2014-11-06T09:53:39-06:00 2013-12-31 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2013-01-01 020497927 Wentworth-Douglass Physician Corporation WENT 6037425252 789 Central Avenue Dover NH 038202526 Peter E Walcek CFO/VP of Finance 6037422804 2014-10-16 1 Nicholas E Porto P01310283 2078792100 2013 2015-11-30 17:44:51Z Wentworth Health Partners Gregory J Walker 789 Central Avenue Dover NH 038202526 32781726 0 X N/A X 1998 NH Improve the health of the community by providing high quality healthcare. 10 4 371 4 58764 0 76795 5031 30632994 32670189 0 -1320 75343 73599 30785132 32747499 0 0 0 0 33913580 37618695 0 0 0 14964696 15457889 48878276 53076584 -18093144 -20329085 4939969 5111146 5726634 6464459 -786665 -1353313 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 48435245 32530595 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 2013, the Corporation provided for a total of 202,511 patient visits. 587427 154429 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 200% of the federal poverty guidelines. In 2013, a total of 2,898 patient visits were recorded, resulting in a net community benefit cost of $385,142.In addition, WDPC provided community benefits totaling nearly $398,000 in 2013. 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 200% of the federal poverty level. In 2013 WDPC provided $398,000 of financial aid (stated at cost). Medicaid Costs Exceeding Reimbursement totaled $169,503 for the Corporation in 2013. 49022672 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 1 371 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 William R Brandon MD part year Executive Director 65.00 0.00 X 280106 0 17097 Ellen L Caille part year Executive Vice President 2.00 48.00 X 0 305409 83380 Paul R Cass DO Director/Physician 2.00 50.00 X 0 443435 84428 Barbara F Civiello MD part year Director/Physician 65.00 0.00 X 524033 0 28670 Matthew Goldberg DO Director/Physician 65.00 0.00 X 254892 0 10868 Nancy J Pettinari MD Director/Physician 65.00 0.00 X 248535 0 8066 Gary Usher MD part year Director/Physician 65.00 0.00 X 284245 0 12013 Neil Garvey Chairman 1.00 3.00 X X 0 0 0 Roger Hamel Vice Chairman 1.00 3.00 X X 0 0 0 Michael Steinberg Treasurer 1.00 5.00 X X 0 0 0 Carol Bailey Secretary 1.00 3.00 X X 0 0 0 Gregory J Walker President/CEO, WDH 2.00 53.00 X X 0 725687 151609 Peter E Walcek CFO/VP Finance, WDH 2.00 53.00 X X 0 343239 86022 Roger Evans MD Physician 65.00 0.00 X 452648 0 27185 Girish C Joshi MD Physician 65.00 0.00 X 462813 0 31491 Lazaro A Diaz MD Physician 65.00 0.00 X 471655 0 25929 Silvia Milancovici MD Physician 65.00 0.00 X 416283 0 31494 William S Danford MD Physician 65.00 2.00 X 449001 0 27173 3844211 1817770 625425 94 0 1 0 0 5031 5031 Patient Service Revenue 621110 30818190 30818190 Other Related Function Income 621990 1543460 1484696 58764 Meaningful Use 621110 308539 308539 32670189 104606 31007 73599 73599 73599 1900 3220 -1320 -1320 -1320 32747499 32685024 58764 -1320 X 1668525 1668525 29764586 27912956 1851630 311103 291566 19537 3365314 3153972 211342 2509167 2351591 157576 1910 1910 20004 20004 6458369 5264112 1194257 85498 85498 1313200 1079016 234184 3175854 2976410 199444 241160 162630 78530 241168 241168 613201 613201 783805 783805 Provision for Bad Debt 1503139 1503139 Dental Community Benefi 432998 432998 Pharmacy Expense 292900 292900 Transcription 292090 292090 2593 2593 53076584 49022672 4053912 0 182972 135410 2602573 3078008 8677230 6783199 2150727 1894031 3697 3697 4939969 5111146 5726634 6464459 5726634 6464459 X -786665 -1353313 -786665 -1353313 4939969 5111146 X -20329085 19762437 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2839441 2228073 611368 5837789 4555126 1282663 1894031 X 32342915 28414 28414 32314501 432998 432998 32747499 52672000 28414 28414 52643586 432998 432998 53076584 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 2010. Part XI, Line 2d - Other Adjustments: Occupancy Expenses Allocated to Building Rental 28,414. Part XI, Line 4b - Other Adjustments: Dental Community Benefit 432,998. Part XII, Line 2d - Other Adjustments: Occupancy Expenses Allocated to Building Rental 28,414. Part XII, Line 4b - Other Adjustments: Dental Community Benefit 432,998. 1 1 0 0 0 0 0 1 0 William R Brandon MD part year Executive Director 251046 0 25439 0 3621 0 1324 0 15773 0 297203 0 0 0 Ellen L Caille part year Executive Vice President 0 241615 0 36274 0 27520 0 51911 0 31469 0 388789 0 0 Paul R Cass DO Director/Physician 0 352160 0 64354 0 26921 0 68458 0 15970 0 527863 0 0 Barbara F Civiello MD part year Director/Physician 387554 0 114259 0 22220 0 10200 0 18470 0 552703 0 0 0 Matthew Goldberg DO Director/Physician 173668 0 76581 0 4643 0 7818 0 3050 0 265760 0 0 0 Nancy J Pettinari MD Director/Physician 181450 0 63026 0 4059 0 7336 0 730 0 256601 0 0 0 Gary Usher MD part year Director/Physician 229796 0 49715 0 4734 0 0 0 12013 0 296258 0 0 0 Gregory J Walker President/CEO, WDH 0 410195 0 111478 0 204014 0 125854 0 25755 0 877296 0 0 Peter E Walcek CFO/VP Finance, WDH 0 294269 0 38390 0 10580 0 59527 0 26495 0 429261 0 0 Roger Evans MD Physician 422901 0 9500 0 20247 0 10200 0 16985 0 479833 0 0 0 Girish C Joshi MD Physician 260802 0 197912 0 4099 0 8473 0 23018 0 494304 0 0 0 Lazaro A Diaz MD Physician 392178 0 57757 0 21720 0 0 0 25929 0 497584 0 0 0 Silvia Milancovici MD Physician 380136 0 13966 0 22181 0 7499 0 23995 0 447777 0 0 0 William S Danford MD Physician 345129 0 99152 0 4720 0 2501 0 24672 0 476174 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, Lines 4a-b In 2013, William R. Brandon (former board member/executive director) received a gross serverance payment of $185,790. Gregory J. Walker (President/CEO) - 2013 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 2013, 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 20123 plan year, for those individuals identified in Schedule J - Part II, are as follows: Peter E. Walcek = $47,405, Ellen L. Caille = $41,730, 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 12/31/13 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 President/CEO 0 Gregory J. Walker, President/CEO is an officer of Granite Shield Insurance Exchange (GSIE). Wentworth-Douglass Hospital made a capital contribution of $250,000 to Granite Shield Insurance Exchange (GSIE) in February of 2011 bringing the Hospital's ownership interest in GSIE to approximately 11%. WDH also made captive insurance payments totaling $1,653,470 to GSIE in 2013. 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 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 the Wentworth-Douglass Hospital (WDH) independent Board Members 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 2013 compensation reported for Gregory Walker, Peter Walcek, and Ellen Caille was paid by Wentworth-Douglass Hospital for their services as full-time executives. Gregory Walker and Peter Walcek each worked an average of 55 hours per week and Ellen Caille 50 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 Temp Help: Program service expenses 3,332. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,332. Purchased Services: Program service expenses 5,260,780. Management and general expenses 1,038,993. Fundraising expenses 0. Total expenses 6,299,773. Consulting: Program service expenses 0. Management and general expenses 155,264. Fundraising expenses 0. Total expenses 155,264. Form 990, Part XI, line 9: Equity Transfer from Wentworth-Douglass Hospital 19,762,437. Form 990, Part XII, Line 2c Audit Review Process: The audit process for WDPC is overseen by the Finance Committee, in conjunction with that for Wentworth-Douglass Hospital. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2012 and 2013. Consolidated financial statements were prepared for 2013. 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 200, Dover, NH Barrington Health Center, 8 Century Pines Drive, Barrington, NH Bellamy Health Center, 15 Old Rollinsford Road, 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 Diabetes Services: Inpatient Services, 789 Central Avenue, 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 203, Dover, NH Palliative 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 Medicine, 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 302, Dover, NH WHP Cardiovascular Group, 19 Old Rollinsford Road, Dover, NH WHP Thoracic Surgery Specialists, 789 Central Avenue, Dover, NH Wound Healing Institute, 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-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