2015-10-28T10:25:58-05:00 2014-12-31 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2014-01-01 020497927 Wentworth-Douglass Physician Corporation WENT 6037425252 789 Central Avenue Dover NH 038202526 Peter E Walcek CFO/VP of Finance 6037422804 2015-10-19 1 Nicholas E Porto P01310283 2078792100 2015-10-19 2014 2016-02-25 16:41:14Z Wentworth Health Partners Gregory J Walker 789 Central Avenue Dover NH 038202526 35282963 0 X N/A X 1998 NH Improve the health of the community by providing high quality healthcare. 10 4 402 4 38120 -10346 5031 9128 32670189 35165930 -1320 533 73599 75480 32747499 35251071 0 0 0 0 37618695 40771874 0 0 0 15457889 15783015 53076584 56554889 -20329085 -21303818 5111146 6434572 6464459 7506377 -1353313 -1071805 X Improve the health of the community by providing high quality health care that exceeds expectations through an integrated network of highly qualified professionals. 0 0 51899458 0 35071827 Wentworth-Douglass Physician Corporation (WDPC) was formed in response to a community needs assessment that identified a lack of primary care and specialty services in the community. The formation of the Physician Corporation and recruitment of primary care and specialty physicians closed the gap by improving access to medical services in Dover, NH and surrounding areas. (See Schedule O for a list of facilities operated by WDPC.)In 2014, the Corporation provided for a total of 217,480 patient visits. 533345 0 131463 The Wentworth-Douglass Community Dental Center is open to low-income, uninsured adults and children living in Wentworth-Douglass Hospital's primary service area (Dover, Durham, Madbury, Lee, Barrington, Somersworth, Rollinsford, NH and Berwick and So. Berwick, ME) or patients of the physician practices who have a family income at or below 300% of the federal poverty guidelines. In 2014, a total of 3,049 patient visits were recorded, resulting in a net community benefit cost of approximately $382,000.WDPC provided community benefits totaling nearly $940,000 in 2014, which includes $180,000 in behavioral health (continued on Schedule O) services. The Corporation supports numerous community based programs, including the Community Dental Center.WDPC provides financial aid information and resources to assist patients with their healthcare bills. Medical care is provided at no charge for eligible patients at 250% of the federal poverty level. In 2014, WDPC provided $378,000 of financial aid (stated at cost). Medicaid Costs Exceeding Reimbursement totaled $572,000 for the Corporation in 2014. 52432803 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 1 402 1 1 1 0 0 0 0 0 0 0 0 0 X 10 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Peter E Walcek CFOVP of Finance 6037402804 789 Central Avenue Dover NH 038202526 X Paul R Cass DO Director/Physician 2.00 48.00 X 0 456586 87125 Matthew Goldberg DO Director/Physician 65.00 X 239575 0 13425 Nancy J Pettinari MD Director/Physician 65.00 X 288484 0 11347 Gary Usher MD Director/Physician 65.00 X 306242 0 5537 Neil Garvey Director (thru. 4/14) 1.00 2.50 X 0 0 0 Roger Hamel Chairman 1.00 6.00 X X 0 0 0 Carol Bailey Vice Chairman 1.00 4.00 X X 0 0 0 Michael Steinberg Treasurer 1.00 4.00 X X 0 0 0 John Salmon Secretary (eff. 4/14) 1.00 4.00 X X 0 0 0 Gregory J Walker President/CEO, WDH 2.00 53.00 X X 0 778792 153784 Peter E Walcek CFO/VP Finance, WDH 2.00 53.00 X X 0 382174 93713 Barbara F Civiello MD Physician 65.00 X 561150 0 33156 Paul T Berry MD Physician 65.00 X 538094 0 27049 Henry L Sonneborn MD Physician 65.00 X 515558 0 19726 Lazaro A Diaz MD Physician 65.00 X 472692 0 27908 Christopher Lawson MD Physician 65.00 X 430218 0 11555 3352013 1617552 484325 95 0 1 0 0 9128 9128 Patient Service Revenue 621110 33262322 33262322 Other Related Function Income 621990 1386679 1348559 38120 Meaningful Use 621110 516929 516929 35165930 107221 31741 75480 75480 75480 684 151 533 533 533 35251071 35203290 38120 533 X 864610 864610 33163094 31139711 2023383 343628 322048 21580 3681058 3449888 231170 2719484 2548700 170784 20000 20000 6446994 5367973 1079021 42845 42845 1669467 1368335 301132 3409174 3224826 184348 261201 213378 47823 623726 623726 873096 873096 Provision for Bad Debt 1343871 1343871 Dental Community Benefi 401882 401882 Pharmacy Expense 369446 369446 Transcription 321313 321313 56554889 52432803 4122086 0 135410 390186 3078008 3796784 9612501 7368596 1894031 2243905 3697 3697 5111146 6434572 6464459 7506377 6464459 7506377 X -1353313 -1071805 -1353313 -1071805 5111146 6434572 X -21303818 21585326 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2967572 2352488 615084 6644929 5016108 1628821 2243905 X 34880930 31741 31741 34849189 401882 401882 35251071 56184748 31741 31741 56153007 401882 401882 56554889 Part X, Line 2: WDHS, the Hospital, WDPC and the Foundation are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes pursuant to Section 501(a) of the Code. Management evaluated these not-for-profit corporations' tax positions and concluded these not-for-profit corporations have maintained their tax-exempt status, do not have any significant unrelated business income and have taken no uncertain tax positions that require adjustment to or disclosure in the accompanying consolidated financial statements. With few exceptions, these not-for-profit corporations are no longer subject to tax examination by the U.S. federal or state tax authorities for years prior to 2011. Part XI, Line 2d - Other Adjustments: Occupancy Expenses Allocated to Building Rental 31,741. Part XI, Line 4b - Other Adjustments: Dental Community Benefit 401,882. Part XII, Line 2d - Other Adjustments: Occupancy Expenses Allocated to Building Rental 31,741. Part XII, Line 4b - Other Adjustments: Dental Community Benefit 401,882. 0 1 0 0 0 0 0 1 0 Paul R Cass DO Director/Physician 0 356293 0 83859 0 16434 0 68708 0 18417 0 543711 0 0 Matthew Goldberg DO Director/Physician 205506 0 30957 0 3112 0 10425 0 3000 0 253000 0 0 0 Nancy J Pettinari MD Director/Physician 245535 0 39801 0 3148 0 10897 0 450 0 299831 0 0 0 Gary Usher MD Director/Physician 270047 0 34836 0 1359 0 0 0 5537 0 311779 0 0 0 Gregory J Walker President/CEO, WDH 0 434558 0 140346 0 203888 0 126104 0 27680 0 932576 0 0 Peter E Walcek CFO/VP Finance, WDH 0 315967 0 58236 0 7971 0 65197 0 28516 0 475887 0 0 Barbara F Civiello MD Physician 404662 0 145617 0 10871 0 13539 0 19617 0 594306 0 0 0 Paul T Berry MD Physician 262104 0 257888 0 18102 0 8684 0 18365 0 565143 0 0 0 Henry L Sonneborn MD Physician 365905 0 141481 0 8172 0 2609 0 17117 0 535284 0 0 0 Lazaro A Diaz MD Physician 405043 0 57757 0 9892 0 0 0 27908 0 500600 0 0 0 Christopher Lawson MD Physician 357020 0 54306 0 18892 0 3216 0 8339 0 441773 0 0 0 Part I, Line 3 The President/CEO of Wentworth-Douglass Physician Corp is an employee of Wentworth-Douglass Hospital, a related organization, and WDPC does not maintain any procedures to establish his compensation. However, the Hospital uses its executive committee, an independent national compensation consultant, compensation surveys, and requires final approval by its independent Board Members to determined executive compensation for all vice-presidents and above. Part I, Line 4b Gregory J. Walker (President/CEO) - 2014 total contributions to the 457(f) plan = $113,104. This supplemental retirement plan contribution is intended to fund benefits accruing and payable at retirement for multiple years of service that began in calendar year 1997. In 2014, the Hospital funded a supplemental executive retirement plan which provides benefits to other qualifying executives. The contributions are intended to provide a forfeitable supplemental retirement benefit and are being provided in consideration for many years of service to the Hospital. The respective contributions for the 2014 plan year, for those individuals identified in Schedule J - Part II, are as follows: Peter E. Walcek = $48,897 and Paul R. Cass = $55,708. WDH sponsors a split-dollar life insurance employee benefit program for certain officers and key employees. Split dollar life insurance is an arrangement in which the employee is the owner of the life insurance policy and the premiums are paid by the employer. Pursuant to WDH's split-dollar agreement, and the collateral assignment therein, the employer's share of the policy premiums paid is recovered either upon termination of the policy or at the death of the participant. Note that the split-dollar arrangement is part of an employee benefit program and economically not a direct extension of credit. Furthermore, the reportable compensation of the respective employees includes the annual value of the life insurance. Total premiums paid during the year ending 12/31/14 were $21,444 for Peter E. Walcek. The taxable value of the life insurance policy has been included in each individuals' W-2. The policies are intended to provide an additional retirement benefit for these individuals' multiple years of service. Part I, Line 7 At-risk compensation for Wentworth-Douglass executives, which is subject to review and paid annually. Wentworth-Douglass Physician Corporation has an incentive-based compensation model that uses relative value units (RVUs) as a measure for determining physician compensation within the Medical Group Management Association published salary ranges. The model includes a base salary plus incentive compensation that has both productivity and performance components inclusive of patient satisfaction and quality. Both budgeted performance and actual performance are measured. Gregory J Walker Peter E Walcek President/CEO and CFO/VP Finance 0 Gregory J. Walker, President/CEO and Peter E. Walcek, CFO/VP of Finance are officers of Granite Shield Insurance Exchange (GSIE). Wentworth-Douglass Hospital's ownership interest in 2014 remained approximately 11%. WDH also made captive insurance payments totaling $2,433,607 to GSIE in 2014. Insurance payments for Wentworth-Douglass Physician Corp. are included in that total. 0 Form 990, Part VI, Section A, line 6 Wentworth-Douglass Health System (WDHS), a New Hampshire nonprofit corporation, was formed in 2012 as the result of the corporate restructuring of Wentworth-Douglass Hospital (WDH) into an integrated health system. WDHS serves as the parent company of WDH and its affiliates Wentworth-Douglass Hospital and Health Foundation (WDHHF) and Wentworth-Douglass Physician Corporation (WDPC), all of which are New Hampshire nonprofit corporations that have been recognized as being 501(c)(3) organizations. These corporations share a common mission with WDH. WDHS is intended to act as a supporting organization of WDH, serving in the role of the "parent company" of the Hospital and the affiliates. WDHS is the sole member of WDPC. Form 990, Part VI, Section A, line 7a WDHS will appoint the Board members for WDPC. Form 990, Part VI, Section A, line 7b Wentworth-Douglass Health System has the power to appoint and remove directors of WDPC, and all actions pertaining to the property, business, and affairs of WDPC, including WDPC's annual budget, are subject to the approval of WDHS. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is initially reviewed in detail by key Wentworth-Douglass Hospital finance employees. Thereafter, the final draft is presented to the full board prior to filing with the IRS. Each member of the Board and Finance Committee is provided with a draft of the Form 990 in advance of each meeting. Form 990, Part VI, Section B, line 12c A copy of WDPC'S Conflict Of Interest Policy is distributed annually to all officers, trustees, medical staff officers and committee members, and the management team. All are required to report any conflicts and sign, date, and return the policy, whether or not a conflict exists, to confirm compliance. Conflicts are disclosed in accordance with State of New Hampshire RSA 7:19-a, in the local newspaper, and submitted to the New Hampshire Attorney General. Form 990, Part VI, Section B, line 15 CEO's Compensation: The compensation and benefits of Wentworth-Douglass Hospital's CEO are reviewed, adjusted and voted on by all independent members of the Wentworth-Douglass Hospital (WDH) board annually. See WDH's separate Form 990 for further details. Compensation of Key Employees: The CEO reviews the salaries of key employees annually and recommends compensation based on performance, salary ranges and market competitive data. Compensation data is provided by an independent national consulting firm every other year. The CEO presents salary range data for key employees to the board annually for approval. Using the Board approved salary range data, the CEO recommends salary increases for vice presidents to the WDH Board for approval and the vice presidents recommend salary increases for Directors and other management positions to the CEO, for approval. All compensation for vice presidents and above requires final approval by the WDH independent Board Members. Form 990, Part VI, Section C, line 19 Wentworth-Douglass Physician Corporation (WDPC) files audited financial statements annually with the New Hampshire Attorney General's Charitable Trust Unit and informs the Director of Charitable Trusts of any pecuniary benefit transactions that have occurred between the Foundation and a board member or officer. Notices of such transactions of $5,000 or more are also published in the local newspaper in accordance with NH RSA 7:19-a, II(d). Current copies of the Bylaws, Conflict Of Interest Policy, and Form 990 are on file with the Charitable Trust Unit. The Organization also makes these documents available upon request. Form 990, Part VII, Section A: Reportable Compensation from Related Organizations: The 2014 compensation reported for Gregory J. Walker and Peter E. Walcek was paid by Wentworth-Douglass Hospital for their services as full-time executives. Gregory J. Walker and Peter E. Walcek each worked an average of 55 hours per week. Of the respective hours worked by each, an average of 2 hours per week was dedicated to Wentworth-Douglass Physician Corporation. Form 990, Part IX, line 11g Temporary Help: Program service expenses 103,018. Management and general expenses 0. Fundraising expenses 0. Total expenses 103,018. Purchased Services: Program service expenses 5,264,955. Management and general expenses 1,039,817. Fundraising expenses 0. Total expenses 6,304,772. Consulting: Program service expenses 0. Management and general expenses 39,204. Fundraising expenses 0. Total expenses 39,204. Form 990, Part XI, line 9: Equity Transfer from Wentworth-Douglass Hospital 21,585,326. Form 990, Part XII, Line 2c: Audit Review Process: WDH's Finance Committee oversees the audit process for Wentworth-Douglass Hospital and all related organizations. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2013 and 2014. Form 990, Part III, Line 4a: WDPC'S Facilities: Wentworth-Douglass Physician Corporation does not file a separate annual community benefit report. Rather, Wentworth-Douglass Hospital (WDH) includes WDPC data with its community benefit report that is filed annually with the State of New Hampshire. WDHS owns 100% of WDPC, and oversees all of WDPC's primary care and specialty practices, outpatient physician clinics and its dental clinic, which are located as follows: Adult & Children's Medicine, 10 Members Way, Suite 201, Dover, NH Allergy Associates of NH, 10 Members Way, Suite 401, Dover, NH Barrington Health Center, 8 Century Pines Drive, Suite 2, Barrington, NH Bellamy Health Center, 15 Old Rollinsford Road, Suite 204, Dover, NH Center for Medical Genetics, 15 Old Rollinsford Road, Suite 201, Dover, NH Coastal Neurology Services, 158 E. NH Route 108, Suite 5, Dover, NH Dover Family Practice, 10 Members Way, Suite 203, Dover, NH Dover Internal and Geriatric Medicine, 10 Members Way, Suite 301, Dover, NH Dover Women's Health, 700 Central Avenue, Dover, NH Durham Health Center, 36 Madbury Road, Durham, NH Endocrinology and Diabetes, 10 Members Way, Suite 400, Dover, NH Great Bay Family Practice, 60 Exeter Road, Suite 300, Newmarket, NH Gynecology and Infertility Associates, 15 Old Rollinsford Road, Suite 102, Dover, NH Hilltop Family Practice, 85 Main Street, Somersworth, NH Lee Family Practice, 65 Calef Highway, Suite 200, Lee, NH Manchester Urology Association at Dover, 10 Members Way, Suite 402, Dover, NH Marshwood Family Care, 19 Levesque Drive, Suite 2, Eliot, ME Outpatient Diabetes Services, 10 Members Way, Suite 400, Dover, NH Pallitative Care, 789 Central Avenue, Level 2, Dover, NH Plastic Surgery Specialists, 10 Members Way, Suite 303, Dover, NH Primary Care of Dover, 10 Members Way, Suite 300, Dover, NH Seacoast Arthritis & Osteoporosis Center, 10 Members Way, Suite 403, Dover, NH Seacoast Cancer Center, 789 Central Avenue, Dover, NH Seacoast General Surgery, 750 Central Avenue, Suite N, Dover, NH Seacoast Integrative Therapy, 15 Old Rollinsford Road, Dover, NH Seacoast Pulmonary (Intensivists), 789 Central Avenue, Level 1, Dover, NH South Berwick Family Practice, 31 Colcord Street, South Berwick, ME Strafford Medical Associates, 10 Members Way, Suite 302, Dover, NH Summit Infectious Disease, 789 Central Avenue, Dover, NH The Hosptial Medicine Team (formerly Hospitalists), 789 Central Avenue, Level 2, Dover, NH WD Community Dental Center, 668 Central Avenue, Dover, NH WHP After Hours, 10 Members Way, Suite 203, Dover, NH WHP Behavioral Health Services, 10 Members Way, Suite 201, Dover, NH WHP Cardiovascular Group, 19 Old Rollinsford Road, Dover, NH WHP Thoracic Surgery Specialists, 789 Central Avenue, Level 1, Dover, NH Wound Healing Institute and Hyperbaric Oxygen Center, 789 Central Avenue, Dover, NH Wentworth-Douglass Hospital 789 Central Avenue Dover NH 03820 020260334 Health care NH 501(c)(3) Line 3 Wentworth-Douglass Health System 0 Wentworth-Douglass Hospital & Health Foundation 789 Central Avenue Dover NH 03820 510491062 Philanthropic fund raising & stewardship NH 501(c)(3) Line 11b, II Wentworth-Douglass Health System 0 Wentworth-Douglass Health System 789 Central Avenue Dover NH 03820 461635259 Support and further charitable activities of Hospital and related entities NH 501(c)(3) Line 11b, II N/A 0 Wentworth Surgery Center LLC PO Box 71 Somersworth NH 03878 900975592 Surgery Center NH N/A Wentworth-Douglass Community Health Corporation 789 Central Avenue Dover NH 03820 020399963 Health fitness center NH N/A C 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0