2016-08-15T08:57:15-05:00 2015-09-30 440160260 BKD LLP 1201 WALNUT SUITE 1700 KANSAS CITY MO 64106 990 2014-10-01 060250773 THE WILLIAM W BACKUS HOSPITAL WILL 8608898331 326 WASHINGTON STREET NORWICH CT 06360 DANIEL E LOHR SENIOR VP/CFO 8608898331 2016-08-15 1 MICHAEL J ENGLE P00482834 8162216300 2014 2016-09-27 15:27:22Z DANIEL E LOHR 326 WASHINGTON STREET NORWICH CT 06360 352632566 0 X WWW.BACKUSHOSPITAL.ORG X 1891 CT THE WILLIAM W.BACKUS HOSPITAL DELIVERS AND COORDINATES A CONTINUUM OF HIGH-QUALITY HEALTH CARE THAT IS SENSITIVE TO THE NEEDS OF INDIVIDUALS IN EASTERN CONNECTICUT. THE HOSPITAL IS COMMITTED TO BEING RESPONSIVE AND ACCOUNTABLE TO THOSE FOR WHOSE BENEFIT IT EXISTS, AND TO IMPROVING THE HEALTH OF ITS COMMUNITIES. 14 10 2059 412 2757558 525284 2374100 1626345 302711330 294807000 9511371 7159759 2179591 2525641 316776392 306118745 145509 178641 0 0 134279532 133334931 0 0 405448 124191524 124142781 258616565 257656353 58159827 48462392 513864285 533869094 158969385 166315438 354894900 367553656 X THE WILLIAM W BACKUS HOSPITAL DELIVERS AND COORDINATES A CONTINUUM OF HIGH QUALITY HEALTH CARE THAT IS SENSITIVE TO THE NEEDS OF INDIVIDUALS IN EASTERN CONNECTICUT. THE HOSPITAL IS COMMITTED TO BEING RESPONSIVE AND ACCOUNTABLE TO THOSE FOR WHOSE BENEFIT IT EXISTS, AND TO IMPROVING THE HEALTH OF ITS COMMUNITIES. 0 0 214347071 178641 293780904 IN FISCAL YEAR 2015, BACKUS HOSPITAL HAD 9,878 ADMISSIONS, 79,930 EMERGENCY DEPARTMENT VISITS, AND 500,449 OUTPATIENT VISITS. THE HOSPITAL DELIVERED 903 BABIES AND 6,427 SAME DAY SURGICAL PROCEDURES. BACKUS PERFORMED 140,645 OUTPATIENT IMAGING EXAMS, 7,127 MRI EXAMINATIONS, 7,791 PSYCHIATRIC CLINICAL VISITS AND 7,582 PSYCHIATRIC PARTIAL HOSPITAL VISITS. 214347071 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 0 0 1 0 0 1 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 192 0 1 2059 1 1 1 0 0 0 0 1 1 0 0 0 0 X 14 10 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X X DANIEL LOHR 8608898331 326 WASHINGTON STREET NORWICH CT 06360 DAVID WHITEHEAD DIRECTOR/PRESIDENT/SENIOR VP 30.00 30.00 X X 0 806006 50532 ELIZABETH CONWAY DIRECTOR/VICE CHAIR 3.00 2.00 X X 0 0 0 DEBORAH MONAHAN DIRECTOR/SECRETARY 3.00 2.00 X X 0 0 0 KARLA FOX DIRECTOR/CHAIR 3.00 3.00 X X 0 0 0 ANTHONY JOYCE DIRECTOR/VICE CHAIRMAN 3.00 3.00 X X 0 0 0 JOHN BILDATERM 615 DIRECTOR 2.00 2.00 X 0 0 0 STEPHEN BRIGGSTERM 615 DIRECTOR 2.00 2.00 X 0 0 0 JAMES CARDON MDTERM 615 DIRECTOR 2.00 40.00 X 0 593699 111496 NANCY GENTESTERM 615 DIRECTOR 2.00 2.00 X 0 0 0 PETER MANERITERM 615 DIRECTOR 2.00 2.00 X 0 0 0 PAUL MAXFIELDTERM 615 DIRECTOR 2.00 2.00 X 0 0 0 LYNNE QUINTAL-HILL DIRECTOR 2.00 2.00 X 0 0 0 DONNA ROMITOTERM 615 DIRECTOR 2.00 2.00 X 0 0 0 DENNIS SLATERTERM 615 DIRECTOR 2.00 2.00 X 0 0 0 MARK TRAMONTOZZI DIRECTOR 2.00 2.00 X 0 0 0 ELLIOT JOSEPHTERM 615 DIRECTOR 2.00 60.00 X 0 1895364 299299 JAMES WATSON MD DIRECTOR 2.00 2.00 X 0 0 0 CAROLYN DRESCHER DIRECTOR 2.00 2.00 X 0 0 0 MARY BARRY MD DIRECTOR 2.00 2.00 X 0 25545 1954 CATINA CABAN-OWEN DIRECTOR 2.00 2.00 X 0 0 0 DIANE WISHNAFSKI DIRECTOR 2.00 2.00 X 0 0 0 CARMEN CID DIRECTOR 2.00 2.00 X 0 0 0 MARGARET MARCHAK DIRECTOR/SECRETARY 3.00 60.00 X X 0 541910 108761 DANIEL LOHR SENIOR VP/CFO 30.00 30.00 X 0 593901 44016 CAROLYN TRANTALIS VP OPERATIONS EAST REGION 30.00 30.00 X 0 267884 39198 MARY BYLONE VP PATIENT CARE EAST REGIO 40.00 X 0 279774 32407 ROBERT SIDMAN MD PHYSICIAN 40.00 X 529422 0 34490 SERGIO CASILLA MD PHYSICIAN 40.00 X 512758 0 34032 ZHENXIANG LIU MD PHYSICIAN 40.00 X 487488 0 32900 MARIANO LIBRIJO MD PHYSICIAN 40.00 X 400217 0 18618 NATHAN SIEGEL MD PHYSICIAN 40.00 X 375699 0 28333 PETER SHEA FORMER MEDICAL DIRECTOR 40.00 X 0 508802 30598 2305584 5512885 866634 206 1 1 0 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 MEDICAL SERVICES 3289768 YALE NEW HAVEN HOSPITAL 20 YORK STREET NEW HAVEN CT 06504 MEDICAL SERVICES 1185182 NUANCE COMMUNICATIONS PO BOX 7247-6924 PHILADELPHIA PA 19170 TRANSCRIPTION 1071503 BARTON & ASSOCIATES PO BOX 417844 BOSTON MA 02241 MEDICAL SERVICES 887981 NORTH AMERICAN PARTNERS IN ANESTHESIA 68 SOUTH SERVICE RD MELVILLE NY 11747 MEDICAL SERVICES 862008 35 80749 505 523817 1021274 542 1626345 OUTPATIENT 900099 119454979 119454979 INPATIENT 900099 115111919 115111919 EMERGENCY DEPT 900099 56739762 56739762 LAB COURIER SERVICE 621500 2707915 2707915 EHR REVENUE 900099 792425 792425 294807000 1345377 1345377 1827156 2372818 -545662 -545662 -545662 49206334 344000 43448307 287645 5758027 56355 5814382 5814382 24320 80749 56715 -32395 -32395 464268 348336 115932 115932 CAFETERIA 722320 1256304 1256304 PURCHASE DISCOUNTS 900099 349861 349861 CONTRACT SERVICES 621400 270932 270932 1110669 1061026 49643 2987766 306118745 293780904 2757558 7953938 168591 168591 10050 10050 109726012 102968974 6620106 136932 1827651 1715102 110268 2281 13957345 13097838 842089 17418 7823923 7342118 472041 9764 763020 763020 342992 342992 46273 46273 374896 374896 18804512 11266674 7537838 32857 7198 25659 4270300 3208473 1059664 2163 3529736 394737 3134999 5789715 486037 5303678 271664 156498 115166 2933 2933 3140928 3140928 8889011 7013515 1875496 14309494 6088464 8221030 3767856 3154911 612945 MEDICAL EXPENSES 37711790 37711790 BAD DEBT 8486887 8486887 MAINT/SERVICE CONTRACTS 5262533 3918238 1344295 LAB EXPENSES 4153352 4153352 4192032 2997624 983177 211231 257656353 214347071 42903834 405448 2710787 3266435 184674883 189891820 460 142 36980052 36077266 11760 8773 3836103 3679710 2589705 3850954 308065176 188485953 127834702 119579223 145614943 69130964 12632 92436024 9598258 15947783 513864285 533869094 22981573 18341304 1463627 1395217 134524185 146578917 158969385 166315438 X 343007454 355541298 3534497 3907265 8352949 8105093 354894900 367553656 513864285 533869094 X 48462392 -7578595 -340854 -27884187 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 46273 0 0 0 46273 0 PART II-B, LINE 1: LOBBYING ACTIVITIES ARE PRIMARILY COMPRISED OF THE PORTION OF DUES PAID TO THE CONNECTICUT HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION THAT THOSE INSTITUTIONS DEEM LOBBYING BASED ON THE MEDICARE DEFINITION. 5719446 5719446 5551985 169678 2217 5719446 5396859 159637 4511 5551985 5396859 5226 5226 5396859 5320786 5000 76505 5432 5396859 1.00000 0 1 1 5011878 5011878 10381267 119487496 41411817 88456946 64841123 62663413 2177710 107097123 84410723 22686400 1246289 1246289 119579223 CT HOSP LAB 12632 C ENDOWMENT LLC 92423392 F 92436024 DUE TO 3RD PARTIES 9211505 EMPLOYEE RELATED OBLIGATIONS 54080931 SELF-INSURED PROF LIABILITY 9768153 CAPITAL LEASE OBLIGATIONS 7265536 OTHER LIABILITIES 4464677 DUE FROM AFFILIATES 1676365 TAX EXEMPT SERIES E BOND PREMIUM 1411682 LT INTERCOMPANY DEBT SERIES E 58700068 146578917 300138954 0 300138954 340854 5638937 5979791 306118745 259641280 2429533 2429533 257211747 368646 75960 444606 257656353 PART V, LINE 4: THE PERMANENTLY RESTRICTED ENDOWMENT FUNDS ARE MEANT TO PROVIDE LONG TERM SUPPORT FOR CAPITAL AND OPERATING PROGRAMS FOR THE HOSPITAL IN ACCORDANCE WITH THE DONOR'S WISHES. PART XI, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY INCOME-121,229 UNREALIZED LOSS ON INVESTMENTS-7,947,241 RENTAL EXPENSES-(2,372,818) GOLF TOURNAMENT EXPENSES-(56,715) PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES-2,372,818 GOLF TOURNAMENT EXPENSES-56,715 PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES-75,866 K-1 PASSTHRU LOSS-94 SCHEDULE D PART X LINE 2 ASC 740-10, UNCERTAIN TAX POSITIONS, PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THIS INTERPRETATION ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, AND DISCLOSURE REQUIREMENTS FOR UNCERTAIN TAX POSITIONS. MANAGEMENT HAD EVALUATED THE IMPLICATIONS OF ASC 740-10 AND DETERMINED THAT ITS IMPACT ON THE FINANCIAL STATEMENTS IS NOT SIGNIFICANT. CENTRAL AMERICA/CARIBBEAN 0 0 PROGRAM SERVICES INSURANCE PERMIUMS 6796267 0 0 0 0 0 0 6796267 0 6796267 1 0 0 0 0 0 GOLF TOURNAMENT 60640 43640 17000 9018 10820 11513 2360 SEDER GOLF TOURNAMENT 44429 37109 7320 2891 7520 7775 4818 105069 80749 24320 11909 18340 19288 7178 56715 -32395 1 1 1 X 250.000000000000 1 X 1 1 0 1 1 1391546 1391546 0.00560 58395538 35173932 23221606 0.09320 59787084 35173932 24613152 0.09880 594342 350 593992 0.00240 249266 3025 246241 0.00100 2002630 2002630 0.00800 75245 75245 0.00030 2921483 3375 2918108 0.01170 62708567 35177307 27531260 0.11050 67130 67130 0.00030 3168 3168 0.00000 946 946 0.00000 71244 71244 0.00030 0 8486887 2274706 75109601 81393471 -6283870 X 1 1 1 1 THE WILLIAM W BACKUS HOSPITAL 326 WASHINGTON STREET NORWICH CT 06360 X X X THE WILLIAM W BACKUS HOSPITAL 1 0 0 1 X X X X X X X X X X 14 1 0 0 1 X WWW.BACKUSHOSPITAL.ORG X X 1 14 0 1 0 1 X 250.000000000000 400.000000000000 X X X X X 1 1 X X X X X 1 X WWW.BACKUSHOSPITAL.ORG X WWW.BACKUSHOSPITAL.ORG X WWW.BACKUSHOSPITAL.ORG X X X X X 1 X 0 X X X X 1 X 0 0 THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 3J: THIS ASSESSMENT INCORPORATED DATA FROM BOTH QUANTITATIVE AND QUALITATIVE SOURCES. QUANTITATIVE DATA INPUT INCLUDE PRIMARY RESEARCH AND SECONDARY RESEARCH. THE SURVEY INSTRUMENT USED FOR THIS STUDY WAS BASED LARGELY ON THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS), AS WELL AS VARIOUS OTHER PUBLIC HEALTH SURVEYS AND CUSTOMIZED QUESTIONS ADDRESSING GAPS IN INDICATOR DATA RELATIVE TO HEALTH PROMOTION AND DISEASE PREVENTION OBJECTIVES AND OTHER RECOGNIZED HEALTH ISSUES.TO ENSURE THE BEST REPRESENTATION OF THE POPULATION SURVEYED, A TELEPHONE INTERVIEW METHODOLOGY - ONE THAT INCORPORATES BOTH LANDLINE AND CELL PHONE INTERVIEWS - WAS EMPLOYED. THE SAMPLE DESIGN USED FOR THIS EFFORT CONSISTED OF A RANDOM SAMPLE OF 614 INDIVIDUALS AGE 18 AND OLDER IN THE BACKUS HOSPITAL SERVICE AREA. BECAUSE THE STUDY WAS PART OF A LARGER EFFORT INVOLVING MULTIPLE REGIONS AND HOSPITAL SERVICE AREAS, THE SURVEYS WERE DISTRIBUTED AMONG VARIOUS STRATA. ONCE THE INTERVIEWS WERE COMPLETED, THESE WERE WEIGHTED IN PROPORTION TO THE ACTUAL POPULATION DISTRIBUTION SO AS TO APPROPRIATELY REPRESENT THE HARTFORD REGION AS A WHOLE.A VARIETY OF EXISTING (SECONDARY) DATA SOURCES WAS CONSULTED TO COMPLEMENT THE RESEARCH QUALITY OF THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 5: TO SOLICIT INPUT FROM KEY INFORMANTS, INDIVIDUALS WHO HAVE A BROAD INTEREST IN THE HEALTH OF THE COMMUNITY, AN ONLINE KEY INFORMANT SURVEY WAS ALSO IMPLEMENTED AS PART OF THIS PROCESS. THESE INDIVIDUALS INCLUDED PHYSICIANS, PUBLIC HEALTH REPRESENTATIVES, HEALTH PROFESSIONALS, SOCIAL SERVICE PROVIDERS AND A VARIETY OF OTHER COMMUNITY LEADERS. AMERICAN AMBULANCE SERVICE, INC. AMERICAN RED CROSS BLOOD SERVICES BACKUS HOSPITAL CATHOLIC CHARITIES GENERATIONS FAMILY HEALTH CENTER, INC. MOHEGAN TRIBE NORWICH ADULT EDUCATION / RELIANCE HOUSE, INC. ROSE CITY SENIOR CENTER SOUTHEASTERN REGIONAL ACTION COUNCIL ST. VINCENT DE PAUL PLACE NORWICH THREE RIVERS COMMUNITY COLLEGE NURSING PROGRAM TOWN OF WINDHAM TVCCA UNCAS HEALTH DISTRICT UNITED COMMUNITY AND FAMILY SERVICES WINDHAM HOSPITAL WINDHAM REGION NO FREEZE PROJECTPARTICIPANTS WERE CHOSEN BECAUSE OF THEIR ABILITY TO IDENTIFY PRIMARY CONCERNS OF THE POPULATIONS WITH WHOM THEY WORK, AS WELL AS OF THE COMMUNITY OVERALL. KEY INFORMANTS WERE CONTACTED BY EMAIL, INTRODUCING THE PURPOSE OF THE SURVEY AND PROVIDING A LINK TO TAKE A SURVEY ONLINE. KEY INFORMANTS WERE ASKED TO RATE THE DEGREES TO WHICH VARIOUS HEALTH ISSUES WERE A PROBLEM IN THE HARTFORD REGION. FOLLOW-UP QUESTIONS ASKED THEM TO DESCRIBE WHY THEY IDENTIFIED AREAS AS SUCH, AND HOW THESE MIGHT BE BETTER ADDRESSED. BACKUS HOSPITAL RECOGNIZES THAT IT CANNOT MEASURE ALL POSSIBLE ASPECTS OF HEALTH IN THE COMMUNITY, NOR CAN IT ADEQUATELY REPRESENT ALL POSSIBLE POPULATIONS OF INTEREST. IN TERMS OF CONTENT, THE ASSESSMENT WAS DESIGNED TO PROVIDE A COMPREHENSIVE AND BROAD PICTURE OF THE HEALTH OF THE OVERALL COMMUNITY. THE CHNA ANALYSIS AND REPORT YIELDED A WEALTH OF INFORMATION ABOUT THE HEALTH STATUS, BEHAVIORS AND NEEDS FOR OUR POPULATION. A DISTINCT ADVANTAGE OF THE PRIMARY QUANTITATIVE (SURVEY) RESEARCH IS THE ABILITY TO SEGMENT FINDINGS BY GEOGRAPHIC, DEMOGRAPHIC AND HEALTH CHARACTERISTICS TO IDENTIFY THE PRIMARY AND CHRONIC DISEASE NEEDS AND OTHER HEALTH ISSUES OF VULNERABLE POPULATIONS, SUCH AS UNINSURED PERSONS, LOW-INCOME PERSONS, AND RACIAL/ETHNIC MINORITY GROUPS. FOR ADDITIONAL STATISTICS ABOUT UNINSURED, LOW-INCOME, AND MINORITY HEALTH NEEDS PLEASE REFER TO THE COMPLETE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT, WHICH CAN BE VIEWED ONLINE AT: HTTPS://BACKUSHOSPITAL.ORG/ABOUT-US/COMMUNITY-OUTREACH/HEALTH-NEEDS-ASSESSMENTAFTER REVIEWING THE COMMUNITY HEALTH NEEDS ASSESSMENT FINDINGS, THE COMMUNITY REPRESENTATIVES MET ON JUNE 11, 2015 TO DETERMINE THE HEALTH NEEDS TO BE PRIORITIZED FOR ACTION. DURING A DETAILED PRESENTATION OF THE CHNA FINDINGS, WE USED AUDIENCE RESPONSE SYSTEM (ARS) TECHNOLOGIES TO LEAD STEERING COMMITTEE MEMBERS THROUGH A PROCESS OF UNDERSTANDING KEY LOCAL DATA FINDINGS (AREAS OF OPPORTUNITY) AND RANKING IDENTIFIED HEALTH ISSUES AGAINST THE FOLLOWING ESTABLISHED, UNIFORM CRITERIA: MAGNITUDE, IMPACT/SERIOUSNESS/FEASIBILITY, CONSEQUENCES OF INACTION. FROM THIS EXERCISE, THE AREAS OF OPPORTUNITY WERE PRIORITIZED AS FOLLOWS BY THE COMMITTEE: MENTAL HEALTH, NUTRITION, PHYSICAL ACTIVITY & WEIGHT STATUS, DIABETES, SUBSTANCE ABUSE, CANCER, HEART DISEASE AND STROKE. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 7D: THE NEEDS ASSESSMENT WAS PUBLISHED IN MARCH 2015 AND IS AVAILABLE ON THE HOSPITAL'S WEBSITE. IN ADDITION, COPIES WERE MADE AVAILABLE TO OUR COMMUNITY PARTNERS.PART V,SECTION B, LINE 9:ALTHOUGH THE APPROVED IMPLEMENATION STRATEGY DATE REFLECTS 2014 YEAR, THE IMPLEMENTATION STRATEGY WAS APPROVED IN DECEMBER 2015. THE ORGANIZATION REPORTS ITS DATE ON A FISCAL YEAR BASIS. AS A RESULT, THE CURRENT SOFTWARE PREVENTS THE DISCLOSURE OF THE 2015 DATE ON THE CURRENT FORM. THE CORRECT DATE (2015) WILL BE REFLECTED ON THE FY16 FORM. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 11: AS INDIVIDUAL ORGANIZATIONS BEGIN TO PARSE OUT THE INFORMATION FROM THE 2015 COMMUNITY HEALTH NEEDS ASSESSMENT, IT IS BACKUS HOSPITAL'S GOAL THAT THIS WILL FOSTER GREATER DESIRE TO EMBARK ON A COMMUNITY-WIDE COMMUNITY HEALTH IMPROVEMENT PLANNING PROCESS. BACKUS HOSPITAL HAS EXPRESSED THIS INTENTION TO PARTNERING ORGANIZATIONS AND IS COMMITTED TO BEING A PRODUCTIVE MEMBER IN THIS PROCESS AS IT EVOLVES. SINCE THE CHIP IS STILL BEING DEVELOPED AND NOT REQUIRED TO BE DONE UNTIL FEBRUARY OF 2016 THE ACTIONS THAT WILL BE TAKEN TO ADDRESS IDENTIFIED NEEDS HAVE NOT BEEN FINALIZED. IN ADDITION, FORMAL COLLABORATIVES HAVE BEEN FORMED, AND SYSTEM-WIDE INITIATIVES HAVE BEEN LAUNCHED THAT ADDRESS NUTRITION EDUCATION SUCH AS OUR PARTNERSHIP WITH A STATEWIDE SUPER MARKET RETAILER. IN ACKNOWLEDGING THE WIDE RANGE OF PRIORITY HEALTH ISSUES THAT EMERGED FROM THE CHNA PROCESS, BACKUS HOSPITAL DETERMINED THAT IT COULD ONLY EFFECTIVELY FOCUS ON THOSE WHICH IT DEEMED MOST PRESSING, MOST UNDER-ADDRESSED, AND MOST WITHIN ITS ABILITY TO INFLUENCE: - NUTRITION, PHYSICAL ACTIVITY & WEIGHT (OBESITY), CANCER, DIABETES, HEART DISEASE & STROKE, AND RESPIRATORY DISEASES- ACCESS TO CARE, INCLUDING ORAL HEALTH, DEMENTIAS, AND ALZHEIMER'S DISEASE- MENTAL HEALTH & SUBSTANCE USE, INCLUDING TOBACCO USE OTHER IDENTIFIED NEEDS WERE:- RESPIRATORY DISEASES - INJURY & VIOLENCE - INFANT HEALTH & FAMILY PLANNING - POTENTIALLY DISABLING CONDITIONS IN ACKNOWLEDGING THE WIDE RANGE OF PRIORITY HEALTH ISSUES THAT EMERGED FROM THE CHNA PROCESS, BACKUS HOSPITAL DETERMINED THAT IT COULD ONLY EFFECTIVELY FOCUS ON THOSE WHICH IT DEEMED MOST PRESSING, MOST UNDER-ADDRESSED, AND MOST WITHIN ITS ABILITY TO INFLUENCE. HEALTH PRIORITIES NOT CHOSEN FOR ACTION:INFANT HEALTH AND FAMILY PLANNING-BACKUS HOSPITAL HAS LIMITED RESOURCES, SERVICES AND EXPERTISE AVAILABLE TO ADDRESS FAMILY PLANNING AND INFANT HEALTH. OTHER COMMUNITY PARTNERS SUCH AS UCFS AND MADONNA PLACE HAVE INFRASTUCTURE AND PROGRAMS IN PLACE TO BETTER MEET THIS NEED.VIOLENCE-BACKUS HOSPITAL BELIEVES THAT THIS PRIORITY AREA FALLS MORE WITHIN THE PURVIEW OF SAFE FUTURES, THE FORMER WOMEN'S SHELTER. BACKUS IS A COMMUNITY PARTNER AND HAS ARRANGED FOR SAFE FUTURES TO OPEN AN OFFICE IN THE MEDICAL OFFICE BUILDING, ADJOINING THE HOSPITAL.INJURY-BACKUS HOSPITAL HAS LIMITED RESOURCES, SERVICES AND EXPERTISE AVAILABLE TO ADDRESS INJURY PREVENTION.POTENTIALLY DISABLING CONDITIONS-BACKUS HOSPITAL HAS LIMITED RESOURCES, SERVICES AND EXPERTISE AVAILABLE TO ADDRESS POTENTIALLY DISABLING CONDITIONS. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 13H: FAMILY ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE ALSO INCLUDE FAMILY SIZE, EMPLOYMENT STATUS AND AMOUNT. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 15E: IN ADDITION, PATIENT MAY ASK NURSE, PHYSICIAN, CHAPLAIN, OR STAFF MEMBER FROM PATIENT REGISTRATION, PATIENT FINANCIAL SERVICES, OFFICE OF PROFESSIONAL SERVICES, CASE COORDINATION, OR SOCIAL SERVICES ABOUT INITIATING THE FINANCIAL ASSISTANCE APPLICATION PROCESS. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 16I: PATIENTS ARE INFORMED DIRECTLY BY STAFF OF THE AVAILABILITY OF THE FINANCIAL ASSISTANCE POLICY. THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 22D: FOR FY 15, THE HOSPITAL DID A COMPUTATION TO DETERMINE ON AVERAGE INSURANCE COMPANIES REIMBURSEMENT FOR TYPES OF SERVICES RENDERED. THE AVERAGE (DISCOUNT) WAS OFFERED TO ALL SELF-PAY PATIENTS WITHOUT REGARDS TO FINANCIAL ABILITY. PATIENTS WHO WERE UNABLE TO PAY THEIR BILLS WERE ABLE TO APPLY FOR FINANCIAL ASSISTANCE. BASED UPON FACTORS INCLUDING FAMILY SIZE & INCOME, PATIENTS WERE ELIGIBLE TO RECEIVE WRITE-OFFS RANGING 25-100%.THE HOSPITAL FINANCIAL ASSISTANCE POLICY (EFFECTIVE JANUARY 1, 2016) IN COMPLIANCE WITH IRS CODE SEC 501R. PER THE HOSPITAL'S POLICY, NO INDIVIDUAL WHO IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE WILL BE CHARGED MORE FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE THAN THE AMOUNT GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE COVERING SUCH CARE. THE BASIS TO WHICH ANY DISCOUNT IS APPLIED IS EQUIVALENT TO THE BILLED CHARGES POSTED TO A PATIENT ACCOUNT MINUS ANY PRIOR INSURANCE PAYMENTS AND ADJUSTMENTS FROM THE PATIENTS INSURANCE (IF APPLICABLE). STARTING JANUARY 1, 2016, THE HOSPITAL USED THE IRS 501R PRESCRIBED METHODOLOGY TO COMPUTE SELF-PAY DISCOUNT (AGB DISCOUNT). PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: WWW.BACKUSHOSPITAL.ORG THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: WWW.BACKUSHOSPITAL.ORG THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: WWW.BACKUSHOSPITAL.ORG 11 BACKUS OUTPATIENT CARE CENTER 111 SALEM TURNPIKE NORWICH CT 06360 OUTPATIENT SERVICES MEDICAL OFFICE BUILDING 330 WASHINGTON STREET NORWICH CT 06360 RADIATION THERAPY/LAB COLCHESTER BACKUS HEALTH CENTER 163 BROADWAY COLCHESTER CT 06415 RADIOLOGY/LAB/PRIMARY CARE MONTVILLE BACKUS HEALTH CARE 80 NORWICH/NEW LONDON TURNPIKE UNCASVILLE CT 06382 RADIOLOGY/LAB/PRIMARY CARE LEDYARD BACKUS HEALTH CENTER 2 LORENZ PARKWAY LEDYARD CT 06339 LAB/PRIMARY CARE FAMILY HEALTH CENTER AT CROSSROADS 196 PARKWAY SOUTH WATERFORD CT 06385 PRIMARY CARE/REHAB/ORTHOPEDICS INFECTIOUS DISEASE CLINIC 107 LAFAYETTE STREET NORWICH CT 06360 CLINIC NORTH STONINGTON BACKUS HEALTH CENTER 82 NORWICH-WESTERLY ROAD NORTH STONINGTON CT 06359 PRIMARY CARE NORWICHTOWN BACKUS PATIENT SERVICE CTR 55 TOWN STREET NORWICH CT 06360 LAB PLAINFIELD EMERGENCY CENTER 582 NORWICH ROAD PLAINFIELD CT 06374 LAB/RADIOLOGY/EMERGENCY SERVICES JEWETT CITY PATIENT SERVICE CENTER 70 MAIN STREET JEWETT CITY CT 06351 LAB PART I, LINE 7: THE ORGANIZATION UTILIZED THE RATIO OF COST TO CHARGE (RCC), DERIVED FROM THE FY2015 MEDICARE COST REPORT WHICH ALREADY INCORPORATES OR IS NET OF NON-PATIENT CARE COSTS (I.E. BAD DEBT, NON-PATIENT CARE, ETC). THE RATIO WAS FURTHER REDUCED TO INCORPORATE THE DIRECTLY INDENTIFIED COMMUNTIY EXPENSES. THIS COST TO CHARGE RATIO WAS USED TO CALCULATE COSTS FOR PART I LINES 7A & B. THE COSTS ASSOCIATED WITH THE ACTIVITIES REPORTED ON PART I, LINE 7E WERE CAPTURED USING ACTUAL TIME MULTIPLIED BY AN AVERAGE SALARY RATE. COSTS REPORTED IN PART III, SECTION B 6, WERE CALCULATED FROM THE MEDICARE COST REPORT AND REDUCED FOR MEDICARE COSTS PREVIOUSLY REPORTED ON PART I, LINES 7 F & G. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 8,486,887. PART III, LINE 4: PLEASE SEE THE TEXT OF THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE ON PAGES 16-19 OF THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: PROVIDING FOR THOSE IN NEED, INCLUDING MEDICARE PATIENTS AND SERVING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY IS AN ESSENTIAL PART OF THE ORGANIZATION'S MISSION. THE HOSPITAL SERVES ALL PATIENTS WITHOUT REGARD TO ANY PAYMENT SHORTFALL. THEREFORE THE MEDICARE SHORTFALL SHOULD BE CONSIDERED TO BE A COMMUNITY BENEFIT. THE ORGANIZATION MEDICARE COST REPORT WAS USED TO ACCUMULATE ACTUAL COSTS RELATED TO PART III, SECTION B, LINE 6. PART III, LINE 9B: IN THE SELF-PAY POLICY, SECTION IIB, STATES THAT THE MEDICAL BUREAU OF ECONOMICS (MBE) RECEIVES A WEEKLY LIST OF PATIENTS WHO WERE SENT FINANCIAL ASSISTANCE APPLICATIONS FROM BACKUS STAFF. THIS INFORMATION IS FROM THE PATIENT ACCOUNTS OR FINANCIAL COUNSELING DEPARTMENTS. MBE'S COLLECTION ACTIVITY ON THESE PATIENTS IS HAULTED UNTIL IT HAS BEEN DETERMINED IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S POLICY,BY THE HOSPITAL FINANCIAL COUNCELING UNIT. COLLECTION ACTION IS ONLY RESUMED ONCE IT IS DETERMINED THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: IN 2015, THE WILLIAM W. BACKUS HOSPITAL COMMISSIONED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED BY PROFESSIONAL RESEARCH CONSULTANTS, INC, A PROFESSIONAL RESEARCH FIRM. THE ASSESSMENT CONSISTED OF 614 TELEPHONE INTERVIEWS WHICH WERE CONDUCTED THROUGHOUT THE HOSPITAL'S SERVICE REGION (BOTH NEW LONDON AND WINDHAM COUNTIES). THE ASSESSMENT ALSO INCLUDED A DETAILED ANALYSIS OF SECONDARY DATA SOURCES, AS WELL AS KEY INFORMANT INTERVIEWS AND THREE FOCUS GROUPS. PART VI, LINE 3: NOTIFICATION ABOUT CHARITABLE CARE AND ASSISTANCE PROGRAMS IS AVAILABLE AT ALL REGISTRATION AREAS, ON AND OFF THE MAIN HOSPITAL CAMPUS, IN WAITING AREAS, IN THE PATIENT HANDBOOK, ON OUR WEBSITE, AND ON PROMINENTLY PLACED SIGNS (IN ENGLISH AND IN SPANISH). ADDITIONALLY, CARE MANAGEMENT STAFF MEET WITH PARENTS, FAMILY, CLERGY, AND OTHERS AS APPROPRIATE TO DISCUSS ASSISTANCE PROGRAMS AND SERVICES THAT MAY BE AVAILABLE. IN ADDITION TO THE COMPLETE FINANCIAL ASSISTANCE POLICY AND APPLICATION FOR FINANCIAL ASSISTANCE, HERE IS THE INFORMATION INCLUDED ON THE HOSPITAL WEBSITE:FINANCIAL ASSISTANCEBACKUS HOSPITAL PROVIDES FINANCIAL ASSISTANCE PROGRAMS FOR CERTAIN QUALIFIED PATIENTS WHO ARE UNABLE TO PAY ALL OR PART OF THEIR BILL FOR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES RENDERED AT THE HOSPITAL.IF YOU ARE COPING WITH A FINANCIAL HARDSHIP, AND ARE FACING DEBTS OWED TO BACKUS HOSPITAL, FINANCIAL ASSISTANCE MAY BE AVAILABLE TO YOU.INCOME VERIFICATIONBACKUS REQUESTS INCOME INFORMATION FROM THE APPLICANT. VERIFICATION OF REPORTED INCOME SHOULD BE INCLUDED WITHIN THE APPLICATION PACKAGE.APPROPRIATE VERIFICATION SOURCES INCLUDE:- MOST RECENT FEDERAL TAX RETURN AND W-2- MOST RECENT 3 PAYROLL CHECKS- COPIES OF UNEMPLOYMENT CHECKS- COPIES OF ANY PENSION, ALIMONY, CHILD SUPPORT OR OTHER SOURCES OF INCOME- COPIES OF SOCIAL SECURITY EARNINGS, IF ANY- ANY OTHER PERTINENT INFORMATIONIF THE APPLICANT HAS NO INCOME A STATEMENT DETAILING THE CURRENT METHOD OF SUPPORT WILL BE ACCEPTED. PROOF OF INCOME OR EARNINGS IS REQUIRED WITH APPLICATION OR THE APPLICATION WILL NOT BE CONSIDERED.FINANCIAL ASSISTANCE OPTIONSTHE LEVEL OF FINANCIAL ASSISTANCE THAT YOU MAY BE ELIGIBLE TO RECEIVE WILL BE BASED UPON THE CRITERIA DEFINED IN THE FINANCIAL ASSISTANCE POLICY.THE WILLIAM W. BACKUS HOSPITAL CONSIDERS FINANCIAL ASSISTANCE AWARDS ON A CASE-BY-CASE BASIS. PLEASE CONTACT US IF YOU HAVE QUESTIONS REGARDING ELIGIBILITY.FINANCIALLY INDIGENTFINANCIALLY INDIGENT IS DEFINED AS AN INDIVIDUAL WHOSE TOTAL GROSS ANNUAL INCOME IS LESS THAN OR EQUAL TO 250% OF THE FEDERAL POVERTY GUIDELINES (FPG).PATIENTS AT OR BELOW 250% FPG ARE ELIGIBLE FOR A 100% DISCOUNT OFF OF THEIR OUTSTANDING BALANCES. INDIVIDUALS ABOVE 250% UP TO 400% FPG ARE ELIGIBLE FOR A DISCOUNT BASED ON THEIR TOTAL GROSS ANNUAL INCOME.MEDICALLY INDIGENTBACKUS HOSPITAL CONSIDERS AN INDIVIDUAL TO BE MEDICALLY INDIGENT IF THEIR TOTAL ANNUAL GROSS INCOME IS ABOVE 400% FPG AND THEIR OUTSTANDING MEDICAL OBLIGATIONS ARE GREATER THAN 50% OF THEIR TOTAL ANNUAL GROSS INCOME.THESE INDIVIDUALS MAY BE ELIGIBLE FOR A DISCOUNT SEPARATE FROM TRADITIONAL FINANCIAL ASSISTANCE. PLEASE REFER TO THE FINANCIAL ASSISTANCE POLICY FOR DETAILS REGARDING ELIGIBILITY AND THE DISCOUNT SCHEDULE.MEDICALLY INDIGENT IS DEFINED BY THE IRS AS: "PERSONS WHOM THE ORGANIZATION HAS DETERMINED ARE UNABLE TO PAY SOME OR ALL OF THEIR MEDICAL BILLS BECAUSE THEIR MEDICAL BILLS EXCEED A CERTAIN PERCENTAGE OF THEIR FAMILY OR HOUSEHOLD INCOME OR ASSETS (FOR EXAMPLE, DUE TO CATASTROPHIC COSTS OR CONDITIONS), EVEN THOUGH THEY HAVE INCOME OR ASSETS THAT OTHERWISE EXCEED THE GENERALLY APPLICABLE ELIGIBILITY REQUIREMENTS FOR FREE OR DISCOUNTED CARE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY."BACKUS HOSPITAL TREATS EACH APPLICATION INDIVIDUALLY. IF YOU HAVE ANY QUESTIONS ABOUT YOUR SPECIFIC SITUATION, PLEASE CONTACT OUR CUSTOMER SERVICE REPRESENTATIVES AT 860-889-8331, EXT. 2917, MONDAY THROUGH FRIDAY FROM 7:30 AM TO 4 PM.FINANCIAL ASSISTANCE LETTERTHE WILLIAM W. BACKUS HOSPITAL PROVIDES FINANCIAL ASSISTANCE FOR CERTAIN QUALIFIED PATIENTS WHO ARE UNABLE TO PAY ALL OR PART OF THEIR BILL FOR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES RENDERED AT THE HOSPITAL.IF YOU ARE COPING WITH A FINANCIAL HARDSHIP AND ARE FACING DEBTS OWED TO THE WILLIAM W. BACKUS HOSPITAL, FINANCIAL ASSISTANCE SUCH AS FREE CARE OR A SLIDING SCALE DISCOUNT MAY BE AVAILABLE TO YOU. THE FINANCIAL COUNSELING PROCESS WILL INDICATE WHAT OPTIONS EXIST TO ASSIST YOU WITH YOUR OUTSTANDING BALANCE.FINANCIAL ASSISTANCE APPLIES TO BACKUS HOSPITAL BILLS ONLY. IT DOES NOT APPLY TO RADIOLOGISTS, PATHOLOGISTS, ANESTHESIOLOGISTS OR OTHER PROFESSIONAL SERVICES INVOLVED IN YOUR CARE THAT ARE BILLED SEPARATELY.FREQUENTLY ASKED QUESTIONS 1. DOES THE HOSPITAL HAVE A FINANCIAL ASSISTANCE POLICY?THE WILLIAM W. BACKUS HOSPITAL DOES HAVE A WRITTEN FINANCIAL ASSISTANCE POLICY THAT DEFINES THE DISCOUNT STRUCTURE AND PROGRAMS AVAILABLE TO QUALIFYING PATIENTS.THE WILLIAM W. BACKUS HOSPITAL BASES ALL FINANCIAL ASSISTANCE ON THE MOST CURRENT FEDERAL POVERTY GUIDELINES (FPG), WHICH ARE BASED ON THE GROSS INCOME AND HOUSEHOLD SIZE.BACKUS GRANTS 100% CHARITY CARE TO THOSE APPLICANTS WHOSE GROSS HOUSEHOLD INCOME IS AT OR BELOW 250% FPG. A SLIDING DISCOUNT IS AVAILABLE TO THOSE PATIENTS WHO HAVE GROSS INCOME UP TO 400% FPG.CURRENTLY, THE FEDERAL GOVERNMENT DEFINES 100% OF POVERTY AS AN INDIVIDUAL EARNING A GROSS INCOME OF $11,770 PER YEAR. THE WILLIAM W. BACKUS HOSPITAL FINANCIAL ASSISTANCE POLICY GRANTS 100% CHARITY CARE TO A FAMILY OF ONE EARNING UP TO $29,425 PER YEAR, OR 250% FPG. INCOME THRESHOLDS INCREASE RELATIVE TO HOUSEHOLD SIZE. A DISCOUNT IS AVAILABLE FOR APPLICANTS EARNING UP TO 400% FPG.2. WHAT SERVICES DOES THE FINANCIAL ASSISTANCE POLICY COVER?THE WILLIAM W. BACKUS HOSPITAL'S FINANCIAL ASSISTANCE POLICY COVERS SERVICES RENDERED AT THE WILLIAM W. BACKUS HOSPITAL, INCLUDING INPATIENT, EMERGENCY, AND OUTPATIENT PROCEDURES.FINANCIAL ASSISTANCE MAY NOT BE GRANTED FOR SOME PROCEDURES, SUCH AS ELECTIVE PROCEDURES OR SOME SPECIAL SITUATIONS, SUCH AS THAT OF AN INDIVIDUAL WHO IS ELIGIBLE FOR INSURANCE BUT HAS REFUSED TO APPLY OR FUNDS ARE AVAILABLE THROUGH ANOTHER SOURCE FOR PAYMENT (I.E. SETTLEMENTS, STATE FUNDED PROGRAMS).FINANCIAL ASSISTANCE APPLIES TO BACKUS HOSPITAL BILLS ONLY. IT DOES NOT APPLY TO RADIOLOGISTS, PATHOLOGISTS, ANESTHESIOLOGISTS OR OTHER PROFESSIONAL SERVICES INVOLVED IN YOUR CARE THAT ARE BILLED SEPARATELY.3. DOES THE HOSPITAL PROVIDE PERSONNEL TO HELP WITH APPLICATIONS AND TO ANSWER QUESTIONS?THE WILLIAM W. BACKUS HOSPITAL EMPLOYS FINANCIAL COUNSELORS TO HELP PATIENTS APPLY FOR FINANCIAL ASSISTANCE, MEDICAID, AND OTHER STATE HEALTH PROGRAMS.THE HOSPITAL ALSO HAS RESOURCES TO HELP WITH APPLICATIONS FOR STATE NUTRITIONAL ASSISTANCE PROGRAMS (SNAP) AND PHARMACY ASSISTANCE PROGRAMS. FINANCIAL COUNSELORS CAN HELP TO DETERMINE APPROPRIATE REFERRALS TO THESE RESOURCES.THE WILLIAM W. BACKUS HOSPITAL PROVIDES LANGUAGE TRANSLATION VIA CYRACOM AND MARTTI LANGUAGE LINES.4. DOES THE HOSPITAL COMMUNICATE THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THE COMMUNITY?THE WILLIAM W. BACKUS HOSPITAL BELIEVES IT IS IMPORTANT TO COMMUNICATE THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THE COMMUNITIES IT SERVES. THEREFORE, A NOTICE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE IS INCLUDED WITH THE PAPER BILL SENT TO THE PATIENT'S HOME, IS POSTED IN ALL MAIN REGISTRATION AREAS, IS AVAILABLE ON THE HOSPITAL'S WEBSITE, AND UPON REQUEST OF HOSPITAL STAFF OR REPRESENTATIVES.5. DOES THE HOSPITAL EVER DENY CARE BASED ON INABILITY TO PAY?THE WILLIAM W. BACKUS HOSPITAL WILL NEVER DELAY OR DENY EMERGENCY CARE OR NECESSARY SERVICES DUE TO AN INABILITY TO PAY.6. DOES THE HOSPITAL HAVE A PROGRAM FOR PATIENTS WHO DON'T QUALIFY FOR TRADITIONAL FINANCIAL ASSISTANCE BUT INCUR CATASTROPHIC MEDICAL DEBTS?THE HOSPITAL HAS A WRITTEN POLICY THAT COVERS CATASTROPHIC FINANCIAL ASSISTANCE FOR THE MEDICALLY INDIGENT. THE POLICY IS INCLUDED IN THE FINANCIAL ASSISTANCE POLICY, IS AVAILABLE ON THE WEBSITE, AND UPON REQUEST. PART VI, LINE 4: THE WILLIAM W. BACKUS HOSPITAL IS LOCATED IN NORWICH, 45 MINUTES SOUTHEAST OF HARTFORD, IN THE PAST DECADE, THE REGION HAS UNDERGONE MAJOR ECONOMIC CHANGES, DUE TO THE OPERATION OF TWO NATIVE-AMERICAN OWNED ENTERTAINMENT VENUES BRINGING THOUSANDS OF VISITORS INTO THE REGION EACH DAY. THE CASINOS ARE THE LARGEST EMPLOYERS, AND ARE EXPERIENCING FINANCIAL DIFFICULTIES AS THE ECONOMY DECLINES. THE HOSPITAL'S SERVICE AREA HAS AN ESTIMATED POPULATION OF ABOUT 243,000. THE SERVICE AREA CONSISTS OF LARGER COMMUNITIES, SUCH AS NEW LONDON AND GROTON, AND SMALLER LOWER-DENSITY RURAL COMMUNITIES. THE SERVICE AREAS CONTAIN MUNICIPALITIES IN THE NEW LONDON AND WINDHAM COUNTIES. PART VI, LINE 5: HOSPITAL EMPLOYEES VOLUNTEER THEIR SERVICES ON DOZENS OF COMMUNITY NOT-FOR-PROFIT ORGANIZATIONS, MANY OF WHICH HAS HEALTHCARE AS A PRIMARY OR MAJOR FOCUS. EXAMPLES INCLUDE THE FOUNDATION OF THREE RIVERS COMMUNITY COLLEGE (WHICH PROVIDES FUNDING FOR NURSING STUDENT EDUCATION AND EQUIPMENT), THE REGION'S NON-PROFIT HOSPICE ORGANIZATION, THE NORWICH CHAMBER OF COMMERCE HEALTH CARE COMMITTEE, UNITED WAY OF SOUTHEASTERN CONNECTICUT (WHICH PROVIDES FUNDING FOR MANY REGIONAL HUMAN SERVICES, INCLUDING THOSE THAT ARE HEALTH-RELATED); AS WELL AS SERVICES AND BOARD MEMBERSHIP ON THE REGION'S FEDERALLY QUALIFIED HEALTH CENTERS. ADDITIONALLY, BACKUS PERSONNEL VOLUNTEER ON OTHER BOARDS AND ORGANIZATIONS THAT ADVANCE THE QUALITY OF LIFE AND ECONOMIC WELL-BEING OF THE REGION, INCLUDING THE LOCAL LIBRARY, FAMILY SUPPORT AND SOCIAL SERVICE ORGANIZATIONS, THE REGIONAL CHAMBER OF COMMERCE, NUMEROUS CIVIC AND GOVERNMENTAL BODIES, AND VARIOUS VOLUNTEER COMPANIES AND AMBULANCE SERVICES. MEMBERS OF THE ADMINISTRATIVE STAFF ROUTINELY SUBMIT GOVERNMENT TESTIMONY ON BEHALF OF THE REGIONAL NOT-FOR-PROFIT HEALTH-RELATED ORGANIZATIONS, AND PROVIDE RESEARCH AND ADVOCACY FOR THE HEALTH ACCESS. THE HOSPITAL CONTRIBUTES CASH AND IN-KIND DONATIONS TO AREA NONPROFITS TO SUPPORT THEIR MISSION TO BETTER THE COMMUNITIES WHICH THEY SERVE. SUCH DONATIONS INCLUDE OFFICE SPACE FOR THE LOCAL DOMESTIC ABUSE NETWORK AND SUPPORT OF A LOCAL CHARITY WHOSE MISSION IS TO STRENGTHEN FAMILIES. PART VI, LINE 6: HARTFORD HEALTHCARE CORPORATION (HHC) IS ORGANIZED AS A SUPPORT ORGANIZATION TO GOVERN, MANAGE AND PROVIDE SUPPORT SERVICES TO ITS AFFILIATES. HHC, THROUGH ITS AFFILIATES INCLUDING HARTFORD HOSPITAL, STRIVES TO IMPROVE HEALTH USING THE "TRIPLE AIM" MODEL: IMPROVING QUALITY AND EXPERIENCE OF CARE; IMPROVING HEALTH OF THE POPULATION (POPULATION HEALTH) AND REDUCING COSTS. THE STRATEGIC PLANNING AND COMMUNITY BENEFIT COMMITTEE OF THE HHC BOARD OF DIRECTORS ENSURES THE OVERSIGHT FOR THESE SERVICES BY EACH HOSPITAL COMMUNITY. IN ADDITION, HHC CONTINUES TO TAKE IMPORTANT STEPS TOWARD ACHIEVING ITS VISION OF BEING "NATIONALLY RESPECTED FOR EXCELLENCE IN PATIENT CARE AND MOST TRUSTED FOR PERSONALIZED, COORDINATED CARE". HHC AFFILIATION CREATES A STRONG, INTEGRATED HEALTH CARE DELIVERY SYSTEM WITH A FULL CONTINUUM OF CARE ACROSS A BROADER GEOGRAPHIC AREA. THIS ALLOWS THE SMALL COMMUNITIES EASY AND EXPEDIENT ACCESS TO THE MORE EXTENSIVE AND SPECIALIZED SERVICES THE LARGER HOSPITALS ARE ABLE TO OFFER. THIS INCLUDES CONTINUING EDUCATION OF HEALTH CARE PROFESSIONALS AT ALL THE AFFILIATED INSTITUTIONS THROUGH THE CENTER OF EDUCATION, SIMULATION AND INNOVATION LOCATED AT HARTFORD HOSPITAL, THE LARGEST OF THE SYSTEM HOSPITALS. THE AFFILIATION FURTHER ENHANCES THE HOSPITALS' ABILITIES TO SUPPORT THEIR MISSIONS, IDENTITY, AND RESPECTIVE COMMUNITY ROLES. THIS IS ACHIEVED THROUGH INTEGRATED PLANNING AND COMMUNICATION TO MEET THE CHANGING NEEDS OF THE REGION. THIS INCLUDES RESPONSIBLE DECISION MAKING AND APPROPRIATE SHARING OF SERVICES, RESOURCES AND TECHNOLOGIES, AS WELL AS CONTAINMENT STRATEGIES. ADDITIONALLY, THE HOSPITAL IS AFFILIATED WITH SEVERAL OTHER NON HOSPITAL CHARITABLE ORGANIZATIONS. THESE ORGANIZATIONS PROVIDE SIGNIFICANT BENEFITS TO THE COMMUNITY. THESE BENEFITS ARE NOT REPORTED IN THE COMMUNITY BENEFIT DATA PROVIDED BY THE HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES CT 1 CHAMBER OF COMMERCE OF SE CT 914 HARTFORD TPKE WATERFORD CT 06385 060475490 501C6 16800 SPONSORSHIPSPONSORSHIP NORTHEAST CT COUNCIL OF GOVERNMENT 125 PUTNAM PIKE DAYVILLE CT 06241 060850466 DAYVILLE CT 20000 PARAMEDIC PROGRAM CT SPORTS FOUNDATION INC 445 BOSTON POST RD STE 203B OLD SAYBROOK CT 06475 061240574 501C3 15000 SPONSORSHIP UNITED COMMUNITY & FAMILY SERVICES INC 34 E TOWN STREET NORWICH CT 06360 060653142 501C3 10000 SPONSORSHIP BROADWAY KIDS 12 PENNSYLVANIA AVE NIANTIC CT 06357 10000 SPONSORSHIP AMERICAN CANCER SOCIETY 825 BROOK STREET ROCKY HILL CT 06067 131788491 501C3 5500 SPONSORSHIP NURSING SCHOOL/SPONSORSHIP 4 2 SCHOLARSHIP 3 10050 PART I, LINE 2: DONATIONS MADE FOR LOCAL EVENTS, SUCH AS SPONSORSHIPS ARE TYPICALLY ATTENDED BY HOSPITAL EMPLOYEES. THREE SCHOLARSHIPS IN THE AMOUNT OF $3350 EACH ARE AWARDED TO STUDENTS WHO WILL ATTEND SCHOOL EITHER FOR NURSING OR IN THE MEDICAL FIELD. THE APPLICANTS ARE REVIEWED BY THE SCHOLARSHIP COMMITTEE OF THE AUXILIARY AND WINNERS ARE BASED ON ACADEMICS AS WELL AS COMMUNITY SERVICE. X X X X 0 1 0 0 0 0 0 1 0 DAVID WHITEHEAD DIRECTOR/PRESIDENT/SENIOR VP 0 539164 0 140531 0 126311 0 14040 0 36492 0 856538 0 108000 JAMES CARDON MDTERM 615 DIRECTOR 0 442633 0 144696 0 6370 0 77862 0 33634 0 705195 0 0 ELLIOT JOSEPHTERM 615 DIRECTOR 0 1152379 0 513373 0 229612 0 239138 0 60161 0 2194663 0 0 MARGARET MARCHAK DIRECTOR/SECRETARY 0 432566 0 101007 0 8337 0 72165 0 36596 0 650671 0 0 DANIEL LOHR SENIOR VP/CFO 0 375616 0 85582 0 132703 0 14040 0 29976 0 637917 0 74000 CAROLYN TRANTALIS VP OPERATIONS EAST REGION 0 215367 0 50771 0 1746 0 15600 0 23598 0 307082 0 0 MARY BYLONE VP PATIENT CARE EAST REGIO 0 219944 0 47630 0 12200 0 14040 0 18367 0 312181 0 0 ROBERT SIDMAN MD PHYSICIAN 343323 0 168180 0 17919 0 14040 0 20450 0 563912 0 0 0 SERGIO CASILLA MD PHYSICIAN 512483 0 0 0 275 0 14040 0 19992 0 546790 0 0 0 ZHENXIANG LIU MD PHYSICIAN 430825 0 56243 0 420 0 12509 0 20391 0 520388 0 0 0 MARIANO LIBRIJO MD PHYSICIAN 368294 0 31759 0 164 0 12354 0 6264 0 418835 0 0 0 NATHAN SIEGEL MD PHYSICIAN 313504 0 61920 0 275 0 14040 0 14293 0 404032 0 0 0 PETER SHEA FORMER MEDICAL DIRECTOR 0 383189 0 45000 0 80613 0 0 0 30598 0 539400 0 73000 PART I, LINE 4B HARTFORD HEALTHCARE CORPORATION MAINTAINS A 457(F) PLAN. PARTICIPANTS INCLUDE CERTAIN OFFICERS AND KEY EMPLOYEES AT THE PRESIDENT, EXECUTIVE VICE PRESIDENT, SENIOR VICE PRESIDENT AND VICE PRESIDENT LEVELS. CONTRIBUTIONS ARE MADE BY HARTFORD HEALTHCARE CORPORATION TO THE PLAN BASED ON A PERCENTAGE OF THE PARTICIPANT'S COMPENSATION. PARTICIPANTS VEST IN THE PLAN AT THE EARLIER OF REACHING AGE 55 AND HAVING 5 YEARS OF SERVICE, DEATH, DISABLIITY, INVOLUNTARY SEPARATION WITHOUT REASONABLE CAUSE OR UPON REACHING AGE 65. EACH PARTICIPANT CEASES TO BE ELIGABLE FOR FURTHER CONTRIBUTIONS BY HARTFORD HEALTHCARE CORPORATION ON THE DATE OF THE PARTICIPANT'S SEPARATION FROM SERVICE. PARTICIPANTS RECEIVE A ONE-TIME LUMP SUM PAYMENT OF THE ACCUMULATED AMOUNT DURING THE 30-DAY PERIOD FOLLOWING THE PARTICIPANT'S SEPARATION FROM SERVICE. 2014 SERP ACCRUALS MADE ON BEHALF OF THE FOLLOWING INDIVIDUALS: MR. ELLIOT JOSEPH $210,538 MS. MARGARET MARCHAK $53,965 DR. JAMES CARDON $59,662 2014 SERP PAYMENTS WERE MADE TO THE FOLLOWING INDIVIDUALS: MR. DANIEL LOHR $74,000 DR. PETER SHEA $73,000 MR. DAVID WHITEHEAD $108,000 MR. ELLIOT JOSEPH $132,336* *FOR THIS INDIVIDUAL, VESTING OCCURRED, CAUSING TAXABLE INCOME. A PORTION OF THE VESTED AMOUNT WAS USED TO PAY THE ASSOCIATED TAX LIABILITY, THE REMAINING BALANCE STAYED IN THE SERP ACCOUNT. PART I, LINE 7 HARTFORD HEALTHCARE CORP HAS AN AT RISK PLAN THAT PROVIDES AT-RISK AWARD OPPORTUNITIES TO MOTIVATE ELIGIBLE EXECUTIVES TO PUT FORTH MAXIMUM EFFORT TO ACCOMPLISH SPECIFIED ANNUAL GOALS. THE PAYMENT OF AN AWARD TO ANY SENIOR EXECUTIVE IS CONTINGENT ON THE SYSTEM ACHIEVING PRE-ESTABLISHED PERFORMANCE GOALS AND MAINTAINING FINANCIAL STABILITY, PARTICIPANTS ACHIEVING PRE-ESTABLISHED PERFORMANCE GOALS, AND ON APPROVAL OF THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 2 ALL OFFICERS AND DIRECTORS HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER. FORM 990, PART VI, SECTION A, LINE 4 THE AMENDED AND RESTATED CERTIFICATE OF INCORPORATION OF THE CORPORATION INCLUDES THE FOLLOWING SUBSTANTIVE AMENDMENTS: 1. THE CORPORATION'S PURPOSES HAVE BEEN REVISED BUT ARE CONSISTENT WITH ITS CHARITABLE PURPOSES. 2. THE BOARD'S ROLE WAS REVISED TO FOCUS ON QUALITY IN HEALTH CARE. 3. SECTION 12 RELATING TO THE INDEMNIFICATION OF DIRECTORS, OFFICERS, AND COMMITTEE MEMBERS OF THE CORPORATION HAS BEEN REVISED CONSISTENT WITH CONNECTICUT LAW. THE ORGANIZATIONS' GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION A, LINE 6 HARTFORD HEALTHCARE CORPORATION, A NOT-FOR-PROFIT 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF THE WILLIAM W BACKUS HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER OF THE ORGANIZATION HAS THE AUTHORITY TO APPROVE/REMOVE MEMBERS OF THE GOVERNING BODY FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER OF THE ORGANIZATION HAS THE RIGHT TO REVIEW, APPROVE, DISAPPROVE AND DENY SIGNIFICANT TRANSACTIONS SUCH AS MERGERS, AQUISITIONS, DISSOLUTIONS, ETC. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED BY THE ACCOUNTING STAFF AND THEN REVIEWED BY AN INDEPENDENT ACCOUNTING FIRM. THE 990 IS THEN REVIEWED BY THE CFO AND ANY QUESTIONS ADDRESSED. THE FINAL 990 IS THEN PROVIDED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL'S BOARD HAS ADOPTED THE POLICY OF THE MEMBER, HARTFORD HEALTHCARE CORPORATION (HHC). HHC'S CONFLICT OF INTEREST POLICY (POLICY) REQUIRES ALL COVERED INDIVIDUALS, INCLUDING BOARD MEMBERS AND OFFICERS, TO PROVIDE A DISCLOSURE OF RELATIONSHIPS THAT CREATE OR HAVE THE APPEARANCE OF CREATING A CONFLICT OF INTEREST OR COMMITMENT. THE POLICY REQUIRES UPDATES IF CHANGES IN CIRCUMSTANCES ARISE DURING THE YEAR THAT EITHER (A) CREATE A NEW POTENTIAL CONFLICT OF INTEREST OR COMMITMENT OR (B) CHANGE OR ELIMINATE A CONFLICT OF INTEREST OR COMMITMENT PREVIOUSLY DISCLOSED. CONFLICT OF INTEREST DISCLOSURE STATEMENTS ARE MAINTAINED BY THE HHC OFFICE OF COMPLIANCE, AUDIT & PRIVACY (OCAP). EMPLOYEE DISCLOSURES ARE REVIEWED BY OCAP IN COLLABORATION WITH THE COVERED INDIVIDUALS' SUPERVISOR WHEN DEEMED APPROPRIATE, TO DETERMINE IF THERE IS A POTENTIAL CONFLICT. OVERSIGHT REVIEW OF EMPLOYEE DISCLOSURES IS PROVIDED BY THE HHC CONFLICT OF INTEREST COMMITTEE (THE COMMITTEE) WHICH INCLUDES REPRESENTATION FROM THE MEDICAL STAFF, THE LEGAL DEPARTMENT, HUMAN RESOURCES, SUPPLY CHAIN MANAGEMENT AND COMPLIANCE. THE COMMITTEE ASSESSES AND MAY RECOMMEND THE CONFLICTING INTEREST EITHER BE (A) ELIMINATED FOR A CONTINUED RELATIONSHIP WITH HHC, OR (B) MANAGED THROUGH A MANAGEMENT PLAN. BOARD MEMBER DISCLOSURES ARE REPORTED TO THE HHC NOMINATING AND GOVERNANCE COMMITTEE FOR DETERMINATIONS OF CONFLICTS AND THE MANAGEMENT OF THEM, WHERE APPLICABLE. FORM 990, PART VI, SECTION B, LINE 15 THE INDEPENDENT EXECUTIVE COMPENSATION COMMITTEE (COMMITTEE) OF THE BOARD OF DIRECTORS OF HARTFORD HEALTHCARE ON BEHALF OF BACKUS HOSPITAL HIRES AN OUTSIDE CONSULTANT, INTEGRATED HEALTHCARE STRATEGIES, A DIVISION OF GALLAGHER BENEFIT SERVICES, INC., TO DETERMINE BEST PRACTICES IN GOVERNING EXECUTIVE COMPENSATION. THE FOLLOWING STEPS WERE TAKEN: - INDEPENDENT EXECUTIVE COMPENSATION COMMITTEE (COMMITTEE) OF THE BOARD OF DIRECTORS OF HARTFORD HEALTHCARE, ON BEHALF OF BACKUS HOSPITAL, ESTABLISHED AND REGULARLY REVIEWS EXECUTIVE COMPENSATION PHILOSOPHY - COMMITTEE REGULARLY REVIEWS SCOPE AND DEPTH OF POSITIONS TAKING INTO ACCOUNT COMPLEXITY AND THE FINANCIAL IMPACT AND ACCOUNTABILITY OF ALL "DISQUALIFIED PERSONS" - NATIONAL PEER GROUP SELECTED FOR COMPARATIVE PURPOSES BASED ON ORGANIZATIONAL SIZE, OPERATING REVENUE, GEOGRAPHY AND OTHER RELEVANT FACTORS - ANALYSIS OF CURRENT TOTAL COMPENSATION VERSUS MARKET PERFORMED BY INDEPENDENT THIRD PARTY COMPENSATION CONSULTING FIRM, REVIEWED BY THE COMMITTEE - RECOMMENDATIONS MADE BASED ON DATA ANALYSIS TO ENSURE APPROPRIATE COMPETITIVE POSITIONING WITHIN PARAMETERS OF COMPENSATION PHILOSOPHY - CEO COMPENSATION REVIEWED BY COMMITTEE BASED ON COMPARATIVE MARKET INFORMATION AND ORGANIZATIONAL PERFORMANCE - ALL CHANGES REVIEWED AND APPROVED BY EXECUTIVE COMPENSATION COMMITTEE THE CEO COMPENSATION DETERMINATION PROCESS IS REVIEWED ON AN ANNUAL BASIS. ALL OTHER EXECUTIVE COMPENSATION IS REGULARLY REVIEWED FOR SCOPE AND DEPTH OF POSITIONS TAKING INTO ACCOUNT COMPLEXITY AND THE FINANCIAL IMPACT AND ACCOUNTABILITY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE FOR INSPECTION UPON REQUEST AT THE ORGANIZATIONS ADDRESS. FORM 990, PART XI, LINE 9: K-1 PASSTHROUGH 94. TRANSFER TO AFFILIATES -12,663,772. DECREASE IN ASSETS HELD IN TRUST -247,856. CHANGE IN PENSION FUNDING -14,972,653. 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