2013-11-11T08:06:47-06:00 2012-12-31 381357951 PLANTE & MORAN PLLC 600 E FRONT ST SUITE 300 TRAVERSE CITY MI 49686 990 2012-01-01 381303843 OTSEGO MEMORIAL HOSPITAL ASSOCIATION OTSE 9897312100 825 N CENTER GAYLORD MI 49735 THOMAS LEMON 9897312100 2013-11-04 1 P00053797 2319477800 2012 2016-02-25 16:41:14Z OTSEGO COUNTY MEMORIAL HOSPITAL ASSOCIATION THOMAS LEMON CEO 825 N CENTER GAYLORD MI 49735 84320184 0 X WWW.MYOMH.ORG X 1946 MI TO PROVIDE QUALITY HEALTHCARE THAT MEETS THE NEEDS OF OUR PATIENTS AND THE COMMUNITIES WE SERVE BY: WORKING IN PARTNERSHIP WITH AREA PHYSICIANS TO PROVIDE PATIENT-FOCUSED CARE WITH QUALITY AND SERVICE SECOND TO NONE; DELIVERING A FULL CONTINUUM OF ACCESSIBLE CARE THAT ADDRESSES THE COMMUNITIES NEEDS; WORKING TO INCREASE THE PUBLIC'S AWARENESS OF THE BREADTH AND DEPTH OF OTSEGO MEMORIAL HOSPITAL'S SERVICES; MEETING THE PROFESSIONAL NEEDS OF OUR DEDICATED STAFF BY PROVIDING THEM WITH OPPORTUNITIES FOR PROFESSIONAL GROWTH AND EDUCATIONAL DEVELOPMENT; AND REMAINING FISCALLY SOUND. 10 9 725 145 0 0 329925 469328 73460197 81251509 122202 795398 357588 405796 74269912 82922031 0 0 0 0 38832855 42170956 0 0 642355 31320215 34137839 70153070 76308795 4116842 6613236 48015526 52622542 31089878 29807579 16925648 22814963 X TO PROVIDE EXCEPTIONAL HEALTHCARE THAT MEETS THE NEEDS OF OUR PATIENTS, AND THE COMMUNITIES WE SERVE. 1 0 40941002 0 62218606 ACUTE INPATIENT AND OUTPATIENT CARE FOR DIAGNOSTIC AND MEDICAL CARE: THERE WERE 70,967 ADMISSIONS FOR MEDICAL SURGICAL (1,085), ICU (321), BIRTHING CENTER (256), AND OUTPATIENT REGISTRATIONS (69,305) THIS PAST YEAR. 14349383 0 15294764 PHYSICIAN DIAGNOSTIC OFFICES AND URGENT CARE CLINIC: THERE WERE 106,749 PATIENTS FOR MED GROUP (66,805), LEWISTON/MONTMORENCY (9,346), URGENT CARE (16,416), INDIAN RIVER (653), AND ORTHOPEDICS (13,529). 2891395 0 3395280 LONG TERM CARE FOR THE ELDERLY: THIS PAST YEAR THERE WERE 103 ADMISSIONS WITH 10,816 MCREYNOLDS HALL PATIENT DAYS USED. 3582091 0 411238 ALL OTHER PROGRAM SERVICES. 3582091 411238 61763871 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 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 1 1 1 0 0 1 25 0 1 725 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X AMY BILYEA CONTROLLER 9897312100 825 N CENTER AVE GAYLORD MI 49735 CHRISTOPHER COLLINS 0.20 0.00 X X 0 0 0 THOMAS TOMASKI 0.20 0.00 X X 0 0 0 MARY SANDERS 0.20 0.50 X X 0 0 0 CAROLYN STUDY 0.20 0.50 X X 0 0 0 DAVID BRINEY 0.20 0.50 X 0 0 0 SCOTT CHESLEY 0.20 0.00 X 0 0 0 DR PETER HANDLEY 39.50 0.50 X 250454 0 33990 DONALD SKLARCZYK 0.20 0.00 X 0 0 0 DR BECKY ASHLEY 0.20 0.00 X 0 0 0 MARCUS WEGMEYER 0.20 0.00 X 0 0 0 THOMAS LEMON 39.50 0.50 X 233711 0 26136 ROBERT COURTOIS 39.50 0.50 X 146378 0 39500 BARBARA MILLER 40.00 0.00 X 157396 0 0 DR CHANGXIN LI 40.00 0.00 X 608684 0 23191 DR JOHN MOFFAT 40.00 0.00 X 935025 0 22500 DR LOUIS HABRYL 40.00 0.00 X 603034 0 22500 DR ARMIN AALAMI HARANDI 40.00 0.00 X 442978 0 34000 DR MEDINA SHALTRY 40.00 0.00 X 397652 0 0 3775312 0 201817 45 0 1 0 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINNEAPOLIS MN 55480 DIAGNOSTIC SERVICES 497619 MEDICAL INFORMATION TECHNOLOGY PO BOX 74569 CHICAGO IL 60696 INFORMATION TECHNOLOGY 397520 SIEMENS MEDICAL SOLUTIONS DEPT CH 14195 PALATINE IL 60055 MEDICAL EQUIPMENT SERVICE 393482 NORTHERN MICHIGAN HEMATOLOGY 416 CONNABLE PETOSKEY MI 49770 PHYSICIAN ONCOLOGY SERVICES 342833 AHSA LLC PO BOX 945 TRAVERSE CITY MI 49685 TEMPORARY LOCUM SERVICES 274419 13 6562 422911 24032 15823 469328 PATIENT SERVICE REVENUE 622110 78926987 78926987 OTHER RELATED REVENUE 622110 2324522 2324522 81251509 223582 223582 181559 72106 109453 109453 109453 796774 1101089 795585 530462 1189 570627 571816 571816 CAFETERIA REVENUE 722210 227964 227964 REVENUE FROM JOINT VENTURE 523000 68379 68379 296343 82922031 81319888 0 1132815 1015255 333228 682027 32461299 28281274 4020973 159052 934672 800616 129599 4457 5722667 2994126 2728426 115 2037063 1744895 282453 9715 163475 163475 209861 209861 39611 39611 3543312 2199397 1099308 244607 65932 10719 55213 800124 249205 490596 60323 1294511 476487 817519 505 89885 42679 39637 7569 200977 138868 56283 5826 1390946 1025065 363064 2817 2816968 2075979 735283 5706 885386 193464 691922 MEDICAL & OTHER SUPPLIE 13787957 13378836 408224 897 PROVISION FOR BAD DEBT 3778631 3778631 QUALITY ASSESSMENT FEES 2016717 2016717 REPAIRS AND MAINTENANCE 1845392 1093243 730574 21575 1208154 941161 203015 63978 76308795 61763871 13902569 642355 1577324 2174381 976379 1712855 5358931 4952226 8000 4000 1192161 1363756 2016581 2073296 54543707 26363676 27518637 28180031 5447514 9613898 428411 1165198 3491588 1382901 48015526 52622542 7402106 7269458 15417 0 20736517 19748695 570885 435339 2364953 2354087 31089878 29807579 X 15826331 22807763 1099317 7200 16925648 22814963 48015526 52622542 X 6613236 432316 -1156237 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 5567 5567 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: SUPPORTED LOBBYING ACTIVITIES THROUGH ANNUAL DUES PAID TO MICHIGAN HEALTH & HOSPITAL ASSOCIATION. 869562 869562 35999485 14306997 21692488 373203 281131 92072 17242201 11775548 5466653 59256 59256 28180031 COST REPORT SETTLEMENT PAYABLE 2354087 2354087 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE ORGANIZATION AND RECOGNIZE A TAX LIABILITY IF THE ORGANIZATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE ORGANIZATION AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2012, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO DECEMBER 31, 2008. 1 1 X 1 X 1 X 1 1 1 0 1 1 1 903 637403 477268 160135 0.00220 1 21476 13271143 12302714 968429 0.01340 2 22379 13908546 12779982 1128564 0.01560 261 2621 116913 6530 110383 0.00150 63 67 63623 63623 0.00090 1 12942111 11474213 1467898 0.02020 5 254 19398 0 19398 0.00030 330 2942 13142045 11480743 1661302 0.02290 332 25321 27050591 24260725 2789866 0.03850 4 2000 812 0 812 0.00000 106 120 22612 0 22612 0.00030 110 2120 23424 23424 0.00030 1 3778631 594326 17063951 16139329 924622 X 1 1 1 1 OTSEGO MEMORIAL HOSPITAL ASSOCIATION

825 N CENTER AVE GAYLORD MI 49735

X X X LONG-TERM CARE FACILITY AND PHYSICIAN CLINICS OTSEGO MEMORIAL HOSPITAL ASSOCIATION 1 1 1 200.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 0 6 N'ORTHOPEDICS CLINIC

2147 PROFESSIONAL DRIVE GAYLORD MI 49735

OUTPATIENT CLINIC MCREYNOLDS HALL

825 N CENTER AVENUE GAYLORD MI 49735

LONG-TERM CARE LEWISTON CLINIC

3040 BOURN STREET LEWISTON MI 49756

OUTPATIENT CLINIC MEDCARE CLINIC

1996 WALDEN DRIVE GAYLORD MI 49735

OUTPATIENT CLINIC DIALYSIS SERVICES OF GAYLORD

1989 WALDEN DRIVE GAYLORD MI 49735

KIDNEY DIALYSIS INDIAN RIVER CLINIC

3696 SOUTH STRAITS HWY INDIAN RIVER MI 49749

OUTPATIENT CLINIC PART I, LINE 3C: UNDER ITS ASSISTANCE PROGRAM OTSEGO MEMORIAL HOSPITAL WILL MAKE AVAILABLE A REASONABLE AMOUNT OF UNCOMPENSATED OR REDUCED PRICE SERVICES TO PERSONS ELIGIBLE UNDER APPLICABLE GUIDELINES. OTSEGO MEMORIAL HOSPITAL'S ASSISTANCE PROGRAM SERVICES ARE NOT LIMITED TO ANY SPECIFIC HOSPITAL SERVICE. INDIVIDUAL ELIGIBILITY FOR ASSISTANCE IS DETERMINED BY MEASURING FAMILY INCOME IN RELATION TO FAMILY SIZE AGAINST THE INCOME POVERTY GUIDELINE ESTABLISHED BY THE COMMUNITY SERVICE ADMINISTRATION. IF THE HOSPITAL DETERMINES THAT SERVICES ARE NOT MEDICALLY NECESSARY, THE HOSPITAL CAN DENY SERVICES UNDER THE FINANCIAL ASSISTANCE PROGRAM. PART I, LINE 7: A COST-TO-CHARGE RATIO WAS USED TO COMPLETE THE CHARITY CARE (LINE 7A) AND MEANS-TESTED GOVERNMENT PROGRAMS (LINE 7B). THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2 THAT ACCOMPANIES THE INSTRUCTIONS TO THIS SCHEDULE. THE HOSPITAL'S COST ACCOUNTING RECORDS WERE USED TO COMPLETE THE COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS (LINE 7E), HEALTH PROFESSIONS EDUCATION (LINE 7F), SUBSIDIZED HEALTH SERVICES (LINE 7G) AND CASH AND IN-KIND CONTRIBUTIONS (LINE 7I). PART I, LINE 7G: ALL PHYSICIAN CLINICS ARE INCLUDED AS SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24B - BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE SCHEDULE H, PART I, COLUMN F PERCENTAGE EQUALS $3,778,631. PART II: OTSEGO MEMORIAL HOSPITAL IS INVOLVED IN NUMEROUS COMMUNITY BUILDING ACTIVITIES WHICH PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES. OTSEGO MEMORIAL HOSPITAL STAFF REPRESENT OTSEGO MEMORIAL HOSPITAL ON A VARIETY OF COMMITTEES AND COMMUNITY BOARDS IN WHICH OTSEGO MEMORIAL HOSPITAL OFFERS ASSISTANCE THROUGH STAFF, FACILITIES, AND RESOURCES WITH THE END GOAL OF WORKING TO ADDRESS COMMUNITY ISSUES RELATED TO HEALTH IMPROVEMENT, EDUCATION, POVERTY, WORKFORCE DEVELOPMENT AND ACCESS TO CARE. WE ALSO ENCOURAGE OUR EMPLOYEES TO SERVE IN THE COMMUNITY TO PROMOTE THE HEALTH OF THE COMMUNITIES WE SERVE. AND, WE WORK WITH NEIGHBORHOOD PROGRAMS, INCLUDING PUBLIC AND PRIVATE LOCAL SCHOOLS, OTSEGO COUNTY COMMISSION ON AGING, WORK SITES AND SAFETY NET PROVIDERS TO PROMOTE HEALTH AND WELLNESS AND PREVENT DISEASE. ADDITIONALLY, OTSEGO MEMORIAL HOSPITAL STAFF SIT ON THE MOBILIZING THROUGH ACTION FOR PLANNING AND PARTNERSHIPS (A THOROUGH AND NATIONALLY RECOGNIZED PROGRAM FOR CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT). AS WELL, OTSEGO MEMORIAL HOSPITAL STAFF MEMBERS WERE ACTIVELY INVOLVED IN A BLUE CROSS BLUE SHIELD GRANT RECEIVED BY THE GAYLORD COMMUNITY SCHOOLS TO ENHANCE PHYSICAL ACTIVITY AND PROMOTE HEALTHY EATING IN THE SCHOOLS FOR SCHOOL YEAR 2011-2012. THIS COMMITTEE WAS COMPRISED OF COMMUNITY OFFICIALS, PARENTS, TEACHERS, HOSPITAL STAFF AND PHYSICIANS. PART III, LINE 4: ACCOUNTS RECEIVABLE FINANCIAL STATEMENT FOOTNOTE:ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALULATING THE COLLECTIBILITY OF ACCOUNT RECEIVABLE, THE ORGANIZATION ANALYZES ITS PAST HISTORY 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 EVALULATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNT AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID). 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 ORGANIZATION 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 IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.THE CALCULATION FOR ESTIMATED AMOUNT OF THE ORGANIZATIONS BAD DEBT EXPENSE ATTIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATIONS FINANCIAL ASSISTANCE POLICY, $594,326, IS BASED ON OTSEGO MEMORIAL HOSPITAL'S ACTUAL FINANCIAL ASSISTANCE WRITE-OFFS AS A PERCENTAGE OF ACTUAL UNCOMPENSATED CARE (FINANCIAL ASSISTANCE PLUS BAD DEBT). AN ADDED ASSUMPTION IS USED BASED ON THE IDEA THAT BAD DEBT WOULD LIKELY INCREASE BY A PARTICULAR PERCENTAGE DUE TO THE ECONOMIC CLIMATE IN THE DEMOGRAPHIC AREA.THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2, IS THE BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX. PART III, LINE 8: OTSEGO MEMORIAL HOSPITAL PROVIDES HEALTHCARE TO NINE COMMUNITIES IN OTSEGO AND MONTMORENCY COUNTIES, AND IS THE ONLY HEALTHCARE SYSTEM IN THE AREA AND INCLUDES SEVERAL SMALL TOWNS. THE POPULATION INCLUDES A SIGNIFICANT NUMBER OF RETIREES. SERVICES ARE NOT LIMITED TO RESIDENTS OF THESE COMMUNITIES AS THE AREA HAS A HIGH VOLUME OF TRANSIENTS THAT COME FOR THE NUMEROUS RECREATIONAL ACTIVITIES. THE OUTLYING AREAS ARE PREDOMINANTLY IN A RURAL, AGRICULTURAL BASED SETTING. THE FOLLOWING COSTING METHOD OF COST TO CHARGE RATE IS USED; MEDICARE COSTS DIVIDED BY MEDICARE CHARGES. PART III, LINE 9B: ALL PATIENTS RECEIVING TREATMENT AT OTSEGO MEMORIAL HOSPITAL (INCLUDING CHARITY CARE PATIENTS) ARE RESPONSIBLE FOR PAYING IN FULL ALL CHARGES FOR SUCH TREATMENT, LESS ANY AMOUNTS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, DISCOUNT CONSIDERATIONS OR INSURANCE COVERAGE, PER POINT OF SERVICE COLLECTION POLICY. PART VI, LINE 2: OTSEGO MEMORIAL HOSPITAL CONDUCTED AN EXTENSIVE AND COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSEMENT THROUGHOUT 2012. IN ADDITION, OTSEGO MEMORIAL HOSPITAL USES INPUT FROM PHYSICIANS, MEDICAL PROVIDERS, AND COMMUNITY MEMBERS TO ASSIST IN ITS ASSESSMENT OF THE COMMUNITIES' HEALTHCARE NEEDS. OMH WORKS IN COLLABORATION WITH VARIOUS COMMUNITY GROUPS INCLUDING BUT NOT LIMITED TO: UNITED WAY, OTSEGO COUNTY COMMISSION ON AGING, OTSEGO AREA CHAMBER OF COMMERCE, AND OTHER LOCAL ASSOCIATIONS IN ORDER TO CONTINUE TO UNDERSTAND THE LOCAL HEALTHCARE NEEDS OF OUR SERVICE AREA. PART VI, LINE 3: THE OTSEGO MEMORIAL HOSPITAL REGISTRATION MANAGER TRIES TO SEE THE PATIENTS IN ER OR IP. REGISTRATION STAFF HAVE ALSO BEEN TRAINED TO HAND OUT ASSISTANCE PACKAGES. WHEN THE PATIENT COMES IN ON THE WORK LIST THEY ARE ALSO INFORMED OF THE ASSISTANCE PACKAGE AND/OR APPLICATION. THE FORM IS ALSO ON THE OTSEGO MEMORIAL HOSPITAL WEBSITE AND THE ADMISSIONS OFFICE. THERE ARE ALSO WRITTEN NOTICES AT THE BOTTOM OF THE PATIENT STATEMENTS. WHEN THERE IS A SCHEDULED PROCEDURE AND THE PATIENT DOES NOT HAVE INSURANCE, A CALL IS MADE FOR PAYMENT AND/OR CHARITY CARE ARRANGEMENTS. PART VI, LINE 4: OTSEGO MEMORIAL HOSPITAL PROVIDES HEALTHCARE TO TEN COMMUNITIES LOCATED WITHIN CHEBOYGAN, OTSEGO AND MONTMORENCY COUNTIES (THE COMMUNITIES ARE: ATLANTA, ELMIRA, FREDERIC, GAYLORD, INDIAN RIVER, JOHANNESBURG, LEWISTON, WATER, WOLVERINE, AND VANDERBILT). THE POPULATION INCLUDES A SIGNIFICANT NUMBER OF RETIREES. SERVICES ARE NOT LIMITED TO RESIDENTS OF THESE COMMUNITIES AS THE AREA HAS A HIGH VOLUME OF TRANSIENTS THAT COME FOR NUMEROUS RECREATIONAL AND SEASONAL ACTIVITIES. THE OUTLYING AREAS ARE PREDOMINANTLY IN A RURAL, AGRICULTURAL BASED SETTING. PART VI, LINE 5: OTSEGO MEMORIAL HOSPITAL (OMH) OFFERS A VARIETY OF PROGRAMS AND SERVICES WITH THE END GOAL OF PROMOTING THE GREATER HEALTH OF THE COMMUNITY. OMH PROVIDED DISCOUNTED SPORTS PHYSICALS TO MORE THAN 250 AREA STUDENT ATHLETES, DONATING ONE HUNDRED PERCENT OF THE PROCEEDS BACK TO THE LOCAL SCHOOL ATHLETIC DEPARTMENTS. THE HOSPITAL PARTICIPATES IN A VARIETY OF LOCAL HEALTH EVENTS, INCLUDING OFFERING FREE HEALTH SCREENINGS TO PARTICIPANTS; SCREENINGS INCLUDED BLOOD PRESSURE, PULMONARY, BMI, HEIGHT AND WEIGHT. ADDITIONALLY, THE HOSPITAL OFFERED DISCOUNTED FULL LIPID PROFILE SCREENINGS TO MORE THAN 500 PARTICIPANTS AT A SENIOR EXPO. THE HOSPITAL OFFERS FREE ON SITE HEALTH FAIRS FOR LOCAL BUSINESSES AS REQUESTED. THE HOSPITAL OFFERS A MAMMOGRAPHY ASSISTANCE PROGRAM, TO ENSURE THAT WOMEN WHO DO NOT QUALIFY FOR A FREE MAMMOGRAM THROUGH THE LOCAL HEALTH DEPARTMENT, YET HAVE NO MEANS TO PAY FOR IT PRIVATELY, ARE COVERED AND RECEIVE A SCREENING AND IF NECESSARY DIAGNOSTIC MAMMOGRAM AT NO CHARGE. OMH ALSO WORKS CLOSELY WITH THE LOCAL SCHOOLS TO ASSIST THE HIGH SCHOOL LEVEL MEDICAL OCCUPATIONAL PROGRAM IN JOB SHADOWING AND EDUCATION PROGRAM FOR STUDENTS THROUGHOUT THE FACILITY AND SCHOOL YEAR. NEW PARENTS ARE INVITED TO PARTICIPATE IN CHILDBIRTH EDUCATION CLASSES OFFERED BY OMH STAFF FOR A NOMINAL FEE. ON A QUARTERLY BASIS THE HOSPITAL PRODUCES AND DISTRIBUTES TO MORE THAN 19,000 HOUSEHOLDS THROUGHOUT THE SERVICE AREA LITERATURE ON VARIOUS HEALTHCARE ISSUES AND TOPICS, INCLUDING INFORMATION ON LOCAL HEALTH EVENTS. OMH HAS NUMEROUS MEDICAL PRACTICES THAT ARE FEDERALLY QUALIFIED RURAL HEALTHCARE CLINICS, AS WELL AS OMH IS LOCATED WITHIN A HEALTH PROFESSIONAL SHORTAGE AREA. BOTH OF THESE QUALIFICATIONS DEMONSTRATE OMH'S ISOLATED SERVICE AREA WHICH HAS RESULTED IN CHALLENGING PHYSICIAN RECRUITMENT AND RETENTION. OMH'S COMMITMENT TO PROVIDING THE HIGHEST LEVEL OF CARE STARTS WITH PHYSICIAN AND OTHER PROVIDERS. EXTENSIVE RECRUITMENT ACTIVITIES MUST TAKE PLACE IN ORDER TO PROVIDE CARE TO THESE HEALTH PROFESSIONAL SHORTAGE AREAS. (1). A MAJORITY OF THE HOSPITALS BOARD OF TRUSTEES IS MADE UP OF COMMUNITY REPRESENTATIVES RESIDING WITHIN THE HOSPITALS SERVICE AREA. (2). THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS AS APPROVED BY OUR HOSPITAL BOARD OF DIRECTORS. DUE TO THE SIZE AND RURAL NATURE OF THE HOSPITAL SERVICE AREA, NOT ALL HEALTHCARE SPECIALTIES ARE OFFERED THROUGH THE HOSPITAL. (3). THE HOSPITAL APPLIES SURPLUS FUNDS, INCLUDING DONATIONS FROM THE FOUNDATION, TO ASSIST IN PURCHASING EQUIPMENT FOR PATIENT USE AND FUNDING MANY OF THE COMMUNITY HEALTH EDUCATION PROGRAMS LISTED ABOVE. ADDITIONALLY, THE HOSPITAL WORKS TO USE ANY SURPLUS FUNDS TO CONTINUE TO ADVANCE THE MISSION OF THE ORGANIZATION THROUGH GROWTH AND DEVELOPMENT OPPORTUNITIES. PART VI, LINE 6: OTSEGO MEMORIAL HOSPITAL HAS AN AFFILIATION AGREEMENT WITH MUNSON MEDICAL CENTER WHERE THEY COOPERATE IN PROVIDING HEALTH CARE SERVICES TO THE COMMUNITY. INCLUDED IN THE AFFILIATION AGREEMENT ARE VARIOUS PURCHASED SERVICES, SUCH AS: INFORMATION TECHNOLOGY, LAUNDRY, PHYSICIAN RECRUITMENT ASSISTANCE, REIMBURSEMENT SUPPORT, MANAGEMENT DEVELOPMENT, MOBILE IMAGING, ETC. ALSO INCLUDED IN THE AFFILIATION AGREEMENT ARE COLLABORATION ON VARIOUS INITIATIVES, SUCH AS: ICD-10 IMPLEMENTATION, STRATEGIC PLANNING, CEO AND OTHER FORUMS, EDUCATION, CONSULTING, ETC. OMH WORKS WITH MUNSON MEDICAL CENTER TO OFFER CARDIOLOGY AND SLEEP LAB SERVICES IN OTSEGO COUNTY. REPORTS FILED WITH STATES PART VI, LINE 7 MI X X X X 0 0 0 0 0 0 0 0 0 DR PETER HANDLEY 250094 0 0 0 360 0 33990 0 0 0 284444 0 0 0 THOMAS LEMON 233159 0 0 0 552 0 24881 0 1255 0 259847 0 0 0 ROBERT COURTOIS 145346 0 0 0 1032 0 39500 0 0 0 185878 0 0 0 BARBARA MILLER 155891 0 0 0 1505 0 0 0 0 0 157396 0 0 0 DR CHANGXIN LI 608132 0 0 0 552 0 23191 0 0 0 631875 0 0 0 DR JOHN MOFFAT 933993 0 0 0 1032 0 22500 0 0 0 957525 0 0 0 DR LOUIS HABRYL 601450 0 1584 0 0 0 22500 0 0 0 625534 0 0 0 DR ARMIN AALAMI HARANDI 442762 0 216 0 0 0 34000 0 0 0 476978 0 0 0 DR MEDINA SHALTRY 397292 0 360 0 0 0 0 0 0 0 397652 0 0 0 A GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 368177AB7 2004-11-23 5285000 REFINANCE & CONSTRUCTION 0 0 0 B GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 368177AC5 2004-11-23 5110000 REFINANCE & CONSTRUCTION 0 0 0 C GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 368177AD3 2004-11-23 7465000 REFINANCE & CONSTRUCTION 0 0 0 D GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 2005-02-14 9000000 CONSTRUCTION 0 0 0 A 2942021 2942021 5285000 457147 256111 102861 1419302 2005 0 1 1 1 B 2844583 2844583 5110000 442009 247629 99454 1372295 2005 0 1 1 1 C 4156014 4156014 7465000 645714 361793 145305 2004961 2005 0 1 1 1 D 9000000 9000000 2005 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 C 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 D 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 0 0 D 0 0 0 0 0 0 0 0 0 A 0 B 0 C 0 D 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 OTSEGO MEMORIAL HOSPITAL OPENED A NEW CLINIC IN THE 4TH QUARTER OF 2012 IN INDIAN RIVER, MICHIGAN TO BETTER SERVE THE SURROUNDING COMMUNITIES. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS APPROXIMATELY 200 GENERAL MEMBERS. ANNUAL DUES ARE $5 PER INDIVIDUAL OR $8 PER FAMILY. REQUIREMENTS TO BE A MEMBER ARE A MINIMUM OF EIGHTEEN YEARS OF AGE AND HAS A RESIDENCE IN THE AREA THAT THE HOSPITAL SERVES. EACH MEMBER HAS TWO RIGHTS: ELECTION OF THE BOARD OR OF THE CANDIDATES PROPOSED AND TO VOTE APPROVAL FOR REVISIONS TO CORPORATE BYLAWS. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER HAS TWO RIGHTS: ELECTION OF THE BOARD OR OF THE CANDIDATES PROPOSED AND TO VOTE APPROVAL FOR REVISIONS TO CORPORATE BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER HAS TWO RIGHTS: ELECTION OF THE BOARD OR OF THE CANDIDATES PROPOSED AND TO VOTE APPROVAL FOR REVISIONS TO CORPORATE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BEFORE FILING BY THE FOLLOWING INDIVIDUALS: 1. THE HOSPITAL'S CHIEF EXECUTIVE OFFICER, THOMAS LEMON; 2. THE HOSPITAL'S VP OF FINANCE, ROBERT COURTOIS; AND 3. THE HOSPITAL'S CONTROLLER, AMY BILYEA. THE 990 IS ALSO PRESENTED TO THE ENTIRE HOSPITAL BOARD BEFORE FILING. DURING THIS MEETING MEMBERS HAVE A CHANCE TO ASK QUESTIONS REGARDING THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL'S POLICY REGARDING "CONFLICT OF INTEREST" REQUIRES EACH BOARD MEMBER AND OFFICER TO COMPLETE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES TO DEMONSTRATE CORPORATE COMPLIANCE. THESE FORMS ARE REVIEWED AND ANY CONFLICTS ARE INVESTIGATED BY MANAGEMENT. POTENTIAL CONFLICTS AND RESTRICTIONS ARE DETERMINED AND THEN VOTED UPON, PER POLICY GUIDELINES. IN THE EVENT THAT AN OFFICER OR BOARD MEMBER HAS A CONFLICT OF INTEREST, THAT BOARD MEMBER MUST GIVE WRITTEN NOTICE OF SUCH AN INTEREST OR RELATIONSHIP TO THE BOARD OF DIRECTORS, AND SHALL THEREAFTER REFRAIN FROM VOTING OR OTHERWISE ATTEMPTING TO EXERT ANY INFLUENCE ON THE DECISION. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD'S PERSONNEL SUB-COMMITTEE, WHICH CONSISTS OF FOUR MEMBERS, ANNUALLY REVIEWS THE COMPENSATION OF THE CEO ONLY. THEY UTILIZE MHA SALARY SURVEY DATA, AS WELL AS A MARKET ANALYSIS PERFORMED BY THE HOSPITAL'S HUMAN RESOURCES DEPARTMENT. THE HUMAN RESOURCES MARKET ANALYSIS INCLUDES THREE SOURCES FOR DATA: INTEGRATED HEALTHCARE STRATEGIES, MERCER AND SULLIVAN COTTER, WITH REGRESSION POINT USING $70M IN NET REVENUES AND AN AVERAGE BASED ON HOSPITALS WITHIN A SIMILAR RANGE OF NET REVENUES. EACH OF THE THREE SOURCES USE NATIONAL DATA AND ARE BASED ON A FREE-STANDING HOSPITAL CEO POSITION. THE CEO DETERMINES THE STARTING COMPENSATION FOR THE VICE PRESIDENTS BASED ON MARKET DATA AND ANNUAL INCREASES OCCUR BASED ON PAY-FOR-PERFORMANCE SYSTEMS. THESE PROCESSES WERE LAST UNDERTAKEN IN 2012. FORM 990, PART VI, SECTION C, LINE 19 THE OTSEGO MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY , AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC BY CONTACTING THE HOSPITAL AT 825 N. CENTER GAYLORD MI 49735 OR BY PHONE 989-731-2100. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN INTEREST OF NET ASSETS OF CHARITABLE FOUNDATION -733,322. NET ASSETS RELEASED FROM RESTRICTION -422,911. ROUNDING -4. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. OTSEGO MEMORIAL HOSPITAL FOUNDATION 825 N CENTER STREET GAYLORD MI 49735 382135473 FUNDRAISING MI 501(C)(3) LINE 11A, I OTSEGO MEMORIAL HOSPITAL ASSOCIATION 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 OTSEGO MEMORIAL HOSPITAL FOUNDATION C 422911 CASH OTSEGO MEMORIAL HOSPITAL FOUNDATION L 159775 ACTUAL COST ALLOCATION