2015-05-11T16:00:31-05:00 2014-09-30 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2013-10-01 390938661 BURNETT MEDICAL CENTER INC BURN 7154635353 257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840 CHARLIE FAUGHT CFO 7154635353 2015-05-11 1 HOLLY POKRANDT CPA P00449155 7158323407 2015-04-30 2013 2016-03-07 17:11:31Z CHARLES FAUGHT 257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840 20969021 0 X WWW.BURNETTMEDICALCENTER.ORG X 1957 WI THE MISSION OF BURNETT MEDICAL CENTER IS TO PROVIDE COMPASSIONATE, COMPREHENSIVE, COMMUNITY HEALTHCARE THAT EXCEEDS OUR CUSTOMER'S EXPECTATIONS. OUR MISSION, AS WELL AS OUR VISION AND VALUES, SERVES AS A GUIDELINE FOR DAILY DECISION MAKING AND REPRESENTS THE PRINCIPLES AND PRACTICES THAT WE CONSTANTLY APPLY. THE COMFORT AND CARE OF OUR PATIENTS IS A MAJOR FOCUS OF OURS. WE WANT TO BE THE HEALTHCARE PROVIDER OF "CHOICE" - PROVIDING EXPERT AND COST EFFECTIVE CARE IN A "HOMETOWN" ATMOSPHERE. ANOTHER OBJECTIVE OF OURS IS TO PROVIDE EDUCATION THAT WILL INCREASE HEALTH AWARENESS. PART OF OUR MISSION IS TO CONTINUALLY PUT THE "CARE" IN HEALTHCARE. MORE HEALTHCARE INFORMATION IS NOW AVAILABLE FROM OUR WEB SITE, WHICH ALSO PROVIDES PATIENT EDUCATION RESOURCES FOR THOSE WE SERVE. 7 7 263 11 0 0 84284 53248 19850355 20053755 4492 44307 0 0 19939131 20151310 0 0 0 0 10991071 11033913 0 0 0 9500185 9662167 20491256 20696080 -552125 -544770 23612760 22835231 16390966 16103125 7221794 6732106 X THE MISSION OF BURNETT MEDICAL CENTER IS TO PROVIDE COMPASSIONATE, COMPREHENSIVE, COMMUNITY HEALTHCARE. 0 0 12002400 12734133 BURNETT MEDICAL CENTER, INC., LOCATED IN RURAL NORTHWEST WISCONSIN IS A 17 BED CRITICAL ACCESS HOSPITAL THAT PROVIDES THE FOLLOWING SERVICES THROUGHOUT A THREE COUNTY REGION:ACUTE CARE HAS 50+ EMPLOYEES WHO ALSO WORK IN OBSTETRICS, OPERATING ROOM, EMERGENCY ROOM, AND POST ANESTHESIA RECOVERY. WE PROVIDE GENERAL INPATIENT MEDICAL AND SURGICAL CARE, AS WELL AS A LARGE VOLUME OF OUTPATIENT SERVICES WHICH INCLUDE BUT ARE NOT LIMITED TO: OP SURGERY, CHEMOTHERAPY, BLOOD TRANSFUSION, AND IV THERAPY. ALL OF THE RN STAFF IS ACLS ACCREDITED AND THE ENTIRE STAFF IS CERTIFIED IN CPR. THE GOAL OF THE NURSING STAFF IS TO PROVIDE EXCELLENT PATIENT CARE, CLOSE TO HOME, NEAR FAMILY AND FRIENDS.WE ALSO PROVIDE A FULL RANGE OF SERVICES FROM A 24/7 EMERGENCY ROOM TO CARDIAC REHABILITATION, AND WE PROVIDE OTHER THERAPEUTIC AND DIAGNOSTIC SERVICES VIA RADIOLOGY, LAB, PHYSICAL THERAPY, AND OCCUPATIONAL THERAPY.DURING FY 2014 IN A TOTAL OF 1,511 PATIENT DAYS WE SERVED 435 PATIENTS IN OUR INPATIENT AND SWING BED PROGRAMS AND ALSO HAD 39 BIRTHS. WE PERFORMED 650 SURGICAL PROCEDURES, SAW 4,325 PATIENTS IN EMERGENCY AND URGENT CARE, AND PROVIDED SERVICES FOR OVER 17,000 OTHER OUTPATIENT VISITS. GROSS HOSPITAL REVENUE OF $76,512 WAS PROVIDED AS CHARITY CARE TO 32 DIFFERENT PATIENTS FOR 154 EPISODES OF CARE.SINCE JUNE OF 2004, BURNETT MEDICAL CENTER, INC. HAS BEEN PARTICIPATING IN A PROGRAM DEVELOPED BY ABBOTT NORTHWESTERN HOSPITAL AND THE MINNEAPOLIS HEART INSTITUTE. THE LEVEL 1 HEART ATTACK PROGRAM IS AN INNOVATIVE APPROACH TO TREATING PATIENTS SUFFERING FROM A HEART ATTACK. THE KEY INGREDIENT FOR SUCCESS IS SPEED IN TREATMENT. THE GOAL IS TO TREAT AND TRANSPORT PATIENTS WITHIN 120 MINUTES, MEANING 120 MINUTES FROM THE TIME A PATIENT ENTERS THE EMERGENCY ROOM UNTIL THE FIRST BALLOON IS INFLATED OR STENT PLACED AT ABBOTT NORTHWESTERN HOSPITAL (ABNW).BECAUSE RURAL HOSPITALS DO NOT HAVE THE CAPABILITY TO DO ANGIOPLASTY, IT IS IMPORTANT TO MOVE A HEART ATTACK PATIENT TO THE NEAREST HOSPITAL THAT HAS A HEART CATHETERIZATION LAB. THE LEVEL 1 PROGRAM HAS A DEFINITE PROTOCOL TO MOVE THESE PATIENTS QUICKLY DURING THAT "GOLDEN HOUR" WHEN ANGIOPLASTY IS THE MOST SUCCESSFUL.BURNETT MEDICAL CENTER, INC. IS ONE OF 30 HOSPITALS IN MINNESOTA AND WISCONSIN PARTICIPATING IN THE LEVEL 1 PROGRAM. CLEARLY, THE LEVEL 1 PROGRAM IS ADVANTAGEOUS TO RESIDENTS OF BURNETT COUNTY, KNOWING THAT CARDIOVASCULAR DISEASE IS THE LEADING CAUSE OF DEATH FOR MEN AND WOMEN IN THE UNITED STATES. THIS TEAM APPROACH GIVES PATIENTS THE ADVANTAGE OF TIME WHICH TRANSLATES TO BETTER OUTCOMES AND DECREASED MORTALITY. BURNETT MEDICAL CENTER, INC.'S MEDICAL AND NURSING STAFF HAVE BEEN TRAINED FOR THIS PROGRAM AND ARE PREPARED AND PLEASED TO PROVIDE QUICK ACCESS TO EFFICIENT CARDIAC CARE THROUGH THE LEVEL 1 HEART ATTACK PROGRAM. 2904275 4071088 BURNETT MEDICAL CENTER CLINIC IS LOCATED JUST OFF HIGHWAY 70 IN GRANTSBURG AND IS PART OF OUR EXPANDED FACILITY. THE CLINIC IS STAFFED BY 24 EMPLOYEES INCLUDING (5) PHYSICIANS, (1) PHYSICIAN ASSISTANTS, (1) CERTIFIED NURSE PRACTITIONER, AND (1) CERTIFIED NURSE MIDWIFE.WE ARE PLEASED TO OFFER OUR PATIENTS A RANGE OF SERVICES INCLUDING: PHYSICALS (INCLUDING WELL CHILD CHECKS, PRE-OPERATIVE, DOT, ETC.), OBSTETRICAL EXAMS, HEALTH STATUS ASSESSMENTS, DIAGNOSIS AND TREATMENT OF COMMON, ACUTE, AND CHRONIC HEALTH CONDITIONS, IMMUNIZATIONS, FAMILY PLANNING, DIABETIC EDUCATION, WOMEN'S HEALTH, COLONOSCOPY PROCEDURES, FRACTURE CARE, VASECTOMIES, ROUTINE LABORATORY TESTING, EKG'S, AND HOLTER MONITORING. ADDITIONALLY, THE CLINIC LABORATORY IS A CERTIFIED COLLECTION SITE FOR URINE DRUG SCREENING.HOURS OF OPERATION HAVE BEEN EXPANDED TO ALLOW PEOPLE INCREASED ACCESS, INCLUDING WORKING FAMILIES WITH SCHOOL-AGE CHILDREN, PEOPLE THAT WORK VARYING SHIFTS, ETC. OUR PROVIDERS HAVE COLLABORATIVE RELATIONSHIPS WITH AREA INDUSTRIES, INCLUDING THE LOCAL SCHOOL SYSTEMS. THIS ALLOWS BURNETT MEDICAL CENTER CLINIC TO PROVIDE EDUCATIONAL OPPORTUNITIES TO EMPLOYEES OF THESE INDUSTRIES, INCLUDING BLOODBORNE PATHOGENS TRAINING, HEALTH EDUCATION TO SCHOOL CHILDREN, AND PARTICIPATION IN EMPLOYEE HEALTH FAIRS. BURNETT MEDICAL CENTER CLINIC PROVIDERS PARTICIPATE IN THE LOCAL ROTARY GROUP AND IN COUNTY COALITIONS TO REDUCE PRESCRIPTION DRUG ABUSE AND IMPROVE AWARENESS OF WELLNESS ACTIVITIES IN THE AREA. WE ALSO SPONSOR AN ANNUAL 5K EVENT THAT RAISES FUNDS FOR A LOCAL CHARITY WHILE PROMOTING HEALTHY LIFESTYLES - THIS YEAR IS OUR 9TH ANNUAL!OVER 16,000 PRIMARY CARE CLINIC VISITS WERE PROVIDED DURING FY 2014. CLINIC GROSS REVENUE OF $33,988 WAS PROVIDED AS CHARITY CARE TO 31 DIFFERENT PATIENTS IN 114 VISITS. 3344496 3248534 THE CONTINUING CARE CENTER OF BURNETT MEDICAL CENTER, INC. OFFERS 46 SEMI-PRIVATE AND 4 PRIVATE ROOM ACCOMMODATIONS AND A FULL RANGE OF HEALTH AND PERSONAL CARE SERVICES. PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY ARE AVAILABLE, AS WELL AS NUTRITIONAL SERVICES, RECREATIONAL ACTIVITIES, AND SOCIAL SERVICES. ADDITIONALLY, ADULT DAY CARE AND RESPITE CARE IS AVAILABLE. THE GOAL OF THE CONTINUING CARE CENTER'S STAFF IS TO PROVIDE NECESSARY HEALTH SERVICES WHILE MAINTAINING AN ATMOSPHERE OF HOPE, HARMONY, HUMOR, AND A "HOME" AWAY FROM HOME.WE STRIVE TO ENHANCE THE QUALITY OF RESIDENTS' LIVES VIA A VENUE FOR COMMUNITY-BASED VOLUNTEERS SHARING THEIR TIME AND TALENT WITH OUR RESIDENTS, SUCH AS MUSICAL BANDS, ROTARY CLUB SPONSORED FUNCTIONS, ETC.DURING FY 2014, WE HAD 17,453 RESIDENT DAYS SERVING ABOUT 120 DIFFERENT RESIDENTS. 18251171 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10 0 263 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X CHARLIE FAUGHT 7154635353 257 WEST SAINT GEORGE AVE GRANTSBURG WI 54840 RYAN BENSON DIRECTOR 0.50 X 0 0 0 DAN DOWLING DIRECTOR 0.50 X 0 0 0 RANDY CAREY DIRECTOR 0.50 X 0 0 0 JOLOUISE MCNALLY DIRECTOR 0.50 X 0 0 0 JAMES RICHISON II PRESIDENT 0.50 X X 0 0 0 MARILYN KOOIKER VICE PRESIDENT 0.50 X X 0 0 0 PATRICK TAYLOR SECRETARY/TREASURER 0.50 X X 0 0 0 CHARLES FAUGHT CFO 40.00 X 116509 0 24106 GORDON LEWIS CEO 40.00 X 199685 0 9640 TIMOTHY NOVICK PHYSICIAN 36.00 X 312422 0 30635 ADEOLA JOLAYEMI PHYSICIAN 40.00 X 190718 0 2010 VESNA RADIVOJEVIC PHYSICIAN 40.00 X 185574 0 2670 DONNA PILLATH ANESTHESIA 40.00 X 183784 0 11377 JOHN DINNIES PHYSICIAN ASSISTANT 40.00 X 153294 0 3741 1341986 0 84179 11 0 1 0 DR BLAISE VITALE MD SC 22592 ASSEMBLY DRIVE GRANTSBURG WI 54840 CLINIC AND ER ROOM PHYSICIAN 353214 SURGERY CLINIC OF SPOONER N6142 LITTLE VL ROAD SPOONER WI 54801 SURGICAL SERVICES 170000 2 8364 44884 53248 HOSPITAL PATIENT SERVICE REVENUE 621990 12734133 12734133 CLINIC PATIENT SERVICE REVNUE 621110 4071088 4071088 NURSING HOME RESIDENT SERVICE REV 623000 3248534 3248534 20053755 46802 46802 815216 817711 -2495 -2495 -2495 20151310 20053755 0 44307 X 360949 360949 8676423 7542628 1133795 1391480 1171618 219862 605061 523408 81653 40206 40206 14489 14489 56765 56765 2556975 2434737 122238 62719 62719 571943 446587 125356 75457 75457 1064032 1064032 79217 61955 17262 1352279 1352279 77978 77978 MEDICAL SUPPLIES 1605011 1605011 BAD DEBT EXPENSE 1195186 1195186 REPAIRS & MAINTENANCE 628073 617405 10668 NURSING HOME BED ASSESS 165618 165618 116219 70707 45512 20696080 18251171 2444909 0 20696080 18251171 2444909 0 168745 1327653 1503188 2821191 2624418 518404 490359 273954 314526 27563024 13758804 14389345 13804220 3491226 3590001 198779 188034 423463 320485 23612760 22835231 1158614 1451920 279535 80336 14704442 14192964 248375 377905 16390966 16103125 X 7209099 6719662 12695 12444 7221794 6732106 23612760 22835231 X -544770 55333 -251 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3448 3448 0 PART II-B, LINE 1: BURNETT MEDICAL CENTER, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND DEVELOPMENT. THE AHA AND WHA HAS NOTIFIED BURNETT MEDICAL CENTER, INC. THAT $3,448 ($2,552 TO AHA AND $896 TO WHA) OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 50000 50000 19919787 8598845 11320942 6708732 5159959 1548773 884505 884505 13804220 457(B) PLAN PAYABLE 283905 AMOUNTS PAYABLE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 94000 377905 X 18956124 0 18956124 1195186 1195186 20151310 19500894 0 19500894 1195186 1195186 20696080 PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE MEDICAL CENTER ASSESSES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAX AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE MEDICAL CENTER RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2014 AND 2013. FEDERAL RETURNS FOR THE YEARS ENDED SEPTEMBER 31, 2011, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT NET AGAINST REVENUE 1,195,186. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NET AGAINST REVENUE 1,195,186. 1 1 1 X 1 X 1 1 1 0 1 1 65302 65302 0.00330 4392324 3912352 479972 0.02460 4457626 3912352 545274 0.02790 15542 9138 6404 0.00030 5348262 3719982 1628280 0.08350 21043 21043 0.00110 5384847 3729120 1655727 0.08490 9842473 7641472 2201001 0.11280 0 699015 349500 4816806 4842134 -25328 X 1 1 1 1 BURNETT MEDICAL CENTER INC 257 WEST SAINT GEORGE AVENUE GRANTSBURG WI 54840 WWW.BURNETTMEDICALCENTER.COM 1034 X X X X BURNETT MEDICAL CENTER INC 1 1 X X X X X X X X X 12 1 0 1 X SEE PART V, LINE 5D X SEE PART V, LINE 5D X X X X X X X X 0 0 1 1 150.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X X 1 0 1 X 0 0 BURNETT MEDICAL CENTER, INC. PART V, SECTION B, LINE 3: THROUGHOUT THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROCESS, SPECIAL ATTENTION WAS FOCUSED ON UNDERSTANDING THE NEEDS OF THE MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS. TO ACHIEVE THIS, EFFORTS WERE MADE TO ENGAGE AND GATHER INPUT FROM INDIVIDUALS REPRESENTING THE BROAD INTERESTS OF THE COMMUNITY SERVED. THIS WAS ACCOMPLISHED IN THE FOLLOWING CAPACITIES: 1. CHNA CORE PARTNERS: AS THE PRIMARY DRIVERS OF THE PROCESS, FACILITATORS OF THE CHNA FROM BURNETT MEDICAL CENTER, BURNETT COUNTY DHHS-PUBLIC HEALTH, AND THE ST. CROIX TRIBAL HEALTH CLINIC, EACH BROUGHT KNOWLEDGE OF THEIR POPULATION SERVED, THEIR NEEDS, AND RESOURCES CURRENTLY AVAILABLE TO ADDRESS THOSE NEEDS. CORE PARTNERS ARE ALSO ACTIVELY INVOLVED IN OTHER COMMUNITY HEALTH-RELATED GROUPS AND CONVEYED INPUT REGARDING THE HEALTH NEEDS OF THE GROUPS' RESPECTIVE TARGET POPULATIONS THROUGHOUT THE PROCESS.2. PILOT COMMUNITY OF WISCONSIN CHIPP INFRASTRUCTURE IMPROVEMENT PROJECT: CHNA PARTNERS TOOK INTO ACCOUNT INPUT FROM STATE AND REGIONAL HEALTH DEPARTMENTS IN PLANNING AND EXECUTING THE CHNA. TOOLS CREATED BY THE HEALTH EDUCATORS AT THE WISCONSIN WESTERN REGION DIVISION OF PUBLIC HEALTH PROVIDED INPUT ON DATA SOURCES TO UTILIZE IN THE ASSESSMENT, HOW TO ANALYZE THE DATA SOURCES TO IDENTIFY SIGNIFICANT HEALTH NEEDS, AND HOW TO EXECUTE THE PROCESS FOR PRIORITIZING SIGNIFICANT HEALTH NEEDS.3. FOCUS GROUPS AND KEY INFORMANT INTERVIEW: FOCUS GROUPS WERE CONDUCTED WITH MEDICAL PROVIDERS AT BURNETT MEDICAL CENTER-ONE BEING THE MEDICAL DIRECTOR FOR THE BURNETT COUNTY HEALTH DEPARTMENT-THE BURNETT COUNTY FAMILY RESOURCE CENTER, AND THE GRANTSBURG AND SIREN/WEBSTER ROTARY CLUBS. THE KEY INFORMANT INTERVIEW WAS COMPLETED WITH A GRANTSBURG SCHOOL DISTRICT PRINCIPAL. QUESTIONS ASKED IN EACH WERE DESIGNATED TO GATHER INPUT ON WHAT PARTICIPANTS FELT TO BE THE BIGGEST ASSETS AND HEALTH CONCERNS AMONG BURNETT COUNTY RESIDENTS. 4. SURVEY: GREAT EFFORT WAS MADE TO GATHER INPUT FROM MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS THROUGH THE SURVEY. DEMOGRAPHIC QUESTIONS-ABOUT INCOME, INSURANCE TYPE, AND RACE/ETHNICITY, AMONG OTHERS-WERE ASKED IN ORDER TO IDENTIFY MEMBERS OF THOSE POPULATIONS AND THUS ENSURE THEIR REPRESENTATION. THE SURVEYS WERE DISTRIBUTED TO VARIOUS LOCATIONS AND GROUPS OF PEOPLE THROUGHOUT BURNETT COUNTY. THE SURVEY INSTRUMENT ASKED RESPONDENTS TO IDENTIFY WHAT THEY PERCEIVED TO BE THE BIGGEST HEALTH PROBLEMS AND RISKY BEHAVIORS AMONG BURNETT COUNTY RESIDENTS.5. COMMUNITY HEALTH MEETING: FINALLY, IN DISCUSSING AND PRIORITIZING THE SIGNIFICANT HEALTH NEEDS IDENTIFIED AT THE COMMUNITY HEALTH MEETING FACILITATED BY CHNA PARTNERS, INPUT WAS GATHERED FROM PUBLIC HEALTH REPRESENTATIVES, NOT-FOR-PROFIT ORGANIZATION PROFESSIONALS, AND OTHER INDIVIDUALS WHO SERVE UNDERSERVED GROUPS. BURNETT MEDICAL CENTER, INC. PART V, SECTION B, LINE 5D: THE CHNA IS AVAILABLE ON THE HOSPITAL'S WEBSITE AT:WWW.BURNETTMEDICALCENTER.COM/DOCS/COMMUNITY_NEEDS_ASSESSMENT_WEB.PDFTHE CHNA IS ALSO AVAILABLE ON THE FOLLOWING WEBSITES:WWW.HEALTHYBURNETT.ORGWWW.GREATRIVERSUNITEDWAY.ORG/OUR-WORK/COMMUNITY-NEEDS-ASSESSMENT/ADDITIONALLY, THE CHNA IS ATTACHED TO THE FORM 990. BURNETT MEDICAL CENTER, INC. PART V, SECTION B, LINE 7: OF THE TWELVE HEALTH FOCUS AREAS OUTLINED IN CHNA, BURNETT MEDICAL CENTER CHOSE NOT TO ADDRESS SEVERAL OF THEM. THESE CERTAIN NEEDS WERE NOT ADDRESSED DUE TO EITHER LACK OF HOSPITAL RESOURCES OR EXPERTISE, THE NEED BEING OF RELATIVELY LOW PRIORITY, AND/OR THE NEED IS CURRENTLY BEING ADDRESSED BY OTHERS. A LISTING OF THESE CERTAIN NEEDS CAN BE FOUND IN THE COMPLETE CHNA. BURNETT MEDICAL CENTER, INC. PART V, SECTION B, LINE 14G: REGISTRATION AND CLINIC PERSONNEL OFTEN REFER UNINSURED AND LOW-INCOME INDIVIDUALS TO A FINANCIAL COUNSELOR TO DISCUSS THE MEDICAL CENTER'S FINANCIAL ASSISTANCE POLICY. BURNETT MEDICAL CENTER, INC. PART V, SECTION B, LINE 20D: THE MEDICAL CENTER DETERMINES THE AMOUNT CHARGED TO FAP-ELIGIBLE INDIVIDUALS USING AN INCOME-BASED SLIDING FEE BASED ON FEDERAL POVERTY GUIDELINES. IF AN INDVIDUAL IS AT 150% OR LESS OF THE FEDERAL PORVERTY GUIDELINES, THEN THEY GENERALLY RECEIVE FREE CARE. IF THE INDIVIDUAL EARNS BETWEEN 150% AND 200% OF THE FEDERAL POVERTY GUIDELINES, THEN THEY RECEIVE A DISCOUNTED PRICE BASED ON A SLIDING FEE SCALE. 2 BURNETT MEDICAL CENTER CLINIC 257 W ST GEORGE AVE GRANTSBURG WI 54840 PROVIDER BASED RURAL HEALTH CLINIC THE CONTINUING CARE CENTER OF BURNETT MEDICAL CENTER 257 W ST GEORGE AVE GRANSTBURG WI 54840 SKILLED NURSING FACILITY PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE MEDICAL CENTER'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: THE COST OF SUBSIDIZED SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF THE SKILLED NURSING HOME, THE CLINIC, AND THE EMERGENCY ROOM DEPARTMENT. THESE SERVICES ARE UNAVAILABLE TO MEMBERS OF THE COMMUNITY OTHER THAN THROUGH BURNETT MEDICAL CENTER, INC. IT HAS BEEN THE GOAL OF BURNETT MEDICAL CENTER, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY.PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $1,195,186. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,195,186. PART II, COMMUNITY BUILDING ACTIVITIES: WE ARE CLOSE TO THE COMMUNITIES WE SERVE AND TAKE AN ACTIVE ROLE IN ADDRESSING THE ROOT FACTORS CONTRIBUTING TO OUR COMMUNITY'S HEALTH STATUS. WE DO SO THROUGH OUR INVOLVEMENT IN COMMUNITY-BUILDING PARTNERSHIPS THAT ADDRESS ECONOMIC DEVELOPMENT AND COMMUNITY HEALTH IMPROVEMENT ISSUES. THE MEDICAL CENTER'S CEO SERVES AS A BOARD MEMBER OF THE GRANTSBURG INDUSTRIAL DEVELOPMENT CORPORATION (GIDC). THIS ORGANIZATION SEEKS TO ENCOURAGE ECONOMIC GROWTH IN BURNETT MEDICAL CENTER, INC.'S PRIMARY SERVICE AREA. GIDC HAS A STRONG HISTORY OF BRINGING NEW INDUSTRY INTO THE AREA WHICH RESULTS IN INCREASED EMPLOYMENT OPPORTUNITIES AND STRENGTHENS THE LOCAL ECONOMY. KNOWING THAT UNEMPLOYMENT LEADS TO AN INCREASE IN UNHEALTHY BEHAVIORS, WHICH IN TURN CAN LEAD TO INCREASED RISK FOR DISEASE OR MORTALITY, GIDC'S MISSION OF ENCOURAGING ECONOMIC GROWTH DIRECTLY IMPACTS THE HEALTH OF BURNETT MEDICAL CENTER, INC.'S SERVICE AREA. FURTHERMORE, THE MEDICAL CENTER'S MARKETING DIRECTOR SERVES ON A LOCAL ADVOCACY GROUP, CITIZENS AGAINST POVERTY, WHICH SEEKS TO ELIMINATE BARRIERS CONTRIBUTING TO HIGH RATES OF POVERTY AMONG SERVICE AREA RESIDENTS. HAVING IDENTIFIED LACK OF ACCESS TO TRANSPORTATION AS A ROOT CAUSE OF POVERTY, THE GROUP'S FOCUS HAS BEEN TO ADVOCATE FOR A MEANS OF PUBLIC TRANSPORTATION IN THE SERVICE AREA. DUE TO THE RURAL NATURE OF THE COMMUNITIES SERVED BY BURNETT MEDICAL CENTER, INC., PROVIDING A MEANS OF TRANSPORTATION FOR RESIDENTS PROMOTES HEALTH BY INCREASING ACCESS TO JOB OPPORTUNITIES, TO GROCERY STORES AND FOOD SHELVES, AND TO HEALTHCARE SERVICES. THE PLANNED INTRODUCTION OF A PUBLIC TRANSPORTATION SYSTEM INTO THE SERVICE AREA THROUGH PARTNERSHIP WITH A NEIGHBORING COUNTY IS ONE EXAMPLE OF HOW THE GROUP'S EFFORTS ARE IMPROVING THE QUALITY OF LIFE OF AREA RESIDENTS. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE MEDICAL CENTER'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CHARITY CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE MEDICAL CENTER ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITY CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES. EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS, A SMALL AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARTIY CARE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE MEDICAL CENTER ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE MEDICAL CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE MEDICAL CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: BURNETT MEDICAL CENTER, INC. IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALY RECEIVED BY THE MEDICAL CENTER FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT BURNETT MEDICAL CENTER, INC. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT BURNETT MEDICAL CENTER, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF GRANTSBURG, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL MEDICAL CENTER PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE MEDICAL CENTER WOULD SHOW A LARGE LOSS ON THESE SERVICES. WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: PATIENTS RECEIVE OUR COMMUNITY CARE APPLICATION WHEN THEY PRESENT FOR SERVICES. THEY ARE ENCOURAGED TO REVIEW THE APPLICATION AND SUBMIT THE REQUIRED INFORMATION TO APPLY FOR POTENTIAL COVERAGE. IF THEY HAVE QUESTIONS OR NEED HELP WITH THE APPLICATION THEY MAY MEET WITH OUR FINANCIAL COUNSELOR AND/OR OUR BUSINESS OFFICE MANAGER. PART VI, LINE 2: WE HAVE USED MARKETING AND DEMOGRAPHIC DATA FOR BOTH OUR PRIMARY AND SECONDARY SERVICE AREAS AS SUPPLIED BY PROPRIETARY SOURCES FROM BOTH THOMSON REUTERS MARKET EXPERT, AND ITS SUCCESSOR COMPANY, TRUVEN ANALYTICS, AND THE MINNESOTA HOSPITAL ASSOCIATION. SUCH MARKET-BASED ANALYSIS PROVIDES ESTIMATES AND PROJECTIONS FOR THE MEDICAL NEEDS OF THOSE THAT LIVE WITHIN OUR SERVICE AREA. WE THEN LOOK AT THE AVAILABILITY OF EXISTING HEALTHCARE PROVIDERS AND SERVICES TO DETERMINE WHAT GAPS MAY EXIST, AND HOW WE CAN BEST BE A PART OF ADDRESSING UNMET NEEDS IN PARTNERSHIP WITH BOTH PUBLIC AND PRIVATE PROVIDERS OF HEALTHCARE SERVICES. THE RESULT OF OUR REVIEW AND ANALYSIS BECOMES A FUNDAMENTAL BASIS FOR THE DEVELOPMENT OF GOALS AND OBJECTIVES IN OUR STRATEGIC PLAN. FURTHER, WE COMPLETED OUR COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AS REQUIRED UNDER THE PATIENT PROTECTION AND AFFORDABLE CARE ACT DURING FY 2013. WE ARE PLEASED THAT WE WERE AWARDED A STATE OF WISCONSIN $5,000 MINI-GRANT WHICH ASSISTED US IN THE CONDUCT OF THE REQUIRED CHNA. IN CONDUCTING THE CHNA, A COMPREHENSIVE HEALTH NEEDS ASSESSMENT, USING BOTH QUANTITATIVE AND QUALITATIVE DATA, WAS PERFORMED IN COLLABORATION WITH TWO KEY COMMUNITY PARTNERS: BURNET COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES-PUBLIC HEALTH AND THE ST. CROIX TRIBAL HEALTH CLINIC. QUANTITATIVE DATA SOURCES, INCLUDING THE COUNTY HEALTH RANKINGS, THE UNITED STATES CENSUS BUREAU, THE WISCONSIN DEPARTMENT OF HEALTH SERVICES, WISCONSIN INTERACTIVE STATISTICS ON HEALTH, AND THE BEHAVIOR RISK FACTOR SURVEILLANCE SYSTEM, WERE USED TO ASSESS THE HEALTH NEEDS OF THE SERVICE AREA BY COMPARING COUNTY-LEVEL DATA FOR GIVEN INDICATORS OF HEALTH TO STATE AND NATIONAL BENCHMARKS. QUALITATIVE DATA WAS GATHERED FROM COMMUNITY MEMBERS AND ORGANIZATIONS TO DEVELOP AN UNDERSTANDING OF COMMUNITY PERCEPTIONS OF THE SERVICE AREA'S HEALTH NEEDS. THIS DATA WAS GATHERED THROUGH (1) AN INTERNET-BASED SURVEY AND PAPER SURVEY OF APPROXIMATELY 500 INDIVIDUALS, (2) FOUR FOCUS GROUPS, AND (3) A KEY INFORMANT INTERVIEW. AFTER DATA WAS COLLECTED, CHNA PARTNERS FACILITATED A COMMUNITY FORUM IN WHICH REPRESENTATIVES OF OTHER HEALTHCARE PROVIDERS, COMMUNITY GROUPS, AND LOCAL NON-PROFIT ORGANIZATIONS THAT HAVE AN INTEREST AND EXPERTISE IN THE HEALTH OF SERVICE AREA RESIDENTS WERE INVITED TO OFFER ADDITIONAL INPUT ON THE HEALTH NEEDS OF THE COMMUNITIES SERVED AND HELP PRIORITIZE THE IDENTIFIED NEEDS. THE RESULTS OF THE ASSESSMENT AND COMMUNITY FORUM WERE USED, ALONG WITH KNOWLEDGE OF EXISTING ASSETS AVAILABLE TO MEET IDENTIFIED HEALTH NEEDS, IN DEVELOPING AN IMPLEMENTATION STRATEGY THAT DELINEATES HOW BURNETT MEDICAL CENTER, INC. WILL TARGET EXISTING PROGRAMS AND RESOURCES, DEPLOY ADDITIONAL RESOURCES, AND COLLABORATE WITH OTHER COMMUNITY ENTITIES TO ADDRESS THE IDENTIFIED HEALTH NEEDS. FURTHERMORE, BURNETT MEDICAL CENTER, INC. HAS TAKEN A LEAD ROLE IN FORMULATING A COMMUNITY-WIDE PLAN TO ADDRESS THE TOP HEALTH NEEDS IDENTIFIED THROUGH THE CHNA. THE PLAN IS BEING EXECUTED BY THE COMMUNITY COLLABORATIVE "HEALTHY BURNETT" THAT WAS CREATED AS A RESULT OF THE CHNA TO ADDRESS THE IDENTIFIED HEALTH NEEDS. PART VI, LINE 3: PATIENTS ARE TOLD ABOUT OUR COMMUNITY CARE PROGRAM BY OUR FINANCIAL COUNSELOR, REGISTRATION STAFF, PATIENT ACCOUNT REPRESENTATIVES AND BUSINESS OFFICE MANAGER. IN ADDITION, WE HAVE SIGNS POSTED IN BOTH OUR CLINIC AND EMERGENCY ROOM REGISTRATION AREAS INFORMING OUR PATIENTS OF THE COMMUNITY CARE PROGRAM AVAILABLE AT OUR FACILITY. IF THE PATIENT FEELS THEY WILL NEED ASSISTANCE WITH THEIR MEDICAL BILLS, THEY ARE ENCOURAGED TO APPLY FOR THE COMMUNITY CARE PROGRAM WITH ALL THE REQUIRED INFORMATION.PATIENTS ALSO HAVE ACCESS TO THE COMMUNITY CARE APPLICATION INFORMATION ON OUR WEBSITE. WHILE WE DO NOT HAVE ANY CERTIFIED APPLICATION COUNSELORS, WE WERE PLEASED TO JOIN THE FEDERAL GOVERNMENT'S CHAMPIONS FOR COVERAGE CAMPAIGN TO HELP PROMOTE THE HEALTH INSURANCE MARKETPLACE. AS A CHAMPION FOR COVERAGE, WE HAVE UNDERTAKEN INITIATIVES TO DIRECT PEOPLE TO THE MARKETPLACE, INCLUDING SENDING OUR PATIENTS TO THE OFFICIAL CONSUMER SOURCES (HEALTHCARE.GOV WEBSITE AND CONSUMER CALL CENTER) TO LEARN ABOUT THE MARKETPLACE AND GET COVERAGE, HANGING POSTERS AND FACT SHEETS IN OUR FACILITY, INCLUDING AN ARTICLE ABOUT THE MARKETPLACE IN OUR QUARTERLY COMMUNITY NEWSLETTER, AND HAVING STAFF LEARN ABOUT THE MARKETPLACE IN EDUCATION SESSIONS. WE HAVE ALSO PARTICIPATED IN A COUNTY-WIDE EDUCATION SESSION ON THE NEW HEALTHCARE EXCHANGE AND HAVE WILLINGLY PROVIDED POSITIVE, RESPONSIVE ANSWERS TO MEDIA INQUIRIES. PART VI, LINE 4: LOCATED IN NORTHWESTERN WISCONSIN, BURNETT COUNTY IS 880 SQUARE MILES WITH 18.8 CITIZENS PER SQUARE MILE (COMPARED TO THE WISCONSIN AVERAGE OF 105 CITIZENS PER SQUARE MILE). BURNETT COUNTY IS THE PRIMARY SERVICE AREA FOR BURNETT MEDICAL CENTER AND IS THE SOLE HOSPITAL IN BURNETT COUNTY. WHILE BURNETT MEDICAL CENTER IS A 17-BED FEDERALLY DESIGNATED CRITICAL ACCESS HOSPITAL, IT ALSO HAS A 50-BED LONG-TERM CARE CENTER, AS WELL AS A PRIMARY CARE CLINIC. FURTHERMORE, BURNETT COUNTY IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA/POPULATION (ID NUMBER 03764), HAVING BEEN SO DESIGNATED ON JUNE 28, 1984. NOT LIMITED TO SERVING JUST BURNETT COUNTY, BURNETT MEDICAL CENTER, INC. ALSO PROVIDES CARE FOR RESIDENTS OF VARYING DEGREES TO RESIDENTS LIVING IN ONE OF THE FOUR ADJOINING WISCONSIN COUNTIES (DOUGLAS, WASHBURN, POLK, AND BARRON) AS WELL AS TWO ADJOINING COUNTIES IN MINNESOTA (PINE AND CHISAGO). BOTH BURNETT COUNTY IN WISCONSIN AND PINE COUNTY IN MINNESOTA ARE DESIGNATED AS MEDICALLY UNDERSERVED AREAS, AND THE REMAINING COUNTIES AFOREMENTIONED, HAVE AREAS WITHIN THEIR COUNTIES DESIGNATED AS MEDICALLY UNDERSERVED AS WELL. DEMOGRAPHICALLY, BASED ON THE MOST CURRENTLY AVAILABLE U.S. CENSUS DATA, THE 2012 ESTIMATES FOR BURNETT COUNTY REFLECT A POPULATION OF 15,382 WHICH IS ABOUT A .5% REDUCTION FROM THE 2010 CENSUS RESULTS. BURNETT COUNTY IS ONE OF WISCONSIN'S POORER COUNTIES WITH NEARLY ONE IN FIVE PERSONS (18.6%) LIVING BELOW THE POVERTY LEVEL COMPARED TO A STATE AVERAGE OF 12.5% AS WELL AS A MEDIAN INCOME OF $39,382, WHICH IS WELL BELOW THE STATE MEDIAN INCOME OF $52,657. DEMOGRAPHICALLY OUR OVER 65 YEARS OLD POPULATION REPRESENTS NEARLY ONE IN FOUR, OR 24.7% OF THE POPULATION, AND APPROACHING NEARLY DOUBLE THE WISCONSIN STATE AVERAGE OF 14.4%. ACCORDING TO THE U.S. CENSUS, WHILE THE COUNTY POPULATION IS COMPRISED OF PREDOMINATELY WHITE PERSONS AT 91.8%, OUR NEXT LARGEST POPULATION IS AMERICAN INDIAN AT 4.8% (COMPARED TO 1.1% OVERALL FOR THE STATE).THERE ARE SIMILARITIES IN OUR SECONDARY SERVICE AREAS. FOR INSTANCE, IN THE NEIGHBORING COUNTIES OF POLK COUNTY IN WISCONSIN AND PINE COUNTY IN MINNESOTA, BASED ON CENSUS BUREAU DATA, THEIR COMPARISONS SHOW THEY TOO HAVE FAR FEWER PERSONS PER SQUARE MILE, AND ARE RELATIVELY LOWER THAN THEIR RESPECTIVE STATE AVERAGES FOR MEDIAN HOUSEHOLD INCOME, AND RELATIVELY HIGHER IN THE 65+ YEARS OF AGE POPULATION, AS WELL AS HAVING GREATER THAN STATE AVERAGE OF BOTH WHITE PERSONS AND AMERICAN INDIANS.DESPITE OUR RURAL LOCATION IN NORTHWEST WISCONSIN, WE ARE IN A RELATIVELY COMPETITIVE MARKET AS RESIDENTS FROM BOTH OUR PRIMARY AND SECONDARY SERVICE AREAS HAVE ACCESS TO TEN HOSPITALS (IN EITHER WISCONSIN OR MINNESOTA) WITHIN 50 MILES OF BURNETT MEDICAL CENTER, INC.'S GEOGRAPHIC LOCATION IN GRANTSBURG, WISCONSIN. AS STATED PREVIOUSLY, BURNETT MEDICAL CENTER, INC. ALSO OPERATES A CLINIC WHICH IS ONE OF MANY COMPETITOR CLINICS WITHIN OUR PRIMARY AND SECONDARY MARKETS. FINALLY, WE TAKE OUR ROLE AS A VITAL PART OF A NECESSARY HEALTHCARE SAFETY NET FOR ALL SERIOUSLY, INCLUDING THE UNINSURED, AS EVIDENCED BY OUR 24/7 EMERGENCY DEPARTMENT WHICH PROVIDES EMERGENT, URGENT, AND PRIMARY CARE TO ALL THAT PRESENT TO THE EMERGENCY DEPARTMENT. PART VI, LINE 5: AS A SOLE COMMUNITY RURAL HOSPITAL WE TAKE PRIDE IN BEING CLOSE TO THOSE WE SERVE. WE SHARE WITH THE COMMUNITY VIA PRINT AND RADIO MEDIA, AS WELL AS A GROWING USE OF OUR WEBSITE AND OTHER SOCIAL MEDIA CONTENT OUTLETS, RELEVANT AND HELPFUL KNOWLEDGE OF OUR SERVICES. WE ALSO SHARE AND PROMOTE OUR MISSION THROUGHOUT THE COMMUNITIES SERVED. WE LEARN DIRECTLY FROM THOSE WE SERVE BY OUR GOVERNING STRUCTURE WHICH IS COMPOSED OF SEVEN UNCOMPENSATED COMMUNITY VOLUNTEERS FROM THROUGHOUT BURNETT COUNTY, THAT RESIDE IN EITHER OUR PRIMARY OR SECONDARY SERVICE AREA, NONE OF WHICH ARE NEITHER EMPLOYEES, CONTRACTORS, NOR FAMILY MEMBERS. WE ENJOY THE CONTINUED SUPPORT OF OUR COMMUNITY WITH THE ESTABLISHMENT OF A HEALTHCARE FOUNDATION WHICH PROVIDES PHILANTHROPIC SUPPORT TO FULFILLING THE HOSPITAL'S MISSION. IN ORDER TO ENSURE CONTINUED AND READY ACCESS TO QUALIFIED HEALTHCARE PROVIDERS, WE TAKE PRIDE IN HAVING AN OPEN MEDICAL STAFF MODEL THAT EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PROVIDERS IN OUR COMMUNITY. WHEN WE HAVE SURPLUS FUNDS, THOSE FUNDS ARE USED FOR IMPROVEMENTS IN PATIENT CARE AND QUALITY, AS EVIDENCED BY OUR RECENT RENOVATIONS TO OUR LONG-TERM CARE CENTER AND OUR RADIOLOGY DEPARTMENT. WE ALSO HAVE CONTINUED INVESTMENTS AS AN EARLY ADOPTER OF THE ELECTRONIC MEDICAL RECORD, SUCCESSFULLY MEETING STAGE ONE MEANINGFUL USE GOALS. ADVOCACY OF THE COMMUNITIES' HEALTHCARE NEEDS ARE DONE LOCALLY BY MEMBERS OF THE BOARD SPEAKING WITH LOCAL OFFICIALS ON RELEVANT ISSUES THAT MAY AFFECT THE HOSPITAL. ADDITIONALLY, THE HOSPITAL'S CEO SERVES AS A MEMBER OF THE WISCONSIN HOSPITAL ASSOCIATION'S BOARD OF DIRECTORS WHICH ADVOCATES FOR INITIATIVES FOR COMMUNITY, STATE, AND NATIONAL EFFORTS FOR IMPROVING THE OVERALL HEALTH OF THE POPULATION AND CONTINUED READY ACCESS TO QUALITY HEALTHCARE FOR ALL. MINDFUL OF THE NEED FOR SUPPORT OF VARIOUS METHODS OF INSURANCE, WE ARE PROUD OF OUR PARTICIPATION IN SUCH GOVERNMENTALLY-SPONSORED HEALTHCARE PROGRAMS SUCH AS MEDICARE, MEDICAID, AND TRICARE. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X 0 0 0 0 0 0 0 0 0 GORDON LEWIS CEO 170041 0 29035 0 609 0 0 0 9640 0 209325 0 0 0 TIMOTHY NOVICK PHYSICIAN 311700 0 0 0 722 0 0 0 30635 0 343057 0 0 0 ADEOLA JOLAYEMI PHYSICIAN 190549 0 0 0 169 0 0 0 2010 0 192728 0 0 0 VESNA RADIVOJEVIC PHYSICIAN 185411 0 0 0 163 0 0 0 2670 0 188244 0 0 0 DONNA PILLATH ANESTHESIA 183758 0 0 0 26 0 0 0 11377 0 195161 0 0 0 JOHN DINNIES PHYSICIAN ASSISTANT 152855 0 0 0 439 0 0 0 3741 0 157035 0 0 0 A BURNETT COUNTY 396005675 2007-03-23 7000000 TO REFINANCE AND PROVIDE FUNDS FOR BUILDING RENOVATION AND EXPANSION 0 0 0 B VILLAGE OF GRANTSBURG 396006277 2007-04-10 5000000 TO PROVIDE FUNDS FOR BUILDING RENOVATION AND EXPANSION 0 0 0 C VILLAGE OF SIREN 396008452 2007-04-25 4850000 TO PROVIDE FUNDS FOR BUILDING RENOVATION AND EXPANSION 0 0 0 A 1108747 7000000 140000 5464764 1395236 2008 1 0 1 1 B 785934 5000000 100000 4900000 2008 0 0 1 1 C 762355 4850000 97000 4753000 2008 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 0 0 0 0 0 B 0 0 1 0 0 0 0 0 0 C 0 0 1 0 0 0 0 0 0 A 0 B 0 C 0 FORM 990, PART VI, SECTION A, LINE 6 EACH PERSON, BUSINESS, CORPORATION, OR ORGANIZATION WHO HAS CONTRIBUTED AND PAID ONE HUNDRED DOLLARS OR MORE TO BURNETT MEDICAL CENTER, INC. "THE MEDICAL CENTER" SHALL BE A LIFETIME MEMBER OF THE MEDICAL CENTER. EACH PERSON, BUSINESS, CORPORATION, OR ORGANIZATION IS ENTITLED TO HOLD A MAXIMUM OF ONE MEMBERSHIP CERTIFICATE. A HUSBAND AND WIFE, OR TWO OR MORE RELATED PERSONS, MAY HOLD A MEMBERSHIP AS JOINT TENANTS, HOWEVER, ONLY ONE VOTE PER MEMBERSHIP SHALL BE PERMITTED. FORM 990, PART VI, SECTION A, LINE 7A THE DUTIES OF THE MEMBERS OF THE MEDICAL CENTER SHALL BE: THE FORMULATION AND DEVELOPMENT OF THE OVERALL PURPOSES, OBJECTIVES, AND PHILOSOPHY OF THE MEDICAL CENTER; THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE MEDICAL CENTER; THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE MEDICAL CENTER; THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS; THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE MEDICAL CENTER; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE MEDICAL CENTER OR ITS MERGER WITH ANOTHER CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS FOR BURNETT MEDICAL CENTER, INC. REVIEWS AND APPROVES FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BURNETT MEDICAL CENTER, INC. HAS A CONFLICT OF INTEREST POLICY. THE PURPOSE OF THIS POLICY IS TO PROTECT THE INTEREST OF THE MEDICAL CENTER WHEN IT IS CONTEMPLATING ENTERING INTO A TRANSACTION OR ARRANGEMENT THAT MIGHT BENEFIT THE PRIVATE INTEREST OF AN OFFICER OR DIRECTOR OF THE CORPORATION. IT IS EXPECTED THAT SUCH PERSONS SHALL EXERCISE THE UTMOST GOOD FAITH IN ALL TRANSACTIONS TOUCHING UPON THEIR DUTIES AT BURNETT MEDICAL CENTER, INC. AND ITS PROPERTY. ALL MEMBERS OF THE BOARD COMPLETE A DISCLOSURE FORM UPON APPOINTMENT, AND REVIEW AND SIGN IT ANNUALLY THEREAFTER. THIS STATEMENT ESTABLISHES THE DUTY OF AN INTERESTED PARTY TO DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST DISCLOSE ALL MATERIAL FACTS. AFTER ANY SUCH DISCLOSURE, HE/SHE SHALL LEAVE THE GOVERNING BOARD MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD MEMBERS. IF THE BOARD HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS OF SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF MEMBERS FAIL TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 BURNETT MEDICAL CENTER INC.'S EXECUTIVE COMPENSATION POLICY IS DESIGNED WITH THE GOAL OF PROVIDING REMUNERATION THAT IS FAIR, REASONABLE, AND COMPETITIVE. THE MEDICAL CENTER'S BOARD MAY ESTABLISH A COMPENSATION COMMITTEE OR MAY ACT AS A COMMITTEE OF THE WHOLE IN EXECUTIVE SESSION. THE COMMITTEE OVERSEES THE TOTAL COMPENSATION PACKAGES TO ENSURE THAT THEY ARE COMPETITIVE WITH OTHER HEALTHCARE ORGANIZATIONS, REFLECT JOB RESPONSIBILITIES AND REQUIREMENTS, AND ARE FAIR, EQUITABLE, AND CONSISTENTLY MANAGED. THE COMMITTEE MEETS AS OFTEN AS IT DEEMS APPROPRIATE TO CARRY OUT ITS RESPONSIBILITIES. IN GENERAL, THE MEDICAL CENTER POSITIONS TOTAL EXECUTIVE COMPENSATION AT THE MEDIAN OF THE MARKET. THE BOARD OF DIRECTORS USES CONTEMPORANEOUS DATA INCLUDING EXECUTIVE COMPENSATION DATA FROM THE WISCONSIN HOSPITAL ASSOCIATION AS A GUIDE WHEN APPROVING THE COMPENSATION OF THE ADMINISTRATOR AND CHIEF FINANCIAL OFFICER. THE POLICY IS MEANT TO BE FLEXIBLE SO THAT COMPENSATION CAN BE ABOVE OR BELOW THE MEDIAN BASED ON EXPERIENCE, PERFORMANCE, SIZE AND COMPLEXITY OF ORGANIZATION, AND BUSINESS NEED TO ATTRACT AND RETAIN EXECUTIVE TALENT. FORM 990, PART VI, SECTION C, LINE 19 BURNETT MEDICAL CENTER, INC. MAKES IT FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS. FORM 990, PART IX, LINE 11G LABORATORY: PROGRAM SERVICE EXPENSES 135,985. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 135,985. RADIOLOGY: PROGRAM SERVICE EXPENSES 190,011. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 190,011. DIETARY: PROGRAM SERVICE EXPENSES 405,665. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 405,665. EMERGENCY ROOM: PROGRAM SERVICE EXPENSES 159,432. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 159,432. LAUNDRY: PROGRAM SERVICE EXPENSES 218,630. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 218,630. PHYSICIAN: PROGRAM SERVICE EXPENSES 442,892. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 442,892. OTHER: PROGRAM SERVICE EXPENSES 882,122. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 882,122. MANAGEMENT & GENERAL: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 122,238. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 122,238. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION: -251. FORM 990, PART XII, LINE 2C: OVERSIGHT OF THE AUDIT: BURNETT MEDICAL CENTER, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.