2016-11-14T08:12:03-06:00 2015-12-31 010494526 Baker Newman & Noyes PO Box 507 Portland ME 04112 990 2015-01-01 020497927 Wentworth-Douglass Physician Corporation WENT 6037425252 789 Central Avenue Dover NH 038202526 Peter E Walcek CFO/V.P. of Finance 6037422804 2016-10-26 1 Nicholas E Porto P01310283 2078792100 2016-10-26 2015 2017-02-10 21:41:12Z Wentworth Health Partners Gregory J Walker 789 Central Avenue Dover NH 038202526 35788673 0 X https://www.wdhospital.com/whp X 1998 NH Improve the health of the community by providing high quality healthcare. 12 4 442 4 186 0 9128 0 35165930 35681675 533 0 75480 76499 35251071 35758174 0 0 0 0 40771874 45729496 0 0 0 15783015 18679279 56554889 64408775 -21303818 -28650601 6434572 5845627 7506377 7505847 -1071805 -1660220 X Improve the health of the community by providing high quality health care that exceeds expectations through an integrated network of highly qualified professionals. 1 0 59674826 0 35757988 Wentworth-Douglass Physician Corporation (WDPC) was formed in response to a community needs assessment that identified a lack of primary care and specialty services in the community. The formation of the Physician Corporation and recruitment of primary care and specialty physicians closed the gap by improving access to medical services in Dover, NH and surrounding areas. (See Schedule O for a list of facilities operated by WDPC.)WDPC provides financial aid and information and resources to assist patients with their healthcare bills. Medical care is provided at no charge for eligible patients at 250% of the federal poverty level (300% of the FPL for Dental Services). (Continued on Schedule O).In 2015, WDPC provided $422,134 of financial aid (stated at cost).Medicaid Costs Exceeding Reimbursement totaled $2,526,203 for WDPC in 2015.Wentworth-Douglass Hospital (The Hospital) subsidizes WDPC primary care practices that operate at a loss. The subsidized losses of these primary care practices do not include the financial aid provided to patients (stated at cost) or the Medicaid cost exceeding reimbursement associated with these practices, and totaled $5,171,668 in 2015. The Hospital subsidizes certain WDPC specialty care practices that operate at a loss. The subsidized losses of these specialty care practices do not include the financial aid provided to patients (stated at cost) or the Medicaid cost exceeding reimbursement associated with these practices, and totaled $3,334,725 in 2015. WDPC supports numerous community based programs, including the Community Dental Center and Behavioral Health Services. In 2015, WDPC acquired Great Bay Mental Health as part of the continued initiative to expand the services offered for behavioral health. WDPC provided $406,004 of behavioral health care services to patients.The Wentworth-Douglass Community Dental Center is open to low-income, uninsured adults and children living in the Hospital's primary service area (Dover, Durham, Madbury, Lee, Barrington, Somersworth, Rollinsford, NH and Berwick and So. Berwick, ME) or patients of the physician practices who have a family income at or below 300% of the federal poverty level, based on the number of members in the household. Minimum payments are charged on a discounted fee schedule based on household income. In 2015, the Dental Center provided $647,682 of community-based clinic services. 59674826 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 442 1 0 0 0 0 0 0 0 0 0 0 X 12 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Peter E Walcek CFOVP of Finance 6037402804 789 Central Avenue Dover NH 038202526 X Ellen Caille FACHE Director/Exec VP, WDH 5.00 50.00 X 0 391139 84401 Paul R Cass DO Director/Physician 5.00 50.00 X 0 453027 90800 Mary Ann Gagnon APRN Director/Physician 50.00 0.00 X 122898 0 31498 Matthew Goldberg DO Director/Physician 50.00 0.00 X 261364 0 19586 Hugh MacDonald MD Director/Physician 50.00 0.00 X 263568 0 35060 Nancy J Pettinari MD Director/Physician (part year) 50.00 0.00 X 311883 0 11631 Gary Usher MD Director/Physician 50.00 0.00 X 318902 0 18099 Roger Hamel Chairman 1.00 6.00 X X 0 0 0 Carol Bailey Vice Chairman 1.00 4.00 X X 0 0 0 Michael Steinberg Treasurer 1.00 4.00 X X 0 0 0 John Salmon Secretary 1.00 4.00 X X 0 0 0 Gregory J Walker President/CEO, WDH 2.00 53.00 X X 0 807205 154460 Peter E Walcek CFO/VP Finance, WDH 2.00 53.00 X X 0 438479 96082 Barbara F Civiello MD Physician 50.00 0.00 X 580333 0 33260 Paul T Berry MD Physician 50.00 0.00 X 535513 0 30615 Joseph A Rodriguez MD Physician 50.00 0.00 X 544332 0 21631 Lazaro A Diaz MD Physician 50.00 0.00 X 566336 0 36566 Faisal Shamshad MD Physician 50.00 0.00 X 541750 0 0 4046879 2089850 663689 104 0 1 0 0 Patient Service Revenue 621110 34433324 34433324 Other Related Function Income 621990 1163355 1163169 186 Meaningful Use 621110 84996 84996 35681675 106998 30499 76499 76499 76499 35758174 35757988 186 0 X 1384489 1384489 36847344 34577929 2269415 332451 308247 24204 4115055 3855776 259279 3050157 2858607 191550 20000 20000 8420317 6963570 1456747 19865 19865 1880791 1566933 313858 3340116 3188326 151790 238554 211313 27241 603705 603705 947429 947429 Pharmacy Expense 1167595 1167595 Provision for Bad Debt 1064179 1064179 Dental Community Benefi 647682 647682 Transcription 329046 329046 64408775 59674826 4733949 0 390186 19239 3796784 3664523 10096978 7938810 2243905 2158168 3697 3697 6434572 5845627 7506377 7505847 7506377 7505847 X -1071805 -1660220 -1071805 -1660220 6434572 5845627 X -28650601 28062186 X X 0 1 X 1 0 X 3027694 2459883 567811 7069284 5478927 1590357 2158168 X 35362087 30471 30471 35331616 426558 426558 35758174 64012688 30471 30471 63982217 426558 426558 64408775 Part X, Line 2: WDHS, the Hospital, WDPC and the Foundation are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes pursuant to Section 501(a) of the Code. Management evaluated these not-for-profit corporations' tax positions and concluded these not-for-profit corporations have maintained their tax-exempt status, do not have any significant unrelated business income and have taken no uncertain tax positions that require adjustment to or disclosure in the accompanying consolidated financial statements. Part XI, Line 2d - Other Adjustments: Occupancy Expenses Allocated to Building Rental 30,471. Part XI, Line 4b - Other Adjustments: Dental Community Benefit (net of allocated overhead) 426,558. Part XII, Line 2d - Other Adjustments: Occupancy Expenses Allocated to Building Rental 30,471. Part XII, Line 4b - Other Adjustments: Dental Community Benefit (net of allocated overhead) 426,558. 0 1 0 0 0 0 0 1 0 Ellen Caille FACHE Director/Exec VP, WDH 0 273673 0 53960 0 63506 0 55735 0 28666 0 475540 0 37500 Paul R Cass DO Director/Physician 0 367330 0 69263 0 16434 0 71186 0 19614 0 543827 0 0 Mary Ann Gagnon APRN Director/Physician 121435 0 1175 0 288 0 5317 0 26181 0 154396 0 0 0 Matthew Goldberg DO Director/Physician 244837 0 15257 0 1270 0 10359 0 9227 0 280950 0 0 0 Hugh MacDonald MD Director/Physician 202338 0 59930 0 1300 0 8281 0 26779 0 298628 0 0 0 Nancy J Pettinari MD Director/Physician (part year) 265058 0 43677 0 3148 0 11158 0 473 0 323514 0 0 0 Gary Usher MD Director/Physician 234614 0 82929 0 1359 0 6860 0 11239 0 337001 0 0 0 Gregory J Walker President/CEO, WDH 0 464287 0 145630 0 197288 0 125844 0 28616 0 961665 0 0 Peter E Walcek CFO/VP Finance, WDH 0 310787 0 60795 0 66897 0 66753 0 29329 0 534561 0 40500 Barbara F Civiello MD Physician 403121 0 157820 0 19392 0 13148 0 20112 0 613593 0 0 0 Paul T Berry MD Physician 276464 0 242377 0 16672 0 10663 0 19952 0 566128 0 0 0 Joseph A Rodriguez MD Physician 345715 0 179904 0 18713 0 11093 0 10538 0 565963 0 0 0 Lazaro A Diaz MD Physician 447097 0 99847 0 19392 0 7950 0 28616 0 602902 0 0 0 Faisal Shamshad MD Physician 541750 0 0 0 0 0 0 0 0 0 541750 0 0 0 Part I, Line 3 The President/CEO of Wentworth-Douglass Physician Corp (WDPC) is an employee of Wentworth-Douglass Hospital (WDH), a related organization, and WDPC does not maintain any procedures to establish his compensation. However, the Hospital uses its executive committee, an independent national compensation consultant, compensation surveys, and requires final approval by its independent Board Members to determined executive compensation for all vice-presidents and above. Part I, Line 4b Gregory J. Walker (President/CEO) - 2015 total contributions to the 457(f) plan = $113,104. This supplemental retirement plan contribution is intended to fund benefits accruing and payable at retirement for multiple years of service that began in calendar year 1997. In 2015, the Hospital funded a supplemental executive retirement plan which provides benefits to other qualifying executives. The contributions are intended to provide a forfeitable supplemental retirement benefit and are being provided in consideration for many years of service to the Hospital. The respective contributions for the 2015 plan year, for those individuals identified in Schedule J - Part II, are as follows: Peter E. Walcek = $50,853, Ellen Caille = $45,135, and Paul R. Cass = $57,936. The following individuals vested in their 2010 457(f) contributions during 2015: Peter E. Walcek = $40,500 and Ellen L. Caille = $37,500. The 2010 amounts are required to be reported on Schedule J, in Column F and as part of the taxable W-2 compensation reported in Column B(iii) of this Form 990. WDH sponsors a split-dollar life insurance employee benefit program for certain officers and key employees. Split dollar life insurance is an arrangement in which the employee is the owner of the life insurance policy and the premiums are paid by the employer. Pursuant to WDH's split-dollar agreement, and the collateral assignment therein, the employer's share of the policy premiums paid is recovered either upon termination of the policy or at the death of the participant. Note that the split-dollar arrangement is part of an employee benefit program and economically not a direct extension of credit. Furthermore, the reportable compensation of the respective employees includes the annual value of the life insurance. Total premiums paid during the year ending 12/31/15 were $21,144 for Peter E. Walcek. The taxable value of the life insurance policy has been included in each individuals' W-2. The policies are intended to provide an additional retirement benefit for these individuals' multiple years of service. Part I, Line 7 At-risk compensation for Wentworth-Douglass executives, which is subject to review and paid annually. Wentworth-Douglass Physician Corporation has an incentive-based compensation model that uses relative value units (RVUs) as a measure for determining physician compensation within the Medical Group Management Association published salary ranges. The model includes a base salary plus incentive compensation that has both productivity and performance components inclusive of patient satisfaction and quality. Both budgeted performance and actual performance are measured. Form 990, Part III, line 2 See narrative for Form 990, Part III, Line 4a below. Form 990, Part III, Line 4a: WDPC'S Facilities: Wentworth-Douglass Physician Corporation does not file a separate annual community benefit report. Rather, Wentworth-Douglass Hospital (WDH) includes WDPC data with its community benefit report that is filed annually with the State of New Hampshire. WDHS owns 100% of WDPC, and oversees all of WDPC's primary care and specialty practices, outpatient physician clinics and its dental clinic, which are located as follows: Adult & Children's Medicine, 10 Members Way, Suite 201, Dover, NH Allergy Associates of NH, 10 Members Way, Suite 401, Dover, NH Barrington Health Center, 8 Century Pines Drive, Suite 2, Barrington, NH Bellamy Health Center, 15 Old Rollinsford Road, Suite 204, Dover, NH Center for Medical Genetics, 15 Old Rollinsford Road, Suite 201, Dover, NH Coastal Neurology Services, 158 E. NH Route 108, Suite 5, Dover, NH Dover Family Practice, 10 Members Way, Suite 203, Dover, NH Dover Internal and Geriatric Medicine, 10 Members Way, Suite 301, Dover, NH Dover Women's Health, 700 Central Avenue, Dover, NH Durham Health Center, 36 Madbury Road, Durham, NH Endocrinology and Diabetes, 10 Members Way, Suite 400, Dover, NH Great Bay Family Practice, 60 Exeter Road, Suite 300, Newmarket, NH Great Bay Mental Health, 10 Members Way, Suite 401, Dover, NH Gynecology and Infertility Associates, 15 Old Rollinsford Road, Suite 102, Dover, NH Hilltop Family Practice, 85 Main Street, Somersworth, NH Lee Family Practice, 65 Calef Highway, Suite 200, Lee, NH Manchester Urology Association at Dover, 10 Members Way, Suite 402, Dover, NH Marshwood Family Care, 19 Levesque Drive, Suite 2, Eliot, ME Outpatient Diabetes Services, 10 Members Way, Suite 400, Dover, NH Supportive & Palliative Care, 789 Central Avenue, Level 2, Dover, NH Plastic Surgery Specialists, 10 Members Way, Suite 303, Dover, NH Primary Care of Dover, 10 Members Way, Suite 300, Dover, NH Seacoast Arthritis & Osteoporosis Center, 10 Members Way, Suite 403, Dover, NH Seacoast Cancer Center, 789 Central Avenue, Dover, NH Seacoast General Surgery, 750 Central Avenue, Suite N, Dover, NH Seacoast Integrative Therapy, 15 Old Rollinsford Road, Suite 204, Dover, NH Seacoast Pulmonary (Intensivists), 789 Central Avenue, Level 1, Dover, NH South Berwick Family Practice, 31 Colcord Street, South Berwick, ME Strafford Medical Associates, 10 Members Way, Suite 302, Dover, NH Summit Infectious Disease, 789 Central Avenue, Dover, NH The Hospital Medicine Team (formerly Hospitalists), 789 Central Avenue, Level 2, Dover, NH Prompt Care, 10 Members Way, Suite 203, Dover, NH Behavioral Health Services, 10 Members Way, Suite 404, Dover, NH Cardiovascular Group, 19 Old Rollinsford Road, Dover, NH Thoracic Surgery Specialists, 789 Central Avenue, Level 1, Dover, NH WD Community Dental Center, 668 Central Avenue, Dover, NH Wound Healing Institute and Hyperbaric Oxygen Center, 789 Central Avenue, Dover, NH Form 990, Part VI, Section A, line 6 Wentworth-Douglass Health System (WDHS), a New Hampshire nonprofit corporation, was formed in 2012 as the result of the corporate restructuring of Wentworth-Douglass Hospital (WDH) into an integrated health system. WDHS serves as the parent company of WDH and its affiliates Wentworth-Douglass Hospital and Health Foundation (WDHHF) and Wentworth-Douglass Physician Corporation (WDPC), all of which are New Hampshire nonprofit corporations that have been recognized as being 501(c)(3) organizations. These corporations share a common mission with WDH. WDHS is intended to act as a supporting organization of WDH, serving in the role of the "parent company" of the Hospital and the affiliates. WDHS is the sole member of WDPC. Form 990, Part VI, Section A, line 7a WDHS will appoint the Board members for WDPC. Form 990, Part VI, Section A, line 7b WDHS has the power to appoint and remove directors of WDPC, and all actions pertaining to the property, business, and affairs of WDPC, including WDPC's annual budget, are subject to the approval of WDHS. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is initially reviewed in detail by key Wentworth-Douglass Hospital (WDH) finance employees. Thereafter, the final draft is presented to the full board prior to filing with the IRS. Each member of the Board and Finance Committee is provided with a draft of the Form 990 in advance of each meeting. Form 990, Part VI, Section B, line 12c A copy of WDPC'S Conflict Of Interest Policy is distributed annually to all officers, trustees, medical staff officers and committee members, and the management team. All are required to report any conflicts and sign, date, and return the policy, whether or not a conflict exists, to confirm compliance. Conflicts are disclosed in accordance with State of New Hampshire RSA 7:19-a, in the local newspaper, and submitted to the New Hampshire Attorney General. Form 990, Part VI, Section B, line 15 CEO's Compensation: The compensation and benefits of WDH's CEO are reviewed, adjusted and voted on by all independent members of the board annually. See WDH's separate Form 990 for further details. Compensation of Key Employees: The CEO reviews the salaries of key employees annually and recommends compensation based on performance, salary ranges and market competitive data. Compensation data is provided by an independent national consulting firm every other year. The CEO presents salary range data for key employees to the board annually for approval. Using the Board approved salary range data, the CEO recommends salary increases for vice presidents to the WDH Board for approval and the vice presidents recommend salary increases for Directors and other management positions to the CEO, for approval. All compensation for vice presidents and above requires final approval by the WDH independent Board Members. Form 990, Part VI, Section C, line 19 Audited financial statements are filed annually with the New Hampshire Attorney General's Charitable Trust Unit. The Director of Charitable Trusts is also informed of any pecuniary benefit transactions that have occurred between the Foundation and a board member or officer. Notices of such transactions of $5,000 or more are also published in the local newspaper in accordance with NH RSA 7:19-a, II(d). Current copies of the Bylaws, Conflict Of Interest Policy, and Form 990 are on file with the Charitable Trust Unit. The Organization also makes these documents available upon request. Form 990, Part VII, Section A: Reportable Compensation from Related Organizations: The 2015 compensation reported for Ellen L. Caille, Dr. Paul R. Cass, Gregory J. Walker and Peter E. Walcek was paid by Wentworth-Douglass Hospital for their services as full-time executives. Gregory J. Walker and Peter E. Walcek each worked an average of 55 hours per week, as did Ellen Caille and Dr. Cass. Of the respective hours worked by Ellen Caille and Dr. Cass, an average of 5 hours per week was dedicated to Wentworth-Douglass Physician Corporation. Form 990, Part IX, line 11g Temporary Help: Program service expenses 63,618. Management and general expenses 0. Fundraising expenses 0. Total expenses 63,618. Purchased Services: Program service expenses 6,899,952. Management and general expenses 1,362,726. Fundraising expenses 0. Total expenses 8,262,678. Consulting: Program service expenses 0. Management and general expenses 94,021. Fundraising expenses 0. Total expenses 94,021. Form 990, Part XI, line 9: Equity Transfer from Wentworth-Douglass Hospital 28,062,186. Form 990, Part XII, Line 2c: Audit Review Process: WDH's Finance Committee oversees the audit process for Wentworth-Douglass Health System and all related organizations. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2014 and 2015. Wentworth-Douglass Hospital 789 Central Avenue Dover NH 03820 020260334 Health care NH 501(c)(3) Line 3 Wentworth-Douglass Health System 0 Wentworth-Douglass Hospital & Health Foundation 789 Central Avenue Dover NH 03820 510491062 Philanthropic fund raising & stewardship NH 501(c)(3) Line 11b, II Wentworth-Douglass Health System 0 Wentworth-Douglass Health System 789 Central Avenue Dover NH 03820 461635259 Support and further charitable activities of Hospital and related entities NH 501(c)(3) Line 11b, II N/A 0 Wentworth Surgery Center LLC PO Box 71 Somersworth NH 03878 900975592 Surgery Center NH N/A Wentworth-Douglass Community Health Corporation 789 Central Avenue Dover NH 03820 020399963 Health fitness center NH N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1