6679240 Food Expense 1229336 1229336 3641696 1150493 2491203 176040298 124262741 51777557 0 6429690 15778370 2261094 3626742 38244282 39104307 4464090 4628137 3603549 3348647 271802166 212267636 62540184 59534530 95118388 87664601 -46432551 -64626741 97337469 110648657 263566195 259707250 26112074 48076253 71626482 69160661 132892 24522 72518828 83084835 170390276 200346271 X 93175919 59360979 93175919 59360979 263566195 259707250 X -2665306 -769648 -30379986 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 1 0 1 0 1 25273 25273 0 Part II-B, Line 1: Mercy Hospital, Iowa City, Iowa is a member of the Iowa Hospital Association (IHA) and America Hospital Association (AHA). A percentage of membership dues paid to IHA and AHA relate to lobbying activities. 17144539 140115 -233781 593487 16457386 17286002 14493 377510 533466 17144539 16775239 456231 744957 690425 17286002 15365728 123098 1673119 386706 16775239 15598237 263507 -400097 95919 15365728 0.57000 0.16600 0.26400 0 1 1 4165665 4165665 141179907 104278978 36900929 125605947 107380950 18224997 850647 607708 242939 59534530 Beneficial Interest-Foundation 16711030 Due from Affiliates 89751177 2011/2018 Bond Fund 4116450 Non-Compete Agreement Value 70000 110648657 Pension Benefit Liability 81476937 Other Long-Term Liabilities 66000 Professional Liability Claims 1541898 83084835 X Part V, Line 4: All Restricted Endowed Funds are used for the benefit of Mercy Hospital Iowa City - capital equipment, employee grants, scholarships, etc. Part X, Line 2: As a result of the implementation of ASC 740, "As of June 30 2020 and 2019, the company recorded no liabilities for unrecognized tax benefits. 1 1 1 X 1 X 1 1 0 1 1 1078339 1078339 0.00640 17715401 11441072 6274329 0.03700 18793740 11441072 7352668 0.04340 611691 611691 0.00360 726 726 0.00000 1147889 814992 332897 0.00200 21950 21950 0.00010 1782256 814992 967264 0.00570 20575996 12256064 8319932 0.04910 3241 3241 0.00000 589129 589129 0.00350 592370 592370 0.00350 0 1858165 0 47410581 53707536 -6296955 X 1 1 1 Iowa City Ambulatory Surgery Center LLC Outpatient Surgery Center 0.51000 0.49000 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 X X X Lab Outreach Mercy Hospital Iowa City Iowa 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X http://www.mercyiowacity.org/community_health X 1 18 1 http://www.mercyiowacity.org/community_health 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X http://www.mercyiowacity.org/patient-financial-assistance X http://www.mercyiowacity.org/patient-financial-assistance X http://www.mercyiowacity.org/patient-financial-assistance 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: The Hospital conducted two focus groups with participants from these organizations, representing broad and deepknowledge of community health needs:- 4 Cs Community Coordinated Child Care- City of Coralville- City of North Liberty- Clear Creek Amana Schools- Coralville Police Department- Iowa City Area Chamber of Commerce- Iowa City Area Development Group- Iowa City Community School District- Iowa City Free Medical and Dental Clinic- Iowa City Police Department- Johnson County Ambulance Service- Johnson County Public Health- Johnson County Social Services- Mercy Hospital Iowa City- Mercy Hospital Emergency Care Unit- Mercy Iowa City- Mercy IC and Mercy Services- Mercy Pediatric Clinic- National Alliance on Mental Illness Johnson County- Rural Health and Safety Clinic of Eastern Iowa- United Action for Youth- United Way- United Way of Johnson and Washington Counties Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 11: The 2018 CHNA summarized twelve areas of opportunity for Community Health Improvement. Mercy Hospital is addressingthose needs as follows:Mental Health - Depression and Social Support: Mercy continues to invest in outpatient psychiatric services. While traditional primary care visits fell throughout the COVID pandemic, the visit volume to our mental health clinic grew significantly. We accommodated the growth in demand by initiating telehealth capability at our mental health clinic. We employ four full time providers which includes one therapist. Our providers also staff the emergency room of our hospital in Johnson county where many patients present with mental health conditions. In addition, our affiliate MercyOne will be rolling out a new ambulatory social service this year that will dedicate a social worker to serve as the primary contact for patients with mental health or emotional needs. Their focus is to manage transitions in care following hospital discharges, emergency department use and post-acute stays where mental illness or substance abuse was a primary reason for the admission or visit. Nutrition, Physical Activity, Diabetes:We will continue to offer a 12 week program to the public taught byregistered dieticians that focuses on behavioral modifications to achievelong-term lifestyle changes to improve overall health.Since 2018, we have employed a board certified physician in endocrinology,diabetes, and metabolism. His ability to effectively treat patients withmetabolic disorders advances our ability to address the adult obesityhealth need. Substance Abuse - Binge Drinking:Our community is home to a major university and excessive drinking haslong been an issue. Our Vice President of Population Health attends thePartnership for Alcohol Safety, a joint project of the University of Iowaand the City of Iowa City. Its mission is to identify and advocate forstrategies that reduce high-risk drinking and related harms.Access to Primary Care Physicians:Mercy will continue to operate primary care clinics in each of our 5primary care counties. This is the most direct way to address access,along with a financial aid policy that reduces the financial barriers for the uninsured. Mercy will also continue support of the Free Medical Clinicin Johnson county. This is an important health care access point for thosewith limited ability to pay.Cancer - Cancer Incidence:Mercy intends to more widely advertise the low dose lung cancer screeningprogram that screens for at-risk patients, especially former heavysmokers. The existing program has resulted in the early identification andtreatment of lung cancers, although many more eligible patients have notyet been screened.Heart Disease & Stroke Mortality Rates:Two additional cardiologists will begin treating patients in 2019 andshould result in at least 25% increase in patient contacts with ourcardiologists. Mercy is also certified as a primary stroke center andintends to maintain that certification.Infant Health - Teen Births:Mercy has budgeted to maintain our Muscatine county clinic staffing levelsfor the next year. This should maintain patients ability to access healthcare resources directly from this clinic. Additionally, we partner withindependent OBGYN groups to assess the market needs in this county.Injury & Violence - Violent Crime Rate:We intend to take no action as reducing the crime rate is not within thescope of our health care delivery system.Oral Health - Regular Dental Care:We intend to take no action regular dental care is not within the scope ofour health care delivery system.Respiratory Disease - Chronic Lower Respiratory Disease:We have employed 2 nurse navigators in 2018, that are focused on reducinghospitalization readmissions and avoidable emergency room visits,especially from patients with chronic conditions. They contact patientsafter they return home after hospital encounters to ensure that patientshave follow-up visits with their normal primary care provider and thatthey understand and are following the medical advice prescribed for them.Sexually Transmitted Disease and Chlamydia Incidence:Mercy is continuing to monitor chlamydia incidence rates and has seenrecent high rates in the eastern portion of our service area. OurInfection Prevention Coordinator plans to provide staff education in theclinic and identify opportunities for community outreach. He will thentrack the incidence rates to see if those efforts have a significantimpact on reducing incidence.Tobacco Use:We continue to provide smoking cessation counseling to a high percentage(85%) of adult smokers who are seen in our clinics. 1 1 - Mercy Home Health Care 500 East Market Street Iowa City IA 52245 Home Health and Private Duty Nursing 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, Ln 7 Col(f): Bad debt expense of $6,679,240 was subtracted for purposes of calculating the percentage in Schedule H, Part I, Line 7, column (f). Part II, Community Building Activities: Economic Development:Mercy works with such groups as the Iowa City Area Chamber of Commerce and Iowa City Area Development Group to support the business community, welcome innovation to the area, and develop the workforce. Mercy continues to partner with the 40-bed Mercy Inpatient Rehabilitation Hospital that employs approximately 100 health care professionals.Community Support:Mercy has provided support to the following community organizations in the form of financial support, promotional collaboration and/or colleague volunteer time:United Way of Johnson and Washington Counties Iowa City HospiceIowa City Free Medical ClinicNAMI (National Alliance for the Mentally Ill), American Cancer SocietyMercy partners with School-Based Health Clinics now located in four of the Iowa City Community School District's public schools. The Healthy Kids School-based Health Clinics are free Medical Clinics whose mission is to work collaboratively with area medical partners to provide accessible primary, mental health and specialty care to children from birth through high school graduation who experience barriers to accessing healthcare. Mercy plans to continue to provide staff and/or supplies for first aid booths at community festivals such as Arts Fest, Jazz Fest and Soul Fest as soon as COVID-19 restrictions lift. Mercy has participated in and sponsored these events for multiple years but due to the COVID-19 pandemic in FY20 events were canceled or deemed unsafe for participation. First Aid provided at the Johnson County Fair was also paused in 2020 due to COVID-19, but Mercy has provided this free service for over 10 years and plans to continue as COVID-19 restrictions lift. Rural Health and Safety of Eastern Iowa Partnership providing free COVID-19 testing, rural health screenings, and farm safety campaigns in their efforts to increase health care outreach and reduce injury prevention in the agricultural areas that make up most of its service area. Physical and mental health screenings, injury prevention education and general health information activities are ongoing during the warm weather months in Johnson and five contiguous counties.Mercy continues to be a lead organization for Thanksgiving in July, an annual summer food drive whose goal is to fill food pantries at a time of year when they have fewer donations and children are out of school, not receiving free and reduced breakfast and lunch. This program was started at Mercy Iowa City in 1995 and has grown to include many other sites in the State of Iowa including Des Moines, Dubuque and the Quad Cities. Mercy's Pastoral Care Department provides clothing to patients who are discharged with nothing to wear, often because what they had when they were admitted is no longer wearable (cut off in the Emergency Room, etc.) and there is no one to bring them anything. Transportation is also provided via paid taxi for patients and/or their family members upon discharge as needed due to lack of transportation means. Mercy's 24-hour "Mercy On Call" service provides medical triage and health information, can schedule provider appointments, and refer callers to local supporting services.SHIIP (Senior Health Insurance Information Program) Volunteers help seniors and those on SSDI navigate through Medicare insurance enrollment with emphasis on the annual Medicare Open Enrollment Period. This is a very robust program for the Johnson Country area. Environmental Improvements:Mercy has been a good neighbor by maintaining its buildings and landscaping at a high level. Mercy also pursues extensive recycling (including newspapers, office paper, magazines, plastics, batteries, cooking oil, construction materials and more) and programs that reduce energy consumption.Leadership Development and Training of Community Members:Mercy lends support to the annual Community Leadership Program of the Iowa City Area Chamber of Commerce, a nine-month leadership development program for 24 individuals who are increasing their professional and personal commitment to the community and typically sponsors a class member each year. Mercy also supports an active Clinical Ladder program for nurses, offers Continuing Education Credit (CEU) courses and conferences open to medical professionals across the State on a regular basis, such as those tailored to Emergency Care, Hospitalist care and Nursing care. Mercy also offers a location for CEU courses for the local Honoring Your Wishes initiative which encourages all adults to have Advance Directives that are current and reflect their wishes. The CEU courses train individuals to become certified counselors to help individuals with their Advance Directives, and to train certified counselors to assist with IPOST which is the Iowa version of the national POLST directive, a medical order for those with terminal conditions. Honoring Your Wishes is the program used at Mercy, and the hospital offers free assistance to anyone in its service area who needs it to complete their documents.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. Mercy is a co-sponsor of the Johnson County SAFE Kids Coalition whose mission is to prevent or reduce preventable injuries to children from birth to age 14. SAFE Kids promotes the correct use of child safety restraints in vehicles, bicycle helmets, and safety education to prevent falls, burns, poisoning and more. Mercy has plans in place to continue its lead partner of Safety Village as done in FY19 into FY21. Safety Village was canceled in FY20 due to COVID-19. It is a two-week summer safety camp for children aged 5-7 held in a miniature village on the grounds of one of our local elementary schools. Each summer, 200 children participate in classes and safety education with local EMS, police, sheriffs, and others/ 2020 was on pause due to COVID-19, but plans remain to continue this partnership as soon as restrictions allow to safely open.Mercy is also a lead partner in Health and Rural Safety of Eastern Iowa initiative which works to reduce preventable injuries in the agricultural community such as heavy equipment, large animal, pesticides and more. This partnership also seeks to increase health screenings and referrals to primary and specialty care for this population, that includes Anabaptist, and provide education to improve health. 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 .2782 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 III, Line 4: Mercy Hospital's Audited Financial Statements includes a footnote for the Provision of Uncollectible Accounts on page 11 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 6/30/20. 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 06/30/20. 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 2018. 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: Evaluation for Medicaid, disability, and other types of coverage is provided for uninsured patients for inpatient stays as well as high dollar outpatient services. 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 2019 was approximately 151,000. 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 33,000 for the 2018-2019 academic year. Johnson County is well-educated, of individuals 25 and older, 95.3 percent are high school graduates and 53 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, 16.0 percent of the Johnson County population lived below the poverty line between 2018 and 2019, compared to 11.2 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 General Support St Patrick Catholic Church 4330 St Patrick Drive Iowa City IA 52240 420680275 501(c)(3) 7500 General Support 1 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 1 1 0 0 0 0 0 1 0 Kimberley Rossiter Assistant Treasurer 132010 0 0 0 4285 0 8637 0 29392 0 174324 0 0 0 Andrew Ashby Physician 576466 0 0 0 18300 0 6650 0 27810 0 629226 0 0 0 Benjamin Green Physician 468786 0 98859 0 9270 0 9862 0 31172 0 617949 0 0 0 Joseph Truszowski Physician 625388 0 0 0 1290 0 9450 0 30429 0 666557 0 0 0 Luke Brunkhorst Physician 476159 0 112724 0 470 0 5848 0 26679 0 621880 0 0 0 Yonas Getachew Physician 591620 0 0 0 18032 0 6743 0 27768 0 644163 0 0 0 Michael Heinrich Former Officer 0 0 0 0 226705 0 0 0 1005 0 227710 0 0 0 Martin Izakovic Former Officer 324682 0 132914 0 57028 0 11486 0 32200 0 558310 0 0 0 Part I, Lines 4a-b Part I, Line 4a - Michael Heinrich, former Treasurer/CFO separated from the organization in July 2017. He had a written severance agreement with Mercy Hospital that was to pay him his salary for a term of 24 months after separation. In calendar year 2019, he was paid $226,705. The last payment was made on 7/5/2019. Part I, Line 4b - Mercy Hospital established an IRC Section 457(f) plan as a way of retaining executives, officers, and select groups of highly compensated employees with supplemental retirement benefits. Supplemental non-qualified retirement plan payments were made during the year to the following listed person in Part VII: Martin Izakovic - $32,209 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 1235000 40501771 4050177 2131594 34320000 2018 1 0 1 1 B 13870000 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 Patricia Murphy, 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. Sean Williams and Kimberley Rossiter have a business relationship as both simultaneously serve together on the Mercy Services Iowa City, Iowa board. 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 11,861,856. Management and general expenses 6,066,668. Total expenses 17,928,524. Form 990, Part XI, line 9: Change in Unrecognized Pension Actuarial Gain -10,022,277. Change in Beneficial Interest in Foundation -662,526. Change in Beneficial Interest of Services -18,675,654. Transfer to Self Insured Trust -1,019,529. Mercy Hospital Foundation 500 East Market Street Iowa City IA 52245 237040506 Foundation/Fundraising IA 501(c)(3) 12-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) 12-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) N/A 0 Mercy Hospital Guild 500 East Market Street Iowa City IA 52245 426099912 Fundraising IA 501(c)(3) 12-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 3675398 3840945 0 1 0.51000 Corridor Radiology LLC 2769 Heartland Drive Suite 307 Coralville IA 52241 430635070 Radiology Services IA Mercy Hospital Related 540460 2060260 0 0 0.51000 Eastern Iowa Rehabilitation Hospital LLC 680 S 4th Street Louisville KY 40202 831589139 Inpatient Rehabilitation Care IA Mercy Hospital Related 123 3049973 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 -16761666 6839310 1.00000 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 Mercy Hospital Foundation C 761447 Cost Mercy Services Iowa City Inc A 925227 Cost Mercy Services Iowa City Inc R 2275000 Cost Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust R 475000 Cost Eastern Iowa Rehabilitation Hospital LLC B 3130000 Cost Mercy Services Iowa City Inc Q 248749 Cost