2015-11-12T09:51:37-06:00 2014-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIRCLE SUITE 4000 INDIANAPOLIS IN 46204 990 2014-01-01 273532963 INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL INC % BROC L BUDDE INDI 3179624575 950 N MERIDIAN STREET SUITE 800 INDIANAPOLIS IN 46204 Cara L Breidster CFO 2015-11-11 JENNIFER D RHODERICK P00395735 3176817000 2014 2016-02-25 16:41:14Z JEFFREY C ZEH 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 30739487 false X HTTP://IUHEALTH.ORG/WHITE-MEMORIAL/ X 2010 IN Improve the health of our patients and community through innovation and excellence in care, education, research, and service. 8 5 231 28 0 47351 179997 30146551 30034155 44772 -5995 949441 -63618 31188115 30144539 31541 25792 0 0 11032544 9443532 0 0 0 18442469 16158452 29506554 25627776 1681561 4516763 38269358 46430226 26843947 30485496 11425411 15944730 X Improve the health of our patients and community through innovation and excellence in care, education, research, and service. false false 22388248 25792 30034155 Indiana University Health White Memorial Hospital, Inc. ("IU Health White Memorial Hospital") is a 25-bed acute-care and critical access hospital that offers a broad range of services to care for its patients without regard to their ability to pay. IU Health White Memorial Hospital offers a comprehensive range of services that includes general medical/surgical services, a 24-hour emergency department, sophisticated diagnostic imaging services, laboratory, chemotherapy, home health and therapy services, as well as labor and delivery suites that provide a home-like setting yet contain all of the equipment needed to assist with labor, delivery and recovery. All patient rooms are private and boast warm colors and natural light to enhance comfort and health in a family-friendly environment that offers pullout beds for overnight stays and wireless internet access. 22388248 true true false true false false false false false true true false false false true false false true false false false false false false false false true true false false true false false false false false false true false false false false false false true true true false false true 53 0 true 231 true false false false false false false false false false false X 8 5 false false false false true true true true false false false true true true true true true true true false IN X BROC L BUDDE 3179624575 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 X LARRY W PAMPEL DDS CHAIR 2.0 5.0 X X 3600 8250 0 KATHLEEN M ALTMAN VICE CHAIR 2.0 0.0 X X 3600 0 0 JANET J FAKER DIRECTOR/SECRETARY 2.0 0.0 X X 3600 0 0 JAMES P BIEN MD DIRECTOR 2.0 55.0 X 0 269004 59707 GARY C COOLEY DIRECTOR 2.0 0.0 X 3600 0 0 ALFONSO W GATMAITAN DIRECTOR 2.0 55.0 X 0 530167 113574 RICHARD G HORTON DIRECTOR 2.0 0.0 X 3600 0 0 RANDALL R MITCHELL DIRECTOR 2.0 5.0 X 3600 9000 0 REGINALD L SHIREMAN DIRECTOR (PARTIAL YEAR) 2.0 0.0 X 2700 0 0 STEPHANIE J LONG RN CEO (PARTIAL YEAR) 50.0 0.0 X 181854 0 25700 BRIAN T SHOCKNEY INTERIM CEO (PARTIAL YEAR) 0.0 55.0 X 0 212964 56756 CARA L BREIDSTER CFO 0.0 55.0 X 0 247859 53881 ADEL M KHDOUR MD CMO 0.0 50.0 X 0 239971 58555 ROBERT B BONNER COORDINATOR, PHARMACY 50.0 0.0 X 113904 0 22969 JULIA M BUNNELL CLINICAL PHARMACIST 50.0 0.0 X 106617 0 28235 MARY E MINIER COO 50.0 0.0 X 103252 0 14270 529927 1517215 433647 4 false true false MONTICELLO EMERGENCY CARE LLC 720 S SIXTH STREET MONTICELLO IN 46960 MEDICAL 528632 INDIANA UNIVERISTY HEALTH ARNETT I 950 N MERIDIAN STREET SUITE 800 INDIANAPOLIS IN 46204 MEDICAL 378002 FREDERIC A HENNEY MD 720 S 6TH STREET SUITE J MONTICELLO IN 47960 MEDICAL 257237 MONTICELLO MED CENTER LLC 826 NORTH 6TH STREET MONTICELLO IN 47960 MEDICAL 251559 FISHER SCIENTIFIC LLC 13551 COLLECTIONS CTR DR CHICAGO IL 60693 MEDICAL 108139 5 6458 172099 1440 179997 NET PATIENT SERVICE REVENUE 621110 29552788 29552788 RENT FROM RELATED 501(C)(3) ORGS. 532000 233529 233529 SHARED SERVICES 541900 14334 14334 EHRC INCENTIVE 900099 233504 233504 30034155 31447 31447 0 0 240058 557506 -317448 0 -317448 -317448 0 0 3767 33675 -3767 -33675 -37442 -37442 0 0 0 CAFETERIA/FOOD SERVICE 721210 79511 79511 EDUCATION 900099 57360 57360 ALL OTHER REVENUE 900099 116959 116959 253830 30144539 30034155 -69613 X 25792 25792 0 0 0 231854 188764 43090 65954 53696 12258 7330320 5967973 1362347 269472 223210 46262 1017011 788538 228473 528921 429740 99181 0 75790 75790 5942 5942 2244 2244 0 1644 1644 4644101 4161885 482216 0 917 917 149486 145551 3935 18578 18578 0 603166 32005 571161 13313 9892 3421 0 9738 8523 1215 1199417 1170005 29412 0 1632276 1491288 140988 169344 132734 36610 DRUGS AND MEDICAL SUPPLIES 2813942 2813942 BAD DEBT 2451979 2451979 INSTITUTIONAL DUES/LICENSES 63281 63281 HOSPITAL ASSESSMENT FEE 385407 385407 1917887 1824548 93339 25627776 22388248 3239528 0 0 930 168380 7444514 0 0 2774279 4460000 0 0 0 0 0 0 363781 320725 94350 101905 37815687 5071339 33534027 32744348 1056669 1061650 0 0 0 0 0 0 277872 296154 38269358 46430226 2069173 3060663 0 0 0 0 0 0 0 0 0 0 229415 2242 0 0 24545359 27422591 26843947 30485496 X 11195020 15704160 52745 52745 177646 187825 11425411 15944730 38269358 46430226 X 4516763 -7622 10178 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 2244 2244 false Schedule C, Part II-B, Line 1i - Other Activities IU Health White Memorial Hospital paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2014 in the amount of $9,212 and $2,673, respectively. Each membership organization notified IU Health White Memorial Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 22.80%, or $2,100 of 2014 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The IHA used 5.38%, or $144 of the 2014 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The total membership dues paid to these organizations by IU Health White Memorial Hospital during 2014 that were attributable to lobbying expenditures was $2,244. 277877 15176 293053 143329 134496 52 277877 133831 15823 6325 143329 152745 -12566 6348 133831 0.00000 0.82002 0.17998 true true true 0 972779 972779 0 30187561 2417674 27769887 0 0 6506097 2587892 3918205 0 149250 65773 83477 32744348 0 INTERCOMPANY PAYABLES (NET) 23520398 DUE TO THIRD-PARTY PAYORS 3843197 SELF-INSURANCE LIABILITIES 58996 27422591 Schedule D, Part V, Line 4 - Intended Use of the Org.'s Endowment Funds The net income from restricted net assets is generally used for equipment, improvements, and maintenance of the hospital's facilities. Schedule D, Part X, Line 2 - FIN 48 (ASC 740) Footnote IU Health White Memorial Hospital is a subsidiary in the consolidated financial statements of IU Health. IU Health adopted FIN 48 in 2007. No disclosures were required in 2014 under GAAP as IU Health does not have any material tax contingencies that required disclosures in the footnotes. true true X true X true X true true true false true true 1725 1368210 1368210 0.05900 2290 4160230 3969217 191013 0.00820 4015 5528440 3969217 1559223 0.06720 18 1455 40325 2500 37825 0.00160 3 223 126051 126051 0.00540 2 31 1614 1614 0.00010 23 1709 167990 2500 165490 0.00710 23 5724 5696430 3971717 1724713 0.07430 1 7449 7449 0.00030 2 14500 5100 5100 0.00020 4 5522 31462 31462 0.00140 1 20 121 121 8 20042 44132 44132 0.00190 false 611712 12382943 11820303 562640 X true true 1 1 IU HEALTH WHITE MEMORIAL HOSPITAL 720 SOUTH SIXTH STREET MONTICELLO IN 47960 HTTP://IUHEALTH.ORG/WHITE-MEMORIAL/ 14-005034-1 X X X X IU HEALTH WHITE MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 13 true false false true X SEE PART V, SECTION C X true 13 true SEE PART V, SECTION C false false true X 200. 400. X X X X X X true true X X X true X X X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 5 - Input from Community In conducting each of its most recent CHNA, IU Health White Memorial Hospital took into account input from persons who represent the broad interests of the community it serves by hosting several community conversation focus groups. These focus groups included public health officials and community leaders to discuss the healthcare needs of the service area and what role IU Health could play in addressing the identified needs. To obtain a more complete picture of the factors that play into IU Health White Memorial Hospital's community's health, input from public health officials and community leaders in White County was gathered through two separate focus group sessions. The first was a two hour live group session at IU Health White Memorial Hospital, and the second was held via a phone conference call for those who were not able to meet in person. IU Health White Memorial Hospital facilitators mailed letters and made follow-up telephone calls inviting public health officials and community leaders to attend the focus group discussion, paying special attention to including organizations that represent the interest of low-income, minority, and uninsured individuals. The goal of soliciting these leaders' feedback was to gather insights into the quantitative data that may not be easily identified from the secondary statistical data alone. Attendees who participated in the focus group included: Melinda Molter - Customer Service Representative (CSR), White Oaks Health Campus - Ms. Molter is representative of a community perspective regarding senior health. As a CSR at White Oaks Health Campus, she works to provide access to various services for seniors within the community. Jerry Horner - Former President of the NCNC, Inc. Board of Directors Jim Annis - Town Council member, White County - Mr. Annis is representative of a community perspective regarding healthy living. As a member of the White County Town Council, he is knowledgeable in the community's needs and resources available to address those needs. Leslie Goss - Executive Director, White County Community Foundation - Ms. Goss is representative of a community perspective regarding economic development. As Executive Director of the Community Foundation in White County, she is knowledgeable on the financial stability of the community and the resources available to it. Tom Fletcher - Superintendent, Twin Lakes Schools, Monticello - Mr. Fletcher is representative of a community perspective regarding children's health and education. As the Superintendent of Twin Lakes Schools, he is familiar with the health issues and needs of children within the community. Don Koleszar - Vice President, White County Economic Development Organization - Mr. Koleszar is representative of a community perspective towards healthy living. As a board member of the White County Economic Development Organization, he is familiar with the general market and income of the community, as well as the obstacles low-income individuals in the area face. Nan Albright - Administrator, Monticello Assisted Living Health Care - Ms. Albright is representative of a community perspective regarding access to healthcare and healthy living. As an employee of Monticello Assisted Living Health Care, she is knowledgeable within the areas of patient care, needs, and access to services. Ken Houston - Mayor, City of Monticello - Mayor Houston is representative of a community perspective regarding healthy living. As mayor of Monticello, he is knowledgeable of the Monticello community's needs and the resources available to address those needs. Cindy Hicks - Manager, White County WorkOne Agency - Ms. Hicks is representative of a community perspective regarding employment in White County. As manager at the White County WorkOne Agency, she understands the issue of unemployment, lack of income, and the needs of the underserved populations, as well as ways to address those needs. Butch Kramer - Town Council member, White County Town Council - Mr. Kramer is representative of a community perspective regarding healthy living. As a member of the White County Town Council, he is knowledgeable on the community's needs and resources available to address those needs. James Mann - City Council member, Monticello City Council - Mr. Mann is representative of a community perspective regarding healthy living. As a member of the Monticello City Council, he is knowledgeable on the community's needs and resources available to address those needs. Randy Price - President and CEO, White County REMC - As the President and CEO of White County REMC, Mr. Price understands that the mission of the organization is to provide superior energy services and meaningful contributions to the community. Upon arrival to the focus group, participants were asked to list five health needs, which should be prioritized in their opinion, for the White County community served by IU Health White Memorial Hospital. These responses were collected and aggregated into a comprehensive list of identified needs to be further discussed later in the session and ranked for severity of need within the community. IU Health White Memorial Hospital facilitators then provided participants with a presentation featuring the mission of IU Health White Memorial Hospital, current outreach priorities, and local health data, including demographics, insurance information, poverty rates, county health rankings, causes of death, physical activity, chronic conditions, preventive behaviors, and community needs index. Upon completion of the data presentation, IU Health White Memorial Hospital facilitated a discussion on the comprehensive list of identified needs from earlier in the session. The objective of this method was intended to inspire candid discussions prior to a second identification of five prioritized health needs by each participant. The votes on the five prioritized health needs were tallied and final input from the group was encouraged during this process in order to validate the previously identified needs. Following additional discussion, participants were also asked to address what they thought the role of the IU Health White Memorial Hospital could be in meeting the local health needs. Schedule H, Part V, Section B, Line 7a - CHNA Website A copy of IU Health White Memorial Hospital's CHNA is available on its website at the following URL: http://iuhealth.org/about-iu-health/in-the-community/ Schedule H, Part V, Section B, Line 10a - Implementation Strategy Website A copy of IU Health White Memorial Hospital's CHNA implementation strategy is available on its website at the following URL: http://iuhealth.org/about-iu-health/in-the-community/ Schedule H, Part V, Section B, Line 11 - Addressing Identified Needs IU Health White Memorial Hospital prioritized and determined which of the community health needs identified in its most recently conducted CHNA were most critical for it to address by using the Hanlon Method of prioritization. This method prioritizes identified needs based upon the prevalence and severity of the need and the effectiveness of interventions available to address the needs. Based upon the Hanlon Method of prioritization, IU Health White Memorial Hospital selected the following four needs to be addressed: - Obesity Prevention - Access to Healthcare - PreK-12 Education - Health Education and Literacy Obesity Prevention To improve the lifestyle of Indiana residents, IU Health has utilized best practice methods to attack obesity in our communities. IU Health is working to improve access to nutritious foods and physical activity in low-income neighborhoods, in addition to providing traditional health education and public advocacy efforts. With these initiatives, IU Health strives to prevent chronic diseases such as obesity and diabetes and increase the awareness of the importance of making healthy choices, since Thirty-six percent of Hoosier adults are overweight and 29.5% are obese, costing the nations billions of dollars each year to treat these chronic health conditions. As part of the overall IU Health Day of Service, IU Health White Memorial Hospital collaborated with the Monticello Parks & Recreation office and had 25 volunteers work through two shifts at Altherr Nature Park. The volunteers removed ivy from the trees and trails, and moved a large amount of stone to cover multiple walking paths in the park. Others enjoyed pruning and raking debris from the flower gardens. Efforts were made with the park system as a way to encourage local residents to get out and get more physical activity by utilizing local parks. In order to provide educational information and promote health and safety to the Monticello community, IU Health White Memorial Hospital hosted its fifth annual Health & Safety Fair on May 3, 2014. More than 400 attendees received education about healthy eating, how to finance medical expenses and participated in BMI and blood pressure screenings. The hospital hosted a Teddy Bear Clinic where kids brought in their stuffed animals for a check-up and kids practiced putting out fires with the fire department and learned about water safety from the Indiana Department of Natural Resources. Access to Affordable Healthcare One of the first steps to improved health outcomes is having access to healthcare resources. To show its commitment to providing affordable healthcare access, IU Health White Memorial Hospital treats all patients regardless of their ability to pay. IU Health White Memorial Hospital is also working to raise awareness and work to identify individuals within our communities that have barriers to care and connect these individuals with better access and consistency of healthcare resources to meet their needs. In addition, IU Health White Memorial Hospital opened a Walk-In clinic in September of 2013. While not a full-service replacement for primary care, patients experiencing healthcare conditions from cold and flu to minor burns can be seen without an appointment. Before the clinic, patients had to utilize the hospital's emergency department or drive 35 miles to an urgent care facility. In 2014, the Walk-In Clinic served 6,128 patients. Level I emergency department visits have decreased greatly since the clinic opened. K-12 Education Education plays a crucial role in health outcomes. Level of education has an impact not only on personal health, but it has multigenerational implications as well. Children with a solid educational foundation and parents who are involved in their education are more likely to embrace healthy lifestyles and habits and succeed generally in life. Additionally, research from The National Center for Public Policy and Higher Education shows that greater educational attainment is associated with health-promoting behaviors, such as increased consumption of fruits and vegetables and other aspects of healthy eating; engaging in physical activity and refraining from smoking. Realizing that educational disparities appear early, IU Health is committed to enhancing childhood education to improve health and lifelong quality of life. Kindergarten Countdown Kindergarten Countdown is a free, four-week summer camp, sponsored by IU Health White Memorial Hospital in partnership with the United Way of White County. This program completed its third year and is held at North White Elementary School in White County. This program is designed to prepare children with little to no preschool experience for their new roles as kindergarten students. The camp is taught by licensed, experienced teachers and takes place in a school setting. Students attend school for half a day to adjust to the routines and procedures of kindergarten to help them transition into school. IU Health White Memorial Hospital supports Kindergarten Countdown as a community initiative to strengthen K-12 education. Since launching the program, IU Health White Memorial Hospital has provided volunteers, school supplies, books and healthy snacks from its cafeteria to the children who participate in the program each year. As part of its commitment to education and the community, IU Health White Memorial Hospital offers a job shadow class to Twin Lakes High School students. Each year, roughly 20 high school students learn about the various departments in the hospital and spend 15 hours a week during the spring semester shadowing IU Health White Memorial employees. The hospital is dedicated to helping local high school students expand their career options through shadowing and learning about careers in the medical field. Also, based upon the Hanlon Method of prioritization, the following identified community health needs were not chosen as one of the needs to be addressed: - Community collaboration and partnership - Senior health - Tobacco use and substance abuse After completing a gap analysis, IU Health White Memorial Hospital determined that the severity of and lack of resources available to address the four needs chosen to be addressed outweighed the severity of and resources available to address the four needs not chosen. Schedule H, Part V, Section B, Line 13b - Income Level Other than FPG In addition to FPG, IU Health White Memorial Hospital may take into consideration a patient's income and/or ability to pay in calculation of a financial assistance award. Schedule H, Part V, Section B, Line 13h - Other FAP Factors IU Health White Memorial Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. Alternate Sources of Assistance When technically feasible, a patient will be required to exhaust all other state and federal assistance programs prior to receiving an award from IU Health White Memorial Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health White Memorial Hospital's Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to their insurance provider at the request of IU Health White Memorial Hospital. Eligible patients who receive medical care from an IU Health White Memorial Hospital facility as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award to which IU Health White Memorial Hospital is entitled. Said patients may be asked to complete a financial assistance application. 2. Presumptive Financial Assistance Eligibility Patients who are deemed to be presumptively eligible for Financial Assistance will receive a Financial Adjustment to their final statement balance based on the patient's individual scoring criteria. Patients are considered to be presumptively eligible for Financial Assistance if the financial need has been determined by the following third parties: Eskenazi Health, formerly Wishard Memorial Hospital, Project Health, Indiana Children's Special Health Care Services, Medicaid, Out-of-State Medicaid, Healthy Indiana Plan, or Volunteers in Medicine. Patients are also considered to be presumptively eligible if they are pending Medicaid approval or have a hospital bill with a maximum balance to be determined by the Financial Assistance Committee and who meet certain risk segmentation scoring criteria. 3. Additional Considerations Financial Assistance may be granted to a deceased patient's account if said patient is found to have no estate. Additionally, IU Health White Memorial Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance application. Schedule H, Part V, Section B, Line 16a - FAP Website A copy of IU Health White Memorial Hospital's FAP is available on the following website: http://iuhealth.org/patients/my-iu-health/billing-services/financial-assis tance/ Schedule H, Part V, Section B, Line 16b - FAP Application Website A copy of IU Health White Memorial Hospital's FAP Application is available on the following website: http://iuhealth.org/patients/my-iu-health/billing-services/financial-assis tance/ Schedule H, Part V, Section B, Line 16i - Other Measures to Publicize IU Health White Memorial Hospital goes to great lengths to ensure patients know that it treats all patients regardless of their ability to pay. Although a complete copy of the financial assistance policy is not attached to each patient statement, a plain language summary is included instead. Additionally, on the back of each patient statement is a telephone number that allows patients to ask any questions about the policy and request financial assistance. Schedule H, Part V, Section B, Line 22d - Other Determination of Charges IU Health White Memorial Hospital limits the amounts charged for Emergency or other Medically Necessary Services provided to individuals eligible for assistance under its FAP to not more than amounts generally billed to individuals who have insurance coverage for such care. The basis for calculating the amount charged to all patients, including those who are eligible for Financial Assistance, is derived through the use of a chargemaster or physician fee schedule and are uniformly applied. All additional discounts required by insurance contract or IU Health White Memorial Hospital's FAP are applied to the chargemaster or physician fee schedule calculated amount. IU Health White Memorial Hospital does not use gross charges in the calculation of the amount to charge a Financial Assistance eligible patient. Schedule H, Part I, Line 3c - Other Factors Used in Determining Elig. Eligibility for financial assistance is determined based upon a patient's household income and number of members in the household. A patient is eligible for financial assistance, when the patient's: - Household income is equal to or less than 200% of the Federal Poverty Guidelines ("FPG"); or - Household income is greater than 400% of the FPG, the patient is an uninsured patient, and qualifies based on an established sliding scale. Additional financial assistance is available for patients whose health insurance does not provide full coverage for all of their medical expenses and whose medical expenses would make them indigent if they were forced to pay full charges. Schedule H, Part I, Line 6a - C.B. Report Prepared by a Related Org. IU Health White Memorial Hospital's community benefit and other investments, encompassing its total community investment, are included in the IU Health Community Benefit Report which is prepared on behalf of and includes IU Health and its related hospital entities in the State of Indiana ("IU Health Statewide System"). The IU Health Community Benefit Report is made available to the public on IU Health's website at http://iuhealth.org/communitybenefit/. The IU Health Community Benefit Report is also distributed to numerous key organizations throughout the State of Indiana in order to broadly share the IU Health Statewide System's community benefit efforts. It is also available by request through the Indiana State Department of Health or IU Health. Schedule H, Part I, Line 7, Column (f) - Bad Debt Expense The amount of bad debt expense included on Form 990, Part IX, Line 25, column (A), but subtracted for purposes of calculating the percentage of total expense is $2,451,979 Schedule H, Part I, Line 7 - Total Community Benefit Expense Schedule H, Part I, Line 7, Column (f), Percent of Total Expense, is based on column (e) Net Community Benefit Expense. The percent of total expense based on column (c) Total Community Benefit Expense, which includes direct offsetting revenue, is 19.89%. Schedule H, Part I, Line 7g - Subsidized Health Services IU Health White Memorial Hospital does not include any costs associated with physician clinics as subsidized health services. Schedule H, Part II - Promotion of Health in Communities Served IU Health White Memorial Hospital participates in a variety of community-building activities that address the underlying quality of life in the communities it serves. IU Health White Memorial Hospital invested over $44,000 in community-building activities by providing investments and resources to local community initiatives that addressed economic development, community health improvement, and workforce development. A few examples of outreach activities include participating in the local United Way's Kindergarten Countdown Camp and CPR training for Twin Lakes School Corporation bus drivers. Additionally, through IU Health White Memorial Hospital's team member community benefit service program, Strength that Cares, team members made a difference in the lives of Hoosiers. In 2014, IU Health White Memorial Hospital contributed to the community in a variety of ways including having team members volunteering their time with the White County Parks and Recreation Department to improve walking trails, landscape, prune and provide general cleanup at Altherr Nature Park in White County during the annual IU Health Day of Service. In addition, team members volunteered with the local United Way's Kindergarten Countdown Camp as a community initiative to strengthen K-12 education. Since launching the program, IU Health White Memorial Hospital has provided volunteers, school supplies, books and healthy snacks to the children who participate in the program. Schedule H, Part III, Line 2 - Methodology Used to Est. Bad Debt Exp. The bad debt expense of $611,712 reported on Schedule H, Part III, Line 2 is reported at cost, as calculated using the cost to charge ratio methodology. Schedule H, Part III, Line 4 - Bad Debt Expense The provision for uncollected patient accounts, for all payors, is recognized when services are provided based upon management's assessment of historical and expected net collections, taking into consideration business and economic conditions, changes and trends in health care coverage and other collection indicators. Periodically, management assesses the adequacy of the allowance for uncollectible accounts based upon accounts receivable payor composition and aging, the significance of individual payors to outstanding accounts receivable balances, and historical write-off experience by payor category, as adjusted for collection indicators. The results of the review are then used to make any modifications to the provision for uncollected patient accounts and the allowance for uncollectible accounts. In addition, IU Health White Memorial Hospital follows established guidelines for placing certain past due patient balances with collection agencies. Patient accounts that are uncollected, including those placed with collection agencies, are initially charged against the allowance for uncollectible accounts in accordance with collection policies of IU Health White Memorial Hospital and, in certain cases, are reclassified to charity care if deemed to otherwise meet financial assistance policies of IU Health White Memorial Hospital. Schedule H, Part III, Line 8 - Medicare Shortfall Although IU Health White Memorial did not have a Medicare shortfall for 2014, the Medicare surplus reported on Schedule H, Part III, Line 7 is calculated, in accordance with the Form 990 instructions, using "allowable costs" from IU Health White Memorial Hospital's Medicare Cost Report. "Allowable costs" for Medicare Cost Report purposes are not reflective of all costs associated with IU Health White Memorial Hospital's participation in Medicare programs. For example, the Medicare Cost Report excludes certain costs such as billed physician services, the costs of Medicare Parts C and D, fee schedule reimbursed services, and durable medical equipment services. Inclusion of all costs associated with IU Health White Memorial Hospital's participation in Medicare programs would switch this surplus to a shortfall. IU Health White Memorial Hospital's Medicare shortfall per the Medicare cost report is attributable to reimbursements that are less than the cost of providing patient care and services to Medicare beneficiaries and does not include any amounts that result from inefficiencies or poor management. IU Health White Memorial Hospital accepts all Medicare patients knowing that there may be shortfalls; therefore it has taken the position that the shortfall should be counted as part of its community benefit. Additionally, it is implied in Internal Revenue Service Revenue Ruling 69-545 that treating Medicare patients is a community benefit. Revenue Ruling 69-545, which established the community benefit standard for nonprofit hospitals, states that if a hospital serves patients with governmental health benefits, including Medicare, then this is an indication that the hospital operates to promote the health of the community. Schedule H, Part III, Line 9b - Written Debt Collection Policy If a patient cannot satisfy standard payment expectations, a financial assistance screening process for alternative sources of balance resolution is completed. Those resolutions may include a discount on charges, Medicaid enrollment, interest-free loan or application for charity care. If a patient does not apply for charity care but otherwise meets the charity care guidelines established by IU Health White Memorial, the charges will be waived and the cost of services would be treated as charity care. Schedule H, Part VI, Line 2 - Needs Assessment Communities are multifaceted and so are their health needs. IU Health White Memorial Hospital understands that the health of individuals and communities are shaped by various social and environmental factors, along with health behaviors and additional influences. IU Health White Memorial Hospital assesses the health care needs of the communities it serves by utilizing the detailed community needs assessment undertaken by organizations such as the White County Health Department, The Indiana State Department of Health, The Centers for Disease Control and Prevention and the United Way of Central Indiana. After completion of the CHNA, IU Health White Memorial Hospital reviewed the information gathered from community leader focus groups, community input surveys and statistical data. The needs identified were analyzed and ranked using the Hanlon method of prioritization to determine the prevalence and severity of community health needs and which ones were most critical. Additionally, the effectiveness of an intervention for each need and IU Health's ability to impact positive change was evaluated. Schedule H, Part VI, Line 3 - Patient Education of Eligibility for Assist. IU Health White Memorial Hospital goes to great lengths to ensure patients know that it treats all patients regardless of their ability to pay. IU Health White Memorial Hospital shares financial assistance information with patients during the admission process, billing process, and online. Helping patients understand that financial support for their care is available is a part of IU Health White Memorial Hospital's commitment to its mission. IU Health White Memorial Hospital's financial assistance policy exists to serve those in need by providing financial relief to patients who ask for assistance after care has been provided. During the admissions process, opportunities for financial assistance are discussed with patients who are identified as self-pay (uninsured) or if they request assistance information. The patient is also provided with an Admissions Packet that outlines information regarding IU Health White Memorial Hospital's financial assistance program. Financial counselors are onsite to assist with financial concerns or questions during the patient's stay. Patient Financial Services Customer Service representatives are also available after the patient's stay to help patients apply for financial assistance, understand their bills, explain what they can expect during the billing process, accept payment (if needed), update their insurance or payor information, and update their address or other demographic information. A plain language summary of the financial assistance policy is printed on the back of each patient statement, while the financial assistance application is mailed to all IU Health White Memorial Hospital patients with a patient balance due after insurance. Additionally, on the back of each patient statement is a telephone number that allows patients the ability to request financial assistance. Uninsured patients are also made aware of this process at the time of registration. IU Health White Memorial Hospital's financial assistance policy utilizes the federal poverty guidelines to determine eligibility. The goal is to make access to quality care within a patient's reach. The IU Health White Memorial Hospital Financial Assistance policy provides the following support to patients that qualify: - Free care for those earning up to 200 percent of federal poverty guidelines; - Discounted care on a sliding scale for families earning from 200 to 400 percent of federal poverty guidelines; and - Financial assistance to patients whose health insurance coverage, if any, does not provide full coverage for all of their medical expenses and whose medical expenses would make them indigent if they were forced to pay full charges. Patients are guided through their course of care with particular sensitivity, reviewing changing circumstances and allowing for financial assistance at any point during the relationship and billing process. For those inpatients that may qualify for the Medicaid program and have not applied, IU Health White Memorial Hospital financial counselors will assist patients with the Medicaid application. If a patient does not apply for financial assistance, but meets the financial assistance guidelines established by IU Health White Memorial Hospital, IU Health White Memorial Hospital will waive charges and treat the cost of services as financial assistance. Schedule H, Part VI, Line 4 - Community Information IU Health White Memorial Hospital is located in White County, Indiana, a county located in central northwest Indiana. White County includes ZIP codes within the towns of Brookston, Burnettsville, Chalmers, Monon, Monticello, Reynolds, and Wolcott. Based on the most recent Census Bureau (2012) statistics, White County's population is 24,466. The county's population estimates by race are 90.2% white, 6.8% Hispanic, 0.4% Asian, 0.8% Black, 0.6% American Indian or Alaska Native, 0.1% Native Hawaiian/Pacific Islander and 1.1% persons reporting two or more races. White county has modest levels of educational attainment. The level of education most of the population has achieved is a high school degree (88.8%). As of 2014, 14.7% of the population had a bachelor's degree or higher. IU Health White Memorial Hospital has a varied payor mix for inpatient services with 56.99% Medicare, 15.97% commercial, 22.97% Medicaid, and 4.07% self-pay. Outpatient services follow a similar pattern with 36.22% commercial, 35.13% Medicare, 16.12% Medicaid, and 12.53% self-pay. Discharge information for the hospital shows the majority of patients are from White County (77.37%), Carroll County (4.62%), Other Indiana Counties (3.87%), and Out-of-State (14.14%). Schedule H, Part VI, Line 5 - Promotion of Community Health IU Health White Memorial Hospital is a subsidiary of IU Health, a tax-exempt healthcare organization, whose Board of Directors is composed of members, of which substantially all are independent community members. IU Health White Memorial Hospital invests in its community to improve the quality of life of its community members. Several community benefit highlights are described below. IU Health White Memorial Hospital hosted its fifth annual Health and Safety Fair at the hospital during 2014. Over 400 people attended and received education about healthy eating habits, bike safety, fall prevention and car seat safety. In addition, an IU Health LifeLine helicopter, along with local police, conservation and fire trucks were on display to tour. The Monticello Fire Department provided their smoke house on site, allowing children to learn how to safely exit a smoky building. IU Health White Memorial Hospital is one of the few locations in the state that underwent Safe Haven training. The hospital provided Shaken Infant Syndrome/Safe Haven training to 32 nursing students and 45 students enrolled in the Twin Lakes School Corporation Medical Terminology Class. The hospital also has two Shaken Infant simulators and its staff works closely with the county prosecutor's office on cases where Shaken Infant Syndrome is suspected. Schedule H, Part VI, Line 6 - Affiliated Health Care System IU Health White Memorial Hospital is a part of the IU Health statewide healthcare system which continues to broaden its reach and positive impact throughout the state of Indiana. IU Health is Indiana's most comprehensive academic medical center and consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health, and IU Health Saxony Hospital. Other entities within the IU Health system are IU Health West Hospital, IU Health North Hospital, IU Health Ball Memorial, IU Health Blackford Hospital, IU Health Bloomington Hospital, IU Health Paoli Hospital, IU Health Bedford Hospital, IU Health Tipton Hospital, IU Health La Porte Hospital, IU Health Starke Hospital, IU Health Morgan and IU Health Goshen Hospital. Although each IU Health hospital prepares and submits its own community benefits plan relative to the local community, IU Health considers its community benefit plan as part of an overall vision for strengthening Indiana's overall health. A comprehensive community outreach strategy and community benefit plan is in place that encompasses the academic medical center downtown Indianapolis, suburban Indianapolis and statewide entities around priority areas that focus on health improvement efforts statewide. IU Health is keenly aware of the positive impact it can have on the communities of need in the state of Indiana by focusing on the most pressing needs in a systematic and strategic way. X X X X false true false false false false false false false JAMES P BIEN MD DIRECTOR 0 248513 0 0 0 20491 0 34500 0 25207 0 328711 0 0 ALFONSO W GATMAITAN DIRECTOR 0 409910 0 111219 0 9038 0 88931 0 24643 0 643741 0 0 STEPHANIE J LONG RN CEO (PARTIAL YEAR) 181231 0 0 0 623 0 7000 0 18700 0 207554 0 0 0 BRIAN T SHOCKNEY INTERIM CEO (PARTIAL YEAR) 0 211122 0 0 0 1842 0 27253 0 29503 0 269720 0 0 CARA L BREIDSTER CFO 0 245741 0 0 0 2118 0 33671 0 20210 0 301740 0 0 ADEL M KHDOUR MD CMO 0 239453 0 0 0 518 0 32244 0 26311 0 298526 0 0 Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan Alfonso W. Gatmaitan participates in an IU Health supplemental executive retirement plan, provisions of which are designed to retain its critical employees. The plan provides for an additional retirement benefit for service through normal retirement and other key dates. If the executive leaves prior to retirement or other key dates, the benefit may be forfeited or reduced. Alfonso W. Gatmaitan has an amount included in column c, deferred compensation, representing the current year unvested contributions made under the supplemental executive retirement plan. No amounts were actually paid to this executive during the year. PHILIP E PRESCOTT SEE PART V 65954 SEE PART V false Schedule L, Part IV, Line 1, Columns(b)(d) - Relationship and Description Philip E. Prescott, a family member of Kathleen Altman, Vice-Chair of IU Health White Memorial Hospital board of directors, served and was compensated as an employee of IU Health White Memorial Hospital. Part VI, Section A, Lines 6, 7a and 7b - Members or Stockholders Line 6: The sole member of IU Health White Memorial Hospital, Inc. is Indiana University Health, Inc. ("IU Health"), a 501(c)(3) tax-exempt organization. Line 7a: The Board of Directors of the IU Health White Memorial Hospital shall consist of up to nine (9) voting members appointed by IU Health, provided that without the consent of the Board of Directors, IU Health may not alter the requirement that at least seventy-five (75%) of the Directors must reside in White County. Line 7b: The following are subject to IU Health's approval: - Any proposed amendment to the Corporation's Articles of Incorporation of Bylaws; - Approval of the Corporation's annual capital and operating budgets; - Approval of any unbudgeted operating or capital budget items or deviations, including any issuance or guarantee of any unbudgeted debt, greater than the budgeted amount by (i) $250,000 per fiscal year per budget line item and (ii) $750,000 per fiscal year in the aggregate; provided, however, the foregoing limit shall be subject to change in the event certain performance standards are not met; - Approval of any strategic plan for the Corporation, including any amendments to a strategic plan; - Approval of any encumbrance, sale or conveyance of assets in excess of five percent (5%), on a cumulative basis, of the Corporation's Net Book Value, during any fiscal year; - Any merger, consolidation, joint venture or affiliation involving the Corporation or any of its affiliates and any other entity; - Appointment and removal of the Corporation's Chief Executive Officer, upon a recommendation of the Board; and - The dissolution of the Corporation or any of its affiliates. Part VI, Section A, Line 8b - Documentation of Meetings IU Health White Memorial Hospital, Inc.'s Board of Directors does not have any committees with the authority to act on behalf of the Board of Directors. Part VI, Section B, Line 11b - Review of Form 990 The CFO and IU Health Arnett's Audit Committee reviewed and approved the Form 990. Following their review and approval, a complete copy of the Form 990 was made available to each board member prior to its filing. Each member was also informed of the availability of IU Health's Tax Department to answer any questions. Part VI, Section B - Lines 12, 13, and 14 IU Health White Memorial Hospital is part of the IU Health system. As the sole member and controlling parent of IU Health White Memorial Hospital, IU Health and its board of directors have mandated that certain policies be followed to ensure greater standardization throughout the system. Thus, IU Health White Memorial Hospital's Board of Directors was not required to separately adopt a conflict of interest, whistleblower, document retention and destruction and joint venture policies because IU Health's Board of Directors had already adopted and required these policies to be followed by its subsidiaries. Part VI, Section B, Line 12c - Conflict of Interest Policy IU Health White Memorial Hospital follows IU Health's Conflict of Interest Policy. IU Health's Conflict of Interest Policy includes the following provisions: All IU Health employees, associates, colleagues and contracted personnel, including employed physicians and paid medical directors ("IU Health Representatives") are covered by and subject to its Conflict of Interest Policy. IU Health regularly and consistently monitors and enforces compliance with the policy through the following procedures: (a) On an annual basis, each IU Health Representative at the level of Manager or above, together with every other person designated by the Corporate Compliance Department ("Department"), must complete, sign and submit a Conflict of Interest Questionnaire ("Questionnaire") to the Department. Governing board members, committee members, corporate officers, medical staff and researchers must comply with the administrative requirements noted in the respective policies and procedures relative to those areas. (b) An IU Health Representative must supplement a Questionnaire in writing, if after completion of the original Questionnaire, a situation arises, or may reasonably be expected to arise, that would change any answer or information on the original Questionnaire if the situation had existed or been anticipated at the time of completion of the original Questionnaire. (c) If a fully and properly completed Questionnaire reveals facts or other information that might reasonably indicate a Conflict of Interest or violation of the policy, the IU Health Representative completing the questionnaire must secure approval by his/her supervisor, evidenced in writing. (d) The Department will review each Questionnaire and determine whether a Conflict of Interest exists and, if so, whether and how it should or may be eliminated, avoided or managed in order to comply with the spirit of the policy and with the best interests of IU Health and its patients. In making the determination, the Corporate Compliance Department may consult with the IU Health Representative's supervisor and other appropriate individuals and groups. (e) The scope of the policy is not limited to those who are required to complete Questionnaires. If an IU Health Representative is involved in a situation or relationship that would constitute a violation of the policy in the absence of disclosure and approval as described above, then the IU Health Representative must disclose the matter to his/her supervisor, secure his/her supervisor's approval in writing, and disclose the matter to the Department. Otherwise, the IU Health Representative is in violation of the policy and subject to corrective action, up to and including termination. (f) The Chief Compliance Officer, in consultation with onsite Compliance personnel, may from time to time appoint standing or ad hoc committees to assist in resolving issues that arise under provisions of the policy. Part VI, Section B, Line 15 - Process for Determining Compensation IU Health White Memorial Hospital has the following process for determining the compensation of its CEO: Periodically, and additionally as needed, IU Health White Memorial Hospital engages an outside compensation consulting firm to conduct a compensation and benefits study for its CEO and other senior executives. The resulting report prepared by the outside compensation consulting firm is provided to IU Health White Memorial Hospital's Human Resources Department for its review in determining compensation. The Board of Directors then reviews the report prepared by the outside compensation consulting firm and the Human Resources Department's recommendations regarding any changes in executive compensation and benefits. Additionally, the CEO has a written contract that is subject to approval by the Board of Directors. Part VI, Section C, Line 19 - Public Disclosure IU Health White Memorial Hospital, Inc.'s Articles of Incorporation are available to the public through the Indiana Secretary of State's web-site. IU Health White Memorial Hospital's conflict of interest policy is described on Form 990, Schedule O. IU Health White Memorial Hospital is a consolidated subsidiary in the consolidated financial statements for Indiana University Health, Inc. ("IU Health"). The consolidated financial statements for IU Health are available to the public through its bond filings. Part XI, Line 9 - Other Changes in Net Assets or Fund Balances During 2014, IU Health White Memorial Hospital, Inc. recorded the following changes in interest in net assets or fund balances: Change in Interest in Restricted Net Assets of Foundations: 10,178 FORM 990 PART IX LINE 11G DESCRIPTION:SHARED SERVICES/PROF. 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