2020-02-18T12:15:27-08:00 2019-03-31 990 2018-04-01 930386823 LEGACY EMANUEL HOSPITAL & HEALTH CENTER LEGA 5034155600 2801 N GANTENBEIN AVENUE PORTLAND OR 97227 ANNA L LOOMIS CFO & TREASURER 2020-02-18 2018 2020-09-23 17:36:50Z KATHRYN CORREIA 2801 N GANTENBEIN AVENUE PORTLAND OR 97227 943829625 false false X WWW.LEGACYHEALTH.ORG X 1912 OR Legacy Emanuel Hospital & Health Center (LEHHC), established in 1912, provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC is part of Legacy Health. 17 12 0 639 21561614 10100814 10209274 910253343 926054878 13932127 7382554 4059 3859 934290343 943650565 188300 73500 0 574883428 606004220 0 0 399751590 401709737 974823318 1007787457 -40532975 -64136892 605104820 486099757 512094437 464183426 93010383 21916331 X Legacy Emanuel Hospital & Health Center(LEHHC), established in 1912, provides acute and tertiary care in northeast Portland, with 554 licensed beds. LEHHC operates Randall Children's hospital, Level I Trauma Center, the Oregon Burn Center and high-risk obstetric services including a Level III NICU. LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC is part of Legacy Health (Legacy).Our mission:Our legacy is good health for our people, our patients, our communities, and our world. We will work as a team to demonstrate our values:Respect - Treat all people with respect and compassion Service - Put the needs of our patients and their families first Quality - Deliver outstanding clinical services within healing environments Excellence - Set high standards and achieve them Responsibility - Be good stewards of our resources, ensuring access to care for all Innovation - Be progressive in our thinking an false false 583234190 73500 481904729 LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC provides training for interns and residents through its nationally accredited graduate medical education program. LEHHC operates primary care teaching clinics at LEHHC and in St. Helens, located approximately 30 miles from the main LEHHC campus. In addition to its core hospital services, LEHHC provides related health services through the following programs:The Randall Children's Hospital; Legacy Research; Legacy Laboratory Services, LLC(Lab); Legacy Metro Lab; Unity Center for Behavioral HealthThe Randall Children's Hospital at Legacy Emanuel is a full-service children's hospital within LEHHC committed to providing care in an environment sensitive to the special needs of children and their families, including premature and critically ill newborns. The Randall Children's Hospital treats children from throughout Oregon, southwest Washington, Alaska and Idaho.Legacy Research is a full-service research facility that supports a wide range of research activity. Legacy Research collaborates with pharmaceutical, biotechnology and medical device companies. Legacy Research is located in northeast Portland (Holladay Park campus).LEHHC is one of four members of an emergency air transport service joint venture, Life Flight Network LLC, which serves Oregon and southwest Washington.In support of its mission, LEHHC voluntarily provides medically necessary patient care services that are discounted or free of charge to persons who have insufficient resources and/or who are uninsured. During fiscal year 2019, LEHHC provided financial assistance on approximately 15,235 patient accounts (of which about 2,410 accounts received discounts totaling 100% of costs) and resulted in LEHHC incurring roughly $19,269,410 in uncompensated costs associated with this program. In addition to charity care, LEHHC provides services under various states' Medicaid programs for financially needy patients, Medicare beneficiaries, and other government programs for which the cost of treating these patients exceeds the government payments received. During fiscal year 2019, LEHHC incurred approximately $131,995,610, $89,202,400 and $3,152,420 in uncompensated costs attributable to Medicaid, Medicare, and other government programs, respectively. LEHHC also provides a variety of other community benefit activities such as medical education, donations to other charitable entities, research, and other health improvement services which totaled roughly $17,518,410 during fiscal year 2019.LEHHC is part of Legacy, which collectively provided over $48 million, $210 million, $178 million, and $5 million in uncompensated care attributable to its financial assistance, Medicaid, Medicare, and other government programs, respectively, in fiscal year 2019. 164584361 208427068 LEHHC is the sole member of Legacy Clinics, LLC, an Oregon limited liability company, which operates over seventy primary care and specialty clinic sites across the Portland-Vancouver Metropolitan area as well as to the Mid-Willamette Valley since the affiliation of Silverton Health with Legacy. In addition, Legacy Clinics operates the hospitalist and intensivist programs at the four Legacy Health Oregon hospitals. 67315610 131946797 Unity Center for Behavioral Health is a 24 hour behavioral and mental health services center located on Legacy's Holladay Park campus. It is a partnership between Legacy Health, Adventist Health, Kaiser Permanente and OHSU that provides immediate psychiatric care. It has 85 adult beds, 22 adolecent beds, 50 short term spaces as well as calming and therapy rooms. 34500584 103776284 849634745 true true false true false false false false false true true false false true true false false true false false false false false false false false true true true true true false false false false false false false false false false false false false false false true true true false false false true 0 0 false 0 false true true false false false false false false 0 false false false false false false false false false false false false X 17 12 false true false false true true true true true false false true true true true true true true true true true OR X X ANNA LOOMIS 5034155600 1919 NW LOVEJOY STREET PORTLAND OR 97209 BISHOP DAVID BRAUER-RIEKE BOARD DIRECTOR 3.00 0.00 X 0 0 0 JEFFREY BARBER BOARD DIRECTOR 3.00 0.00 X 0 17526 0 JONATHAN HILL MD BOARD DIRECTOR 40.00 3.00 X 621841 0 59218 JAMES WALKER BOARD DIRECTOR 3.00 0.00 X 0 15000 0 ROBERT L CORNIE BOARD DIRECTOR 4.00 0.00 X 0 25000 0 JEFFREY D FULLMAN MD Chairman 4.00 1.00 X X 0 55315 0 GAYLE GOSCHIE BOARD DIRECTOR 3.00 0.00 X 0 15000 0 RONALD S KING VICE CHAIR 4.00 0.00 X X 0 17500 0 PATRICK REITEN BOARD DIRECTOR 3.00 0.00 X 0 15000 0 JERRY D PETTY BOARD DIRECTOR 3.00 0.00 X 0 7500 0 RT REV MICHAEL J HANLEY BOARD MEMBER 3.00 0.00 X 0 0 0 SHERYL MANNING BOARD DIRECTOR 4.00 0.00 X 0 25000 0 ROBERT E DEWITT SR VP & SEC 0.00 40.00 X X 0 549817 45505 LESLIE ROOT MD BOARD DIRECTOR 40.00 4.00 X 197180 0 10465 GEORGE J BROWN MD President & CEO 0.00 40.00 X X 0 1482645 48794 DAVID RAMUS BOARD DIRECTOR 3.00 0.00 X 0 25000 0 CHARLES WILHOITE VICE CHAIR 3.00 0.00 X X 0 25000 0 NANCY R LOCKE BOARD DIRECTOR 3.00 0.00 X 0 25000 0 SARAH K JENSEN INTERIM CFO 0.00 40.00 X X 0 279152 25102 DIANE PINNEY BOARD DIRECTOR 4.00 0.00 X 0 7500 0 SAMIR DESAI MD BOARD DIRECTOR 3.00 0.00 X 0 16500 0 LYNN T GUST BOARD DIRECTOR 3.00 0.00 X 0 15000 0 JACK A FRIEDMAN BOARD DIRECTOR 3.00 0.00 X 0 7500 0 KATHRYN CORREIA President & CEO 0.00 40.00 X X 0 798801 89302 ANNA LOOMIS CFO & TREASURER 0.00 40.00 X X 0 237897 29820 MOLLY F BURCHELL MD VP 40.00 0.00 X 407216 0 26312 CAROL A BRADLEY SR VP 0.00 40.00 X 0 598516 53431 LEWIS L LOW MD SR VP 0.00 40.00 X 0 587323 72299 DUNCAN R NEILSON MD VP 40.00 0.00 X 437775 0 66789 DONALD A TOUSSAINT VP 40.00 0.00 X 245015 0 41084 SONJA O STEVES SR VP 0.00 40.00 X 0 415512 58830 EVERETT W NEWCOMB III MD SR VP 0.00 40.00 X 0 764856 54878 MAUREEN A BRADLEY SR VP 0.00 40.00 X 0 277145 33948 JOHN J KENAGY SR VP 0.00 40.00 X 0 434386 58059 BRIAN P YOUNG MD VP 40.00 0.00 X 473693 0 44508 BRONWYN J HOUSTON PRESIDENT CHILDREN'S HOSPITAL 40.00 0.00 X 365352 0 53838 LORI FARRELL MD VP 40.00 0.00 X 333325 0 48426 ERIC WEEKS VP 40.00 0.00 X 207359 0 33001 JOSEPH FRASCELLA VP 40.00 0.00 X 258370 0 26726 TRENT S GREEN HOSPITAL PRESIDENT 40.00 0.00 X 558035 0 57404 CHRISTIANE FARENTINOS MD VP 40.00 0.00 X 239822 0 33796 CATHERINE J MARKIN VP 40.00 0.00 X 486514 0 37600 NAVEEN SACHDEV MD CARDIOLOGIST 40.00 0.00 X 875383 0 46574 ANDREW C TSEN MD CARDIO SURGEON 40.00 0.00 X 799177 0 40200 MONICA C WEHBY MD PED NEUROSURGEON 40.00 0.00 X 786031 0 10425 JOHN P IGUIDBASHIAN MD CARDIO SURGEON 40.00 0.00 X 919711 0 35699 RAMNIK S JHOOTY MD CARDIOLOGIST 40.00 0.00 X 838818 0 27901 MELINDA J MULLER MD FORMER KE 0.00 40.00 X 0 381960 52482 9050617 7122351 1322416 1117 true true false TRAUMA SPECIALISTS LLP 1620 SW TAYLOR PORTLAND OR 97205 MEDICAL SERVICES 9716630 BLOODWORKS NORTHWEST 921 TERRY AVE SEATTLE WA 98104 MEDICAL SERVICES 3505679 OREGON HEALTH SCIENCES UNIV 3181 SW SAM JACKSON PARK RD PORTLAND OR 97239 MEDICAL SERVICES 2128665 NBBJ LP 310 SW 4TH AVE STE 900 PORTLAND OR 97204 ARCHITECT DESIGN 2015742 SPECIALTY CARE INC 3 MARYLAND FARMS STE 200 BRENTWOOD TN 37027 MEDICAL SERVICES 1244656 59 5556418 4575289 77567 7020 10209274 LAB, PHARMACY, ETC 103776284 57505848 46270436 PATIENT PROGRAM REV 1613640064 1613640064 PHYSICIANS 50433392 50433392 REVENUE CLINICS 208427068 208427068 UNITY 131946797 131946797 -1182168727 -1161461255 -24708822 4001350 926054878 7513752 7513752 0 0 37821 33962 3859 3859 3859 13900 145098 -131198 -131198 -131198 0 0 0 0 943650565 900491914 21561614 11387763 28000 28000 45500 45500 0 0 5370664 4805656 565008 0 482224129 440742007 41482122 24404674 22445756 1958918 59806421 53779927 6026494 34198332 31399923 2798409 0 398165 343881 54284 0 0 0 0 27296622 27296622 0 136447746 132798123 3649623 0 0 8947350 8264789 682561 836750 787535 49215 0 0 11235752 9709925 1525827 0 34405212 29896564 4508648 5366383 4667149 699234 ADMINISTRATIVE SERVICES FEES 109551718 16442964 93108754 PROVIDER TAX 42008789 42008789 BAD DEBTS 23925563 23925563 CONSULTING 1289687 246072 1043615 0 1007787457 849634745 158152712 0 -546023 -438112 0 0 140340584 143393168 0 0 579254 476663 9494421 9758636 324372 494134 721556618 385768481 339979035 335788137 0 88278659 -36185107 0 0 26654518 32812238 605104820 486099757 83845882 88070813 428248555 376112613 512094437 464183426 X 91799029 20057683 1211354 1858648 93010383 21916331 605104820 486099757 X -64136892 -6957160 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false X 6709 309879 6709 309879 872709134 1251989775 872715843 1252299654 1000000 1000000 250000 250000 false 2000000 2000000 2000000 2000000 8000000 12000000 364027 272076 296586 316588 1249277 500000 500000 500000 500000 2000000 3000000 11474882 2255825 108358 996178 12842887 11633427 833253 360479 1352282 11474877 12262567 1125971 314161 2069270 11633429 8029966 7174135 -97570 2843964 12262567 7469350 1945101 142846 1527331 8029966 0.82000 0.18000 false true true 4616051 4616051 438936691 197179824 241756867 7466731 3472822 3993909 242789761 185115835 57673926 27747384 27747384 335788137 LIFE FLIGHT NETWORK, LLC 32812237 Rounding 1 32812238 I/C AFFILIATE DEBT 373639979 NONCURRENT ENVIRONMENTAL OBLIGATION 1400261 NONCURRENT WORKERS' COMP LIABILITY 1072373 376112613 902092000 902092000 41558565 41558565 943650565 968527000 968527000 39260457 39260457 1007787457 Part V, Line 4: Intended uses of the endowment fund. Endowment funds disclosed in Part V are used to improve the healthcare of the community as designated by the donors. Emanuel Medical Center Foundation (EMCF) and Randall Children's Hospital Foundation (RCHF) maintain all charitable gifts including endowment funds for the benefit of LEHHC and it's programs. Income from permanently restricted net assets is accounted for in accordance with the donors' instructions.Legacy follows the guidance in the Uniform Prudent Management of Institutional Funds Act (UPMIFA) in determining the net asset classification of all donor-restricted endowment funds. In accordance with UPMIFA and board policy, assets classified as permanent endowments in accordance with donor intent are only utilized for current period expenditures to the extent that earnings on the endowment exceed the original fair value of the donation. To the extent earnings on endowment funds exceed identified expenditures on which to apply those earnings, the earnings are classified as temporarily restricted net assets. Legacy has adopted investment and spending policies for endowment assets to provide a predictable stream of funding to programs supported by its endowment and to maintain the value of the endowment assets. Asset allocation is reviewed quarterly with respect to: i) Legacy's tolerance for risk based on its financial condition and need for cash from investments to support operations; ii) expected asset class return, risk and correlation characteristics; iii) changes in accounting guidance or tax law and iv) changes in bond covenants or other restrictions.Legacy's spending practices are intended to comply with donor's wishes and meet all applicable laws and regulations. Spending must be for a purpose that is consistent with the documented intent of the donor, and may not exceed the amounts annually determined by Legacy. Factors that are considered in addressing the annual spending allocation are: i) market value of the fund relative to the principal of the gift and ii) the level of spending in prior years.From time to time, the fair value of assets associated with individual donor-restricted endowment funds may fall below the level that the donor or UPMIFA requires Legacy to retain as a fund of perpetual duration. Deficiencies of this nature are reported as a reduction to unrestricted net assets and are excluded from the performance indicator. Part XI, Line 4b: Other revenue amounts included on 990 but not included in F/S REVENUE FROM RESEARCH $9744484 OTHER RECLASS OF REV/EXP FOR TAX PURPOSE $29634546 MEDICAL STAFF INCOME $472375 $0 IN KIND DONATION $1707020 ROUNDING $140 Part XII, Line 4b: Other revenue amounts included on 990 but not included in F/S EXPENSE FROM RESEARCH $9097190 OTHER RECLASS OF REV/EXP FOR TAX PURPOSE $29758644 MEDICAL STAFF EXPENSE $515653 ELIMINATE EQUIPMENT DONATIONS $-110933 ROUNDING $-97 true true X true X 300.000000000 true X true true true false true true 19269414 19269414 0.01910 298655045 166659435 131995610 0.13100 9928916 6776496 3152420 0.00310 327853375 173435931 154417444 0.15320 2197805 341748 1856057 0.00180 11185170 3986515 7198655 0.00710 7050083 7050083 0.00700 1413615 1413615 0.00140 21846673 4328263 17518410 0.01730 349700048 177764194 171935854 0.17050 false 23925563 15551616 66036391 83010722 -16974331 X true true 1 1 LEGACY EMANUEL HOSP & HEALTH 2801 N GANTENBEIN AVENUE PORTLAND OR 97229 www.legacyhealth.org 14-0056 X X X X X X X LEGACY EMANUEL HOSP & HEALTH 1 false false true X X X X X X X X X 17 true true true true X www.legacyhealth.org true 17 true www.legacyhealth.org false false true X 300.0000 400.0000 X X X X X true true X X X true X www.legacyhealth.org X www.legacyhealth.org X www.legacyhealth.org X X X X X X true X false X X X X true X false false Facility: LEGACY EMANUEL HOSP & HEALTH - Part V, Section B, Line 5 In 2017, Legacy Emanuel Medical Center participated with 14 other hospitals, four public health departments and two Coordinated Care Organizations in the four-county regional Healthy Columbia Willamette Collaborative Community Health Needs Assessment (HCWC CHNA) which was used as a base for the Legacy Emanuel Community Health Needs Assessment. The results of Legacy's Community Needs Assessment can be found at www.legacyhealth.org.The HCWC CHNA is regional and developed to improve efficiency and effectiveness and also to help meet the requirements of the ACA and Public Health Accreditation. The regional CHNA obtained information from the community through a variety of venues -online surveys and interviews with public health, tribal, regional, state or local health or other departments as well as medically underserved, low income and minority populations and those with chronic disease needs; a review of community engagement/needs assessment projects; and community listening sessions with uninsured and/or low-income community members from diverse culturally-identified and geographic communities. In the latest round of work, the Collaborative also reviewed population data (health-related behaviors, morbidity, mortality); medical data from local CCOs (most frequent conditions Medicaid-covered individuals sought care for); and hospital data (uninsured patients seen in the emergency department for conditions that could have been managed in primary or ambulatory care settings). Our work included the following community partners: Adelante Mujeres Adult Mental Health and Substance Abuse Advisory Council Allies for a Healthier Oregon Ant Farm Calvary Church Central City Concern Clackamas County Public Health Advisory Committee Clackamas Service Center Coalition of Community Health Clinics Elders in Action Commission El Programa Hispano FamilyCare Community Advisory Council Free Clinic of SW Washington Hacienda CDC Health Share of Oregon Community Advisory Council Highland Church & Highland Access, Reentry and Recovery Program Immigrant and Refugee Community Organization The Intertwine Alliance Latino Network Liberation Street Church Lifeline Connections LifeWorks Northwest Multnomah County Health Equity Initiative Native American Youth Association National Alliance on Mental Illness (Clackamas) OHSU Richmond Clinic Health Literacy Committee Oregon Community Health Worker Association Oregon Health Equity Alliance Outside In Oregon Foundation for Reproductive Health Oregon Public Health Institute Project Access NOW Q Center Urban League of Portland Veterans Affairs Hospital Washington County Mental Health and Addictions Advisory Council Washington County Public Health Advisory Council Facility: LEGACY EMANUEL HOSP & HEALTH - Part V, Section B, Line 6a In addition to Legacy Emanuel Medical Center, the other 14 hospitals in the metro area that participated in the Healthy Columbia Willamette Collaborative Community Health Needs Assessment were: Adventist Medical Center, Kaiser Permanente Sunnyside Medical Center, Kaiser Permanente Westside Medical Center, Legacy Good Samaritan Medical Center, Legacy Meridian Park Medical Center, Legacy Mount Hood Medical Center, Legacy Salmon Creek Medical Center, Oregon Health & Science University, Peace Health Southwest Medical Center, Providence Milwaukie Medical Center, Providence Portland Medical Center, Providence St. Vincent Medical Center, Providence Willamette Falls Medical Center and Tuality Health Care/Tuality Community Hospital. Facility: LEGACY EMANUEL HOSP & HEALTH - Part V, Section B, Line 11 The HCWC, through their online survey, listening sessions, and an inventory of community engagement projects, identified the following top five issues faced by the community: Homelessness and the lack of safe, affordable housing Unemployment and lack of living-wage jobs Mental and behavioral health challenges Hunger and lack of healthy, affordable food Lack of access to physical, mental and/or oral health careCompilation of the 2016 HCWC data provided the following emerging health issues faced by the community served: Access to health care No usual source of health care among adults Asthma in low-income and uninsured children Depression in adults Diabetes and hypertension in adults Cancer (breast, colorectal and lung) Lack of dental visits for adultsBased on the 2016 HCWC CHNA findings, Legacy Emanuel is focusing its efforts on the following priority issues:Access to Care Improving residents ability to get the health care services they need, with an emphasis on primary and preventive care and management of chronic conditions such as asthma in children and diabetes and hypertension in adults.Behavioral Health-Expanding the availability of and access to behavioral and mental health services for youth and adults to help address such conditions as depression, suicide, and PTSD.Social Determinants of Health-Addressing the need for policies, systems, services, and environments that support healthy behaviors, which means advancing solutions for such issues as homelessness and affordable housing for the underserved, food scarcity and, once again, access to health care. Education, meaningful employment, and removing barriers to culturally competent services are key to improving the health of the community.Details on the specific initiatives Legacy Emanuel Medical Center is undertaking to address these priority issues can be found in the Community Health Improvement Plan (CHIP), which can be found on the organizations website at www.legacyhealth.org Legacy Medical Clinics LLC 1919 NW Lovejoy Street Portland OR 97209 Physician Clinics Legacy Laboratory Services 1225 NE 2nd Ave Portland OR 97232 Diagnostic Laboratory Services Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense LEHHC uses many different approaches to inform and educate patients on the availability of financial assistance as is described later in Part VI of Schedule H. Still, many patients do not respond to requests for information or provide appropriate documentation to benefit from financial assistance. As a result, LEHHC must report these amounts as bad debt. A portion of bad debt expense should be considered as charity care, using reasonable methodologies to analyze the information. Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit The estimated amount of bad debt expenses attributable to charity care policy was calculated using the demographic profile of household income and average household size in the zip code areas around the hospital. 65% of households in the LEHHC service area would qualify for financial assistance with incomes under 400% of the Federal Poverty Guidelines using this methodology. Part III, Line 4 - Bad Debt Expense The footnote that describes the Legacy bad debt expense can be found on page 14 of the attached audited financial statements. Part III, Line 8 - Explanation Of Shortfall As Community Benefit The entire Medicare shortfall should be considered a community benefit. Medicare shortfalls must be absorbed by the hospital in order to continue treating the elderly in the community served by the hospital. The hospital provides care regardless of this shortfall and thereby relieves the federal government of the burden of paying the full cost for Medicare beneficiaries. The Medicare amounts listed in Part III Section B. on lines 5, 6, and 7 do not represent all of the organization's revenues and costs associated with its participation in Medicare programs. The methodology used in reporting in Part III Section B Medicare is inconsistent with the other sections in Schedule H, as the instructions limit Medicare revenues and allowable cost to those from only the Medicare Cost Report. Revenue and costs from Medicare Part C patients, Part B physician services billed by the organization, and clinical laboratory services weren't included. In addition, hospitals incur other costs to provide care that Medicare does not allow in the cost report, such as Physician Call pay to ensure adequate physician coverage for the ED.The total revenues and costs attributable to all Medicare services are $165,606,279 and $254,808,682 respectively. This results in a total Medicare shortfall of $89,202,403.Costing Methodology (Part III, Line 8).Medicare allowable costs were calculated using the costing methodologies in the Medicare Cost Report. The cost report arrives at total allowable hospital cost through a cost finding process that includes direct cost allocations and a step-down allocation of indirect or overhead costs. Inpatient operating costs are composed of general inpatient routine and ICU unit costs derived from cost per diems, as well as inpatient ancillary service costs that utilize cost to charge ratios to arrive at cost. Apportionment of cost applicable to hospital outpatient services is through the application of cost to charge ratios. This excludes other costs incurred to provide services of the hospital to the community that the cost report deems as unallowable costs, such as Physician on-call pay. Part III, Line 9b - Provisions On Collection Practices For Qualified Patients Legacy provides care without charge or at amounts less than its established rates to patients who meet certain criteria under its financial assistance policy. Since Legacy does not pursue collection of amounts determined to qualify as charity care, they are excluded from net patient service revenues. Part VI, Line 2 - Needs Assessment The described CHNA provides the primary source for assessing needs. Senior leadership, in conjunction with the Board of Directors, Community Benefit and Community Relations staff continually assess the needs of the communities it serves through a compilation of primary and secondary market research (qualitative and quantitative), medical staff input, reviewing national trends and practices, working with local foundations and funders regarding their assessments, and working with local community-based partners to understand their needs. The goal is to understand the needs and develop programs specific to the community. Involvement is both proactive and responsive - a leadership role in initiating programs as well as being readily available as a collaborative partner when the community asks. The outcome of these assessments is the development of both long-term and fiscal year plans that are supported by a yearly budget that is proposed by staff and approved by the Board of Directors. These are then aligned to the community health needs identified in the formal CHNA. The region served by LEHHC, along with most of Oregon, is experiencing significant challenges in population growth, economic development, education and health care. Recognizing that social and economic determinants impact health, LEHHC has been and will remain committed to addressing these issues to improve the health of all residents in the community, including equity among ethnically diverse populations. Part VI, Line 3 - Patient Education of Eligibility for Assistance LEHHC employs financial counselors and social workers that assist patients in obtaining coverage for their healthcare needs. This includes assistance with workers compensation, motor vehicle accident policies, COBRA, veterans assistance, Legacys financial assistance program, and public assistance programs, such as Medicaid. The criteria for financial assistance under LEHHC's program is determined based on eligibility for insurance coverage, household income, qualified assets, catastrophic medical events, or other information supporting a patients inability to pay for medically necessary services provided. Specifically, the LEHHC Financial Assistance Program provides an uninsured discount of 35% to patients who are self-pay. Further discounts are available for patients, on a sliding scale, whose household income is less than 400% of the federal poverty level (FPL) or roughly $103,000 for a family of four. For patients whose household income is at or below 300%t of the FPL, a full subsidy is available. In addition to the household income criteria, the patients qualified assets (e.g. 25% of household assets), and other catastrophic or economic circumstances are considered in determining eligibility. In addition to financial counselors and social workers, LEHHC makes every effort to communicate its Financial Assistance Program to all patients. This includes signage in main admitting areas of the hospital and brochures explaining financial assistance in all patient care areas, translated for patients/individuals with limited English proficiency (LEP). Financial counselors are available to assist patients in understanding and applying for available resources, including the LEHHC Financial Assistance Program. LEHHC's website also has information about the availability of financial assistance. LEHHC offers financial assistance customer service Monday through Friday, as well as the availability of voicemail so patients can leave confidential, detailed messages during non-business hours. Patients are encouraged to sign up for MyHealth, a secure online tool to access their medical record. Using their MyHealth account they can correspond with a financial counselor via email. Finally, all of Legacys billing statements include information regarding the availability of financial assistance. If LEHHC requires the use of a collection agency, those agencies are required to provide a telephone number that patients can call to request financial assistance.Annual education is provided to all billing and admitting staff, so they can be kept informed of and speak with knowledge about current financial assistance policies and options. LEHHC provides copies of the latest policies in main admitting areas, as well as with the hospital financial counselor, online via the website and through MyHealth.Since 2008, the four-county metro area health delivery systems (encompassing all hospitals in the area) and safety net clinics have partnered to establish a seamless, coordinated program to provide care for the low income uninsured, Project Access. This program enables low income uninsured patients to receive continuity of care in earlier stages of acuity due to the collaboration among nearly 3,000 providers and all health systems. LEHHC also contributes to this program, which pays the premiums for 827 families in the region who cannot afford to make those payments on their own. Part VI, Line 4 - Community Information LEHHC is located across the Willamette River slightly north of downtown and is in one of the oldest urban neighborhoods in Portland. The primary service area extends from the Columbia River in the north to south of Highway 99E and from Walker Road and St. Helens in the west to NE/SE 161st in the east. The inner primary service area includes the close-in Portland neighborhoods of Boise, Eliot, Kenton, Piedmont, St. Johns, Irvington, Alameda, Lloyd District/Sullivans Gulch, Rose City and Laurelhurst. Primary service area ZIP codes include: 97002, 97005-97009, 97013, 97015, 97022, 97024, 9702, 97030, 97032, 97034, 97035, 97045, 97051, 97055, 97056, 97060, 97062, 97068, 97070, 97071, 97080, 97086, 97089, 97113, 97123, 97124, 97140, 97201, 97202, 97203, 97205, 97206, 97209-97233, 97236, 97239, 97266, 97267.The most recently available demographic data is from 2018 to 2023. When available, data at the primary service area level is used, followed by the county (Multnomah) and then the state (Oregon). County data is used most frequently because there is a lack of available data at the zip code level, particularly related to race and ethnicity.The population of the primary service area for Legacy Emanuel was 1.4 million approximately with a 1.1% growth from 2017 to 2018.In 2018 the LEHHC primary service area was 69.3% non-Hispanic white, 11.7% Hispanic, 6.1% African American, 8.9% Asian and Pacific Islander, 1.4% Native American, and 4.7% two or more races. The foreign-born population represents 14.2% of total population in the area, an increase of nearly 20 percent since 2005.The African American/Black population continues to be most concentrated in the historical neighborhoods of North/Northeast Portland, but increased housing prices have resulted in the community moving increasingly to East Multnomah County. Multnomah County continues to have three to six times the percentage population of African Americans as the other three counties. Hispanics are moving into the service area at a higher rate than any other group. The Portland Native American community is the ninth largest urban Native American population in the US. With high child poverty and unemployment rates, the Native American community struggles across multiple indicators in contrast to the non-Hispanic white community. The immigrant and refugee population is increasing significantly. Recent immigrants and refugees are more likely to be culturally and linguistically isolated. A small but increasing African refugee population has settled primarily in North and NE Portland and is distinct from the African American/Black population. Available data suggests that the African population is generally poorer than other communities.Census numbers do not adequately represent the true and changing picture of the population. More than 100 languages are spoken in the Portland public schools. Schools near LEHHC are 40% - 70% children of color made up primarily of African-American and increasingly Hispanic students. Schools are experiencing a 50% English-as-a-Second-Language rate and a 50-80% reduced-cost or free lunch rates.Multnomah Countys median household income (MHI) average for the years 2013-2017 was $60,369 with 14.4 percent of the population living below poverty. However, there is a much greater disparity of MHI between communities of color earning half the incomes of non-Hispanic whites in Multnomah County. In Multnomah County, while non-Hispanic white MHI was at $55,346, African Americans had the lowest MHI at $27,347 followed by American Indian/Alaska Native at $29,695 and, Hispanic/Latinosat $36,572. In contrast, Asians MHI was $54,561. Families living below poverty level show non-Hispanic white at 7.9 percent relative to Asians at 12.6 percent, multiracial at 19.6 percent, Black/African American at 32.6 percent, Hispanic/Latino at 30.7 percent and American Indian/Alaska Native at 35.5 percent. The 2017 overall high school graduation rate in Multnomah County was 91 percent. Two of three school districts show the non-Hispanic white cohort to have a graduate rate more than fifty percent greater than Native Americans. Portland School District, the largest school district, shows a 15 percent difference between graduation rates for it's non-Hispanic white student population and it's African-American and Hispanics students. The Dignity Health and Truven Health Community Needs Index (CNI) is accepted as the national standard in identifying communities with health disparities and comparing relative need. A higher score indicated a greater need. The locations of two of the top four self-pay zip codes for all Legacy hospitals are in close proximity of LEHHC in St. Johns (97203), Montavilla (97216), Cully (97218), Maywood Park (97220), Boise Elliott (97227), and Lents (97266).The LEHHC five mile primary service area includes four other tertiary hospitals. LEHHC operates a Level I trauma center and Randall Children's Hospital at Legacy Emanuel Medical Center. OHSU located on the southwest side of town operates a Level 1 trauma center, a children's hospital and has the only medical school in Portland. Providence Health operates one hospital about five miles west of LEHHC and the other three miles southeast. Kaiser Permanente formerly operated a hospital about a mile north of LEHHC; but continues to maintain a strong clinic presence in the area.LEHHCs primary service area includes two Medically Underserved Areas (MUA): St. Johns community and SE Portland. With the long-standing income disparities in the LEHHC area, safety net services have expanded in the last decade. Multnomah County Health Department operates FQHCs in many locations throughout Portland. Near Emanuel is the site of a NARA (Native American Rehabilitation Association) FQHC. Additionally, the North by Northeast Community Health Center provides primary care for the uninsured and Medicaid low-income residents, primarily African-American. Legacy Emanuels internal medicine residency program operates a teaching clinic and a midwifery clinic serving the low income and often uninsured.Since 2008, the four-county metro area health delivery systems (encompassing all hospitals in the area) and safety net clinics have partnered to establish a seamless, coordinated program (Project Access NOW) to provide care for the low income uninsured. This program enables low income uninsured patients to receive continuity of care in earlier stages of acuity due to the collaboration among nearly 3,000 providers and all health systems. Legacy Emanuel also contributes to Project Access NOWs Premium Assistance program, which pays the premiums for 827 families in the region who cannot afford to make those payments on their own.In FY 2019, LEHHC provided about $19.2 million in charity care which accounts for 8% of total unreimbursed costs of $244 million.Legacy Emanuels charity care policy includes patients with incomes up to 400 percent of Federal Poverty Level (FPL). Part VI, Line 5 - Promotion of Community Health Legacy Emanuel collaborates with other health care providers, community-based organizations, business and the public on projects to improve the health of the community. One example of clinically based partnerships include, among others: CARES NW (Child Abuse Response and Evaluation Services) is a collaboration among three health systems; Legacy Emanuel serves as the employer and donates the infrastructure. Additionally, the first collaborative medical initiative of its kind in the Pacific Northwest, Unity Center for Behavioral Health, is a joint effort between Adventist Health, Kaiser Permanente, Oregon Health & Science University and Legacy Health, providing psychiatric emergency services. Legacy has collaborated with more than a dozen community mental health partners in developing this new psychiatric center.Over 20 years ago, LEHHC recognized that nonprofit organizations spend valuable dollars on office space and infrastructure dollars better spent on meeting their missions. Since then LEHHC has provided free office space to some nonprofit partners, in-kind lab donations to safety net clinics in its service area and other infrastructure services to nonprofit organizations on its campus. Non-cash donations of resources include clinical and non-clinical services and items, e.g., screenings and support services, internships, information and referral services and health fairs. Legacys warehouse is open to nonprofit organizations to obtain surplus equipment and furniture. In addition, conference room space is made available to local nonprofits for Board and community meetings.As a hospital located in a high density, inner city neighborhood, LEHHC's security department patrols the neighborhoods as a service to those communities. Emanuel employees, local businesses and neighborhood associations collaborated to revitalize a neighboring park which was previously used for drug and other illegal activities. Since that time police incidents have decreased significantly.LEHHC clinical staff is involved with local communities through many child safety programs. In 1986, nurses in Emanuel Hospitals Level I Trauma Center developed the Trauma Nurses Talk Tough (TNTT) program. Taught by trauma and emergency medical professionals, the program reaches thousands of people each year. The American Hospital Association awarded the TNTT program its NOVA Award. In addition, Legacy staff members conduct free education to show parents how to properly install car seats. Last year, Legacy staff fit and sold more than 4,852 bicycle helmets to children at a nominal or no fee based on need. Legacy staff members also provide new parents with training to reduce the incidences of shaken baby syndrome as well as an education and awareness program about window safety (to prevent child fall).As a tertiary center, LEHHC provides several unique services to a four state region (Alaska, Washington, Oregon and Idaho) such as its Level I trauma center, Randall Childrens Hospital, burn center, and high-risk obstetric services, including a Level III NICU. In addition, LEHHC provides training for interns and residents through its nationally accredited graduate medical education program and partners with schools to provide training and education for nursing and other health professionals. Part VI, Line 6 - Affilated Health Care System LEHHC is a subsidiary of Legacy Health (Legacy). Legacy is an integrated health system based in Portland, Oregon and primarily operates six acute care hospitals and related services (e.g., physician practices, hospice, preferred provider network) in the four county metro area of Portland and SW Washington and Marion County. In addition, Legacy Health is a collaborative partner with Unity Center for Behavioral Health.The Legacy Board is comprised of community and business leaders as well as representatives of the medical staff. The LEHHC medical staff is open, with physicians submitting credentialing information reviewed according to LEHHC policies and standards. While there is investment in a variety of community-based activities and programs as a part of its non-profit status, an overwhelming majority of Legacy and LEHHC's community benefit comes in the form of providing uncompensated care. Legacy's policy of providing care regardless of the ability to pay makes it one of the region's largest providers of uncompensated care in the four-county metropolitan area.In 1998, the Legacy Health Board approved a $10 million Community Health Fund from operating revenue to address major community health issues. Currently, $600,000 is granted annually to community-based projects addressing racial and ethnic inequities and root causes. These dollars are in addition to Legacys other generous charitable contributions. The Community Health Fund has provided 52 grants since 1998 totaling over $9.4 million 60 percent of which have gone to programs serving communities of color. Annually, up to six 3-year grants totaling $150,000 are awarded in our community. An example grant is Legacys partnership with Human Solutions. Human Solutions is a non-profit Community Development Corporation that owns and operates 17 affordable housing communities. The Community Health Fund grant will allow the organization to increase Permanent Supportive Housing staff and care for residents within East Portland and East Multnomah County.In 2010, Legacy Health established the Health Literacy initiative. Communication with patients such that patients both understand and act upon the information required of and provided to them is critical to their health outcomes. Patients must use information to navigate the health system (complete insurance and government forms, sign consents, schedule appointments), manage diseases and acquire preventive screenings. Providers (defined as all staff interacting with or developing materials used by patients) are responsible for ensuring that patients can act on the information provided. Funded by the Community Health Fund in 2012, Legacy hosted the first Oregon and SW Washington Health Literacy Conference. 360 people from 69 organizations attended. Since 2012, the Health Literacy Conference has been organized every year with more than 500 health professionals attending each year from 80 organizations. Legacy Health is now the recognized leader in moving health literacy forward both in the health delivery system and broader community. 585 people attended the 2019 Health Literacy Conference.Recognizing that education, employment and income inequities exist for communities of diversity, and that health professions are lacking in diversity, Legacy established the Health Occupation Profession and Education - HOPE program (formerly Youth Employment in Summer-YES). Between 5 and 15 students of ethnically diverse communities receive paid summer employment in departments where they work with health professionals and earn college scholarships between $3,000 and $10,000 annually. Students must remain in school and pursued health careers in order to continue in the program. Some students remain in the program as long as seven years and graduated with degrees in a variety of healthcare fields. The vast majority of the students are the first in the families to go to college. To date, there have been more than 86 participating HOPE students.In addition to the Community Health Fund, Legacy provided cash donations to local health and human service, education, economic development and civic organizations. Donations focus on organizations with year-round relationships through programs and board representationspecifically focused organizations addressing disparities. A few examples include Central City Concern, Native American Youth and Family Center, and Basic Rigts Oregon. In addition, Legacy Health lab services provided in in-kind services to the local safety net clinics in Legacy Emanuel's service area. Part VI, Line 7 - States Filing of Community Benefit Report OR true MEDICAL TEAMS INTERNATIONAL 14150 SW MILTON CT TIGARD OR 97224 930878944 501(c)(3) 0 28000 COST EQUIPMENT & SUPPLIES FOR DISASTER ASSISTANCE 1 0 PATIENT NEEDS FOR SAFE DISCHARGE 30000 TRANSPORTATION BURN/WOUND GARMENTS 200 15500 COMPRESSION GARMENTS Grantmaker's Description of How Grants are Used Legacy reviews all organizations prior to donating cash or supplies to ensure their 501(c)(3) status. Legacy regularly donates supplies to Medical Teams International for disaster relief. Several Legacy medical staff members, volunteer for Medical Teams International. X true true false true false true true true true false true true ANDREW C TSEN MD CARDIO SURGEON 794887 4290 8255 31945 839377 ANNA LOOMIS CFO & TREASURER 172306 53500 12091 16038 13782 267717 BRIAN P YOUNG MD VP 417882 55811 9137 35371 518201 BRONWYN J HOUSTON PRESIDENT CHILDREN'S HOSPITAL 364306 1046 22237 31601 419190 CAROL A BRADLEY SR VP 388574 34262 175680 22312 31119 651947 131313 CATHERINE J MARKIN VP 345237 104669 36608 37600 524114 CHRISTIANE FARENTINOS MD VP 239887 -65 9486 24310 273618 DONALD A TOUSSAINT VP 235111 9904 23897 17187 286099 3288 DUNCAN R NEILSON MD VP 407968 29807 13750 53039 504564 ERIC WEEKS VP 207763 -404 17943 15058 240360 EVERETT W NEWCOMB III MD SR VP 674989 89867 17875 37003 819734 29824 GEORGE J BROWN MD President & CEO 650860 687778 144007 24047 24747 1531439 73934 JOHN J KENAGY SR VP 417047 17339 24465 33594 492445 JOHN P IGUIDBASHIAN MD CARDIO SURGEON 823314 96397 5095 30604 955410 JONATHAN HILL MD BOARD DIRECTOR 485014 129938 6889 6875 52343 681059 JOSEPH FRASCELLA VP 254284 4086 9131 17595 285096 KATHRYN CORREIA President & CEO 630871 121720 46210 70485 18817 888103 LESLIE ROOT MD BOARD DIRECTOR 152829 44718 -367 6980 3485 207645 LEWIS L LOW MD SR VP 578313 9010 44620 27679 659622 LORI FARRELL MD VP 332462 2500 -1637 25763 22663 381751 MAUREEN A BRADLEY SR VP 273745 3400 16019 17929 311093 MELINDA J MULLER MD FORMER KE 382676 -716 17508 34974 434442 MOLLY F BURCHELL MD VP 401524 500 5192 1260 25052 433528 MONICA C WEHBY MD PED NEUROSURGEON 750006 33600 2425 -3046 13471 796456 NAVEEN SACHDEV MD CARDIOLOGIST 725005 100962 49416 13750 32824 921957 RAMNIK S JHOOTY MD CARDIOLOGIST 565005 234517 39296 6585 21316 866719 ROBERT E DEWITT SR VP & SEC 465289 84528 27385 18120 595322 SARAH K JENSEN INTERIM CFO 261081 18785 -714 12550 12552 304254 SONJA O STEVES SR VP 379245 37924 -1657 32642 26188 474342 TRENT S GREEN HOSPITAL PRESIDENT 533578 24457 23189 34215 615439 Part I, Line 1a: Relevant information in regards to selections on 1a. Legacy does periodically reimburse for some travel of companions. During 2018, some travel expenses for companions of Legacy Board Directors and executives were reimbursed. These transactions follow Legacys reimbursement policy requiring documentation and approval of the expenses, prior to reimbursement. These payments are taxable to the individuals and are reported on a W-2 for employees or a 1099 for Board Directors. Part I, Line 5b: Explanation of organization compensation based on revenues of related organization Physicians employed by Legacy affiliates are paid a bonus contingent upon their revenue generated during the year measured by industry standard relative value units (RVU). Part I, Line 6b: Explanation of organization compensation contingent on net earnings from related or Legacy has an at-risk incentive compensation plan for management. The plan is based on meeting goals related to employee engagement, work processes, customer service, clinical quality, financial management, and certain key strategic tactics. In order to payout any at-risk incentive compensation, Legacy must exceed operating margin targets. Part I, Line 8: Amounts reported on 990 VII pursuant to initial contract exemption described in Regs Legacy enters into initial employment agreements with executives that qualify under the initial contract exception. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee relies on comparable market data and all decisions are documented. Part III, Additional Information Sch J, Part 1, Question 3 Regarding Compensation PracticesDirectors for Legacy started receiving compensation for their services in August 2014. They also receive expense reimbursements related to their duties. Any expense reimbursements to board members are reviewed by the Director of Tax for determining 1099 tax reporting. In addition to the Board of Directors compensation, during 2018, Dr. Hill received compensation related to his duties as Medical Director at Legacy Emanuel Hospital. Dr. Root also received compensation for medical services provided to Legacy Emanuel Hospital. Dr. Fullman and Dr. Desai received compensation for medical services provided to Legacy Meridian Park Hospital and Legacy Mount Hood Medical Center respectively. There was no other reportable compensation received by any board member during 2018.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior management personnel. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for executive positions. The Committee oversees the system's governance procedures with respect to intermediate sanctions legislation and the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures.Sch J, Part II, Column Breakdown Of W-2 Or Misc-1099:Column B(i) - Base compensation consists of regular base pay including employee elected deferrals for retirement plans (403(b) and 457(b) plans).Column B(ii) - The incentive compensation program for Legacy is based on predetermined criteria and reviewed and approved by the Board. Bonuses are paid to key employees for interim duties outside their primary responsibilities (e.g. Acting in Capacity).Column B(iii) - Other compensation consists of deferred compensation amounts paid to executives during the current year and were reported on prior form 990 returns. These amounts include arrangements that contain elements of a substantial risk of forfeiture conditioned on continued employment, vesting and/or a noncompete provision upon termination of employment. Distributions from 457(b) plans, reported to the employee on a 1099-R, are also included as other compensation. In addition, imputed income for insurance, cell phone and other benefits is included in other compensation as well as any severance related payments. Column C - Deferred compensation includes contributions to defined contribution plans, amounts deferred under the 457(f) plan including earnings, earnings in the 457(b) plan, and the value of the pension restoration plan. Earnings on the 457(f) and 457(b) include gains and losses on the underlying investments. The defined contribution plan is available to all employees as they become qualified to participate. The pension restoration plan provides executive pension benefits in excess of IRS mandated limits on eligible compensation to key executives. The benefits are unfunded and subject to forfeiture. Executive pension benefits are intended to make the executive's retirement benefit, as a proportion of their final average salary, comparable to all other employees, and are treated as income when paid.The Legacy Health Board approved the goals and long-term objectives for the Executive Long-Term Incentive Plan effective April 1, 2017 for 3 years ending on March 31, 2020. The plan is discretionary and can be terminated at any time. The purpose of the Plan is to achieve market share growth in key areas identified in Legacy Healths strategic plan. Targets for operating margins and clinical quality are required over the three-year period and all goals are measured at March 31, 2020.Column D - Nontaxable benefits include company paid health and welfare and long term care and disability benefits under group plans.Column F - Current year compensation reported as deferred in prior years. Form 990, Part III, Line 4d: Other Program Services Description OTHER PROGRAM SERVICES 4: Unity Center for Behavioral Health is a 24 hour behavioral and mental health services center located on Legacy's Holladay Park campus. It is a partnership between Legacy Health, Adventist Health, Kaiser Permanente and OHSU that provides immediate psychiatric care. It has 85 adult beds, 22 adolecent beds, 50 short term spaces as well as calming and therapy rooms. Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company Legacy Health (Legacy) provides management services for all of its affiliated companies which includes, accounting, purchasing, contracting, legal, human resources, information technology, billing, facilities, budgeting, transcription, security, public relations, strategic planning, organization development.Cascade Pathology Services provides a Medical Director and pathologists who oversee the pathology laboratory services at LEMHHC. The amount paid for the year ended March 31, 2019 was $764,640. Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder Legacy Health is the sole member of Legacy Emanuel Hospital & Health Center. Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body The Board of Directors includes the following members: (a) The Bishop of the Oregon Synod of the Evangelical Lutheran Church inAmerica (the "Oregon Synod") or the Bishop's designee, who shall serve ex officio;(b) The Bishop of the Episcopal Diocese of Oregon (the "Episcopal Diocese")or the Bishop's designee, who shall serve ex officio;(c) One (1) person elected by the Legacy Health Board of Directors pursuant to the process set forth in the Bylaws; provided, however, that such person shall be an active member of a Lutheran congregation in the Oregon Synod ("Lutheran Director");(d) One (1) person elected by the Legacy Health Board of Directors pursuant to the process set forth in the Bylaws; provided, however, that such person shall be an active member of an Episcopal congregation in the Episcopal Diocese known to his/her parish priest, or alternatively a member of the clergy in the Episcopal Diocese ("Episcopal Director"). Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders The election of Lutheran Director is subject to the approval by the Bishop of the Oregon Synod, who may object to the newly-elected director for any reason by delivering written notice to the Legacy President or the Chair of the Board of Directors no later than one week after the election. If the Bishop timely objects to the election of the new Lutheran Director, the election will be ineffective and that person will not be a director; otherwise, if no timely objection is received, that person shall be conclusively presumed to be the Lutheran Director for his/her full term or the remainder of an unexpired term to which elected. The election of the Episcopal Director is subject to approval by the Bishop of the Episcopal Diocese, who may object to the newly elected director for any reason by delivering written notice to the Legacy President or Chair of the Board of Directors no later than one week after the election. The election of the Episcopal Director is also subject to approval by the Standing Committee of the Episcopal Diocese, who may object to the newly elected director only on the grounds that he/she is not an active member of an Episcopal congregation or a member of the Episcopal clergy in the Episcopal Diocese; such objection to be effected by delivering written notice to the Legacy President or Chair of the Board of Directors within five days after the next meeting of the Standing Committee or 45 days after the election, whichever is earlier. If the Bishop or Standing Committee timely object to the election of the new Episcopal Director, the election will be ineffective and that person will not be a director; otherwise, if no timely objection is received, that person shall be conclusively presumed to be the Episcopal Director for his/her full term or the remainder of an unexpired term to which elected. Form 990, Part VI, Line 11b: Form 990 Review Process The Legacy Board received a copy of the 990 return prior to filing. At the direction of the entire Board, the Board Compensation Committee reviewed the compensation disclosures and the Board Audit Committee received a memorandum with a draft 990 return highlighting key areas and requesting feedback. Questions from the Board Audit Committee are answered and changes made where appropriate. Any significant differences from the draft 990 to the final 990 return are provided to the Board Audit Committee. Depending on the deadline for the 990 return filing and the Board Audit Committee meeting this discussion may take place following the filing of the return. Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts The following is a summary of Legacy's policy and procedures for conflict of interest disclosure, monitoring and resolution.All Legacy employees and non-employees in leadership positions (e.g., Board members, Foundation Trustees, Medical Directors) are required to disclose potential conflicts of interest as the conflict arises. All employees are required to disclose any conflict of interest per the Standard of Conduct policy. Certain groups have annual formal disclosure requirements. Executives and non-employees in leadership positions complete the Conflict Disclosure Statement from the Standards of Conduct policy annually. Officers, Directors, Trustees, Key and Highly Compensated employees are also required to complete a questionnaire covering business relationships, business transactions with interested parties, loans and grants. Conflict Disclosure Statements and questionnaires are returned to Legacy Corporate Compliance or Tax Department for review of the disclosure. If a conflict is disclosed, or identified through any other means, Legacy Corporate Compliance ensures that management mitigates the risk (e.g.,discontinues relationship with vendor, segregates responsibilities, recuses Board member from voting in area of conflict) and that the conflict and mitigation steps are reported to the appropriate level (e.g., Compliance Committee, Audit Committee of the Board). Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees The following describes the compensation practices of Legacy and its affiliates.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior management personnel. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee oversees the system's governance procedures with respect to the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures. Form 990, Part VI, Line 19: Other Organization Documents Publicly Available Legacy Health's audited and interim consolidated financial statements are publicly available on the Electronic Municipal Market Access(EMMA) (www.emma.msrb.org) and DAC Bond (www.dacbond.com) websites. Legacy's audited consolidated financial statements include consolidating schedules which highlights LEHHC's financial results.When changes are made to the LEHHC Articles or Bylaws, LEHHC discloses and attaches copies to the IRS Form 990, which are publicly available by request or on various public websites such as Guidestar(www.guidestar.org). Other governing documents are not available to the public. Other Changes In Net Assets Or Fund Balances - Other Decreases ADDITIONAL MINIMUM PENSION LIABILITY = -$7750666 Other Changes In Net Assets Or Fund Balances - Other Increases CAPITAL CONTRIBUTION FROM FDNT = $432450 Other Changes In Net Assets Or Fund Balances - Other Increases CAPITAL CONTRIBUTION FROM RESEARCH = $110933 Other Changes In Net Assets Or Fund Balances - Other Increases DEFERRED REVENUE - UNITY = $300000 Other Changes In Net Assets Or Fund Balances - Other Decreases Gift Shop Operations Fund = -$42856 Other Changes In Net Assets Or Fund Balances - Other Decreases IN KIND DONATION = -$7020 Other Changes In Net Assets Or Fund Balances - Other Decreases ROUNDING = -$1 Form 990, Part IV, question 12 Legacy has an audit of its consolidated financial statement which includes consolidating schedules highlighting LEHHC's financial results. Form 990, Part VI, question 2 Legacy Health System CPC, LLC (CPC) is a common pay agent for Legacy and its affiliates. The CPC files all required federal employment tax returns for Legacy and its affiliates. The number of employees reported on Form W-3 for LEHHC, the lab & clinics is 6,553. Form 990, Part X LEHHC participates in the Legacy investment pooled funds which include professionally managed equity and fixed income securities in both separately managed portfolios and commingled investment accounts. Investment returns are prorated according to each affiliate's share of the pool. Form 990, Schedule J Schedule J Reporting of Officers and Senior Management on Legacy Affilate Returns. The Legacy Officers, Senior Vice Presidents and other key employees may have responsibilities for the operations of the entire health system, including the affiliated entities. Their compensation is paid from and reported on the Legacy return(EIN 23-7426300). The compensation is reported again for informational purposes on related affiliated entity returns including, Legacy Emanuel Hospital & Health Center, Legacy Good Samaritan Hospital and Medical Center, Legacy Meridian Park Hospital, Legacy Mount Hood Medical Center, Legacy Salmon Creek Hospital, Silverton Health, Legacy Visiting Nurse Association, and Legacy Adventist Venture. 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