2018-10-31T10:21:03-05:00 2017-12-31 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2017-01-01 363311936 Stevens Community Medical Center STEV 3205891313 400 E 1st St Morris MN 56267 John Rau President/CEO 3205891313 2018-10-30 1 Kim Hunwardsen CPA P00484560 6122536500 2018-10-30 8.39.233.11 2018-10-30 07:59:55 CD P D8A1E5117AA53286D53F57459EBB2DE5C7CA50FC F9BEE9501A3B4F00F190E63700B8BF2BC70C7B96 2017 2018-06-14 16:35:46Z John Rau 400 E 1st St Morris MN 56267 40448834 0 X www.scmcinc.org X 1984 MN Promotion of health 13 9 359 145 0 0 160346 185450 39066666 39970867 125654 231798 56003 54415 39408669 40442530 27408 26840 0 0 21771219 22439061 0 0 0 15829227 16471291 37627854 38937192 1780815 1505338 52655412 54340001 4985777 5163688 47669635 49176313 X Stevens Community Medical Center's mission is to strive for excellence in the delivery of inpatient and outpatient care through cooperation with qualified health care providers; through the provision of appropriate facilities and technology; and through active promotion of health education among the public.Our pledge to the recipients of this Medical Center's health care is to address their needs in as expert, efficient, compassionate, and convenient manner as possible. 0 0 31721317 26840 39970867 Stevens Community Medical Center is a not-for-profit integrated health care system. The mission of the Medical Center is to make available high quality health care. The Medical Center serves the population of West Central Minnesota and is becoming a regional health care center."CARING IS OUR REASON FOR BEING"SCMC provides quality medical healthcare regardless of race, creed, sex, national origin, handicap, age or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of SCMC, it is recognized that not all individuals possess the ability to purchase essential medical services. To further that, our mission is to serve the community with respect to providing health care services and health care education. For example, the Medical Center is committed to providing medical services to all members of its community, provide free care and/or subsidized care, promote health activities and programs to support the community, and provide care to persons covered by governmental programs at below cost. Therefore, financial assistance will be considered where the need and/or an individual's inability to pay exists. SCMC had 31,480 hospital outpatient visits, 29,505 clinic and urgent care visits, 2,451 inpatient days, 8,249 outpatient counseling visits, 97 deliveries, 486 surgeries, 2,570 emergency room visits, and 25,250 therapy treatments in 2017. SCMC also owns and operates the Courage Cottage, an adult foster care facility specializing in care for the terminally ill. In 2017, 12 residents were served, and the cost to provide their care was subsidized by community donations.Recognizing its mission to the community, SCMC provides services to Medicare, Medicaid, and other patients covered by governmental programs, sometimes at a reimbursement below cost. The total discounts accepted for providing care to patients was $23,922,374 in 2017. The charges foregone for services supplied under SCMC's charity care policy (free and/or subsidized care) was $802,000 in 2017.Charity care is also provided through many reduced price services and free SCMC programs and information offered throughout the year based on activities and services which SCMC believes will serve a bona fide community need. These include: various brochures to educate patients; staff speaking for a variety of community events including SCMC sponsored "health nights," elderly and adult education; sponsoring a smoking cessation program and a variety of other "wellness" type programs at subsidized cost; providing meeting facilities for various community groups; offering support groups; and providing assistance to educators through our work with student nurses. 31721317 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 121 0 1 359 1 0 0 0 0 0 0 0 0 0 0 X 13 9 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 0 0 MN X Kerrie McEvilly 3205897627 400 E 1st St Morris MN 56267 David Paul Chair 1.00 X X 0 0 0 Paul Groneberg Vice Chair 1.00 X X 0 0 0 Jan Hagen Treasurer 1.00 X X 0 0 0 Ward Voorhees Secretary 1.00 X X 0 0 0 Pieranna Garavaso Director 1.00 X 0 0 0 Jodi DeCamp Director 1.00 X 0 0 0 Bart Finzel Director 1.00 X 0 0 0 Paul Martin Director 1.00 X 0 0 0 Darryl Larson Director 1.00 X 0 0 0 Patrick Burke MD Director / Physician 30.00 X 154144 0 41894 Elizabeth Meichsner MD Director/Physician 40.00 X 255738 0 49524 Toby Christie-Perkins DO Director/Physician 40.00 X 388252 0 48782 Jason Breuer President / CEO 40.00 X X 233742 0 45317 Kerrie McEvilly Vice President of Finance 40.00 X 168163 0 13033 Andrea Giambi DO Radiologist 40.00 X 479463 0 41631 Michael Holte MD Orthopedic Surgeon 40.00 X 729755 0 42881 Randell Lussenden CRNA 40.00 X 466776 0 30777 Brent Barnstuble MD Physician 40.00 X 381973 0 46182 Somkiat Viratyosin MD General Surgeon 40.00 X 387648 0 53507 3645654 0 413528 36 0 1 0 Freelance Physician 3737 Moraga Ave San Diego CA 92117 ER & Urgent Care MD 1246593 JE Dunn North Central Inc 800 Washington Ave N Ste 600 Minneapolis MN 55401 Construction Services 982207 NovaCare Rehabilitation 4714 Gettysburg Rd Mechanicsburg PA 17055 Therapy Services 622833 Cerner Health Serv IncSiemens 51 Valley Stream Parkway Malvern PA 19355 IS Support 406221 Technical Life Care Medical Co 2720 Mounds View Blvd Mounds View MN 55112 Equipment Support 204887 11 185450 185450 Patient service revenue 622110 39874988 39874988 Supporting revenue 900099 95879 95879 39970867 226728 226728 54558 0 54558 54558 54558 5070 0 5070 5070 5070 6161 6304 -143 -143 40442530 39970867 0 286213 X 26840 26840 1404225 942111 462114 16788946 13433180 3355766 811869 629614 182255 2262885 1499678 763207 1171136 905908 265228 76324 76324 78811 78811 4772486 4132092 640394 104852 3024 101828 1892230 1476155 416075 443337 443337 434631 29123 405508 103071 91062 12009 59840 46821 13019 2551480 2551480 330761 330761 Medical supplies 3673334 3673334 Bad debts expense 624780 624780 MN Care tax 612880 612880 Pharmacy 340B Program C 416859 416859 295615 295615 38937192 31721317 7215875 0 156207 42916 10918136 12013845 7314062 7507754 1235387 1243631 325153 196634 48813497 27799931 21724435 21013566 10669009 12182047 313023 139608 52655412 54340001 4985777 5003688 0 160000 4985777 5163688 X 47482415 49087719 187220 88594 47669635 49176313 52655412 54340001 X 1505338 1340 X 0 1 X 1 0 X 1 25648 6162 7502 24308 0 371723 371723 29555713 13258101 16297612 18186093 14186233 3999860 699968 355597 344371 21013566 Estimated third party payor settlements 160000 160000 X 39819090 -623583 -623583 40442673 -143 -143 40442530 38312412 0 38312412 624780 624780 38937192 Part IV, Line 1b: The organization holds the assets for the Stevens Community Medical Center Ladies' Auxiliary/Gift Shop. The assets are not included on the books of the Medical Center. The revenue and expense have been recorded on the applicable lines of the Form 990. Part X, Line 2: The Medical Center is organized as a Minnesota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Medical Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Medical Center is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Medical Center has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Medical Center believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Medical Center would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for bad debts in revenue for financial statements -624,780. Auxiliary contribution eliminated for tax 1,197. Part XI, Line 4b - Other Adjustments: Auxiliary net income not included in financial statements -143. Part XII, Line 4b - Other Adjustments: Provision for bad debts in revenue for financial statements 624,780. 1 1 X 1 X 1 X 190.000000000000 1 1 1 0 1 1 464000 464000 0.01210 4560906 3557474 1003432 0.02620 2530174 1695827 834347 0.02180 7555080 5253301 2301779 0.06010 109364 109364 0.00290 100496 100496 0.00260 1435 1435 0.00000 211295 211295 0.00550 7766375 5253301 2513074 0.06560 26637 26637 0.00070 61456 61456 0.00160 88093 88093 0.00230 0 624780 63671 10968862 11023367 -54505 X 1 1 1 1 Stevens Community Medical Center 400 East 1st Street Morris MN 56267 www.scmcinc.org 00653 X X X X one provider based clinic Stevens Community Medical Center 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X See Section C X 1 16 1 See Section C 0 1 X 100.000000000000 190.000000000000 X X X X X X 1 1 X X X X 1 X https://www.scmcinc.org/forms-and-faqs/financial-assistance X https://www.scmcinc.org/forms-and-faqs/financial-assistance X https://www.scmcinc.org/forms-and-faqs/financial-assistance X X X X X X 1 X 0 X X X X 1 X 0 0 Stevens Community Medical Center Part V, Section B, Line 5: Stevens Community Medical Center received input from a wide representation of the community it serves when conducting the 2016 Community Health Needs Assessment. We hosted a community forum in November 2016 at the Morris Senior Center that was attended by 38 individuals (another 10 were invited but unable to attend). Participants included wide representation from the community including the areas of child care, elder care, agriculture, minority populations, human services, local business managers, physicians, mental health providers, university and high school students, and others. Multiple staff members from Horizon Public Health were active participants as well. We utilized a "World Cafe" format for engaging in discussion to identify the most significant community health needs as well as the community's current strengths and weaknesses in meeting those needs. It was a very productive evening and there are plans for future collaboration to go into more depth on some of the issues discussed. SCMC then designed its 3-year implementation plan to outline how we might best be able to address some of the identified needs. Stevens Community Medical Center Part V, Section B, Line 11: 2017 Efforts in Addressing the Significant Needs Identified in 2016 CHNA 1. Mental Health - SCMC Behavioral Medicine Department provided a forum for area high school students and their families - specifically for students entering into early adulthood. Morris area and surrounding schools, guidance counselors and other mental health professionals were invited to attend. The goal was to cover useful and practical information and to provide education about self-care and resilience while transitioning into college, or other life paths that students may take. This presentation provided a proactive approach to educate students about mental health and building/creating resilience. A panel with current college students also answered questions from the high school seniors. There were about 200 students and parents/families that attended the March 22, 2017 presentation. Two providers participated in the Day at Home event located in Alexandria, MN in fall of 2017. Several representatives from the MN Legislature were present to hear the concerns/needs of both mental health professionals and consumers. Two providers also participated in the Stevens County Health fair in the Fall of 2017 educating county employees on what services are available in the Behavioral Medicine Department and educational materials were provided on how to manage stress. In December of 2017, SCMC contracted with a Child and Adolescent Psychiatrist. This provider was available via telemedicine two days a week for children ages 6-17. 2. Access to Healthcare Providers - In 2017 we successfully hired Dr. Jason Hughes as a Family Medicine Physician, who is also Board Certified in emergency medicine. We also added nurse practitioner Donna Piotter, FNP-BC, to increase access to Urgent Care appointments. As a result, SCMC saw 218 more Urgent Care patients in 2017 than in 2016. Dr. Jason Huikko also joined the team of providers as a Family Medicine Physician, which added additional OB services as well. The effort still continues to search for internal medicine physician. SCMC already has a signed agreement with Dr. Timothy Jay to join the organization after finishing his residency in 2020 as an Orthopedic Surgeon.3. Transportation - Research was done on a couple of grants as it related to transportation services. In addition, SCMC considered the option of purchasing a vehicle of our own for this purpose. Ultimately, this option was ruled out based on the determination that providing transportation outside the scope of our own patients' appointments would not align with the primary mission and tax-exempt purpose of this organization. SCMC will continue to work with other community organizations to try to assist in addressing this need. 4. Health impact of poor lifestyle choices - In 2017, SCMC again sponsored the annual Fall into Health event where the primary goal was to communicate the importance of healthy choices to our community, all ages welcome. We offered access to free lab tests, a free community (healthy) meal, many information booths staffed by SCMC and others where healthy choices were promoted. The SCMC provider panel and keynote speaker's message all encouraged the community's healthy choices and answered questions about the future of health and the importance of staying on top of it (physical, mental, and environmental.)The Power of Produce was another event that has continued to grow and thrive during the summer months. P.O.P. participated with the local Farmers Market and each week Power of Produce would create a new activity educating and attracting the younger generation by showing them the fun in eating healthy and making good food choices. This project is led and organized by the SCMC dietician with the help of summer interns and the marketing department at SCMC.In 2017, the SCMC Registered Dietitian (RD) led a comprehensive weight management program called Renew Weight Management Program, impacting 13 people. SCMC connected with the Regional Fitness Center in our community to offer the fitness component of the program. The registered dietitian also offered group nutrition classes to various community groups. This included Morris Area Elementary School ECFE where the RD discussed toddler and pre-K nutrition with 15 parents. She also led health-conscious grocery store tours with 50 total participants as part of the University of Minnesota-Morris employee wellness program. The Stevens Community Medical Center cafeteria has expanded the selections of fresh produce by contracting with a local distributor, Bix. A grab-and-go cooler added in 2017 provides a place for fresh sandwiches, fruit cups, milk, cheese, and yogurt offerings. This has been well received by our customers, which is primarily staff but also includes patients, visitors, and community members. The grab-and-go cooler options are available for purchase throughout the day, which makes it convenient for all employee break times. A salad bar in the cafeteria features fresh and healthy options daily. The food service department also made a change to their menus in 2017, offering attractive and healthful options daily. The 2017 Turkey Trot sponsored by the Courage Cottage had 69 participants. This was a fun, healthy, community activity that also served as a fundraiser for the very well received adult foster care home we have available to serve patients. Stevens Community Medical Center Part V, Section B, Line 13h: Federal guidelines and Minnesota Attorney General agreement percentage discounts were used to determine eligibility for discounts. Stevens Community Medical Center Part V, Section B, Line 15e: We send applications for MNSure and assist patients in applying for programs where there is a need and possibility for basis of eligibility. We are also HPE (Hospital Presumptive Eligibility) providers and can screen and submit short term MA approvals. Schedule H, Part V, Section B, line 7a: http://www.scmcinc.org/sites/default/files/Community%20Health%20Needs%20Assessment%202016_1.pdf Schedule H, Part V, Section B, line 10a: http://www.scmcinc.org/sites/default/files/Implementation%20Plan%202016%20CHNA_0.pdf 2 1 - Starbuck Clinic 501 Poler Street Starbuck MN 56381 Family practice clinic 2 - Courage Cottage 409 East 1st Street Morris MN 56267 Adult foster care facility Part I, Line 3c: The following factors are used by the Organization to help determine eligibility for Financial Assistance:-Proof of household income (such as social security award letters, pay stubs and tax returns)-Assessing the patient's ability to make reasonable monthly payments on balance owed (through review of expense form reflecting household income and expenses)-When income and expense documentation doesn't reflect an accurate picture of a patient's ability to pay, additional considerations are made (e.g. if wages have changed since the last filed tax return).-SCMC provides assistance in applying for healthcare programs where applicable. Status of insurance is reviewed at application.Along with the above considerations, the Federal Poverty Guidelines (FPG) are reviewed and the most appropriate discount is offered. The organization provides a 23% self-pay discount; and 40 to 80% Financial Assistance discount when income levels meet 190% down to 170% of the FPG. For example, an 80% discount is given for income ranges from 101% to 120% of the FPG. Part I, Line 6a: The community benefit report is available to the public upon request. Part I, Line 7: Charity care expense was converted to cost based on an overall cost-to-charge ratio addressing all patient segments. Medicaid and Other Mean's Tested was converted to cost using the cost-charge-ratio derived from Worksheet 2. Community health improvement services, health professions education, and cash and in-kind contributions are reported based on actual expenses recorded to the general ledger. Part I, Line 7g: N/A Part I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $624,780. Part II, Community Building Activities: In 2017, SCMC supported several significant health related community initiatives such as the Regional Fitness Center, Habitat for Humanity, and the local chapter of the American Cancer Society to name just a few. We also paid over $61,000 in local real estate taxes for our two medical clinics, which would certainly have a positive impact on the health of the communities we serve. Part III, Line 2: Bad debt expense is reported at charges as recorded by the Organization. Part III, Line 3: The estimated amount of bad debt expense attributable to patients eligible under the organization's charity care policy is approximately 10.19% because that is the amount of applications that were denied due to lack of information or no response to Charity Care application process. The full amount of this is not reflected in Part I, line 7 and is considered community benefit. Had the appropriate information been provided and applications completed, this amount would have been considered charity care.Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year. Part III, Line 4: The footnote to the Organization's financial statements that describes bad debt expenses is located in Footnote 1 on page 6 and page 7 of the attached financial statements. Part III, Line 8: Medicare allowable cost is based on the Medicare Cost Report. The Medicare Cost report is completed based on the rules & regulations set forth by Centers for Medicaid and Medicare Services.Stevens Community Medical Center is an acute care hospital. There was a shortfall for 2017 due to sequestration. Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit. Part III, Line 9b: We follow the "MN Attorney General Agreement" guidelines regarding debt collection. The "MN Attorney General Agreement" outlines billing and collections practices we have agreed to follow for our patients. Some of those practices include: We do not attempt to collect a debt unless it is determined insurance has been billed and there is a reasonable basis to believe the patient owes the bill, that we have offered reasonable payment plans and will not refer to a collections agency if patients are meeting these payment terms, we have given patients the opportunity to apply for financial assistance, we allow for negotiation directly with us on complaints from patients after they have been sent to collections and that we agree to charge uninsured patients no more than what we would be reimbursed by our largest insurer. Part VI, Line 2: Many of our department heads are members of other boards or organizations throughout the community. These include the Chamber of Commerce, the Morris Area Community Development Committee, and Morris Area Child Care Center in addition to others. The information obtained from participating in these committees is utilized to continually assess the appropriateness of existing services and the need for potential new areas of health related opportunities. Conference committee meetings are also used to get input from all employees, who are also consumers of our services, regarding areas of potential growth. In addition we conducted a Community Health Needs Assessment in 2016. Part VI, Line 3: Stevens Community Medical Center provides a copy of our charity guidelines and financial assistance contact information to interested patients as part of our intake/screening process; self-pay patients (particularly inpatients) are asked if they have financial concerns and are referred to a financial counselor if a need is discovered. A variety of tools are used to determine potential needs through the registration, prior authorization, and billing processes - social worker's referral, identification of uninsured or underinsured status, and/or a previous history of inability to pay. The charity care guidelines, policy, plain language summary, application, instructions and contact information are posted on our website. We also post financial assistance contact information for persons interested in applying for Charity Care and/or Medicaid in patient common areas such as registration, waiting areas, physician rooms and the Cashier's office.In addition, if payments are not being made after 2-3 statements have been sent, a Financial Counselor will call to inform the patient of their options. At that time, we would send out an application for Charity Care, discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, where applicable. Part VI, Line 4: Stevens Community Medical Center serves the County of Stevens including the towns of Morris, Donnelly, Hancock, Chokio and Alberta. We also serve areas of Pope, Swift, Traverse, Grant, and Big Stone. We anticipate the total primary service area to be approximately 15,000, with a secondary market of an additional 20,000.The service area is primarily rural, with a strong agricultural base. We are also fortunate to have a university presence with the University of Minnesota, Morris. Approximately 64% of our inpatients are Medicare and/or Medicare HMO and another 11% are Medicaid and/or MN Care.There are three hospitals in the area that are larger than SCMC located in towns 50 miles from Morris in different directions. There are also hospitals in Benson, Wheaton, Graceville, Glenwood, Elbow Lake and Appleton, all of which are within a 30 mile radius of Morris.We are considered a federally designated medically underserved area for mental health services. Part VI, Line 5: As described earlier, SCMC has a community Board of Directors that represent specific portions of our service area. Medical staff privileges are extended to all qualified physicians in the community. We also own and operate an adult foster care facility which specializes in the terminally ill. This is currently subsidized by community donations. The Emergency Room is open 24 hours a day 7 days a week and is open to all patients regardless of ability to pay. All our employed physicians attend several educational opportunities, as do the balance of our licensed and professional staff. SCMC works to provide education to staff or opportunities for education on the latest most up to date care techniques and strategies as well as education related to compliance, billing, fraud, abuse and other regulatory rules. SCMC also works with a variety of higher education schools to provide onsite internships, residency experience, and fieldwork. Every dollar generated in excess of expenses at SCMC is reinvested in the organization to improve the services offered to the communities we serve. This includes effectively funding the depreciation of our building and equipment, investment in facilities and equipment, expansion of services to meet community need, and investment in education of staff to provide high quality effective care to our community members. The community health service activities are designed to complement the identified health needs in our area. SCMC promotes community health with partnerships with other community groups such as the Farmer's Market, local food drop, local elementary/high school education programs, providing an athletic trainer to the local high school, and a community health group that coordinates activities such as the Fall Into Health. SCMC's dietician and diabetic educator provide diabetes presentations to local service groups. Much of the emphasis associated with these events is toward prevention and early detection.We are also acutely aware of the fact that a large percentage of the population we serve are senior citizens and value the benefit of the free transit services we provide for clinic appointments.Charity care is also provided through many reduced price services and free SCMC programs and information offered throughout the year based on activities and services which SCMC believes will serve a bona fide community need. These include: various brochures to educate patients; staff speaking for a variety of community events including SCMC sponsored "health nights", elderly and adult education; sponsoring a smoking cessation program and a variety of other "wellness" type programs at subsidized cost; providing meeting facilities for various community groups; offering support groups; and providing assistance to educators through our work with student nurses.SCMC provides many opportunities for community involvement through volunteering. Approximately 150 people volunteer for a variety of activities at SCMC. Volunteers are from a wide range of ages including youth from the local schools.SCMC is the only hospital in Morris.MERC Program/Residency/Internships- SCMC has benefited from Medical Residency and FNP programs that participate in the MERC funding program. This assists SCMC with the costs associated with clinical rotations, such as extra hours and lodging expenditures. It allows SCMC to continue to support the growth of students in Rural Health Care programs. Courage Cottage donations are used to support end of life care, as SCMC identified that as a community need. SCMC's administration advocates with government contacts to encourage measures that will improve the overall health of the community we serve. Part VI, Line 7, Reports Filed With States MN X X 0 0 0 1 0 0 0 0 0 Patrick Burke MD Director / Physician 146919 0 6234 0 991 0 12551 0 30481 0 197176 0 0 0 Elizabeth Meichsner MD Director/Physician 240677 0 10836 0 4225 0 14042 0 35746 0 305526 0 0 0 Toby Christie-Perkins DO Director/Physician 277225 0 100481 0 10546 0 16200 0 34958 0 439410 0 0 0 Jason Breuer President / CEO 224404 0 9122 0 216 0 12735 0 33530 0 280007 0 0 0 Kerrie McEvilly Vice President of Finance 164629 0 101 0 3433 0 13033 0 912 0 182108 0 0 0 Andrea Giambi DO Radiologist 141795 0 316207 0 21461 0 20925 0 23262 0 523650 0 0 0 Michael Holte MD Orthopedic Surgeon 665551 0 39102 0 25102 0 19575 0 25874 0 775204 0 0 0 Randell Lussenden CRNA 128896 0 333986 0 3894 0 20925 0 10896 0 498597 0 0 0 Brent Barnstuble MD Physician 262494 0 101139 0 18340 0 16200 0 32394 0 430567 0 0 0 Somkiat Viratyosin MD General Surgeon 350458 0 102 0 37088 0 20925 0 35054 0 443627 0 0 0 Part I, Line 5 The physicians are eligible to receive quarterly incentive compensation based on their personal gross revenue production for non-ancillary services, according to the terms of their contracts. The CRNAs also receive quarterly bonuses contingent on the services they provide to patients of SCMC. Form 990, Part VI, Section A, line 8b The organization does not have any committees with authority to act on behalf of the governing board. Form 990, Part VI, Section B, line 11b Prior to filing, the 990 is reviewed in detail by the Vice President of Finance and President/CEO. The Board of Directors is given the opportunity to review a copy prior to filing. A copy of the Form 990 is attached to the state filing. The state filing requires a Board Resolution approving the filing. During that time the board is briefed on information contained within the Form 990. Form 990, Part VI, Section B, line 12c The organization has two conflict of interest policies - one that covers officers and directors and one that covers other management staff (including other key employees, if applicable). Potential conflicts identified by officers and directors are reviewed by the remaining board members; those identified by management are reviewed by the President/CEO. Officers and directors are to abstain from voting on any such matter where they have a potential conflict of interest. The President/CEO evaluates each potential conflict identified by management on an individual basis in order to determine the appropriate restrictions to put in place. Form 990, Part VI, Section B, line 15a The Board of Directors references the MN Hospital Association CEO Compensation Survey when reviewing the CEO's compensation on an annual basis. Besides participating in MHA compensation surveys, SCMC also references Medi-Sota and HHRAM compensation surveys that includes 49 hospitals in MN for various positions. The President/CEO reviews salary ranges for officers and key employees of the organization on an annual basis. SCMC receives an annual assessment from Merritt-Hawkins (a recruiting firm) regarding compensation ranges for primary care and specialty physicians. This information is specific to different geographic regions, as well as for groups versus private practices. The President/CEO also reviews the AMGA (American Medical Group Association) compensation survey for physician compensation and the MHA compensation survey for the Vice President of Finance compensation annually. Form 990, Part VI, Section C, line 19 The audited financial statements, governing documents and conflict of interest policy are made available to the general public upon request. The audited financial statements are also attached to the Form 990. Form 990, Part IX, line 11g Repairs and maintenance: Program service expenses 432,675. Management and general expenses 101,457. Fundraising expenses 0. Total expenses 534,132. Purchased services: Program service expenses 3,699,417. Management and general expenses 538,937. Fundraising expenses 0. Total expenses 4,238,354. Form 990, Part XI, line 9: Auxiliary Activity included for tax 143. Auxiliary contribution eliminated for tax 1,197.