2015-05-15T17:35:48-05:00 2014-06-30 Deloitte Tax LLP 555 E Wells St Suite 1400 Milwaukee WI 53202 990 2013-07-01 391834639 Columbia St Mary's Inc COLU 4143262230 4425 North Port Washington Road Suite 301 Glendale WI 53212 Rhonda Andersn Interim CFO 4143262230 2015-05-15 1 Rachel J Becker P00966076 4142713000 2013 2016-02-25 16:41:14Z Travis Andersen 4425 North Port Washington Road Suite 301 Glendale WI 53212 151208194 0 0928 X columbia-stmarys.org X 2001 WI Health care system dedicated to making a positive difference in individuals and our community. 14 12 540 12 49417 3118 376402 364187 116024234 141309835 4455324 4596687 5398028 4937485 126253988 151208194 429175 428000 0 0 38555157 18951026 0 0 0 97433085 87298238 136417417 106677264 -10163429 44530930 493691681 235812966 482096928 186671608 11594753 49141358 X Columbia St. Mary's, Inc. ("CSM") is a health care provider founded in response to identified community needs, which is sponsored by Ascension Health, a Catholic national health system, and Columbia Health System, a non-sectarian community health system. CSM exists to make a positive difference in the health status and lives of individuals and our community, with special concern for those who are vulnerable. CSM and its affiliates are committed to providing high-quality, accessible, values-driven programs and services with equal attention to the physical, spiritual, and emotional dimensions of health. 0 0 64503520 428000 146199053 CSM, Inc exists as the parent corporation in the CSM system, which is comprised of three hospitals, (Columbia St. Mary's Hospital Milwaukee Inc, Columbia St. Mary's Hospital Ozaukee Inc, and Sacred Heart Rehabilitation Institute Inc.), 61 community clinics, the Columbia College of Nursing, a partnership with the Orthopedic Hospital of Wisconsin, a partnership with the Sleep Wellness Institute, and five urgent care centers. During fiscal 2014, CSM'S health system (Sacred Heart Rehabilitation, Columbia St. Mary's Milwaukee, Columbia St. Mary's Ozaukee) provided care to 332,115 patients. The estimated unreimbursed cost of services provided to the elderly, uninsured and underinsured totaled $164,585,590. Refer to the community benefit information in Schedule H for discussion of how CSM makes a positive difference in the health status of its community, focusing on those who are vulnerable. 64503520 1 1 0 0 0 0 0 0 0 0 1 0 1 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 540 0 1 1 0 0 0 0 0 0 0 0 X 14 12 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 X Timothy Waldoch 4143262230 4425 N Port Washington Road STE 301 Glendale WI 53212 X R Bruce McDonald Chair 0.20 0.80 X 0 0 0 George H Hoff Vice Chair 0.20 0.80 X 0 0 0 Robert J Venable Vice Chair 0.20 0.80 X 0 0 0 Randall Perry Secretary/Treasurer 0.20 0.80 X 0 0 0 Tina Chang Board Member 0.20 0.80 X 0 0 0 Patricia J Dolhun MD Board Member 0.20 0.80 X 0 0 0 Kevin Goniu MD Board Member/CSM Physician 0.20 40.80 X 0 459309 140438 Michael Grebe Board Member 0.20 0.80 X 0 0 0 Robert Lyon MD Board Member 0.20 0.80 X 0 0 0 Christine Nuernberg Board Member 0.20 0.80 X 0 0 0 Stephen Robbins MD Board Member (Start 7/1/13) 0.20 0.80 X 0 0 0 Mason G Ross Board Member 0.20 0.80 X 0 0 0 Sister Theresa Sullivan DC Board Member 0.20 0.80 X 0 0 0 Mark R Taylor End 63014 President/CEO 1.00 49.00 X X 1384590 0 113707 Rhonda Anderson CSM President/CFO 5.00 45.00 X 442055 0 15038 Cheryl Hill VP/CHRO 5.00 45.00 X 320704 0 28397 Gerri Lietz-Staffileno VP Hosp Operations 5.00 45.00 X 0 320213 30058 David H Shapiro MD End 413 Chief Medical Officer 5.00 45.00 X 294585 0 356173 Suzanne Sanicola VP Physician Services 5.00 45.00 X 221994 0 32430 William Hart VP / COO 6.00 44.00 X 338325 0 13276 Bruce McCarthy MD President Hosp Div 5.00 45.00 X 598035 0 39781 Constance Bradley End 413 VP Hosp Operations 7.00 43.00 X 0 187443 9777 Allan Spooner President Hospital Division 5.00 45.00 X 605560 0 39781 Jeffrey C Squier Payor Relations & Strategy Officer 40.00 0.00 X 216979 0 36249 Michael E Sanderl VP Mission Integration and Advocacy 40.00 0.00 X 301366 0 29145 Clarissa L Cox VP Quality & Clinical 40.00 0.00 X 202175 0 9129 David Mannes Controller 5.00 45.00 X 176981 0 29139 Patricia L Allen Chief Financial Advsr-Hosp Dev 40.00 0.00 X 169568 0 16490 Marian Purdue End 1012 Former Interim Pres Hosp Div 0.00 0.00 X 153750 0 0 Deborah Friberg End 612 Former President Hosp Div 0.00 0.00 X 232993 0 5671 5659660 966965 944679 34 1 1 0 0 114241 249946 364187 Service Fees 541610 127287440 127287440 Joint Venture Income 622110 13628000 13628000 Medical Staff Dues 561499 194075 194075 Health & Med Ins Rev 611710 119663 119663 Management Fee Income 541610 49417 49417 31240 31240 141309835 4595537 4595537 67671 0 67671 67671 67671 1150 0 1150 1150 1150 OTHER OPERATING REVENU 561499 4869814 4869814 4869814 151208194 146199053 49417 4595537 428000 428000 3790370 1913557 1876813 2493605 954041 1539564 10632899 4282812 6350087 2034152 733194 1300958 69629 69629 893799 106 893693 454945 298053 156892 4088613 408392 3680221 4090563 117027 3973536 188460 30160 158300 2673170 2495739 177431 5167081 4502240 664841 198224 40697 157527 133133 87762 45371 10188837 10188837 8145578 7686569 459009 289833 3647 286186 Service Fees 32652183 28679959 3972224 purchased services 11016119 9845785 1170334 PATIENT CARE SUPPLIES 701805 136061 565744 Minor Equipment 680911 250902 430009 5665355 1539188 4126167 106677264 64503520 42173744 0 2092514 2097433 60700134 17388157 18608148 10008698 35603002 81822 52151 3246515 2793220 38930626 33894830 5841272 5035796 24690729 42873188 32490405 31296567 310337140 124267756 493691681 235812966 19764210 11789287 462332718 174882321 482096928 186671608 X -5081670 32044715 11548826 11969046 5127597 5127597 11594753 49141358 493691681 235812966 X 44530930 7591288 -14575613 X 0 1 X 1 0 X X X X 0 0 0 CSM HOSPITAL MILWAUKEE 390806315 3 1 1 1 0 CSM HOSPITAL OZAUKEE 390807063 3 1 1 1 0 SACRED HEART REHABILITATION INSTITUTE 390902199 3 1 1 1 0 COLUMBIA COLLEGE OF NURSING INC 391596986 2 1 1 1 0 4 0 Schedule A, Line 11 Columbia St. Mary's Inc. supports the provision of healthcare services at the corporations to which it is a member by the provision of centralized administrative support, including billing and collections, IT, managed care contracting, financial services, business development, medical library, CME, property management, administrative costs for clinical institutes (including oncology, cardiology, bariatrics, pediatrics, stroke and neurosciences), research (including oncology, neurosciences and general research), marketing, logistics, external affairs, public relations, and construction. Costs of certain of these departments are charged to the members through a management fee. Transactions with each member are delineated on Schedule R. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 764011 764011 14241740 12891460 1350280 1836550 1812020 24530 21596388 18975531 2620857 491937 215819 276118 5035796 Investments in Unconsolidated Entities 25776545 C Investments in CSM Foundation - Perm Rest 5127597 C INvestments in CSM Foundation - Temp Rest 11969046 C 42873188 Deferred Compensation 220254 Pension Prefunding 53458089 Interest in Investments held by Ascension Health Alliance 70589413 124267756 Intercompany Debt to Ascension Health Alliance 159774672 Accrued Pension 3102722 Deferred Compensation 1297983 Misc Noncurrent Liabilities 2200963 Misc Current Liabilities 2321151 Due to Affiliates 6184830 174882321 X Part X, Line 2: From the consolidated audited financial statements of Ascension Health Alliance and its member organizations ("The System") which include the activity of Columbia St. Mary's Inc.: The System accounts for uncertainty in income tax provisions by applying a recognition threshold and measurement attribute for financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. The System has determined that no material unrecognized tax benefits or liabilities exist as of June 30, 2014. 1 1 1 X 1 X 1 1 0 1 1 312925 312925 0.01820 952850 729229 223621 0.01310 1265775 729229 536546 0.03130 6702 6702 0.00040 6702 6702 0.00040 1272477 729229 543248 0.03170 10792 10792 0.00060 500 500 0.00000 1100 1100 0.00010 12392 12392 0.00070 0 633555 12671 5222751 3816188 1406563 X 1 1 1 Orthopaedic Hospital of Wisconsin LLC Orthopedic Surgeries 0.50000 0.50000 1 1 Orthopaedic Hospital of Wisconsin LLC 475 West River Woods Parkway Glendale WI 53212 www.ohow.com 1006 X Specialty Orthopedic Hospital Orthopaedic Hospital of Wisconsin 1 1 X X X X X X X X X 12 1 1 1 See Section C Line 5d for website X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 0 Orthopaedic Hospital of Wisconsin Part V, Section B, Line 3: The hospital facility took into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge or expertise in public health. The collaboration included participation by the Milwaukee County Health Department and representatives from health departments in Milwaukee County.The CHNA team developed a multi-level assessment process. The first level consisted of a survey of county residents regarding their health status, health access and the perception of community needs. Working together, survey questions were developed and approved. A consultant was contracted to perform the survey using techniques that the consultant had used in similar surveys over ten years. The survey was conducted over the telephone to cell phone owners and "land line" telephone owners. More than 1,900 people were interviewed.The second level of data gathering was performed by the Center for Urban Population Health (CUPH) as secondary data gathering about community needs based on public health and other publicly available information. The third level of data was gathered through a key stakeholder interview process. The MHCP members had agreed upon those diverse people who represented key aspects of the community. A survey tool was developed by the group and interviews were scheduled by MHCP members and by public health students working with the City of Milwaukee Health Department. In all, 35 individual interviews and five group interviews were conducted by team members. Orthopaedic Hospital of Wisconsin Part V, Section B, Line 4: The other hospital facilities with which the reporting hospital facility conducted its CHNA, include Aurora Health Care, Children's Hospital of Wisconsin, Froedtert Health and Wheaton Franciscan Healthcare. These five hospital systems have developed the Milwaukee Health Care Partnership (MHCP) to collaborate efforts to improve understanding of health care needs in Milwaukee and to improve access to health care. Orthopaedic Hospital of Wisconsin Part V, Section B, Line 5d: WWW.COLUMBIA-STMARYS.ORG/SERVINGOURCOMMUNITY Orthopaedic Hospital of Wisconsin Part V, Section B, Line 7: The Milwaukee CHNA identified seven key issues: Infant Mortality, Children's Dental Needs, Breast Cancer, Access to Care in general, Access to Care regarding medical specialists, Inappropriate Use of Emergency Departments and Behavior Health. In the case of OHOW, only access to care was focused on because it is a specialty hospital focusing on orthopedics. Columbia St. Mary's does not have the scope and capacity to address the other identified OHOW needs. Orthopaedic Hospital of Wisconsin Part V, Section B, Line 10: All patients with income less than 200% of the federal poverty level will be eligible for 100% charity care write-off of the charges for services that have been provided. Eligibility may be determined at any point in the revenue cycle. Financial counselors provide assistance to the patients to determine if they are eligible for Medicaid or other public assistance in order to qualify for charity care. Credit reports or other similar reports may be run to verify information provided. Orthopaedic Hospital of Wisconsin Part V, Section B, Line 11: Patients with incomes above 300% of the poverty level may be eligible for some level of discount based on a substantive assessment of their ability to pay. The assessment considers total income and dollar amount of patient responsibility on a sliding scale. A means test is performed that considers income, total medical bill obligations, mortgage payments, utility payments, number of family members, and any disability considerations. Patients who do not qualify for charity care, but are in need of financial assistance, will be offered appropriate extended payment terms or other payment options that take into account the patient's financial status. Orthopaedic Hospital of Wisconsin Part V, Section B, Line 16e: The following steps were followed and considered reasonable efforts for purposes of Question 16:- Notified each individual of the facility's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual.- Individuals were notified of the FAP by methods as noted in Question 14. This includes, but is not limited to, providing the following: - A brief description of eligibility requirements and assistance provided - Directions on how to access the FAP and application on our website and physical location of application forms - Instructions to obtain free copy of FAP and application by mail - Contact information for an individual/nonprofit organization to assist if the individual has questions - Statement of translations of FAP as well as plain language summaries - Statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB - For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP.- For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP- We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Orthopaedic Hospital of Wisconsin Part V, Section B, Line 17e: The following steps were followed and considered reasonable efforts for purposes of Question 17:- Notified each individual of the facility's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual.- Individuals were notified of the FAP by methods as noted in Question 14. This includes, but is not limited to, providing the following: - A brief description of eligibility requirements and assistance provided - Directions on how to access the FAP and application on our website and physical location of application forms - Instructions to obtain free copy of FAP and application by mail - Contact information for an individual/nonprofit organization to assist if the individual has questions - Statement of translations of FAP as well as plain language summaries - Statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB - For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP.- For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP- We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Orthopaedic Hospital of Wisconsin Part V, Section B, Line 20d: All patients eligible for financial assistancec receive a minimum discount of 40% off gross charges for services provided to them. Orthopaedic Hospital of Wisconsin Part V, Section B, Line 21: The following steps were followed and considered reasonable efforts followed for purposes of identifying patients eligible for assistance under the facility's FAP:- Notified each individual of the Hospital's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual.- Individuals were notified of the FAP as noted in Question 14. This includes, but is not limited to,the following: - Brief description of eligibility requirements and assistance provided. - Direct individuals to our website and physical location of application forms - Provided instructions to obtain free copy of FAP and application by mail - Provided contact information for an individual/nonprofit organization to assist if the individual has questions - Provided statement of translations of FAP as well as plain language summaries - Provided statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB- For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP- For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP.- We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Orthopaedic Hospital of Wisconsin Part V, Section B, Line 22: The following steps were followed and considered reasonable efforts followed for purposes of identifying patients eligible for assistance under the facility's FAP:- Notified each individual of the Hospital's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual.- Individuals were notified of the FAP as noted in Question 14. This includes, but is not limited to, the following: - Brief description of eligibility requirements and assistance provided. - Direct individuals to our website and physical location of application forms - Provided instructions to obtain free copy of FAP and application by mail - Provided contact information for an individual/nonprofit organization to assist if the individual has questions - Provided statement of translations of FAP as well as plain language summaries - Provided statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB- For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP- For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP.- We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Part I, Line 3c: The hospitals of CSM provide medically necessary care to all patients, regardless of race, color, creed, ethnic origin, gender, disability or economic status. OHOW's specific policy uses a percentage of Federal Poverty Level (FPL) to determine free and discounted care. At a minimum, patients with income less than or equal to 200% of the FPL, which may be adjusted for cost of living utilizing the local wage index compared to national wage index, will be eligible for 100% charity care write off of charges for services that have been provided to them. Part I, Line 6a: OHOW files an annual community benefit report with the Wisconsin Hospital Association ("WHA"). CSM does not file a community benefit report with the WHA since CSM does not have any patient care revenue. However, CSM is the parent entity of 3 hospitals, Columbia St. Mary's Hospital Milwaukee, Inc., Columbia St. Mary's Hospital Ozaukee, Sacred Heart Rehabilitation, Inc., each of which file community benefit reports with WHA. CSM does, however, describe the benefits that the CSM organization provides to the community on its website. Part I, Line 7: The cost of providing charity care, means tested government programs, and community benefit programs is estimated using internal cost data, and is calculated in compliance with Catholic Health Association ("CHA") guidelines. The organization uses a cost accounting system that addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self pay). The best available data was used to calculate the amounts reported in the table. For certain categories in the table, this was a cost accounting system; in other categories, a specific cost-to-charge ratio was applied.Part I, Line 7g: The organization has not included costs attributable to a physician clinic as part of subsidized health services. Part I, Ln 7 Col(f): CSM's share of the amount of bad debt expense reported by OHOW in 2013 but subtracted for purposes of calculating the percentages in Part I, Line 7, column (f) is $633,555. Part II, Community Building Activities: During 2013, OHOW made a number contributions to organizations that encourage youth fitness and overall health education. Further, in order to accomplish the collaborative work in the community and to oversee access clinics and outreach programs, CSM has a Community Services Department which oversees the CSM Community Benefit Process. CSM, Inc. participates in Community Building activities through programs such as INROADS, which is an opportunity for culturally diverse college students to serve an internship over summer break to familiarize themselves with the challenges and opportunities in health care and gain real world experience. INROADS is reflected in the Community Building section of the report. CSM is a founding member of the Milwaukee Health Care Partnership (MHCP), which is a collaboration between the five Milwaukee health systems and Federally Qualified Health Centers to improve access to health care in the community. The partnership has worked with County health officials to improve behavioral access and Partnership funding supports mental health respite beds in the community. CSM's CEO and VP of Mission Services each spend significant time in MHCP collaborative work. Access to health education and screening in many areas of the city is best accomplished through church collaboration. CSM employs nurses to work in collaboration with churches and community organizations to offer health education, health screening, and care management support to parishioners and community members in a variety of outreach programs affiliated with churches. CSM developed the beginning stages of a collaboration with 44 Church of God in Christ churches in Milwaukee to accomplish better health awareness and improve screening rates. Part III, Line 4: OHOW, which files financial statements separate from CSM, includes the following footnote related to accounts receivables: "The majority of the Hospital's accounts receivables are due from third-party payors under reimbursement agreements and from patients for services provided. Accounts receivable are due upon receipt of invoice. Receivables are stated net of any allowance for contractual discounts and uncollectible accounts by considering the number of days past due, collection history, and the general economy and industry as a whole. Contractual adjustments are based on expected payment rates in accordance with third-party payor agreements. The Hospital writes off accounts receivable when they are determined to be uncollectible. Payments subsequently received are credited to the allowance for doubtful accounts." Part III, Line 8: OHOW follows the Catholic Health Association ("CHA") guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit. Part III, Line 9b: OHOW has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance certain collection practices do not apply. Part VI, Line 2: Columbia St. Mary's, Inc. serves the Milwaukee and Ozaukee communities through a Community Benefit Process overseen by the Milwaukee Community Benefit Committee and the Ozaukee Community Benefit Committee. The process of understanding community needs through a Community Health Needs Assessment and interpreted through the work of Community Benefit Committees to lead to a Community Benefit Plan for Milwaukee and Ozaukee communities is consistent across the organization. Although the Community Benefit Plan occurs primarily in the Milwaukee, Ozaukee and Sacred Heart Rehabilitation Institute settings, the work is also supported by departments behind the scenes across CSM, including accounting, human resources, purchasing, legal counsel and other administrative functions. Programs such as the Orthopaedic Hospital of Wisconsin have also contributed to support of Community Benefit programming. Community Benefit Committees at CSM have consistent roles to support the Community Benefit functions. The roles include the following: - Develop Community Health Needs Assessment (CHNA) to determine community needs- Review CHNA and create Community Benefit Plan to address needs- Incorporate Community Benefit Plan goals in the CSM Integrated Strategic, Operational and Financial Plan (ISOFP) for Board level approval and submission to Ascension Health System - Develop a strategy to measure and increase the impact of Community Benefit Plan elementsThe Community Health Needs Assessments are specific to the demographics and health issues to the community. The Needs Assessments in FY13 involved the gathering of secondary information about the communities from varied public sources including state data, and county data. The most remarkable needs for the service were addressed through Community Benefit Plans for each community. Part VI, Line 3: CSM attempts to identify patients who may be eligible for charity or discounted care as outlined in the charity care policy during the pre-registration, registration, admissions and discharge processes. A copy of the charity care policy is posted in the emergency room, and a summary of the policy is provided to patients with admission and discharge paperwork. CSM has trained financial counselors available to discuss payment options to the patients. Upon making an appointment, the financial counselors will meet with the patient to determine what other financial assistance programs the patient may qualify for. Part VI, Line 4: CSM primarily serves the Milwaukee and Ozaukee counties in southeastern Wisconsin. OHOW is located in an urban community within Milwaukee County. The population of Milwaukee County is approximately 953,000, with over 20% of the households living at or below federal poverty guidelines. The median income is approximately $43,000, over 46% of the population is a minority, and approximately 16% of the population speak a language other than English. Discounts for the uninsured and underinsured are not included in Parts I or II of Schedule H. Part VI, Line 5: A hallmark of CSM, Inc. is the ability to proactively meet health needs through preventive programs and programs to allow access to primary and specialty care. The programs are most often delivered through partnership with other non-profit organizations in health and social services. Each hospital has access improvement programs including: St. Bens Clinic for the Homeless, Seton Dental Clinic, Community Chronic Disease Management Clinic, Huiras Family Community Health Center, El Centro de Salude Clinic sponsored by the Columbia College of Nursing, the CSM OB/Clinic and the CSM Family Health Center. A particularly strong partner in these activities has been the Medical College of Wisconsin in sponsorship of programs: - The Family Health Center, a residency-based Family Medicine clinic that provides primary care to more than 9,000 individuals in the community.- The OB/GYN Clinic, a residency-based program that serves over 150 patients, 250 OB appointments per month, and 325 deliveries per year.- The Chronic Disease Management Clinic, which screens and manages hypertension, diabetes, obesity, and smoking for low income adults through a clinic based in a food pantry. In turn, CSM across the hospital settings hosts residents for their training growth and development. All of these services are reported as part of the Community Benefit expenses in Section H of the appropriate hospital report. Part VI, Line 6: The CSM health system focuses on contributing to the positive health status of the communities it serves. CSM is an organization comprised of three hospitals, 61 community clinics, The Columbia College of Nursing, a partnership with the Orthopaedic Hospital of Wisconsin, a partnership with Sleep Services of Wisconsin, and four Urgent Care Centers. CSM provides care for individuals and families throughout Milwaukee, Ozaukee, Washington, and Sheboygan counties - with more than 160 years of service to individuals and families in these communities.OHOW itself is a specialty hospital which performs more than 5,000 surgical procedures each year and offers the complete range of orthopaedic services, including joint replacements and spine procedures, rehabilitation, diagnostic testing and pain management services. As a member of Ascension Health, the nation's largest Catholic healthcare system, CSM continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. The goal of CSM is to perpetuate the health mission of the church. CSM furthers this goal through delivery of patient services, care to the elderly and indigent, patient education and health awareness programs for the community, and medical research. Our concern for all human life and dignity of each person leads the organization to provide medical services to all people in the community without regard to the patient's race, creed, national origin, economic status, or ability to pay.CSM employs a Community Benefit Philosophy in program planning and implementation. CSM provides for the health of the community through financial support provided to patients by financial discounts and contracts, by developing clinics and services for specific vulnerable groups, by sponsoring community education and training and by collaborating with government programs.During fiscal 2014, the CSM system provided $69,252,511 in unreimbursed services, including $14,778,518 in traditional charity care, $12,524,287 in discounts to the uninsured, $14,687,238 in community benefit programs, and $27,262,467 in other unpaid public programs, including subsidized health care, professional education, financial contributions and community building activities.In addition, the organization's governing body is comprised of local community leaders and physicians, the majority of whom reside within the communities CSM serves and are neither employees nor contractors of the organization, nor family members thereof. The hospital extends medical staff privileges to all qualified physicians in its community; however, the clinics within the organization are served by physicians affiliated with CSM. Part VI, Line 7 CSM does not file a community benefit report since it does not have any patient care revenue. However, CSM's three hospital organizations, Columbia St. Mary's Hospital, Milwaukee, Inc., Columbia St. Mary's Hospital Ozaukee, Inc. and Sacred Heart Rehabilitation Institute, Inc. each file community benefit reports with the Wisconsin Hospital Association. 1 United Way of Greater Milwaukee 225 W Vine Street Milwaukee WI 53212 390806190 501(c)(3) 400000 Federally Qualified Health Centers Funding Milwaukee Development Corporation 756 N Milwaukee Street Milwaukee WI 53202 501(c)(3) 15000 Fund general operations 2 Part I, Line 2: CONTRIBUTIONS TO GOVERNMENTS AND ORGANIZATIONS IN THE UNITED STATES ARE APPROVED BY THE BOARD OF DIRECTORS AND/OR THE PRESIDENT & CEO. ALL RECORDS OF OUTGOING CONTRIBUTIONS ARE RETAINED FOR A PERIOD OF 10 YEARS, PLUS THE CURRENT FISCAL YEAR, AND CAN BE LOCATED AT THE OFFICE CENTER AT 4425 NORTH PORT WASHINGTON RD, GLENDALE, WI 53212. X 1 1 1 1 0 0 0 0 0 1 0 Kevin Goniu MD Board Member/CSM Physician 0 450755 0 0 0 8554 0 107750 0 32688 0 599747 0 0 Mark R Taylor End 63014 President/CEO 584435 0 673131 0 127024 0 85650 0 28057 0 1498297 0 107104 0 Rhonda Anderson CSM President/CFO 417774 0 20000 0 4281 0 7650 0 7388 0 457093 0 0 0 Cheryl Hill VP/CHRO 294224 0 15000 0 11480 0 7650 0 20747 0 349101 0 6093 0 Gerri Lietz-Staffileno VP Hosp Operations 0 283405 0 15000 0 21808 0 7501 0 22557 0 350271 0 5366 David H Shapiro MD End 413 Chief Medical Officer 122544 0 500 0 171541 0 347002 0 9171 0 650758 0 3623 0 Suzanne Sanicola VP Physician Services 187313 0 15000 0 19681 0 6501 0 25929 0 254424 0 0 0 William Hart VP / COO 320148 0 15000 0 3177 0 7650 0 5626 0 351601 0 0 0 Bruce McCarthy MD President Hosp Div 541696 0 20000 0 36339 0 7650 0 32131 0 637816 0 0 0 Constance Bradley End 413 VP Hosp Operations 0 68422 0 0 0 119021 0 1949 0 7828 0 197220 0 0 Allan Spooner President Hospital Division 480119 0 90366 0 35075 0 7650 0 32131 0 645341 0 0 0 Jeffrey C Squier Payor Relations & Strategy Officer 215460 0 1204 0 315 0 6786 0 29463 0 253228 0 0 0 Michael E Sanderl VP Mission Integration and Advocacy 181095 0 52727 0 67544 0 5553 0 23592 0 330511 0 0 0 Clarissa L Cox VP Quality & Clinical 178937 0 15000 0 8238 0 5850 0 3279 0 211304 0 5019 0 David Mannes Controller 145204 0 31668 0 109 0 4570 0 24569 0 206120 0 0 0 Patricia L Allen Chief Financial Advsr-Hosp Dev 167922 0 1500 0 146 0 5179 0 11311 0 186058 0 0 0 Marian Purdue End 1012 Former Interim Pres Hosp Div 153750 0 0 0 0 0 0 0 0 0 153750 0 0 0 Deborah Friberg End 612 Former President Hosp Div 0 0 232993 0 0 0 0 0 5671 0 238664 0 0 0 Part I, Line 1a Payments were made to new president hospital division to assist with moving expenses and the sale of his home in calendar year 2013. Part I, Line 3 Ascension Health, a related organization of Columbia St. Mary's, Inc. uses the following to establish the compensation of the organization's President: - Compensation Committee - Independent Compensation Consultant - Compensation Survey or Study - Approval by the Board or Compensation Committee. Part I, Lines 4a-b Part I, Line 4a: Severance Payments: Deborah Friberg - $232,993 Constance J. Bradley: $118,575 David H. Shapiro, MD: $156,925 Part I, Line 4b: Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. The organization that paid the salaries of the individuals listed in Schedule H, Part II paid out of the supplemental nonqualified retirement plan in the amounts as noted: Mark R. Taylor - $107,104 Gerri G. Lietz-Staffileno - $5,366 Chery L. Hill - $6,093 Constance J. Bradley - $2,391 David H. Shapiro, MD - $3,623 Part I, Line 7 Part I, Line 7: Board Members, Officers, Key Employees and Highest Compensated Employees who are employed by the CSM Organizations and are medical doctors are eligible to receive a percentage of the revenue generated from patients they served, based on established guidelines. Officers and Key Employees participate in a management incentive place, whereby certain financial triggers of the CSM System as approved by the Board must be met before any eligible employee may receive payment of the incentive. Once the trigger is met, the incentive is measured based on various established goals, including operating margin, patient satisfaction, quality and productivity. Form 990, Part VI, Section A, line 2 Many of the persons listed in Part VII, Section A have a "business relationship" with each other by virture of employment for Columbia St. Mary's Inc. related entities. Form 990, Part VI, Section A, line 6 CSM has two corporate members: Ascension Health and Columbia Health System. Form 990, Part VI, Section A, line 7a One of CSM'S corporate members, Ascension Health, has the ability to elect members to the governing body of CSM. Form 990, Part VI, Section A, line 7b Ascension Health has designed a system authority matrix which assigns authority for key decisions that are necessary in the operation of the system. Specific areas that are identified in the authority matrix are: new organizations & major transactions; governing documents; appointments/removals; evaluation; debt limits; strategic & financial plans; assets; system policies & procedures. These areas are subject to certain levels of approval by Ascension per the system authority matrix. Columbia Health System has the authority to approve any changes to the governing documents which would affect its interest or rights in CSM, the mission and vision statements of CSM, and any major corporate structural transactions of CSM. Form 990, Part VI, Section B, line 11 Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form to the Board, or a designated committee, to review and answer any questions. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members questions. Form 990, Part VI, Section B, line 12c CSM has a written conflict of interest policy. The organization regularly and consistently monitors and enforces compliance with the policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer, and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflicts of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax exempt purpose. Form 990, Part VI, Section B, line 15b 15a. In determining the compensation of the organization's CEO, the process, performed by Ascension Health, a related organization of Columbia St. Mary's, Inc., included a review and approval by independent persons, comparability data and contemporaneous substantiation of the deliberation and decision. The Compensation Committee reviewed and approved the compensation. In the review of the compensation, the CEO was compared to individuals at other organizations in the area who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the committee minutes. The individual was not present when her compensation was decided. 15b. In determining compensation of other officers and key employees of the organization, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The compensation committee of the board of directors reviewed and approved the compensation. In the review of the compensations, the other officers and key employees of the organization were compared to other hospitals' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. Form 990, Part VI, Section C, line 19 The organization will provide any documents open to public inspection upon request. Form 990, Part VII, Section B: Independent Contractor Reporting Compensation of independent contractors is paid by and reported on the Form 1096, Annual Summary and Transmittal of U.S. Information Returns, of Ascension Health EIN 31-1662309. Expenses are allocated to and reimbursed by the filing organization to Ascension Health. As such, the organization has not reported independent contractors paid on Form 990, Part VII, Section B. Form 990, Part XI, line 9: DEFERRED PENSION COSTS 1,679,051. Equity Transfer - Temporarily Restricted 420,220. TRANSFER -A FFILIATES -16,056,484. TRANSFER - SPONSOR -618,400. COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 390806315 HOSPITAL WI 501(c)(3) 3 COLUMBIA ST MARY'S INC 1 COLUMBIA ST MARY'S HOSPITAL OZAUKEE INC 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 390807063 HOSPITAL WI 501(c)(3) 3 COLUMBIA ST MARY'S INC 1 SACRED HEART REHABILITATION INSTITUTE INC 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 390902199 REHAB FACILITY WI 501(c)(3) 3 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 1 COLUMBIA COLLEGE OF NURSING INC 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 391596986 COLLEGE WI 501(c)(3) 2 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 1 ASCENSION HEALTH PO BOX 45998 ST LOUIS MO 631455998 311662309 National Health System MO 501(c)(3) 11 Ascension Health Alliance 1 HORIZON HOME CARE & HOSPICE INC 8949 N DEERBROOK TRL MILWAUKEE WI 53223 391171298 HOME CARE/HOSPICE WI 501(c)(3) 3 N/A 0 COLUMBIA HEALTH SYSTEM 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 391494977 Health System WI 501(c)(3) 11 N/A 0 COLUMBIA ST MARY'S FOUNDATION INC 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 391494981 FOUNDATION WI 501(C)(3) 7 N/A 0 ASCENSION HEALTH ALLIANCE PO BOX 45998 ST LOUIS MO 631455998 453358926 NATIONAL HEALTH SYSTEM MO 501(c)(3) 11A N/A 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC 575 RIVERWOODS PKWY GLENDALE WI 53212 392015655 HEALTH CARE WI COLUMBIA ST MARY'S INC RELATED 14052074 28030348 0 1 0.50000 SLEEP SERVICES OF WISCONSIN LLC 111 E KILBOURN AVE STE 1300 MILWAUKEE WI 53202 273148310 SLEEP SERVICES WI cOLUMBIA ST MARY'S INC RELATED -142654 1067789 0 1 0.50000 CSM STRATEGIC ALLIANCE 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391871856 HEALTHCARE WI COLUMBIA ST MARY'S INC C -2000 424000 0.50000 0 MADISON MEDICAL AFFILIATES INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391855720 HEALTHCARE WI COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC C 1.00000 1 PROSPECT MEDICAL COMMONS CONDO ASSOCIATION 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 208042108 CONDO ASSOC WI COLUMBIA ST MARY'S INC C 134042 0.70000 1 0 0 1 0 1 0 0 0 0 1 1 1 0 0 1 1 1 1 0 Columbia St Mary's Hospital Milwaukee Inc L 90776749 Columbia St Mary's Hospital Ozaukee L 30251387 Sacred Heart Rehabilitation Institute L 2823792 Madison Medical Affiliates L 1376604 Ascension Health E 2285921 Ascension Health E 157488751 Ascension Health M 882000 Ascension Health M 1419795 AScension Health M 6827509 AScension Health M 250887 AScension Health M 6615000 Ascension Health M 298384 Ascension Health M 2922000 AScension Health M 1007381 Ascension Health M 31842033 Orthopaedic Hospital of Wisconsin O 11708468 Ascension Health K 73733 Madison Medical Affiliates R 8500000 Columbia Health System R 320016 Columbia St Mary's Foundation inc C 114241 Madison Medical Affiliates J 50821 Madison Medical Affiliates L 1319417 Madison Medical Affiliates L 2389248 Columbia Center L 126648 Orthopaedic Hospital of Wisconsin L 1105666 Columbia College of Nursing J 1111171