2020-08-17T08:24:11-05:00 2019-09-30 010494526 Baker Newman & Noyes LLC 280 Fore Street Portland ME 04101 990 2018-10-01 042767602 CHMC Surgical Foundation Inc CHMC 6173554022 300 Longwood Avenue No Fegan3 Boston MA 02115 Steven J Fishman MD President 6173554022 2020-08-11 0 Nicholas E Porto P01310283 8002447444 2020-08-11 208.105.168.164 2020-08-11 16:09:17 ED P 8D27C340D9F2F89D467D155AEFB91C71D643DA43 DA1D1F22D002DE74304CAE64996AD19EA354FE22 2018 2020-09-23 17:36:50Z Steven J Fishman MD 300 Longwood Avenue Boston MA 02115 41550929 0 X N/A X 1982 MA The Foundation provides surgical services and educational services to Boston (see Schedule O) Children's Hospital and Harvard Medical School. The Foundation also provides care for patients regardless of their ability to pay, as well as providing and subsidizing hospital and community based services that are either unavailable or limited elsewhere in the community. 7 0 26 0 -6156 -6156 75977 3347679 30747467 30861882 657727 843673 322077 0 31803248 35053234 1086915 790923 0 0 23453104 23234248 0 0 0 3452050 3707909 27992069 27733080 3811179 7320154 57108153 63029765 20395537 23878685 36712616 39151080 X The Foundation provides surgical services primarily to patients at Boston Children's Hospital and at satellite locations. The Foundation carries on and promotes basic and applied medical research and education in the field of surgery by teaching (see Schedule O) students and other medical and scientific personnel. The Foundation also provides care for patients regardless of their ability to pay. 0 0 23109808 790923 27226343 The Foundation was organized to operate for the benefit of Boston Children's Hospital and Harvard Medical School, to provide surgical services to patients, and to conduct and promote research and education in the field of pediatric surgery. The Foundation may charge for patient care and other medical services, provided that any net income be used for the charitable, scientific, and educational purposes for which the Foundation was created. The Foundation also provides care for patients regardless of their ability to pay, as well as providing and subsidizing hospital and community based services that are either unavailable or limited elsewhere in the community. 519322 571177 The Foundation receives income from Boston Children's Hospital for providing administration, supervision, and teaching services. The Foundation carries on and promotes basic and applied medical research and education in the field of surgery by teaching students and other medical and scientific personnel; by providing or supplementing income to research personnel through fellowships, research grants, and stipends; and by giving lectures and publishing information concerning problems and research results in the field of pediatric surgery in order to educate the general public and the medical profession. 2336947 3064362 The Foundation provides clinical services in certain clinics and satellite locations of Boston Children's Hospital (the Hospital) at agreed upon rates for reimbursement. 25966077 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 26 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 7 0 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X Tom Jaksic MD 6173554022 300 Longwood Avenue Boston MA 02115 Steven J Fishman MD Clerk (10/18-6/19)/President (7/19-9/19) 45.00 15.00 X X 1266611 0 130762 Robert C Shamberger MD President (10/18-6/19) 45.00 15.00 X X 975967 0 131111 Tom Jaksic MD Treasurer 60.00 0.00 X X 847139 0 129241 Heung Bae Kim MD Clerk (7/19-9/19) 60.00 0.00 X X 834073 0 129467 Craig W Lillehei MD Director 60.00 0.00 X 795660 0 99610 Biren P Modi MD Director 60.00 0.00 X 726421 0 168424 Terry L Buchmiller MD Director 60.00 0.00 X 930392 0 103233 Christopher Weldon MD Director 60.00 0.00 X 779818 0 139233 Physicians Org at CH Inc Independent Board Member 2.00 0.00 X 0 0 0 Russell Jennings MD Physician 60.00 0.00 X 885071 0 128949 Mark Puder MD Physician 60.00 0.00 X 841236 0 126966 Thomas Hamilton MD Physician 60.00 0.00 X 789709 0 136806 Belinda Hsi Dickie MD Physician 60.00 0.00 X 776227 0 180052 Konstatinos Papadakis MD Physician 60.00 0.00 X 758162 0 141652 11206486 0 1745506 23 0 1 0 0 3342679 5000 3347679 Patient service revenue 621300 27226343 27226343 Clinical and other revenue 621300 3064362 3064362 Education and research 611710 571177 571177 30861882 463879 -6156 470035 6877489 6497695 379794 379794 379794 35053234 30861882 -6156 849829 790923 790923 4415138 4415138 15405053 14266326 1138727 809160 809160 2108833 1746405 362428 496064 451418 44646 40431 40431 50949 50949 24396 24396 56101 56101 509 509 905494 844499 60995 209515 209515 17995 17995 164099 164099 5833 5833 562461 518539 43922 PO Dues 661710 661710 Billing and collection 537425 537425 Coordinated Specialty P 385712 385712 Research expenses 85279 85279 27733080 25966077 1767003 0 4804570 5148228 817728 245324 4607808 4439495 231000 568367 400000 185129 193188 48540 27775 26598 20765 27982073 29309848 14276290 15709890 3839590 7332027 57108153 63029765 102803 417002 4324464 2763732 15968270 20697951 20395537 23878685 X 34828707 34688137 1883909 4462943 36712616 39151080 57108153 63029765 X 7320154 577808 -5459498 X X 0 1 X 1 0 X 60000 128125 75977 3347679 3611781 24972218 27167996 29156776 30747466 30861882 142906338 25032218 27167996 29284901 30823443 34209561 146518119 0 0 0 146518119 367136 368706 394620 432320 470035 2032817 367136 368706 394620 432320 470035 2032817 3555 1946 3060 -1990 -6156 415 273327 322077 595404 25402909 27811975 29682581 31575850 34673440 149146755 0.98240 0.98220 0.01360 0.01350 X Schedule A, Part III, Line 12, Explanation of Other Income: Insurance rebate - 2015 Amount: $ 273,327. 2017 Amount: $ 322,077. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1883909 3167000 587966 4462943 1883962 53 1883909 3051785 1167823 1883962 4641282 1589497 3051785 4659481 60000 78199 4641282 0.00000 0.00000 1.00000 0 0 48540 27775 20765 20765 Interest in the P.O. Pooled Investment Fund 15709890 F 15709890 Due from Boston Children's Hospital 3376794 Due from Physicians Org. at CH, Inc. 816350 Due from Dana Farber Cancer Institute 38210 Due from Harvard Medical School 327042 Due from Boston Medical Center 78559 Due from New England Organ Bank 2500 Due from CHPA, Inc. 71778 Malpractice Claims receivable 1362598 Due from BCH - Egan Family Charitable Fund 1200000 Due from Brigham & Women's 36343 Due from CV Surgery 19817 Due from Urology 586 Due from Anesthesia 1450 7332027 Due to Boston Children's Hospital 1776713 Due to Physicians Org. at CH, Inc 293100 Due to Boston Medical Center 4417 Accrued salaries and benefits 3967605 Accrued deferred compensation 7663544 Accrued professional liability 1807137 Due to Harvard 300000 Due to CHMC Anesthesia Foundation, Inc. 18750 Due to Brigham & Women's 19872 Accrued defined benefit plan 4846813 20697951 X 30171544 577808 -5459498 -4881690 35053234 0 35053234 27733080 0 27733080 0 27733080 Part V, Line 4: The endowment funds represent assets held in trust that are available to pay for future benefits to participants for a deferred compensation benefit plan and investments whose use have been restricted by donors to a specific time period and purpose. Part X, Line 2: The Foundation is a tax-exempt corporation as described in Section 501(c)(3) of the Internal Revenue Code (the Code), and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. In addition, the Foundation qualifies for the charitable contribution deduction under Section 170(b)(1)(A), and has been classified as an organization that is not a private foundation under Section 509(a)(2). Tax-exempt organizations could be required to record an obligation for income taxes as the result of a tax position they have historically taken on various tax exposure items, including unrelated business income or tax status. Management of the Foundation has evaluated the positions taken on the Foundation's filed tax returns and has concluded that no uncertain income tax positions exist at September 30, 2019. The Foundation's tax years from 2016 through 2019 are potentially subject to examination. Part XI, Line 2d - Other Adjustments: Pension adjustment -5,459,498. 1 Boston Children's Hospital 300 Longwood Avenue Boston MA 02115 042774441 501(c)(3) 784431 N/A N/A Research 1 0 Part I, Line 2: Monitoring is provided by CHMC Surgical Foundation, Inc. (the Foundation) through oversight of the terms and conditions of a written grant agreement. Multiyear agreements require yearly progress and financial reports for continuation of funding. During the year ended September 30, 2019, the Foundation only provided grant donations to other 501(c)(3) organizations. X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 Steven J Fishman MD Clerk (10/18-6/19)/President (7/19-9 714877 0 500526 0 51208 0 85000 0 45762 0 1397373 0 0 0 Robert C Shamberger MD President (10/18-6/19) 792860 0 155000 0 28107 0 85000 0 46111 0 1107078 0 0 0 Tom Jaksic MD Treasurer 679399 0 115819 0 51921 0 85000 0 44241 0 976380 0 0 0 Heung Bae Kim MD Clerk (7/19-9/19) 544989 0 246452 0 42632 0 85000 0 44467 0 963540 0 0 0 Craig W Lillehei MD Director 533525 0 223911 0 38224 0 55000 0 44610 0 895270 0 0 0 Biren P Modi MD Director 393717 0 295638 0 37066 0 127000 0 41424 0 894845 0 0 0 Terry L Buchmiller MD Director 596682 0 293769 0 39941 0 85000 0 18233 0 1033625 0 0 0 Christopher Weldon MD Director 428353 0 311112 0 40353 0 95000 0 44233 0 919051 0 0 0 Russell Jennings MD Physician 618079 0 214408 0 52584 0 85000 0 43949 0 1014020 0 0 0 Mark Puder MD Physician 500897 0 292192 0 48147 0 85000 0 41966 0 968202 0 0 0 Thomas Hamilton MD Physician 454593 0 292934 0 42182 0 95000 0 41806 0 926515 0 0 0 Belinda Hsi Dickie MD Physician 360201 0 354898 0 61128 0 138000 0 42052 0 956279 0 0 0 Konstatinos Papadakis MD Physician 466953 0 252375 0 38834 0 95000 0 46652 0 899814 0 0 0 Part I, Line 1a The Foundation provides gross-up payments for mortgage forgiveness, long-term disability insurance, and life insurance. These payments are included as taxable wages during the year. All permanent full-time employees of the Foundation are eligible for the gross-up payments. Part I, Line 4b CHMC Surgical Foundation, Inc. (the Foundation) established a Defined Benefit Pension Plan, effective October 1, 2006, to provide its employees with fair and adequate retirement benefits. The plan calls for benefits to be paid to eligible employees at retirement based upon years of service with the Foundation and compensation rates near retirement. Contributions to the plan reflect benefits attributed to employees' services to date, as well as services expected to be earned in the future. During the year ended September 30, 2019, the Foundation made the following contributions to the plan: Robert C. Shamberger, MD, $30,000; Tom Jaksic, MD, $30,000; Steven J. Fishman, MD, $30,000; Heung Bae Kim, MD, $30,000; Russell Jennings, MD, $30,000; Terry L. Buchmiller, MD, $30,000; Mark Puder, MD, $30,000; Biren P. Modi, MD, $72,000; Christopher Weldon, MD, $40,000; Thomas E. Hamilton, MD, $40,000; Belinda Hsi Dickie, MD, $83,000; and Konstatinos Papadakis, MD, $40,000. Part I, Line 7 Bonus compensation amounts are determined by the Chief of CHMC Surgical Foundation, Inc. (the Foundation). The amounts are discretionary based on job performance and the financial performance of the Foundation. Belinda Hsi Dickie MD Physician Housing loan X 300000 231000 0 1 1 231000 Schedule L, Part II, Loans to and from Interested Persons: CHMC Surgical Foundation, Inc. (the Foundation) has provided several secured and unsecured loans to employees. The loans were made for recruitment and retention purposes, to assist physician employees in the purchase of their primary residence. The amounts for the recruitment loans were determined by restricted donations provided by Boston Children's Hospital for use in recruitment. The loans will be forgiven over the terms of the notes if the recipients remain employed at the Foundation or its affiliates. The amount of the loan forgiveness will be included with accrued interest, if applicable, as compensation in the year forgiven. The balance of the loans outstanding are $613,000 at September 30, 2019. Future principal amounts due are as follows: $107,068 in 2020; $107,066 in 2021; $107,066 in 2022; $54,430 in 2023; $44,430 in 2024; and $210,940 thereafter. Loan amounts to individuals reported in Part VII have been disclosed in Schedule L, Part II, the balance of the notes receivable are with individuals who are not required to be disclosed in Schedule L per the IRS instructions. Form 990, Part VI, Section A, line 1 The majority of CHMC Surgical Foundation, Inc.'s (the Foundation's) board members are physicians who are not independent from the Foundation. However, the Foundation is part of an integrated delivery system with Boston Children's Hospital (the Hospital) which does have a community board. The Foundation was organized in 1982. At that time, the board was composed entirely of physicians, a board structure that was approved by the Internal Revenue Service. The Foundation has since adjusted the board structure to make it more responsive to the hospital by adding the Physicians Organization at Children's Hospital, Inc. (the PO) as a member. See Schedule O, Part VI, Questions 3, 6, 7b, and 12 for more details of the PO's rights. Form 990, Part VI, Section A, line 3 The Physicians Organization at Children's Hospital, Inc. (the PO) is a Class "C" member of CHMC Surgical Foundation, Inc. (the Foundation). The PO is responsible for providing management services to the Foundation. The PO has the power to approve the independent auditor and legal counsel of the Foundation from a list of firms mutually agreed to by the PO and the Foundation. The PO also has the right to review, but not to approve, the annual budgets and by-law changes of the Foundation. Lastly, Boston Children's Hospital has the right to review for compliance with applicable law, the general terms of and any modification to physician compensation and benefit plans for all physician employees of the Foundation. Form 990, Part VI, Section A, line 6 CHMC Surgical Foundation, Inc. (the Foundation) has three classes of members. The Chief of the Department of Surgery (the Department) of Boston Children's Hospital (the Hospital) is a Class "A" member. Each person who is a member of the Foundation, other than the Chief of the Foundation, who holds a medical staff appointment under the auspices of the Chief Surgeon from Harvard University Medical School, and who is a full time employee at the Hospital, shall be a Class "B" member. In addition, upon the recommendation of the Chief Surgeon and with the approval of the President of the Hospital or his designee, exceptions may be made to permit other physicians who are members of the Department to be Class "B" members. The Physicians Organization at Children's Hospital, Inc. is a Class "C" member of the Foundation. Form 990, Part VI, Section A, line 7a According to the Articles of Organization, the Chief of the Department of Surgery (the Department) of Boston Children's Hospital is the Class "A" member of CHMC Surgical Foundation, Inc. (the Foundation). Each person who is a member of the Foundation, other than the Chief of the Department, is a Class "B" member of the Foundation. The Class "A and "B" members of the Foundation elect the Board of Directors from nominees presented by the Executive Committee at their annual meeting. Each member is entitled to one vote upon any question at any meeting of the members. Form 990, Part VI, Section A, line 7b The Physicians Organization at Children's Hospital, Inc. (the PO) is a Class "C" member of CHMC Surgical Foundation, Inc. (the Foundation). The PO is responsible for providing management services to the Foundation. The PO has the power to approve the independent auditor and legal counsel of the Foundation from a list of firms mutually agreed to by the PO and the Foundation. The PO also has the right to review, but not to approve, the annual budgets and by-law changes of the Foundation. Lastly, Boston Children's Hospital has the right to review for compliance with applicable laws, the general terms of and any modification to physician compensation and benefit plans for all physician employees of the Foundation. As a Class "C" member of the Foundation, the PO attends the Foundation's annual meeting. Form 990, Part VI, Section B, line 11b The detailed review will be conducted by the President of the Foundation, Steven J. Fishman, MD, and the administrator, Todd Katzman. A copy of the Form 990 will be provided to the board prior to filing. The detailed review will be conducted before filing the return with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c The Physicians Organization at Children's Hospital, Inc. (the PO) and Boston Children's Hospital (the Hospital) administer an annual conflict of interest disclosure process to all of their member Foundations, which asks physicians (officers, top management, and highly compensated employees) and selected Foundation staff to disclose potential conflicts. A disclosure statement will be circulated annually to members of the PO. The audit committee shall determine those individuals (including medical staff members) who shall be required to complete the disclosure statement. The audit committee, at its discretion, may either: 1) refer any or all disclosure statements to the Board of Directors; 2) appoint an ad hoc committee to review and resolve any conflict of interest issues; or 3) review and resolve any conflict of interest issues personally or through a designee(s). Any person not receiving a disclosure statement nevertheless has an affirmative obligation to disclose to the PO President, PO General Counsel, or his/her supervisor whenever he/she believes he/she has or may have a conflict of interest. Similarly, each person completing a disclosure statement has an affirmative obligation to update the statement any time circumstances change and/or he/she believes that a conflict of interest may exist. In the event a conflict of interest is found to exist, the Foundation prohibits the member from voting on any matter to which the conflict relates or otherwise influencing the voting on such matter. Form 990, Part VI, Section B, line 15 Faculty compensation must comply with the Boston Children's Hospital (the Hospital) Physician Compensation Guidelines. These guidelines are developed in consultation with an independent external compensation consulting firm and are approved by the independent Compensation Committee of the Board of Children's Medical Center Corporation and the Hospital. The guidelines set the maximum compensation limits based on a peer group analysis for the Foundation. The maximum compensation limits are based on pediatric specialty, sub-specialty, academic rank and include productivity adjustments. Any proposed compensation that exceeds the limits must be prospectively approved by the independent compensation committee of the Board of the Hospital. Annual compensation for individual faculty members is set by the President of the CHMC Surgical Foundation, Inc. (the Foundation), reviewed and approved by the Foundation in accordance with the Foundation's compensation policies and procedures. The Foundation's President's compensation is reviewed and approved annually on a prospective basis by the Boston Children's Hospital Chief Executive Officer and President/Chief Operating Officer. Form 990, Part VI, Section C, line 19 The Foundation maintains all financial records, conflict of interest policies, and governing documents at its main office at 300 Longwood Avenue, Boston, MA 02115. The documents are available upon request. Form 990, Part XI, line 9: Pension adjustment -5,459,498. Form 990, Part XII, Line 2c: The audit process and scope has not changed from the prior year. Boston Children's Hospital 300 Longwood Avenue Boston MA 02115 042774441 Hospital MA 501(c)(3) Line 3 N/A 0 Physicians Organization at Children's Hospital Inc 300 Longwood Avenue Boston MA 02115 043266103 Management services MA 501(c)(3) Line 12c, III-FI N/A 0 0 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0