2018-05-11T12:16:14-05:00 2017-06-30 990 2016-07-01 390816818 St Elizabeth Hospital Inc STEL 3147338000 1506 South Oneida Street Appleton WI 549151397 Tonya Mershon Tax Officer 2018-05-11 2016 2022-09-23 18:48:47Z Bernard Sherry 400 W River Woods Parkway Glendale WI 53212 206516004 false 0928 X www.affinityhealth.org X 1899 WI To improve the health and well-being of all people in the communities we serve. 12 9 1381 280 222740 0 494496 220952 195730799 204834164 27515 109291 5265614 854356 201518424 206018763 0 0 83567284 64712182 0 0 86159250 106309044 169726534 171021226 31791890 34997537 227851961 214170022 90381683 95406975 137470278 118763047 Our Mission as part of a Catholic health care system is to further the healing ministry of Jesus by continually improving the health and well-being of all people, especially the poor, in the communities we serve. false false 108896873 204661878 ST. ELIZABETH HOSPITAL, INC. PROVIDES INPATIENT, OUTPATIENT, EMERGENCY ROOM, AND ANCILLARY SERVICES REGARDLESS OF AN INDIVIDUAL'S ABILITY TO PAY. THE HOSPITAL ALSO PROVIDES EDUCATIONAL PROGRAMS AND SERVICES ON HEALTH CARE ISSUES TO THE COMMUNITY IT SERVES. SEE SCHEDULE H FOR FURTHER DETAILS. 108896873 true true false true false false false false false false true false false false true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true true true false false true 38 0 true 1381 true true true false false false false false false false false false X 12 9 false false false false true true true true true false false false true true true true true false false false WI X David Mannes 4144654571 400 W River Woods Parkway Glendale WI 53212 JOHN RUSSO CHAIRMAN 0.3 1.5 X X 0 0 0 WAYNE WIETING VICE-CHAIRMAN 0.3 1.5 X X 0 0 0 MARK W FAUSTICH MD SECRETARY 0.3 41.1 X X 0 464782 33026 BRIAN WALLACE TREASURER 0.3 1.5 X X 0 0 0 LANE EARNS BOARD MEMBER 0.3 1.5 X 0 0 0 MARLIN GREENFIELD BOARD MEMBER 0.3 1.5 X 0 0 0 MARK KEHRBERG MD BOARD MEMBER 0.4 1.6 X 0 0 0 KEVIN RAFLOFSKY BOARD MEMBER 0.3 0 X 0 0 0 KATHRYN SIEMAN BOARD MEMBER 0.3 1.5 X 0 0 0 SUDEEP S SODHI MD BOARD MEMBER 0.3 41.1 X 0 969587 48890 MONICA VOMASTIC BOARD MEMBER 0.3 1.5 X 0 0 0 WENDY SCHROEDER DO BOARD MEMBER 0.3 41.1 X 0 331895 49240 MONICA A HILT PRESIDENT, ST. ELIZABETH HOSPITAL 28.0 12.0 X 0 732037 40775 DANIEL E NEUFELDER SR. VP HOSP OPS (END 9/2016) 10.0 29.5 X 0 1825757 28416 LAWRENCE DONATELLE VICE PRESIDENT OF MEDICAL AFFAIRS 40.0 0.0 X 0 334728 38062 TONYA L DEDERING Reg Dir Foundations 40.0 0.6 X 215649 0 37793 MICHAEL A HOFMANN Dir Patient Care Srvcs 40.0 0 X 154444 0 32171 FAYE E KAMRATH Dir Radiology Srvcs 40.0 0 X 165654 0 25448 NANETTE W KRIZENEKSY RN Lead-ICU MrktS 40.0 0 X 181642 0 42742 SCOTT D MOON Sr Medical Physicist 40.0 0.0 X 158382 58105 30232 NICHOLAS DESIEN FORMER OFFICER (END 12/2015) 0.0 0.0 X 0 2710823 443 JEFFREY FRANCIS FORMER OFFICER (END 9/2015) 0.0 0.0 X 0 225000 0 875771 7652714 407238 37 true true false INTEGRATED HEALTH NETWORK OF WISCONSIN LLC 19601 W BLUEMOUND ROAD SUITE 200 BROOKFIELD WI 53045 MEDICAL SERVICES 548322 GREEN BAY ONCOLOGY LTD 1726 SHAWANO AVE GREEN BAY WI 543033216 ONCOLOGY SERVICES 362082 MOSAIC FAMILY HEALTH INC 229 S MORRISON STREET APPLETON WI 549115725 PHYSICIAN SERVICES 151492 3 X 208769 8426 3757 220952 NET PATIENT REVENUE 621990 202024511 201808871 215640 RENT FROM AFFILIATES 531120 2633631 2633631 PHARMACY REVENUE 446110 647318 647318 Income from Affiliates 561000 530925 530925 EHR Incentive Revenue 621990 350048 350048 -1352269 -1352269 0 0 204834164 -33009 -33009 17776 17776 0 17776 17776 142300 0 0 142300 142300 142300 1047040 497241 549799 549799 EDUCATION REVENUE 611430 43354 43354 FITNESS CLUB 713940 20520 20520 RESEARCH REVENUE 900099 9440 9440 213467 0 7100 206367 286781 206018763 204661878 222740 913193 51717607 46776622 4940985 914490 827122 87368 8273030 7482644 790386 3807055 3443338 363717 9000 9000 1080 1080 8936 8936 4368757 2764998 1603759 0 5142 4592 550 879848 437266 442582 55760 13966 41794 4075598 1306754 2768844 64766 48494 16272 36479 33441 3038 2210647 2210647 12650175 6328905 6321270 269613 269613 Medical Supplies 35173376 35173376 Corporate Overhead Allocation 29762149 29762149 Purchased Services 9681674 2220932 7460742 Provider Tax Expense 4320293 4320293 2735751 2024343 711408 0 171021226 108896873 62124353 0 5035 4930 13105349 772689 0 4937 29468960 31032880 0 0 0 2816246 4045032 264588 262709 211856923 43394856 175694919 168462067 0 1764898 3257666 0 4731966 6327112 227851961 214170022 10238047 11794454 209636 240282 79934000 83372239 90381683 95406975 X 137222396 118445336 247882 317711 137470278 118763047 227851961 214170022 X 34997537 -48377 -53656391 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 8936 8936 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY Lobbying expenses represent the portion of dues paid to national and state hospital associations that is specifically allocable to lobbying. St. Elizabeth Hospital, Inc. does not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office. Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY Lobbying expenses represent the portion of dues paid to national and state hospital associations that is specifically allocable to lobbying. St. Elizabeth Hospital, Inc. does not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office. 4067024 4067024 153525042 19382660 134142382 6425 321 6104 47767162 23579937 24187225 6491270 431938 6059332 168462067 Pension Liability 457(b) Plan Deferred tax liability other liabilities Estimated Settlement to Third-Party Payor 3370800 Due to Affiliates 15558097 Lease Liability 156334 Net Long-Term Debt 62740319 FIN48 Liability 326774 Other Miscellaneous Liabilities 145331 Recovery Tail Liability 443017 AH Savings Plan Liability 631567 83372239 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote THE SYSTEM ACCOUNTS FOR UNCERTAINTY IN INCOME TAX POSITIONS BY APPLYING A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THE SYSTEM HAS DETERMINED THAT NO MATERIAL UNRECOGNIZED TAX BENEFITS OR LIABILITIES EXIST AS OF JUNE 30, 2017. true true X true X 250 true X true true true false true true 0 0 1632937 0 1632937 0.0095 0 0 2781115 0 2781115 0.0163 0 0 3176 0 3176 0.0000 0 0 4417228 0 4417228 0.0258 9 1608 266720 8940 257780 0.0015 3 5 1711868 176948 1534920 0.0090 2 0 4007989 2480713 1527276 0.0089 1 0 19064 0 19064 0.0001 8 219 75327 0 75327 0.0004 23 1832 6080968 2666601 3414367 0.0200 23 1832 10498196 2666601 7831595 0.0458 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 false 2202750 0 77694514 76248945 1445569 X true true 1 1 St Elizabeth Hospital Inc 1506 South Oneida Street Appleton WI 54915 www.affinityhealth.org 88 X X X X St Elizabeth Hospital Inc 1 false false true X X X X X X X X X 15 true true true true X http://www.affinityhealth.org/Affinity-Files/Community-Health-Needs-Assessments/2016/StElizabethHosp X true 15 true http://www.affinityhealth.org/Affinity-Files/Community-Health-Needs-Assessments/2016/StElizabethHosp false true X 250.0 400.0 X X X X X true true X X X true X https://healthcare.ascension.org/financial-assistance/wisconsin X https://healthcare.ascension.org/financial-assistance/wisconsin X https://healthcare.ascension.org/financial-assistance/wisconsin X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - St. Elizabeth Hospital, Inc.. St. Elizabeth Hospital's CHNA process included three specific efforts to seek input from community members, including members of medically underserved, low-income and minority populations and from organizations that serve those populations. First, a telephone survey of Calumet County residents was conducted in early calendar year 2015. The survey resulted in the Outagamie County Behavioral Risk Factor Surveillance System (BRFSS) Study: 2015 Report, and included questions health practices and health-related risk behaviors. Second, in August and September 2015, key informant interviews were conducted with stakeholders in the community, including with leaders of organizations that serve the medically underserved, low-income and minority populations. Participants were asked about the most important health issues for the region as well as existing strategies, resources and barriers in addressing them. (See below for list of key informants' organizations.) Finally, in September and October 2015, a survey was distributed electronically to a variety of community partners and agencies that serve vulnerable populations, including the Women, Infants and Children (WIC) clinics, senior centers, food pantries, community clinics and others. The survey was available in Spanish for those organizations and agencies that serve Spanish-speaking individuals. The survey asked about the most important health issues for the region. Key informant interviews were conducted with representatives of the agencies listed below. These agencies serve Outagamie County exclusively. (Note: Some agencies are listed multiple times, reflecting interviews with multiple representatives from that organization.) * Outagamie County Sheriff's Department *, *** * Valley Baptist Church *, **, *** * Outagamie County * University of Wisconsin- Extension *, *** * Outagamie County Aging and Disability Resource Center *, **, *** * Outagamie County Public Health- Women, Infants, and Children (WIC) Program *, *** * City of Appleton *** * Early Intervention Program (Birth to Three) * Outagamie County * Outagamie County * Community Early Learning Center Board * Appleton Downtown, Inc. * ThedaCare * Catalpa Health and Outagamie County * Rawhide Boys Ranch Key informant interviews were conducted with representatives of the agencies listed below. These agencies serve the Fox Valley Region. (Note: Some agencies are listed multiple times, reflecting interviews with multiple representatives from that organization.) * University of Wisconsin- Oshkosh Head Start *, ** * Samaritan Counseling Center *, **, *** * YMCA of the Fox Cities *, **, *** * City of Appleton Health Department *, **,*** * University of Wisconsin-Oshkosh Head Start *, ** * N. E. W. Mental Health Connection *, **, *** * Heart of the Valley Chamber of Commerce * Wisconsin DNR; Menasha Health Department * Goodwill Industries of North Central WI *, **, *** * Affinity Health System* *, **, *** * Casa Hispana *,*** * Common Ground *, *** * ESTHER *, *** * University of Wisconsin- Oshkosh Head Start *, ** * J.J. Keller Foundation *, ** * ThedaCare Trauma * St. Therese Church *, *** * INCLUDE *, **, *** * Appleton Health Department *, **, *** * Hope Clinic/Alliance *, **, *** * United Way Fox Cities *, **, *** * Appleton Health Department * Catalpa Health *, **, *** * ThedaCare at Work; Well City Fox Cities * East Central Wisconsin Regional Planning Commission * Appleton Health Department ** * Affinity Health System* *, **, *** * Outagamie County * Appleton Health Department * ThedaCare * Children's Hospital of Wisconsin- Fox Valley *, **, *** * Homeless Connections * * Children's Hospital of Wisconsin- Fox Valley *, **, *** * Child Care Resource & Referral *, *** * Children's Hospital of Wisconsin- Fox Valley * City of Appleton Health Department * African Heritage, Inc. *** * Hispanic Chamber of Commerce of WI *, *** * Weight of the Fox Valley/ United Way * Affinity Health System* *, **, *** * St. Elizabeth Hospital, Affinity Health System* *, **, *** * Harbor House *, **, *** * Wisconsin Safe and Healthy Schools Center *, *** * Children's Hospital of Wisconsin- Fox Valley *, **, *** * Partnership Community Health Ctr. *, **, *** * Parent Connection of Family Services * City of Appleton Police * ThedaCare Trauma * U.S. Venture, Inc. * * Partnership Community Health Ctr. *, **, *** * ThedaCare *, **, *** * University of Wisconsin- Oshkosh Head Start *, ** * Big Brothers Big Sisters of the Fox Valley * * Evolve *, **, *** * Denotes that the organization and/or the key informant's position represents low-income populations ** Denotes that the organization and/or the key informant's position represents medically underserved populations *** Denotes that the organization and/or the key informant's position represents minority populations * Affinity Health System is part of Ministry Health Care Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - St. Elizabeth Hospital, Inc.. The CHNA was conducted with the following hospital facility(s): Calumet Medical Center Mercy Medical Center Children's Hospital of Wisconsin - Fox Valley Aurora Medical Center Oshkosh ThedaCare Regional Medical Center - Appleton (formerly Appleton Medical Center) ThedaCare Regional Medical Center - Neenah (formerly ThedaClark) Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - St. Elizabeth Hospital, Inc.. The CHNA was conducted with the following non-hospital facility(s): Calumet Public Health Department Outagamie County Public Health Department Winnebago County Public Health Department City of Appleton Public Health Department City of Menasha Public Health Department Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - ST. ELIZABETH HOSPITAL, INC.. Using the CHNA completed in June 2016, the hospital developed, adopted, and worked on executing a three-year Implementation Strategy to address priority community health needs. In Fiscal Year 2017 (Tax Year 2016), the hospital implemented the following plan to address the priority needs: Mental Health: -- To reduce suicide rates in Outagamie County. -- Participated in the Zero Suicide initiative, which facilitated the self-assessments of six organization as they integrated suicide prevention strategies in their organizational policies. -- Financially supported the delivery of school-based behavioral health services in area school districts. Alcohol Misuse: -- To explore community based resources addressing alcohol misuse issues. -- Worked with community partners to develop an asset inventory tool to better understand the current status of community based alcohol misuse prevention efforts. Nutrition: -- Increase the proportion of residents of Outagamie County and the tri-county region overall, who have a healthy Body Mass Index. -- Participated in the regional Weight of the Fox Valley coalition, which successfully facilitated the adoption of a healthy weight-supportive resolution by 12 regional municipalities. Ascension NE Wisconsin St. Elizabeth Hospital also financially supported the Weight of the Fox Valley. -- Continued to pursue Baby Friendly Hospital status. The description below includes the needs not being addressed as well as the reason why the needs are not being addressed. In addition to the three health issues selected as top priority, stakeholders identified several other significant health issues in Outagamie County. These issues will be or are being addressed by other organizations in the community. While these issues will not be addressed by St. Elizabeth Hospital as priority health needs, we will provide support to those community efforts whenever possible. Chronic Disease Prevention: The stakeholders identified chronic diseases as an important health issue to be addressed in the community. Discussions with community leaders, public health organizations and St. Elizabeth leaders, revealed that by tackling the nutrition and physical activity needs of the community, often seen as proxy for obesity prevention, chronic diseases would also be positively affected. Many stated that many of the chronic diseases that need attention such as, diabetes, hypertension, high cholesterol, etc. can be positively influenced by working on obesity prevention efforts. Healthy Growth and Development: Many stakeholders identified healthy growth and development, especially early childhood growth and development, as a health need. Many community members there saw a need to support the development of healthy, well-rounded individuals. At the same time, respondents stated there are many existing organizations and programs in the community that address these issues, including the Fox Valley Early Childhood Coalition, Parent Connection, Community Early Learning Center, Birth To 3 Program, The Boys and Girls Club, Head Start, as well as school-based and YMCA- based programs. Given the variety of existing efforts in the community, St. Elizabeth will continue to support the public health departments and community organizations already in existence to address healthy growth and development issues whenever possible. 0 Schedule H, Part I, Line 3c Other Factors other than FPG It is the policy of St. Elizabeth Hospital, Inc. to provide medically necessary health care services to people in the communities it serves, regardless of their ability to pay. Affinity Care financial assistance is granted based upon the patient's inability to pay and to individuals who are uninsured, underinsured or medically indigent. Affinity Care works in collaboration with other financial (both public and private) assistance programs. This is to ensure holistic wellness of patients by facilitating knowledge of abailable services and programs for health while practicing good stewardship of funds. Key criteria utilized to determine eligibility for Affinity Care financial assistance includes family size, federal poverty income guidelines and available assets. The available asset test includes consideration of the amount of equity in a home, automobiles, and savings accounts which are considered part of total allowable income when assessing against the federal poverty income guidelines. Schedule H, Part V, Section B, Line 17 Billing and Collection Policy During tax year 2017, the organization learned via verbal comments of IRS agents at public events that the IRS intends that the "readily obtainable" standard in the 501(r) regulations for the AGB calculation and billing and collection policy is only met if those items are posted to the organization's web site. The organization had interpreted that web posting standard to be a safe harbor after consulting with external counsel and tax advisors, and timely took other steps to make the information readily obtainable. Consequently, the organization does not believe its decision to not post these documents to its web site rises to the level of a failure, nor does it believe the circumstances were either willful or egregious, having otherwise timely taken the steps necessary to attain and continue to maintain compliance with the other requirements related to the billing and collection policy and the AGB, as part of its policies and procedures for ensuring compliance with all aspects of 501(r). However, the organization is making this voluntary disclosure in order to communicate to the IRS the changes it is undertaking in response to the recent IRS informal guidance on this specific point concerning the "readily obtainable" standard, and the fact that the organization has started the work necessary to post its AGB information and billing and collection policy to its web site and will complete those additional postings as soon as reasonably possible. The other web postings required under 501(r) (i.e., those related to the community health needs assessment and the financial assistance policy) were timely completed and continue to remain in place as required. The organization believes its safeguards worked as intended in this case (i.e., the organization has regular communications with a number of external law firms and tax consultants and the timely attention to the recent guidance was supported by the framework of regular access to subject matter experts). These changes are in the process of being incorporated into corporate policies and procedures that apply to the organization. Schedule H, Part I, Line 6a Community benefit report prepared by related organization ST. ELIZABETH HOSPITAL, INC. IS INCLUDED IN THE ANNUAL COMMUNITY BENEFIT REPORT WHICH IS PUBLISHED BY MINISTRY HEALTH CARE, INC. (EIN: 39-1490371) AND AVAILABLE TO THE PUBLIC ON ITS WEBSITE, WWW.MINISTRYHEALTH.ORG. THIS REPORT INCLUDES ALL OF THE RELATED ENTITIES WITHIN THE MINISTRY HEALTH CARE NETWORK OF HOSPITALS, CLINICS AND OTHER HEALTH-RELATED ORGANIZATIONS. Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance The cost of providing charity care, means-tested government programs, and other community benefit programs is estimated using internal cost data, and is calculated in compliance with Catholic Health Association ("CHA") guidelines. The organization uses a cost accounting system that addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self pay). The best available data was used to calculate the amounts reported in the table. For the information in the table, a cost-to-charge ratio was calculated and applied. Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted, the Corporation follows established guidelines for placing certain past-due patient balances within collection agencies, subject to the terms of certain restrictions on collection efforts as determined by Ascension Health. Accounts receivable are written off after collection efforts have been followed in accordance with the Corporation's policies. After applying the cost-to-charge ratio, the share of the bad debt expense in fiscal year 2017 was $5,722,954 at charges, ($2,202,750 at cost). Schedule H, Part III, Line 3 Bad Debt Expense Methodology The provision for doubtful accounts is based upon management's assessment of expected net collections considering historical experience, economic conditions, trends in healthcare coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payor category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for doubtful accounts. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote The organization is part of the Ascension Health Alliance's consolidated audit in which the footnote that discusses the bad debt expense is located on page 19. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs A cost to charge ratio is applied to the organization's Medicare Expense to determine the Medicare allowable costs reported in the organization's Medicare Cost Report. Ascension Health and its related health ministries follow the Catholic Health Association (CHA) guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance ST. ELIZABETH HOSPITAL, INC FOLLOWS THE ASCENSION GUIDELINES FOR COLLECTION PRACTICES RELATED TO PATIENTS QUALIFYING FOR CHARITY OR FINANCIAL ASSISTANCE. A PATIENT CAN APPLY FOR CHARITY OR FINANCIAL ASSISTANCE AT ANY TIME DURING THE COLLECTION CYCLE. ONCE QUALIFYING DOCUMENTATION IS RECEIVED THE PATIENT'S ACCOUNT IS ADJUSTED. PATIENT ACCOUNTS FOR THE QUALIFYING PATIENT IN THE PREVIOUS SIX MONTHS MAY ALSO BE CONSIDERED FOR CHARITY OR FINANCIAL ASSISTANCE. ONCE A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE, ALL COLLECTION ACTIVITY IS SUSPENDED. Schedule H, Part V, Section B, Line 16a FAP website - St. Elizabeth Hospital, Inc.: Line 16a URL: https://healthcare.ascension.org/financial-assistance/wisconsin; Schedule H, Part V, Section B, Line 16b FAP Application website - St. Elizabeth Hospital, Inc.: Line 16b URL: https://healthcare.ascension.org/financial-assistance/wisconsin; Schedule H, Part V, Section B, Line 16c FAP plain language summary website - St. Elizabeth Hospital, Inc.: Line 16c URL: https://healthcare.ascension.org/financial-assistance/wisconsin; Schedule H, Part VI, Line 2 Needs assessment In addition to the CHNA reported in Part V, Section B, Saint Elizabeth's Hospital uses both hospital data and reliable, third party reports, including data from government sources, to assess the health needs of the community it serves. These reports provide information about key health, socioeconomic, and demographic indicators that point to areas of need. Saint Elizabeth's Hospital utilizes this information to determine develop programs and services to be provided for the community. These needs and initiatives are presented to senior leadership and board members to ensure the findings are considered in developing the organization's strategy, policy development, and internal financial and operational decisions. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance St. Elizabeth Hospital, Inc. goes to great lengths in order to inform and educate patients/persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs and under the organizations Affinity Care Policy. The Affinity Care Policy and application is posted on the Organization's website. Admissions and other key areas contain summary information of the Affinity Care Policy. As part of the intake/discharge process, patients are provided with a copy of the policy and other information for financial assistance. If during the course of the patient registration process, care encounter, treatment, or upon discharge it becomes evident that a patient may need financial assistance, the patient shall be referred to the organizations Affinity Care Program. Patients may be identified as needing financial assistance at any time during the course of an encounter. A referral for consideration of Affinity Care financial assistance can be initiated by any member of the Hospital's workforce, including medical staff members, who become aware of the patients potential need for Affinity Care financial assistance. The Affinity Care brochure was also translated into dialects prevalent in the community in order to reach out to those that may speak another language (Spanish and Hmong). Patient registration staff and financial counselors are provided with guidelines to follow when interacting with patients. As part of the Affinity Care process, patients must register with the county public assistance to see if they may qualify under any other federal or state programs. Schedule H, Part VI, Line 4 Community information While there is growing agreement in the United States about what constitutes a non-profit hospitals "community benefit," this is a work in progress. St. Elizabeth Hospital, Inc. provided significant charity care and other community benefits as defined by the IRS. But in addition, we believe that we provide a critically important community benefit, which is not quantified. St. Elizabeth Hospital, Inc., like most community hospitals, was created and is maintained in order to provide care locally, care that without our hospital, may not be available locally. Certain specialized services available include: I/P adult behavioral health services, I/P adolescent behavioral health services and neonatal intensive care services. The City of Appleton is located in Outagamie, Calumet, and Winnebago counties. According to the 2008-2012 American Community Survey 5-Year Estimates, there were 72,575 people living in Appleton, consisting of 28,428 households and 18,074 families. The population density of Appleton was 2,984.9 people per square mile. The population consisted of 86.0% White, 4.7% Hispanic, 1.6% African American, 0.5% Native American, 5.3% Asian, and 1.9% Other. Of the 28,428 households in Appleton, 32.8% of those had children under the age of 18, living at home. The 28,428 households are categorized as 49% married couples living together, 4.1% had a male head of household with no wife present, 10.5% had a female head of household with no husband present, and 47% were non-families. 29.6% of the households consisted of individuals and 10.1% had someone 65 and older living alone. The age population is widely spread. 28.9% were under 18, 6.5% were 19-24, 26.8% were 25-44, 26.3% were 45-64, and 11.5% were 65+. The median income for a household was $52,605 and the median income for a family was $66,781. The per capita income for the city was $27,106. The largest industry in Appleton is educational, health and social services (21.5%). Manufacturing (20.4%) and retail trade (11.4%) are the next largest industries in Appleton. Roughly 8% of families and 10.5% of the population were below the poverty line. That includes 13.5% of those under 18 years old and 7.4% of those 65 and older. The unadjusted seasonal unemployment rate for Outagamie, Calumet, and Winnebago Counties was 4.0%, 3.7%, and 4.3%, respectively, compared to a state unemployment rate of 5.1% and a national unemployment rate of 7.9%. Schedule H, Part VI, Line 5 Promotion of community health The Organization strives to further its exempt purposes by the following: (1) The Organization's governing board consists primarily of persons who reside within the primary service area who are not employees of the Organization. (2) As mentioned, the Organization provides several services which are not otherwise available being in a rural setting. (3) Based on the Organization's mission, emergency rooms are made available to all patients regardless of the ability to pay. (4) The Organization also participates in the education and training of healthcare professionals through internship programs. Certain specialized services available include: dental services to primarily the indigent, fertility clinic services and WIC home visits to new mothers and infants. Schedule H, Part VI, Line 6 Affiliated health care system ST. ELIZABETH HOSPITAL, INC. IS AN AFFILIATE OF MINISTRY HEALTH, INC. AND ASCENSION HEALTH. ST. ELIZABETH HOSPITAL, INC.'S AFFILIATES ARE LARGE MULTI-FACETED, INTEGRATED, NOT-FOR-PROFIT MINISTRIES INCLUDING HOSPITAL AND NON-HOSPITAL MINISTRIES (PHYSICIAN GROUP PRACTICES, HOSPITAL ORGANIZATIONS, RESEARCH, HOME HEALTH, DURABLE MEDICAL EQUIPMENT AND SENIOR FACILITIES). THESE MINISTRIES WORK TOGETHER TO CARE FOR PATIENTS, JOINED BY COMMON SYSTEMS AND A PHILOSOPHY OF SERVING AS A HEALING PRESENCE WITH SPECIAL CONCERN FOR OUR NEIGHBORS ESPECIALLY THOSE WHO ARE VULNERABLE. THIS COMMUNITY BENEFIT HAPPENS THROUGH ITS FOCUS ON PATIENT CARE, EDUCATION AND RESEARCH. THE ORGANIZATIONS WORK TOGETHER TO SERVE THEIR COMMUNITIES AT THE LOCAL, REGIONAL, STATE AND NATIONAL LEVEL. ASCENSION HEALTH ALLIANCE, D/B/A ASCENSION (ASCENSION), IS A MISSOURI NONPROFIT CORPORATION FORMED ON SEPTEMBER 13, 2011. ASCENSION IS THE SOLE CORPORATE MEMBER AND PARENT ORGANIZATION OF ASCENSION HEALTH, A CATHOLIC NATIONAL HEALTH SYSTEM CONSISTING PRIMARILY OF NONPROFIT CORPORATIONS THAT OWN AND OPERATE LOCAL HEALTHCARE FACILITIES, OR HEALTH MINISTRIES, LOCATED IN 23 OF THE UNITED STATES AND THE DISTRICT OF COLUMBIA. ASCENSION IS SPONSORED BY ASCENSION SPONSOR, A PUBLIC JURIDIC PERSON. THE PARTICIPATING OF ASCENSION SPONSOR ARE THE DAUGHTERS OF CHARITY OF ST. VINCENT DE PAUL, ST. LOUISE PROVINCE; THE CONGREGATION OF ST. JOSEPH; THE CONGREGATION OF THE SISTERS OF ST. JOSEPH OF CARONDELET; THE CONGREGATION OF ALEXIAN BROTHERS OF THE IMMACULATE CONCEPTION PROVINCE, INC. - AMERICAN PROVINCE; AND THE SISTERS OF THE SORROWFUL MOTHER OF THE THIRD ORDER OF ST.FRANCIS OF ASSISI - US/CARIBBEAN PROVINCE. The System directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing and dedicates its resources to spiritually centered care that sustains and improves the health of the individuals and communities it serves. In accordance with the System's mission of service to those persons living in poverty and to other vulnerable persons, each Health Ministry accepts patients regardless of their ability to pay. The System uses four categories to identify the resources utilized for the care of persons living in poverty and for community benefit programs: Traditional charity care includes the cost of services provided to persons who cannot afford health care because of inadequate resources and/or who are uninsured or underinsured. Unpaid cost of public programs, excluding Medicare, represents the unpaid cost of services provided to persons covered by public programs for persons living in poverty and for other vulnerable persons. Cost of other programs for persons living in poverty and for other vulnerable persons includes unreimbursed costs of programs intentionally designed to serve the persons living in poverty and the other vulnerable persons of the community, including substance abusers, the homeless, victims of child abuse, and persons with acquired immune deficiency syndrome. Community benefit consists of the unreimbursed costs of community benefit programs and services for the general community, not solely for the persons living in poverty, including health promotion and education, health clinics and screenings, and medical research. Discounts are provided to all uninsured patients, including those with the means to pay. Discounts provided to those patients who did not qualify for assistance under charity care guidelines are not included in the cost of providing care to persons living in poverty or in the cost of other community benefit programs. The cost of providing care to persons living in poverty and of other community benefit programs is estimated using internal cost data and is estimated by reducing charges forgone by a factor derived from the ratio of total operating expenses to billed charges for patient care. true true false false false false false false false MARK W FAUSTICH MD SECRETARY 0 452697 0 5000 0 7085 0 17225 0 15801 0 497808 0 0 SUDEEP S SODHI MD BOARD MEMBER 0 961795 0 0 0 7792 0 17225 0 31665 0 1018477 0 0 WENDY SCHROEDER DO BOARD MEMBER 0 328887 0 2000 0 1008 0 14575 0 34665 0 381135 0 0 NICHOLAS DESIEN FORMER OFFICER (END 12/2015) 0 190823 0 0 0 2520000 0 443 0 0 0 2711266 0 0 JEFFREY FRANCIS FORMER OFFICER (END 9/2015) 0 0 0 0 0 225000 0 0 0 0 0 225000 0 0 MONICA A HILT PRESIDENT, ST. ELIZABETH HOSPITAL 0 493948 0 231779 0 6310 0 17225 0 23550 0 772812 0 0 DANIEL E NEUFELDER SR. VP HOSP OPS (END 9/2016) 0 861918 0 713099 0 250740 0 15900 0 12516 0 1854173 0 0 LAWRENCE DONATELLE VICE PRESIDENT OF MEDICAL AFFAIRS 0 306377 0 20790 0 7561 0 17225 0 20837 0 372790 0 0 TONYA L DEDERING Reg Dir Foundations 170417 0 27000 0 18232 0 9900 0 27893 0 253442 0 0 0 MICHAEL A HOFMANN Dir Patient Care Srvcs 125580 0 0 0 28864 0 8198 0 23973 0 186615 0 0 0 FAYE E KAMRATH Dir Radiology Srvcs 133671 0 0 0 31983 0 8899 0 16549 0 191102 0 0 0 NANETTE W KRIZENEKSY RN Lead-ICU MrktS 180143 0 0 0 1499 0 12167 0 30575 0 224384 0 0 0 SCOTT D MOON Sr Medical Physicist 157888 57917 0 0 494 188 4833 9480 11738 4181 174953 71766 0 0 Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation Ministry Health Care, Inc., a related organization of St. Elizabeth Hospital, Inc., uses the following to establish the compensation of the organization's CEO: - Compensation Committee, - Independent Compensation Consultant, - Compensation Survey or Study, and - Approval by the Board or Compensation Committee. Schedule J, Part I, Line 4a Severance or change-of-control payment The following individual(s) received severance payments from the organization or a related organization: Nicholas Desien - $2,520,000 Jeffrey Francis - $225,000 Daniel Neufelder - $234,000 Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. No individuals received current year distributions. Form 990, Part VI, Line 15a PROCESS TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL THE PROCESS OF DETERMINING THE AMOUNT OF COMPENSATION PAID TO THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR OR TOP MANAGEMENT OFFICIAL IS PERFORMED BY MINISTRY HEALTH CARE, INC. AND ITS SUBSIDIARY ORGANIZATIONS. MINISTRY HEALTH CARE, INC. IS THE SOLE CORPORATE MEMBER OF ST. ELIZABETH HOSPITAL, INC. THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE EXECUTIVE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR OR TOP MANAGEMENT OFFICIAL'S SALARY WAS COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE MINUTES. THE INDIVIDUAL WAS NOT PRESENT WHEN THEIR COMPENSATION WAS DECIDED. Form 990, Part VI - Corporate Member Change Due to a reorganization effective January 1, 2016, Affinity Health System is no longer a corporate member of St. Elizabeth Hospital, Inc. Ministry Healthcare, Inc. became the sole corporate member at that time. Form 990, Part VI, Line 15b PROCESS TO ESTABLISH COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES THE PROCESS OF DETERMINING THE AMOUNT OF COMPENSATION PAID TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES IS PERFORMED BY MINISTRY HEALTH CARE, INC. AND ITS SUBSIDIARY ORGANIZATIONS. MINISTRY HEALTH CARE, INC. IS THE SOLE CORPORATE MEMBER OF ST. ELIZABETH HOSPITAL, INC. THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE EXECUTIVE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE OFFICERS' SALARIES WERE COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE MINUTES. INDIVIDUALS WERE NOT PRESENT WHEN THEIR COMPENSATION WAS DECIDED. Form 990, Part VI, Line 6 Classes of members or stockholders St. Elizabeth Hospital, Inc. has a single corporate member, Ministry Healthcare, Inc. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body St. Elizabeth Hospital, Inc. has a single corporate member, Ministry Healthcare, Inc., who has the ability to elect members to the governing body of St. Elizabeth Hospital Inc. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders All decisions that have a material impact to St. Elizabeth Hospital, Inc. financial information or corporation as a whole are subject to approval by its sole corporate member, Ministry Healthcare, Inc. Form 990, Part VI, Line 11b Review of form 990 by governing body DURING THE RETURN PREPARATION PROCESS, THE TAX DEPARTMENT WORKS WITH OTHER FUNCTIONAL AREAS INCLUDING FINANCE, ACCOUNTING, TREASURY, LEGAL, HUMAN RESOURCES, AND CORPORATE COMPLIANCE FOR ADVICE, INFORMATION AND ASSISTANCE IN ORDER TO PREPARE A COMPLETE AND ACCURATE RETURN. UPON COMPLETION, THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S INTERNAL TAX DEPARTMENT WHICH CONSISTS OF ATTORNEYS AND CPAS. A COMPLETE FINAL COPY OF THE RETURN IS PROVIDED TO THE ORGANIZATION'S PRESIDENT, FINANCIAL OFFICER, AND/OR OTHER KEY OFFICERS IN LIEU OF THE FULL BOARD. Form 990, Part VI, Line 12c Conflict of interest policy The organization regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflicts of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Line 19 Required documents available to the public The Organization will provide any documents open to public inspection upon request. Form 990, Part VIII, Line 2f Other Program Service Revenue Income from Joint Ventures - Total Revenue: -1352269, Related or Exempt Function Revenue: -1352269, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part VIII, Line 11d Other Miscellaneous Revenue Other Miscellaneous Revenue - Total Revenue: 213467, Related or Exempt Function Revenue: , Unrelated Business Revenue: 7100, Revenue Excluded from Tax Under Sections 512, 513, or 514: 206367; Form 990, Part XI, Line 9 Other changes in net assets or fund balances FASB 136 - 63411; Catalpa Temp Restricted Investment - 69829; Net Asset Transfers with Affiliates - -53789631; Form 990, Part XII, Line 2b Audited Financial Statements The activity of St. Elizabeth Hospital, Inc. is reported in the consolidated financial statements of Ascension Health Alliance. No individual audit of St. Elizabeth Hospital, Inc. is completed. Therefore, the attached audited financial statements are of Ascension Health Alliance and Affiliates, which include the activity of St. Elizabeth Hospital, Inc. Form 990, Part XII, Line 2c Audit Committee St. Elizabeth Hospital, Inc. is included in the consolidated financial statements of Ascension Health Alliance. The Finance and Audit committee of Ascension Health Alliance's Board assumes responsibility for the consolidated organization as a whole. 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