2020-11-10T13:20:41-06:00 2019-12-31 910189318 Moss Adams LLP 3121 W March Ln Ste 200 Stockton CA 952192367 990 2019-01-01 941044474 Lodi Memorial Hospital Association Inc LODI 9164060000 975 S Fairmont Avenue Lodi CA 952405118 Jason Whitney Treasurer 9164060000 2020-10-29 1 Tracy S Paglia P00366884 2099556100 2020-10-29 172.9.161.112 2020-10-29 20:23:40 PD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 2CA4604677747A1B8287DC7DD1B2F222DAF5CAE3 2019 2021-01-29 14:40:06Z Adventist Health Lodi Memorial Daniel Wolcott 975 S Fairmont Avenue Lodi CA 952405118 246312858 0 1071 X www.adventisthealth.org/lodi-memorial/ X 1945 CA Living God's love by inspiring health, wholeness and hope. 14 12 1536 81 0 0 778608 2735423 241771008 241327051 1253387 1960474 406019 83563 244209022 246106511 285718 100085 0 0 107063428 102001240 0 0 390753 130569171 143924606 237918317 246025931 6290705 80580 303047094 239446881 229243113 166271894 73803981 73174987 X Living God's love by inspiring health, wholeness and hope. 0 0 198682967 100085 241327051 See Schedule O 198682967 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 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 0 0 1536 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 12 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CA X Jay Lipps VP System Controller 9164061092 PO Box 619135 Roseville CA 95661 X Ferch Wayne President, CCR 8.33 41.67 X 0 4448122 47838 Reiner Scott Dir/Chair 0.00 50.00 X X 0 1995696 53734 Wing Bill Dir/Vice Chair/Asst Secr 0.00 50.00 X X 0 1572254 46583 Reppert Joseph CFO/Asst Secr thru 08/2019 0.00 50.00 X 0 1209069 57565 Larsen David Finance Officer, CCR thru 04/19 8.33 41.67 X 0 777379 316645 Wagner Jack Former Asst Secr thru 03/18 0.00 0.00 X 0 778475 29189 Wolcott Daniel President 50.00 0.00 X 0 722077 59517 Jobe Meredith Secretary 0.00 50.00 X 0 730385 45909 Chen Steven Finance Officer, CCR 8.33 41.67 X 0 671517 59363 Iris Patricia Medical Officer 8.33 41.67 X 0 406188 28331 Moreno Debbe CNO thru 09/19 0.00 50.00 X 0 377063 45351 Whitney Jason Treasurer 50.00 0.00 X 0 357622 56322 McCollough Brooke Operations Executive 0.00 50.00 X 0 335104 54777 Gruzensky Denton Reg HP Dir, CCR 8.33 41.67 X 0 321342 45976 Beck-Atwater Sandra Director Hospital Pharmacy 50.00 0.00 X 223072 0 39463 Carmody Thomas Physician Assistant 50.00 0.00 X 228102 0 26749 Brown Mary RN, House Supervisor 50.00 0.00 X 216357 0 26677 Markovich Jennifer Director, RN 50.00 0.00 X 199081 0 27445 Stump Valerie Director, RN 50.00 0.00 X 205738 0 20070 PickeringChristine Communication Dir, CCR 8.33 41.67 X 0 163858 30977 Ziegele Paul Former Treas thru 05/2018 0.00 0.00 X 0 150324 33920 Reiner Richard Director 0.00 4.00 X 0 28588 0 Davis Andrew Director 0.00 4.00 X 0 28246 0 Cherry Robert Director 0.00 4.00 X 0 26315 0 Heinrich Kerry Director 0.00 4.00 X 0 20102 0 Innocent Larry Director 0.00 4.00 X 0 18852 0 Woodson Marc Director 0.00 4.00 X 0 15000 0 Graham Ricardo Director 0.00 4.00 X 0 8848 0 Banks David Director 0.00 4.00 X 0 6382 0 Freedman John Director 0.00 4.00 X 0 2367 0 Salazar Velino Director 0.00 4.00 X 0 553 0 Ocampo Lucy Director 0.00 4.00 X 0 0 0 Philip Celeste Director 0.00 4.00 X 0 0 0 1072350 15171728 1152401 298 1 1 0 Regents of the University of California 1111 Franklin Street 12th floor Oakland CA 94607 Physician Professional Fees 8192891 CEP America - Anesthesia PC 2100 Powell Street Suite 900 Emeryville CA 94608 Physician Professional Fees 3082069 Satellite Healthcare Inc PO Box 45545 San Francisco CA 94145 Dialysis Coverage 757211 PT Solutions Holdings LLC PO Box 724557 Atlanta GA 31139 Physical, Speech, and Occupational Thera 661819 Restorix Health 445 Hamilton Avenue Suite 800 White Plains NY 10601 Physician Professional Fees 599093 35 75466 2659957 2735423 Patient service revenue 621400 237998487 237998487 Prop 56/Tobacco Tax 900099 1758705 1758705 Other program revenue 621990 875601 875601 Dietary service revenue 621400 694258 694258 241327051 1957850 1957850 245603 171432 74171 74171 74171 2624 0 2624 2624 2624 44307 34915 9392 9392 246106511 241327051 0 2044037 X 100085 100085 421629 421629 80276648 74574385 5392946 309317 3788427 3630633 142456 15338 11699480 11027643 635945 35892 5815056 5496945 294595 23516 18640618 18640618 208827 112446 96381 21799 21799 20960 20960 48175904 34033530 14142374 4615 3529 1086 887709 741392 140287 6030 7476415 1651416 5824999 6411260 5474516 936744 220360 128776 91584 151380 89228 62152 4482397 4478024 4373 10909977 10880560 29417 369664 369664 Patient care supplies 30475598 30335727 139211 660 Hospital Medi-Cal Quali 14431881 14431881 Leased equipment expens 603215 602123 1092 432027 77875 354152 246025931 198682967 46952211 390753 99693 0 87961565 38010058 21949 20750 33008053 31272151 3772055 3299452 468288 1008686 264650484 142769954 125227456 121880530 3976079 0 9686702 8977126 38825254 34978128 303047094 239446881 19029968 20120044 210213145 146151850 229243113 166271894 X 73262660 70003285 541321 3171702 73803981 73174987 303047094 239446881 X 80580 -709574 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 20960 20960 0 Part II-B, Line 1: The Hospital belongs to industry and professional associations for which a portion of the membership dues is used for lobbying activities. Expenditures to Noteware were paid for the purpose of working with legislators and government officials relating to legislation affecting hospitals and healthcare. 541320 2659952 29572 3171700 602023 569686 630389 541320 562343 689003 3000 41917 602023 547340 148830 133827 562343 599512 2186902 2239075 547339 0.00000 0.00000 1.00000 0 0 9811038 9811038 187005423 91844796 95160627 3225181 3012936 212245 56882510 44733558 12148952 7726332 3178664 4547668 121880530 Receivables from related organizations 17913122 Receivables from third-party payors 16586819 State Board of Pharmacy receivable 345251 Other assets 132936 34978128 Payable to related organizations 140985413 Other liabilities 4726136 Conditional asset retirement 440301 146151850 X Part V, Line 4: Board-designated, temporary and permanently restricted endowment funds are for specified operating and capital projects. The funds are released as project costs are expended. Part X, Line 2: The principal operations of the System is exempt from taxation pursuant to Internal Revenue Code Section 501(c)(3) and related state provisions. The System recognizes tax benefits from any uncertain tax positions only if it is more-likely-than-not the tax position will be sustained, based solely on its technical merits, with the taxing authority having full knowledge of all relevant information. The System records a liability for unrecognized tax benefits from uncertain tax positions as discrete tax adjustments in the first interim period the more-likely-than-not threshold is not met. The System recognizes deferred tax assets and liabilities for temporary differences between the financial reporting basis and the tax basis of its assets and liabilities along with net operating loss and tax credit carryovers only for tax positions that meet the more-likely-than-not recognition criteria. At December 31, 2019 and 2018, no such assets or liabilities were recorded. The System currently files Form 990 (informational return of organizations exempt from income taxes) and Form 990-T (business income tax return for an exempt organization) in the U.S. federal jurisdiction and the state of California. The System is not subject to income tax examinations prior to 2015 in major tax jurisdictions. 1 1 X 1 X 1 X 1 1 1 0 1 1 419866 0 419866 0.00170 85494723 66403494 19091229 0.07760 85914589 66403494 19511095 0.07930 1101795 607700 494095 0.00200 385004 385004 0.00160 9276824 124863 9151961 0.03720 38259 900 37359 0.00020 10801882 733463 10068419 0.04100 96716471 67136957 29579514 0.12030 3491 3491 0.00000 1647 1647 0.00000 8775 8775 0.00000 13913 13913 0.00000 1 1902169 196100 60688759 63180458 -2491699 X 1 1 2 Endoscopy Center of Lodi LLC Ambulatory Surgery Center 0.78000 0.00000 0.22000 3 Lodi Outpatient Surgery Center Ambulatory Surgery Center 0.78000 0.00000 0.22000 2 1 Lodi Memorial Hospital Association Inc dba AHLM 975 S Fairmont Ave Lodi CA 95240 www.adventisthealth.org/lodi-memorial/ 030000056 X X X A 2 Lodi Memorial Hospital - West dba AHLM 800 Lower Sacramento Road Acute Phys Lodi CA 95242 www.adventisthealth.org/lodi-memorial/ 030000056 X X Outpatient departments at this campus A Facility Reporting Group - A 0 0 1 X X X X X X X X X 19 1 1 1 1 X See Sch H Part VI - Needs Assessment X See Sch H Part VI - Needs Assessment X 1 19 1 See Sch H Part VI - Needs Assessment 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X Sch H Part VI-Patient Educ X Sch H Part VI-Patient Educ X Sch H Part VI-Patient Educ X X X X X X 1 X 0 X X X X 1 X 0 0 Part V, Section B Facility Reporting Group A Facility Reporting Group A consists of: - Facility 1: Lodi Memorial Hospital Association, Inc. dba A, - Facility 2: Lodi Memorial Hospital - West dba AHLM Facility Reporting Group - A Part V, Section B, line 5: The 2019 CHNA data collection process can be summarized as follows: 1. Review of prior CHNA reporting efforts; 2. Collection of most recently available demographic, socioeconomic and health indicator data; and3. Data gathering from community members. Community input was provided by a broad range of community members using key informant interviews, focus groups, and surveys. Individuals with the knowledge, information, and expertise relevant to the health needs of the community were consulted. These individuals included representatives from local governmental and public health agencies as well as leaders, representatives, or members of underserved, low-income, and minority populations. Additionally, where applicable, other individuals with expertise of local health needs were consulted. Thirteen key informant interviews individuals representing diverse sectors in San Joaquin County including: public health, health care, community-based organizations, social services, education and government. Thirty-one community resident focus groups were conducted in geographic areas within San Joaquin County, including Stockton, Lodi, Tracy and Manteca. Nineteen groups were conducted in English, ten were conducted in Spanish, one was conducted in Tagalog and one was conducted in Cambodian. Participants were teens, adults, and older adults, who represented underserved, low-income, and varied ethnic communities.Secondary data sources include collected data on key health indicators, morbidity, mortality, and various social determinants of health from the Kaiser Permanente CHNA Data Platform, Health Places Index, American Community Survey and various other state and federal databases. Facility Reporting Group - A Part V, Section B, line 6a: Hospitals that participated in the 2019 CHNA process included Dameron Hospital, Kaiser Permanente, Sutter Health and Dignity Health St. Joseph's Medical Center. Facility Reporting Group - A Part V, Section B, line 6b: Other non-hospital facilities that participated in the 2019 CHNA process included Community Medical Centers, First 5 San Joaquin, Health Net, Health Plan of San Joaquin, San Joaquin County Public Health Services. Facility Reporting Group - A Part V, Section B, line 11: Our 2016 CHNA identified three priority areas for our community health investments from 2017-2019 which are Wellness (diabetes and obesity prevention), Access to Care (including mental health) and Youth Development. The results from the CHNA have guided the following interventions on how we could best provide for our community and the most vulnerable among us. Priority Need 1 - Wellness (Diabetes and Obesity Prevention): Our Goal is to increase community knowledge of healthy nutrition through educational programming, the partnership with community organizations and faith congregations to conduct children focused nutritional education and the collaboration with area organizations and churches to conduct health eating lecture events. We also want to offer support services to enhance physical activity, partner with area organizations to increase opportunity for activity within our community and collaborate with area organizations to promote a broader awareness about the importance of activity. Interventions: 1. Diabetes Among Friends is a five-week series of diabetes education to prevent prediabetes progression to type 2 and to improve management in those with type 1 and type 2 diabetes. The program is designed to take important nutrition and activity education out to the most critical areas in the community. The lessons include "Getting to know Diabetes," "Healthy Eating," "Healthy Coping & Physical Activity," "Diabetes Medications, and Staying Healthy with Diabetes." Number of community members served: 66.2. Healthy Choices is another class offered free of charge to community members. The class is held once a month. Each class is designed to educate and provide the skills to support sustainable, health-improving behavior change. Our team of physicians, nurses, dietitians and health coaches will offer lectures, interactive workshops and health coaching. Some of the topics will include: Tips to improve weight control, disease prevention and management including: high blood pressure, high cholesterol, diabetes, heart disease, healthy cooking 101: cooking demonstrations, healthy meals, sweets and holiday recipes, nutrition education, label reading and tips for eating out and stress management. Number of community members served: 151.3. Dancing for Health Nutrition Education & Zumba Class: AHLM partnered with San Joaquin County Public Health Services and the First Baptist Church to run a program that included Zumba, a nutritional health lesson, and a nutrition demo with healthy foods. The event was free to community members, with a specific focus on our Latino population, as Latinos face higher rates of obesity and diabetes in our county. Pre and post surveys administered in the Dancing for Health Nutrition Education & Zumba Class, demonstrated that participants' awareness of healthy food options increased. Some of the participants shared changes they were making in their food choices and lifestyles based on what they learned in the class. Number of community members served: 23.4. Adventist Health Lodi Memorial offered ongoing and consistent opportunities for the community to increase nutritional knowledge. Those programs included a range of learning environments, from small groups to community health expos and fairs. Staff time and organizational financial resources were utilized to accomplish this objective. The list of those outreach initiatives includes: diabetes preventions talk, health fairs were held in various locations and times, including the Sikh Temple, Walk for the Health of It and Love Lodi. Cooking classes for youth were held at Lodi Middle School and Millswood Middle School. Nutrition and diabetes prevention talk was also done for community members at a monthly support group with healthy cooking demos and physician and dietician lectures were held at our West Campus. Number of community members served: 251.Priority Need 2 - Access to Care (Including Mental Health): Our goal is to increase access to primary care, provide education on care access points for at risk populations and promote enrollment of uninsured into appropriate government programs. Interventions: 1. Enrollment Assistance/Public Medical Programs - Enrollment Assistance/Public Medical Programs - The admissions office at Adventist Health Lodi Memorial screens for insurance coverage and refers uninsured patients to a service call Parallone. Parallone assists with setting these patients up with Medi-Cal. Adventist Health Lodi Memorial uses a service called Cryacomm (Language Access Network), which offers over-the-phone interpreter services. This service has over 250 available languages. This service can be used to assist patients who do not speak English. Number of community members served: 420.2. Enrollment Assistance/Public Medical Programs - Provided free services through the WEROC Clinic for those that did not qualify for insurance. Number of community members served: 692.3. Recruited primary care providers to meet access to demand: five providers were recruited in 2019. These include gastroenterologists, orthopedic doctors, an anesthesiologist, a primary care provider, and family practice provider. 4. AHLM continues to provide mental health resources online under the patient resources tab. Priority Need 3 - Youth Development: We envision a community where the youth will thrive through early youth development with an emphasis on literacy, education, mentorship, and the support of organizations dedicated to helping youth in the community. Interventions:1. Camp Hutchins - Camp Hutchins is a professional child care and preschool for children three to five years of age. The program is designed specifically for children in preparation for kindergarten with creative and cultural experiences in music, art, literature, group and hands-on learning activities. Camp Hutchins has a year-round swimming pool, provides opportunity for outdoor play, and transportation from local schools to the program. Camp Hutchins also provides students lunch and snacks. Number of community members served: 95 children had 15,882 visits. 2. School Based Health Education Programs - Adventist Health Lodi Memorial's exercise physiologist attended Westwood Nutrition, Health, & Safety Fair. He provided interactive presentation questioning and guiding topics related to physical activity and health, i.e. asking recommended exercise minutes for children, why should we exercise, what is exercise, what exercises do you enjoy. Students then performed a team relay applying cardio, strength, and mobility. Adventist Health also hosted a health and nutrition booth. Another school-based program was led by our community outreach nurse who provides the students with healthy foods cooking demos and recipes. Lastly, Heritage Elementary School hosted a community event which included gardening activities, medical screenings, a farmer's market, summer meal access to children, and more. Adventist Health Lodi Memorial had two booths - one provided physical activity and the other was a nutritional "rethink your drink" type of booth. The physical activity booth provided education, and a tug of war event for the children. Community members served: 735. 18 1 - Lodi Outpatient Surgical Center 521 S Ham Lane Suite F Lodi CA 95242 Ambulatory Surgical Center 2 - AHLM Wound & Hyperbaric Care 2415 W Vine Street Suite 106 Lodi CA 95242 Outpatient Clinic - Hyperbaric & Wound Care 3 - Endoscopy Center of Lodi LLC 840 S Fairmont Avenue Suite 1 Lodi CA 95240 Ambulatory Endoscopy/Surgical Center 4 - AHLM Millsbridge Family Medicine 1901 W Kettleman Lane Suite 200 Lodi CA 95242 Community Clinic - Family Medicine 5 - Galt Family and Specialty Care 387 Civic Drive Galt CA 95632 Outpatient Clinic - Family Medicine 6 - Advanced Imaging Center at AHLM 1031 S Fairmont Avenue Lodi CA 95240 Outpatient Diagnostic Imaging 7 - AHLM Pediatric Care 2415 W Vine Street Suite 100 Lodi CA 95242 Outpatient Clinic - Pediatric care 8 - Urgent Care Clinic 1235 W Vine Street Suite 20 Lodi CA 95240 Outpatient Clinic - Urgent Care Services 9 - Ham Lane Clinic - Fairmont Ave 845 S Fairmont Avenue Suite 8 Lodi CA 95240 Outpatient Clinic - Cardiology & Pulmonology 10 - AHLM Family Medicine 2415 W Vine Street Suite 105 Lodi CA 95242 Outpatient Clinic - Family Medicine 11 - AHLM OrthopedicsSports Medicine 1235 W Vine Street Suite 22 Lodi CA 95240 Community Clinic - Orthopedics & Sports Medicine 12 - Adventist Health Home Health 800 S Lower Sacramento Road Lodi CA 95242 Home Care Services 13 - AHLM West Pharmacy 2415 W Vine Street Suite 104 B Lodi CA 95240 Retail Pharmacy 14 - AHLM Trinity Multi-Specialty Care 10200 Trinity Parkway Suite 102 Stockton CA 95219 Community Clinic - Multi-specialty Care 15 - Ione Family Care Clinic 305 Preston Avenue Ione CA 95640 Outpatient Clinic - Family Medicine 16 - AHLM Prenatal Care 2415 W Vine Street Suite 103 Lodi CA 95242 Outpatient Clinic - Prenatal Care 17 - AHLM Occupational Medicine 800 S Lower Sacramento Road Lodi CA 95242 Outpatient Clinic - Occupational Medicine 18 - AHLM Walter E Reiss Outreach Clinic 300 W Oak Street Lodi CA 95240 Free Clinic Part I, Line 7: Specific Ratios of Costs to charges are utilized for each department. Where applicable the source of these ratios are the Medicare Cost Report. Part II, Community Building Activities: The hospital is involved in numerous community building activities which promote the health of the communities it serves. Numerous community concerns are addressed, including health improvement, education, poverty, workforce development and access to care. We also encourage our employees to serve on community collaboration boards, health advocacy programs, and physical improvement projects to promote the health of the communities we serve. In addition, we work with neighborhood programs, including schools, work sites and safety net providers to promote health and wellness and prevent disease. These activities are not included elsewhere on Schedule H. Part III, Line 3: The Hospital provided care to all who presented themselves in our emergency room, without asking for proof of insurance. The Hospital's uninsured population continues to increase. Uninsured patients are screened for Medicaid linkage, given assistance in applying for Medicaid and if ineligible for Medicaid are given information regarding the Hospital's Charity Care Policy and encouraged to apply for charity care. Often the information gathered in the Medicaid application will make this determination "automatic". If additional information is required, the Hospital attempts to contact the patient. Those that do not respond will be sent to a collection agency after 120 days and four statements. The Hospital estimates 21% of bad debt expense (calculated at cost) should be considered charity care. The Hospital's bad debt accounts are analyzed by a third party to determine this amount. Part III, Line 4: Costing methodology:Utilizing the previous costing methodology as outlined in response to Part I, Line 7, all patients are assigned a payor class (i.e. charity, self pay, Medicare, Medi-Cal, managed care). The cost by payor is a summation of all patients in the assigned payor class. The amounts written off as bad debt (assigned to a collection agency) are net of any applicable payments or discounts. Any payments received after an account is assigned to a collection agency reduce the bad debt expense in the period received.Uncompensated care and community benefit costs:Our policy is to provide service to all who require it, regardless of their ability to pay. As such, the Hospital provides substantial amounts of uncompensated care. When this care is provided to patients who lack financial resources and therefore are deemed medically indigent, it is classified as charity care. When it is provided to patients who have the means to pay, but decline to do so, it is classified as provision for uncollectible accounts. Some undetermined portion of the provision for uncollectible accounts represents care to indigent patients who the Hospital has been unable to identity as charity. Charity care charges are not reflected in net patient service revenues. In addition, we provide services to poor and underserved persons who cannot afford health care because of inadequate resources and/or are uninsured or underinsured, including patients insured under certain government-reimbursed public aid programs. Such programs pay providers amounts that are less than established charges for the services provided to the recipients and frequently the payments are less than the costs of rendering the services.Patient accounts receivable:Patient accounts receivable for services provided to patients covered under the Medicare and Medicaid (Medi-cal in California) programs, privately sponsored managed care programs for which payment is made based on terms defined under formal contracts, and other payors (including self-pay) are recorded at their estimated realizable value based on contractual billing rates or our standard billing rates for our non-contracted payors. The Hospital regularly reviews accounts and contracts and provide appropriate estimates of contractual allowances that are then netted against patient accounts receivable. The Hospital also provides an estimated allowance for uncollectible accounts based on the Hospital's evaluation of the aging of our patient accounts receivable, the Hospital's historical collection experience for each type of payor and other relevant factors.The Hospital's primary concentration of credit risk is patient accounts receivable, which consists of amounts owed by various governmental agencies, insurance companies and private patients. The Hospital grants credit without collateral to the Hospital's patients and third party payors. Part III, Line 8: The Medicare Cost Report apportions the Hospital's costs on the basis of inpatient days and ancillary and outpatient charges to establish the costing methodology. Healthcare delivery by hospitals is a complex, highly regulated business in the united states. Healthcare unit cost inflation is driven by compliance with ever expanding regulatory requirements, shortages of highly skilled labor and involving medical and information technology. The health care "market basket" is unrelated to that of the average individual consumer. Since the 1997 balanced budget act, Medicare annual payment updates have fallen behind actual healthcare cost inflation to the point that Medicare payments to many U.S. hospitals are well below the cost of providing care. These unreimbursed costs are a community benefit for seniors and others in the community as these individuals are continuing to receive care without which many would become dependent on other governmental resources such as Medicaid. The benefit to the community for healthier Medicare recipients is no different than those benefits the community realizes for uninsured and underinsured patients who are eligible for partial and full charity care. Medicare is a safety net for seniors and others.Without Medicare coverage, many individuals would undoubtedly qualify for charity care. In addition to the mismatch between Medicare payment increases and healthcare cost inflation, the highly complex Medicare payment systems and formulas produce disparate payment levels from one hospital to another for the same service. These disparate payment levels create disparate results within groups of hospitals.Reconciliation of Medicare revenue from the Hospital's Medicare Cost Report to GL: Revenue Rec. *Medicare Cost Report revenue 60,688,759 Prior year settlements 4,800,695 Cost report reimbursable bad debts 1,045,492 Non-Cost Report Revenue 14,509,031 Estimates and accrual variances 688,922 Other 1,844,425 Total Medicare revenue 83,577,323*Note: the Medicare Cost Report revenue does not include the bad debt reimbursement. The Cost Report revenue does include the patient co-pay and deductible amounts. Adding the bad debt reimbursement would have duplicated the revenue already accounted for in the co-pay and deductible amounts. Allowable costs are calculated from information in the Medicare Cost Report and paid claim summaries obtained from the Medicare program. Part III, Line 9b: When a patient has requested screening for charity care, the Hospital must immediately cease collection activity and place the account in a charity pending status. If 100% charity is approved, the entire account balance is written off to charity care. If the patient has a sliding scale liability based on the federal poverty guidelines, they are billed only for that liability. If the patient fails to pay their after-charity liability, they are assigned to a collection agency with an identifier that indicates to the agency that the patient is "low income and the following criteria must be followed by the agency:1. They may not report the patient to a credit bureau2. They may not file a lawsuit to recover the outstanding liability3. They may not charge interest Part VI, Line 2: The hospital's 2019 CHNA, the 2020 Community Health Plan (CHP) Update for fiscal year 2019, and the 2020 Implementation Strategy are posted on the hospital's website at:https://www.adventisthealth.org/lodi-memorial/about-us/community-benefit/The two most recent Community Health Needs Assessments, two most recent Implementation Strategy reports and the most recent Community Health Plan Update are also available on the Adventist Health Corporate website at:https://www.adventisthealth.org/about-us/community-benefit/In addition to the CHNA, our hospital engages in a process of continuous quality improvement, focusing on questions such as: are our interventions making a difference in improving health outcomes; are we providing the appropriate resources in the appropriate locations; and how are we using technology to track our health improvements and provide relevant feedback at the local level? Building a healthy community requires multiple stakeholders working together with a common purpose. With that in mind, our hospital leadership serves on a variety of community boards and committees focused on addressing community-specific needs, allowing for ongoing responsiveness to the health care needs of the community and collaboration with local agencies and organizations, enabling maximum effectiveness through collective impact. Part VI, Line 3: The plain language summary of the Financial Assistance Policy (FAP) is posted along with the complete FAP policy and FAP Application on the hospital's website at:https://www.adventisthealth.org/documents/financial-assistance/ENG_PFS-112_Financial-Assistance-Policy.pdf.These documents are available in multiple languages.At the time of registration, patients who are uninsured and underinsured are provided information about government healthcare programs. Patients are also orally informed of their right to request charity assistance. Signs are displayed in the patient business office, patient registration areas and the emergency room in multiple languages informing patients of this right as well. The hospital also provides a brochure during the registration process that explains the hospital billing and collection procedures, and how to request financial assistance. In addition, every billing statement sent to patients contains information on how to request financial assistance. Part VI, Line 4: Adventist Health Lodi Memorial considers San Joaquin County its primary service area as well as the city of Galt. San Joaquin County contains both rural and urban areas. Communities and cities maintain their unique geographic identities, separated by agriculture and open space lands. The county includes seven incorporated cities: Stockton, Tracy, Manteca, Lodi, Lathrop, Ripon and Escalon as well as many small well-established rural communities in the unincorporated areas.The demographic profile of San Joaquin county indicates a total population of 745,424 with 17.8% living in poverty and 24.9% of children living in poverty. Unemployment is 11.7% and the uninsured population is 11.7% as well. Of the population, 41.6% identify as Hispanic/Latino, 31.8% identify as White, 16.7% identify as Asian, 8.2% identify as Black, 5.3% identify as multiple races and 2.0% identify as Native American/Alaska Native. Part VI, Line 5: Our hospital's mission is, "Living God's love by inspiring health, wholeness and hope." Our community benefit work is rooted deep within our mission and merely an extension of our mission and service. We have also incorporated our community benefit work to be an integral component of improving the "triple aim." The "Triple Aim" concept broadly known and accepted within health care includes:1) Improve the experience of care for our residents.2) Improve the health of populations.3) Reduce the per capita costs of health care.Our strategic investments in our community are focused on a more planned, proactive approach to community health. The basic issue of good stewardship is making optimal use of limited charitable funds. Defaulting to charity care in our emergency rooms for the most vulnerable is not consistent with our mission. An upstream and more proactive and strategic allocation of resources enables us to help low income populations avoid preventable pain and suffering; in turn allowing the reallocation of funds to serve an increasing number of people experiencing health disparities.Hospitals and health systems are facing continuous challenges during this historic shift in our health system. Given today's state of health, where cost and heartache is soaring, now more than ever, we believe we can do something to change this. These challenges include a paradigm shift in how hospitals and health systems are positioning themselves and their strategies for success in a new payment environment. This will impact everyone in a community and will require shared responsibility among all stakeholders. As hospitals move toward population health management, community health interventions are a key element in achieving the overall goals of reducing the overall cost of health care, improving the health of the population, and improving access to affordable health services for the community both in outpatient and community settings. The key factor in improving quality and efficiency of the care hospitals provide is to include the larger community they serve as a part of their overall strategy. Population health is not just the overall health of a population, but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthyeven though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced.Community health can serve as a strategic platform to improve the health outcomes of a defined group of people, concentrating on three correlated stages:1) The distribution of specific health statuses and outcomes within a population; 2) Factors that cause the present outcomes distribution; and 3) Interventions that may modify the factors to improve health outcomes.Improving population health requires effective initiatives to: 1) Increase the prevalence of evidence-based preventive health services and preventive health behaviors, 2) Improve care quality and patient safety, and 3) Advance care coordination across the health care continuum. We will work together with our community to ensure the community health improvements are identified and then targeted for programs to influence behaviors to obtain improved health within the whole community. Part VI, Line 6: The hospital is a member of Adventist Health, a health care system which provides healthcare services in diverse markets within the Western United States. A member hospital may share some services with other member hospitals in its geographic area, such as clinical, management and support services. Using today's technology, hospitals outside the geographic area can provide support through remote services such as telepharmacy and robotics surgery. The Corporate Office provides important shared administrative support for member hospitals' rural health clinics and home care agencies, quality of care, other clinical needs, financing and risk management, and shared clinical and financial information technology. As many experienced and new physicians search for alternatives to independent practice, there is also corporate administrative support for hospital affiliated medical groups that engage physicians through employment or other contracts. This provides stability and growth of qualified physicians across many specialties, which is very important to make healthcare services available and to maintain and improve health within the communities served by all member hospitals. Part VI, Line 7, Reports Filed With States CA 1 CA Health Fund & Trust 1215 K Street Ste 800 Sacramento CA 95814 941498697 501(c)(3) 65385 Hlth srvs un/underinsured pt Lodi District Chamber Of Commerce 35 S School Street Lodi CA 95240 940636200 501(c)(6) 12200 Sponsorships: Job Attraction & Marketing Campaign United Way of San Joaquin County 777 N Pershing Avenue Suite B Stockton CA 95203 941279805 501(c)(3) 22500 Donation to HealthForce Partners 2 1 Part I, Line 2: Through the use of temporarily restricted accounts, we track and monitor the incoming receipts from grants and the utilization of grant funds. Each grant is tracked separately. Should the grantor agency require specific reports, we comply with their reporting requirements. The grants we monitor are specific to the grantor's needs and requests. X X X X 1 1 0 0 0 0 0 0 0 Ferch Wayne President, CCR 0 932651 0 191401 0 3324070 0 16782 0 31056 0 4495960 0 3180848 Reiner Scott Dir/Chair 0 1510024 0 420315 0 65357 0 16782 0 36952 0 2049430 0 0 Wing Bill Dir/Vice Chair/Asst Secr 0 1200390 0 318717 0 53147 0 16782 0 29801 0 1618837 0 0 Reppert Joseph CFO/Asst Secr thru 08/2019 0 581409 0 187572 0 440088 0 16782 0 40783 0 1266634 0 0 Larsen David Finance Officer, CCR thru 04/19 0 536325 0 110451 0 130603 0 276207 0 40438 0 1094024 0 0 Wagner Jack Former Asst Secr thru 03/18 0 0 0 0 0 778475 0 0 0 29189 0 807664 0 0 Wolcott Daniel President 0 469178 0 109652 0 143247 0 16782 0 42735 0 781594 0 0 Jobe Meredith Secretary 0 524870 0 65461 0 140054 0 16782 0 29127 0 776294 0 0 Chen Steven Finance Officer, CCR 0 472282 0 90908 0 108327 0 16782 0 42581 0 730880 0 0 Iris Patricia Medical Officer 0 343750 0 12156 0 50282 0 1855 0 26476 0 434519 0 0 Moreno Debbe CNO thru 09/19 0 255951 0 44076 0 77036 0 16645 0 28706 0 422414 0 0 Whitney Jason Treasurer 0 261779 0 41595 0 54248 0 15808 0 40514 0 413944 0 0 McCollough Brooke Operations Executive 0 250289 0 27511 0 57304 0 11985 0 42792 0 389881 0 0 Gruzensky Denton Reg HP Dir, CCR 0 232276 0 41926 0 47140 0 15932 0 30044 0 367318 0 0 Beck-Atwater Sandra Director Hospital Pharmacy 204005 0 19067 0 0 0 11753 0 27710 0 262535 0 0 0 Carmody Thomas Physician Assistant 223562 0 4540 0 0 0 13063 0 13686 0 254851 0 0 0 Brown Mary RN, House Supervisor 215126 0 0 0 1231 0 6324 0 20353 0 243034 0 0 0 Markovich Jennifer Director, RN 165089 0 30503 0 3489 0 6629 0 20816 0 226526 0 0 0 Stump Valerie Director, RN 181501 0 16073 0 8164 0 6324 0 13746 0 225808 0 0 0 PickeringChristine Communication Dir, CCR 0 146846 0 11637 0 5375 0 8397 0 22580 0 194835 0 0 Ziegele Paul Former Treas thru 05/2018 0 0 0 0 0 150324 0 9077 0 24843 0 184244 0 0 Part I, Lines 4a-b Severance payments are made based upon agreements between certain qualifying employees and Adventist Health Services/West. Details of the terms and conditions of the severance agreements are available to the IRS upon request. Moreno, Debbe - severance payment - $10,295 Reppert, Joseph - severance payment - $194,953 Wagner, Jack - severance payment - $778,453 Ziegele, Paul - severance payment - $123,600 The Supplemental Executive Retirement Plan (SERP) is a defined contribution plan designed to encourage the participants continued employment with Adventist Health and is subject to the participants satisfying specified substantial risks of forfeiture. The SERP benefit distribution occurs when the executive achieves 30 years of Adventist health care service, 20 of which are to be as an executive and at least 10 are to be with Adventist Health System/West, and reaches age 60. Until that time, the SERP benefit is at risk to the creditors of Adventist Health. The SERP benefit is designed to help the executive receive employer-provided retirement benefit income equal to 60% of pre-retirement income. The SERP plan was frozen for new participants in 2016. Larsen, David - funding - $259,425 Ferch, Wayne - vested distribution - $3,180,848 P Gill Obstetrics and Gynecology >35% owned partnership by Parampal Gill, former board member 120024 Physician professional service-OB Clinic 0 P Gill Obstetrics and Gynecology >35% owned partnership by Parampal Gill, former board member 301125 Physician professional service-Emergency room call 0 Form 990, Part III, Line 4a: Adventist Health Lodi Memorial (AHLM) provides quality medical health care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Although reimbursement for services rendered is critical to the operation and stability Adventist Health Lodi Memorial, the organization recognizes that not all individuals possess the ability to pay for essential medical services. Adventist Health's vision is to enhance the health of the communities where we live and serve, by engaging our communities and our patients in a new definition of and partnership for personal community health. In keeping with this commitment to serve all members of the community, the following will be considered when individuals who need health care cannot pay: - providing free care and/or subsidized care - providing care to persons covered by governmental programs at below cost - providing health/wellness activities and community education programs Not only does Adventist Health Lodi Memorial provide low cost care to individuals covered by government-programs and those unable to afford healthcare, it also helps patients find and access private and governmental resources for healthcare benefits. AHLM recognizes below-cost reimbursement as charity and uncompensated care in meeting its mission to the entire community. The unreimbursed cost of providing care to these patients in 2019 was $19,511,095. The following Inpatient services that were provided to all our patients. These services included: - 1,051 Babies delivered - 1,388 Surgeries performed - 30,204 Patient days The following Outpatient services that were provided to all our patients. These services included: - 53,107 Emergency department visits - 3,213 Outpatient Surgeries performed - 75,264 Outpatient visits - 156,071 Clinic visits AHLM recognizes it has an obligation to provide human services above and beyond its role as a healing facility. The following community benefits demonstrate the tangible ways in which the organization is fulfilling its mission. The total unreimbursed cost of these community benefits in 2019 was $10,368,419. Adventist Health's mission statement of Living God's love by inspiring health, wholeness and hope is coupled with a vision to transform the health experience of our communities through collaborative programs, community investments and community outreach. We are inspired by the healing ministry as represented by the life of Jesus Christ and believe we are called to live out our mission intentionally in the communities we serve. In the small towns, suburbs and inner cities we serve, we continue our journey to provide quality healthcare until every person made in God's image has experienced the best health today, hope for tomorrow, and God's love that endures forever. Websites for our community benefit information: https://www.adventisthealth.org/about-us/community-benefit/ Form 990, Part VI, Section A, line 4 The Hospital made changes to Article 8.1, Execution of Legal Documents, which consolidated signature authority. Form 990, Part VI, Section A, line 6 The Hospital is organized as a religious corporation and operates as a not-for-profit hospital. The sole corporate member is Adventist Health System/West, a California not-for-profit religious corporation that operates as a public charity. The Hospital operates as an affiliate of Adventist Health System/West. Form 990, Part VI, Section A, line 7a The Hospital Bylaws define its Board of Directors to be the same individuals who are members of the Adventist Health System/West Board of Directors. Form 990, Part VI, Section A, line 7b The sole corporate member, Adventist Health System/West, must approve all changes to the Articles of Incorporation and Bylaws. Form 990, Part VI, Section B, line 11b This Form 990 including all supporting schedules was prepared by a public accounting firm, reviewed by the System Controller and Market Finance Officer, and shared by electronic communication with the Hospital's Board of Directors prior to filing. Form 990, Part VI, Section B, line 12c During the first quarter of each year, the annual conflict of interest questionnaire is sent to board members, hospital officers, key employees and department directors for completion and signature. The questionnaire is accompanied by a letter of explanation, to illustrate examples of a conflict and to remind the recipient that if any perceived conflict should arise before the next annual questionnaire, he/she is to notify the CEO immediately. The Corporate General Counsel distributes, collects, and reviews for signatures the COIs for all applicable Corporate employees and the board. In addition, the hospital's administration is responsible for keeping record to ensure all hospital-based individuals with director and above positions have submitted their COIs. The Corporate General Counsel reviews all the disclosures on the board and Corporate employees' COIs. Corporate General Counsel retains the COIs for the board members. The officers and key employees' COIs are kept in their personnel files. Further inquiries on any potential significant conflicts are made as needed. Conflicts are documented and reviewed with the Board. Form 990, Part VI, Section B, line 15 The Hospital Board of Directors has established a Human Performance Committee to oversee the executive compensation program. This committee is composed of independent directors with no conflicts of interest. The committee performs the following functions: recommends a total compensation philosophy to the board; assures compliance with the board-approved philosophy; meets annually to review comparability data from outside consultants; recommends any adjustments to current executive compensation, including salary ranges for hospital presidents and finance officers that would be indicated by the data; evaluates executive performance against annual goals; recommends appropriate incentive awards to the board for approval; follows a diligent process that meets regulatory requirements for a rebuttable presumption of reasonableness; records committee deliberations and decisions in timely minutes; selects, engages and supervises any consultant hired to advise and provide comparability data. The board-approved executive compensation philosophy specifies that salary ranges will be established for hospital executives, with midpoints aligned with the 50th percentile of comparable system hospital data, and having a 50 percent spread from minimum to maximum. A hospital CEO has a maximum potential incentive of 30 or 35 percent of base salary based upon size and scope of hospital. (Incentive potential is industry norm) Other hospital executives have a maximum potential incentive of 25 to 30 percent of base salary. Form 990, Part VI, Section C, line 19 The Hospital does not make its governing documents publicly available, beyond required filings of Articles of Incorporation with the Secretary of State. The Hospital does not make its Conflict of Interest Policy available upon request, but does file monthly/quarterly summary financial reports with the state health-planning agency. Form 990, Part VII: In recognition of the time commitment directors make to serve on the Adventist Health System/West boards and committees, directors receive compensation when their employment agreements with their employers allow such payments. For those whose employers do not allow accepting compensation for board service, the funds are directly distributed to charitable organizations as mandated by their employment agreements. In addition, amounts paid for taxable benefits are also reported. Form 990, Part IX, line 11g Physician fees: Program service expenses 29,187,797. Management and general expenses 0. Fundraising expenses 0. Total expenses 29,187,797. Other medical professional fees: Program service expenses 3,155,625. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,155,625. Consulting fees: Program service expenses 0. Management and general expenses 974,466. Fundraising expenses 0. Total expenses 974,466. Contract labor: Program service expenses 0. Management and general expenses 975,739. Fundraising expenses 0. Total expenses 975,739. Repairs and maintenance: Program service expenses 1,690,108. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,690,108. Revenue cycle fees: Program service expenses 0. Management and general expenses 12,192,169. Fundraising expenses 0. Total expenses 12,192,169. Form 990, Part XI, line 9: Change in investments of subsidiaries -709,574. Adventist Health Clearlake Hospital Inc 15630 18th Avenue Clearlake CA 95422 680395149 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Adventist Health Delano PO Box 460 Delano CA 93216 770258013 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Adventist Health Medical Center Tehachapi 1100 Magellan Drive Tehachapi CA 93561 812240617 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Adventist Health Physicians Network PO Box 619135 Roseville CA 95661 680357690 Medical foundation CA 501(c)(3) Line 12b, II Adventist Health SystemWest 0 Adventist Health SystemWest PO Box 619135 Roseville CA 95661 953484589 Integrated health system CA 501(c)(3) Line 10 N/A 0 Adventist Health Tulare 869 North Cherry Street Tulare CA 93274 832351753 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Castle Medical Center 640 Ulukahiki Street Kailua HI 96734 990107330 Hospital HI 501(c)(3) Line 3 Adventist Health SystemWest 0 Feather River Hospital PO Box 619135 Roseville CA 95661 941101228 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Fremont-Rideout Health Group 989 Plumas Street Yuba City CA 95991 942917251 Acute care hospital CA 501(c)(3) Line 12b, II Stone Point Health 0 Glendale Adventist Medical Center 1509 Wilson Terrace Glendale CA 91206 951816017 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Hanford Community Hospital 115 Mall Drive Hanford CA 93230 940535360 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Northwest Medical Foundation of Tillamook 1000 Third Street Tillamook OR 97141 930622075 Hospital OR 501(c)(3) Line 3 Adventist Health SystemWest 0 Paradise Valley Hospital PO Box 619135 Roseville CA 95661 951816034 Discontinued operations CA 501(c)(3) Line 1 Adventist Health SystemWest 0 Portland Adventist Medical Center 10123 SE Market Street Portland OR 97216 930429015 Hospital OR 501(c)(3) Line 3 Adventist Health SystemWest 0 Reedley Community Hospital 372 Cypress Avenue Reedley CA 93654 453220509 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Rideout Memorial Hospital 989 Plumas Street Yuba City CA 95991 941387866 Acute care hospital CA 501(c)(3) Line 3 Fremont-Rideout Health Group 0 San Joaquin Community Hospital 2615 Chester Avenue Bakersfield CA 93301 952294234 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Simi Valley Hospital & Health Care Services 2975 N Sycamore Drive Simi Valley CA 93065 956064971 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Sonora Community Hospital 1000 Greenley Road Sonora CA 95370 941415069 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 St Helena Hospital 10 Woodland Road St Helena CA 94574 941279779 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Stone Point Health PO Box 619135 Roseville CA 95661 823763347 Supporting organization CA 501(c)(3) Line 12b, II Adventist Health SystemWest 0 Ukiah Adventist Hospital 275 Hospital Drive Ukiah CA 95482 941639901 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 United Com-Serve 989 Plumas Street Yuba City CA 95991 943015356 Skilled nursing/assisted living/home health CA 501(c)(3) Line 12b, II Fremont-Rideout Health Group 0 Walla Walla General Hospital PO Box 619135 Roseville CA 95661 910617726 Hospital - closed July 2017 WA 501(c)(3) Line 3 Adventist Health SystemWest 0 Western Health Resources PO Box 619135 Roseville CA 95661 953867863 Home care CA 501(c)(3) Line 10 Adventist Health SystemWest 0 White Memorial Medical Center 1720 Cesar E Chavez Avenue Los Angeles CA 90033 952282647 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Willits Hospital Inc 1 Marcela Drive Willits CA 95490 680108919 Hospital CA 501(c)(3) Line 3 Adventist Health SystemWest 0 Advanced Imaging Center at Lodi Memorial Hospital LLC (AIC) 1001 S Fairmont Avenue Lodi CA 95240 943407786 Diagnostic imaging / MRI outpatient treatment center CA Lodi Memorial Hospital Association Inc Related 308577 382458 0 0 0.51000 Artel LLC (dba Lodi Outpatient Surgery Center) 521 S Ham Lane Suite F Lodi CA 95240 263513966 Ambulatory surgical centers CA Lodi Memorial Hospital Association Inc Related -291424 1069380 0 0 0.78150 Endoscopy Center of Lodi LLC 975 S Fairmont Avenue Lodi CA 95240 261243662 Endoscopy services CA Artel LLC Related 0 0 0.78150 Lodi Regional Health Systems Inc 975 S Fairmont Avenue Lodi CA 95240 680398894 Physician management and medical office building development & management CA Lodi Memorial Hospital Association Inc C 5473926 15853421 1.00000 1 Delta Radiology Inc 975 S Fairmont Avenue Lodi CA 95240 941715690 Radiology services CA Lodi Regional Health Systems Inc C 3986052 6374436 1.00000 1 South Coast Medical Center PO Box 619135 Roseville CA 95661 952037291 Wind down after sale of hospital CA N/A C 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 1 1 1 0 0 Advanced Imaging Center at Lodi O 673450 FMV Artel LLC O 82137 FMV Delta Radiology Inc P 735908 FMV Lodi Regional Health Systems Inc D 869231 FMV Lodi Regional Health Systems Inc K 121238 FMV Lodi Regional Health Systems Inc O 220209 FMV