2013-11-14T06:51:42-06:00 2012-12-31 990 2012-01-01 421019872 NORTHWEST IOWA HOSPITAL CORPORATION NORT 7122793500 2720 STONE PARK BLVD SIOUX CITY IA 51104 JAMES L GOBELL 7122793201 2013-11-07 2012 2016-02-25 16:41:14Z ST LUKE'S REGIONAL MEDICAL CENTER PETER THOREEN 2720 STONE PARK BLVD SIOUX CITY IA 51104 216710590 0 X WWW.UNITYPOINT.ORG/SIOUXCITY X 1974 IA TO IMPROVE THE HEALTH OF THE PEOPLE OF SIOUXLAND. 7 6 1603 307 37925 10781 903624 656771 123251760 126430501 2385996 6342269 1969553 2109355 128510933 135538896 1498715 1277326 0 0 61938942 63941825 0 0 0 56555061 61285081 119992718 126504232 8518215 9034664 182750126 195227166 69653773 74257326 113096353 120969840 X THE MISSION OF NORTHWEST IOWA HOSPITAL CORPORATION, D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER, IS TO IMPROVE THE HEALTH OF THE PEOPLE OF SIOUXLAND. 0 0 87859975 780041 127517170 HEALTH-CARE SERVICESNORTHWEST IOWA HOSPITAL CORPORATION D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER IS AN IMPORTANT ELEMENT OF THE HEALTH CARE DELIVERY SYSTEM THAT SIOUXLAND COMMUNITIES RELY ON EVERY DAY. IT IS COMMITTED TO PROVIDING QUALITY HEALTH CARE AND TO USING ITS RESOURCES TO THE GREATEST COMMUNITY BENEFIT. NORTHWEST IOWA HOSPITAL CORPORATION PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES TO TREAT INDIVIDUALS WITH DISEASES, ILLNESS AND INJURIES WITH VARYING COMPLEXITIES. IT PROVIDES SERVICES TO IMPROVE THE HEALTH OF PATIENTS AND TO BETTER THEIR QUALITY OF LIFE. ALL SERVICES ARE PROVIDED REGARDLESS OF AN INDIVIDUAL'S RACE, CREED, SEX, NATIONALITY, HANDICAP, AGE OR ABILITY TO COMPENSATE FOR SERVICES RENDERED. THESE INCLUDE, BUT ARE NOT LIMITED TO, GENERAL ACUTE CARE, SURGERIES, HOME HEALTH, INTENSIVE CARE AND CRITICAL CARE, MENTAL HEALTH CARE, CARDIOLOGY, ONCOLOGY, REHABILITATION, SKILLED NURSING, BEHAVIORAL DISORDER PROGRAMS, MATERNAL/CHILD CARE, LABORATORY, PALLIATIVE CARE, PHARMACEUTICAL DRUGS, EMERGENCY SERVICES, OUTPATIENT CLINICS, CHECK-UPS AND RADIOLOGY. SOME OF THE SERVICES PROVIDED DO NOT GENERATE ENOUGH INCOME TO OFFSET THEIR COST. IN THE FISCAL PERIOD ENDING DECEMBER 31, 2012, NORTHWEST IOWA HOSPITAL CORPORATION ADMITTED 11,174 PATIENTS. THE HOSPITAL HAD A TOTAL NUMBER OF 42,522 PATIENT DAYS. OUTPATIENT VISITS TOTALED 66,086 AND TOTAL OUTPATIENT SURGERY REGISTRATIONS FOR THE SAME PERIOD WERE 2,064. THERE WERE ALSO 29,242 EMERGENCY ROOM VISITS AND 2,018 BABIES DELIVERED. 12290059 497285 0 COMMUNITY BENEFIT, INCLUDING CHARITY CARECHARITY CARE AND MEANS-TESTED PROGRAMS: NORTHWEST IOWA HOSPITAL CORPORATION PROVIDES CHARITY CARE AND OTHER MEANS-TESTED PROGRAMS WITH THE GOAL TO IMPROVE THE COMMUNITY'S OVERALL HEALTH AND ACCESS TO CARE. THIS INCLUDES HEALTH-CARE SERVICES REGARDLESS OF THE PATIENT'S INSURANCE COVERAGE OR FINANCIAL STATUS. CHARITY CARE AND PARTIAL TO FULL FINANCIAL ASSISTANCE IS PROVIDED TO PATIENTS ON A CASE-BY-CASE BASIS. CHARITY CARE WAS MADE AVAILABLE TO 3,137 PEOPLE AT A VALUE OF $3,797,077 IN 2012. OFTENTIMES, NORTHWEST IOWA HOSPITAL CORPORATION RECEIVES PAYMENTS FROM PAYORS OR PATIENTS THAT ARE LESS THAN IT CHARGES OR SERVICES. NORTHWEST IOWA HOSPITAL CORPORATION PARTICIPATES IN MEDICAID AND OTHER GOVERNMENT SPONSORED HEALTH-CARE PROGRAMS. NORTHWEST IOWA HOSPITAL CORPORATION'S NET COST OF PROVIDING CARE FOR WHICH IT RECEIVES PAYMENT BELOW ITS COST IS $7,578,507 FOR 2012. TOTAL CHARITY CARE AND MEANS-TESTED PROGRAMS REPORTED VALUE WAS $11,375,584. OTHER BENEFITS: NORTHWEST IOWA HOSPITAL CORPORATION PROVIDES SEVERAL OTHER BENEFITS THAT ASSIST THE COMMUNITY. PROGRAMS MAY INCLUDE, BUT ARE NOT LIMITED TO, COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS SUCH AS PREVENTION AND HEALTH SCREENINGS; CONTINUING EDUCATION FOR HEALTH PROFESSIONALS; SUBSIDIZED HEALTH SERVICES; RESEARCH; AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS. NORTHWEST IOWA HOSPITAL CORPORATION COLLABORATES WITH OTHER HOSPITALS, CHURCHES, SCHOOLS, CHAMBERS OF COMMERCE AND DAYCARE CENTERS TO IMPROVE COMMUNITY HEALTH AND EXPAND ACCESS TO HEALTH CARE. NORTHWEST IOWA HOSPITAL CORPORATION HAS DEDICATED STAFF TO ASSIST COMMUNITY BENEFIT EFFORTS. APPROXIMATELY 15,944 PERSONS WERE SERVED THROUGH THESE PROGRAMS. TOTAL OTHER BENEFITS REPORTED VALUE WAS $914,475. 100150034 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 210 0 1 1603 1 1 1 0 0 0 0 0 0 0 0 0 X 7 6 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IA X X JAMES L GOBELL VPCFO 7122793201 2720 STONE PARK BLVD SIOUX CITY IA 51104 JAMES JENSEN 1.00 1.00 X 0 0 0 LEAH JOHNSON MD TO 1112 40.00 1.00 X 28568 0 857 ELLEN KAPLAN 1.00 1.00 X X 0 0 0 KG SKIP PERLEY 1.00 1.00 X X 0 0 0 STEVE SHOOK MD 1.00 1.00 X 0 0 0 GARRETT SMITH 1.00 1.00 X X 0 0 0 RICH WALLER 1.00 1.00 X 0 0 0 JAMES GOBELL 40.00 1.00 X 190301 0 44152 RICHARD HILDEBRAND MD 40.00 1.00 X 375722 0 111349 CHAD MARKHAM 1.00 40.00 X 154852 0 28190 PRISCILLA STOKES 40.00 1.00 X 185933 0 22072 PETER THOREEN 40.00 1.00 X 491055 0 213854 SUSAN UNGER 1.00 40.00 X 156839 0 9511 LYNN WOLD 40.00 1.00 X 269341 0 74718 GARY JOHNSON 40.00 1.00 X 150970 0 25172 ALFRED FLEMING MD 40.00 0.00 X 463719 0 32743 JOHN GOEBEL 40.00 0.00 X 441516 0 32743 FADY JABRE MD 40.00 0.00 X 486195 0 32968 LUIS LEBREDO MD 1.00 40.00 X 621208 0 31419 JEFFREY O'TOOL 40.00 0.00 X 514686 0 33016 MARK JOHNSON TO 1211 0.00 40.00 X 84586 309535 113677 4615491 309535 806441 57 1 1 0 WA KLINGER LLC 2015 E SEVENTH ST SIOUX CITY IA 511028800 CONSTRUCTION/RENOVATION 5572775 ARAMARK MANAGMENT SERVICES 25271 NETWORK PLACE CHICAGO IL 606731252 MANAGEMENT SERVICES/SUPPLIES 2388667 IRGENS DEVELOPMENT PARTNERS 10700 RESEARCH DRIVE SUITE ONE MILWAUKEE WI 53226 PROFESSIONAL SERVICES 1209578 GE MEDICAL SYSTEM 75 REMITTANCE DR STE 1080 CHICAGO IL 606751080 CONTRACTED SERVICES 831850 L&L BUILDERS COMPANY 2205 EAST FOURTH STREET SIOUX CITY IA 51102 CONSTRUCTION/RENOVATION 707089 36 370618 26325 259828 656771 NET PATIENT REVENUE 900099 122846240 122846240 EDUCATION & RESEARCH 900099 2467673 2467673 SUBS & JOINT VENTURES 900099 905617 905617 RENTAL INCOME 531110 90729 90729 PUBLIC HEALTH PROGRAMS 923120 87987 87987 32255 21232 11023 126430501 1296323 1296323 85761318 288827 80232163 772036 5529155 -483209 5045946 5045946 298711 167495 131216 131216 CAFETERIA/FOOD SVCS 722210 1008228 116758 891470 MISCELLANEOUS REVENUE 900099 965345 929739 35606 MANAGEMENT, IT AND SUPPORT SERVIC 561000 2319 2319 2247 2247 1978139 135538896 127468222 37925 7375978 1264934 1264934 12392 12392 2154640 2154640 85186 85186 48938459 40476154 8462305 1978629 1636490 342139 7398498 6119170 1279328 3386413 2800844 585569 2660826 10589 2650237 557871 31911 525960 466486 261327 205159 9585321 7041449 2543872 633090 87933 545157 4477179 3887400 589779 9324613 5911226 3413387 2991158 2589985 401173 458558 285993 172565 243432 203170 40262 2321723 163696 2158027 5438632 5337949 100683 49831 60113 -10282 MEDICAL SUPPLIES 21744680 21670148 74532 MISCELLANEOUS EXPENSE 299594 265874 33720 BAD DEBT EXPENSE 31287 31287 INCOME TAXES 800 800 126504232 100150034 26354198 0 5365800 5310866 12229132 2810739 17828902 21387894 44466833 46543362 2912489 3139673 610655 538046 171503910 113133957 49009110 58369953 44292450 52136046 6034755 4990587 182750126 195227166 10624302 14250862 110063 45000 2589415 1657226 56440056 58194175 69653773 74257326 X 108937763 117189941 2602509 2211327 1556081 1568572 113096353 120969840 182750126 195227166 X 9034664 -1005925 -155252 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 37872570 2529250 3954660 4165 8 80606 44271700 37780619 209844 2060 115833 37872570 33351746 715 4566553 417 137978 37780619 28560952 150000 6779399 2006244 132361 33351746 38652656 1802921 -9229015 2572634 92976 28560952 0.91460 0.03550 0.04990 1 0 5533665 5533665 93753779 61356157 32397622 112000 13333 98667 60527421 49447530 11079891 11577045 2316937 9260108 58369953 DUE TO AFFILIATES 10369145 ASBESTOS REMOVAL LIABILITY 2814692 SELF-INSURANCE RESERVE 3583659 LONG-TERM RETENTION INCENTIVES 1161679 IOWA HEALTH SYSTEM NOTE PAYABLE 40265000 58194175 X 139292000 -1005925 5543894 4537969 134754031 116355 668510 784865 135538896 128652000 4928528 4928528 123723472 116355 2664405 2780760 126504232 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION RETAINS FUNDS FOR INTENDED FUTURE USES, INCLUDING PURCHASE OF EQUIPMENT, INDIGENT CARE, FUNDING OF MISSION RELATED OPERATIONS, AND HEALTH EDUCATION. IN ADDITION, SOME FUNDS ARE HELD FOR INVESTMENT IN PERPETUITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IOWA HEALTH SYSTEM AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE HEALTH SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2009. THE HEALTH SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME DURING THE CARRYFORWARD PERIOD. NO INCOME TAX BENEFIT HAS BEEN RECOGNIZED FOR THE NET OPERATING LOSS CARRYFORWARDS OR OTHER POTENTIAL DEFERRED TAX ASSETS IN THE CONSOLIDATED FINANCIAL STATEMENTS BECAUSE THE HEALTH SYSTEM BELIEVES REALIZATION OF THESE BENEFITS IS UNLIKELY. PART XI, LINE 2D - OTHER ADJUSTMENTS: SUBSIDIARY ELMININATING ENTRIES 5,376,338. COST OF GOODS SOLD 167,495. ROUNDING 61. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUES IN UNRESTRICTED FUND BALANCE 88,799. REVENUES IN TEMPORARILY RESTRICTED FUND BALANCE 32,221. IOWA HEALTH SYSTEM CONTRACTING SERVICES PURCHASE REBATE 370,618. REVENUES NETTED IN EXPENSES 176,872. PART XII, LINE 2D - OTHER ADJUSTMENTS: SUBSIDIARY ELMININATING ENTRIES 4,760,834. COST OF GOODS SOLD 167,495. ROUNDING 199. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES IN UNRESTRICTED FUND BALANCE 2,112,750. EXPENSES IN TEMPORARILY RESTRICTED FUND BALANCE 4,165. IOWA HEALTH SYSTEM CONTRACTING SERVICES PURCHASE REBATE 370,618. REVENUES NETTED IN EXPENSES 176,872. 1 1 X 1 X 1 X 1 1 1 0 1 1 3137 3797077 3797077 0.03000 24918 24413820 16835313 7578507 0.05990 28055 28210897 16835313 11375584 0.08990 26 13375 41910 2260 39650 0.00030 2 957 292252 220316 71936 0.00060 3 684113 518536 165577 0.00130 262 1612 1408868 771556 637312 0.00500 293 15944 2427143 1512668 914475 0.00720 293 43999 30638040 18347981 12290059 0.09710 1 2493 2493 0.00000 1 83306 83306 0.00070 2 85799 85799 0.00070 0 4575449 0 34820826 32943998 1876828 X 1 1 1 PIERCE STREET SAME DAY SURGERY LC AMBULATORY SURGERY CENTER 0.50000 0.05500 0.44500 1 1 ST LUKE'S REGIONAL MEDICAL CENTER

2720 STONEPARK BLVD SIOUX CITY IA 51104

WWW.STLUKES.ORG X X X X ST LUKE'S REGIONAL MEDICAL CENTER 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X 1 1 X X X 1 0 X X X X 1 X 0 0 1 PIERCE STREET SAME DAY SURGERY

2730 PIERCE STREET SIOUX CITY IA 51104

FREESTANDING OUTPATIENT SURGERY CENTER (JOINT VENTURE) PART I, LINE 6A: NORTHWEST IOWA HOSPITAL CORPORATION'S D/B/A/ ST. LUKE'S REGIONAL MEDICAL CENTER'S COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE IOWA HEALTH SYSTEM COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED AT WWW.UNITYPOINT.ORG. THIS SYSTEM-WIDE REPORT IS COMPLETED IN ADDITION TO THE COMMUNITY BENEFIT REPORT FOR THE HOSPITAL AND ITS REGIONAL AFFILIATES. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A. THE AMOUNTS ON LINES 7B-7C (UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS) ARE OBTAINED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO COST ACCOUNTING SYSTEM USE COST-TO-CHARGE RATIO. THE AMOUNTS FOR LINES 7E, F, H, AND I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND ARE BASED ON COST. THE AMOUNTS ON 7G ARE DERIVED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO A COST ACCOUNTING SYSTEM USE THE COST-TO-CHARGE RATIO. 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 $ 31287. PART II: COMMUNITY BUILDING ACTIVITIES ARE ESSENTIAL ROLES FOR HEALTH-CARE ORGANIZATIONS IN THAT THEY ADDRESS MANY OF THE UNDERLYING DETERMINANTS OF HEALTH. RESEARCH HAS CONTINUALLY SHOWN THAT WHEN THE FACTORS INFLUENCING HEALTH ARE EXPLORED, HEALTH CARE ACTUALLY PLAYS THE SMALLEST ROLE PROPORTIONATELY. A REPORT IN THE JOURNAL OF AMERICAN MEDICAL ASSOCIATION AND THE CENTER FOR DISEASE CONTROL (MCGINNIS, 1996) SUGGESTS THAT THE FACTORS AFFECTING HEALTH ARE AS FOLLOWS: LIFESTYLE AND BEHAVIORS, 50%, ENVIRONMENT (HUMAN AND NATURAL), 20%, GENETICS AND HUMAN BIOLOGY, 20%, AND HEALTH CARE, 10%. COMMUNITY BUILDING ACTIVITIES HELP TO ADDRESS THE OTHER INDICATORS OUTSIDE OF THE ROLE TRADITIONALLY PLAYED BY HEALTH-CARE ORGANIZATIONS. THESE ACTIVITIES ARE ALMOST EXCLUSIVELY DONE IN SOME FORM OF PARTNERSHIP IN WHICH THE COMMUNITY OR OTHER ORGANIZATIONS ARE BETTER SUITED TO ADDRESS. HEALTH-CARE ORGANIZATIONS GENERALLY PROVIDE TIMELY AND SPECIFIC RESOURCES TO HELP THESE ISSUES. HEALTH-CARE ORGANIZATIONS CAN BE A RICH AND VALUABLE COMMUNITY RESOURCE IN WAYS NOT TYPICALLY CONSIDERED. OFTEN THE MOST EFFECTIVE WAY TO HELP IMPACT AND IMPROVE THE COMMUNITY HEALTH STATUS IS TO SUPPORT OTHER AGENCIES AND ORGANIZATIONS IN A VARIETY OF WAYS OUTSIDE OF HEALTH SERVICES. AS SUCH, NORTHWEST IOWA HOSPITAL CORPORATION D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER (ST. LUKE'S) SUPPORTS AND CONTRIBUTES TO COMMUNITY ORGANIZATIONS, EVENTS, AND PROGRAMS SUCH AS THE LOCAL CHAMBER, SIOUX CITY GROWTH ORGANIZATION, AND OTHER ECONOMIC DEVELOPMENT ACTIVITIES. ST. LUKE'S ALSO CONTRIBUTES FINANCIALLY TO A WIDE VARIETY OF SIOUXLAND ORGANIZATIONS THAT ADDRESS THE BROADER NEEDS OF THE COMMUNITY. THESE DONATIONS ALLOW OTHER LOCAL, NON-PROFIT ORGANIZATIONS TO FULFILL THEIR MISSIONS TO IMPROVE THE WELL-BEING OF THE COMMUNITY AND CONTRIBUTE TO ITS OVERALL HEALTH. ACCESS TO HEALTHY FOOD IS CRITICAL FOR GOOD HEALTH IS ONE EXAMPLE. ST. LUKE'S WORKS WITH A NONPROFIT ORGANIZATION TO HELP FUND A LOCAL FARMER'S MARKET. THE MARKET OFFERS FARM-FRESH FOOD TO THE COMMUNITY, INCLUDING EBT PARTICIPANTS.WORKING THROUGHOUT THE COMMUNITY IS ALSO IMPORTANT IN DELIVERING COMMUNITY HEALTH. ST. LUKE'S REGIONAL MEDICAL CENTER ALONG WITH OTHER HEALTHCARE AND MENTAL HEALTH AGENCIES MEET TO ASSESS AND PLAN FOR IMPROVED ACCESS AND SERVICES FOR PATIENTS WITH MENTAL ILLNESS; MOST OF WHOM ARE UNDERSERVED. HEALTHY SIOUXLAND INITIATIVE IS ANOTHER COLLABORATIVE GROUP ST. LUKE'S PARTICIPATES IN WITH OTHER HEALTH PROVIDERS AND SOCIAL SERVICE ORGANIZATIONS TO HELP MEET THE COMMUNITY'S HEALTH NEEDS. IN ADDITION, ST. LUKE'S IS ACTIVELY INVOLVED WITH SIOUXLAND COMMUNITY HEALTH CENTER TO RESPOND TO THE UNMET HEALTH CARE NEEDS AMONG THE UNDERSERVED IN THE COMMUNITY. WITH THE GOALS OF INCREASED AWARENESS AND INCREASED NUMBER OF PARTICIPANTS THROUGHOUT THE TRI-STATE AREA, ST. LUKE'S WORKS WITH OTHER HEALTH ORGANIZATIONS TO PROMOTE COLORECTAL CANCER AND MAMMOGRAPHY SCREENINGS.ST. LUKE'S EMPLOYEES, AND IN PARTICULAR ST. LUKE'S LEADERSHIP, ARE ACTIVE IN VOLUNTEERISM FOR NON-PROFIT ORGANIZATIONS, FROM SUPPORT TO LEADERSHIP ROLES. THIS ALLOWS EMPLOYEES TO USE THEIR HEALTHCARE EDUCATION AND EXPERTISE TO IMPACT THE COMMUNITY'S OVERALL HEALTH STATUS. ST. LUKE'S EMPLOYEES ARE PROACTIVE IN EDUCATING THE PEOPLE WE SERVE ABOUT PERTINENT HEALTH INFORMATION THROUGH PUBLIC HEALTH CLASSES, PROFESSIONAL HEALTH EDUCATION PROGRAMS AND PARTICIPATION IN HEALTH FAIRS ACROSS THE TRI-STATE AREA. THE HOSPITAL'S WEBSITE AT WWW.UNITYPOINT.ORG/SIOUXCITY ALSO CONTAINS AN UP-TO-DATE LISTING OF PROGRAMS AND SCREENINGS AS WELL AS PERTINENT HEALTH INFORMATION TO EDUCATE CONSUMERS ABOUT SYMPTOMS, TREATMENT AND HEALTHCARE OPTIONS THEY HAVE IN SIOUXLAND. BY SUPPORTING THE COMMUNITY AND OTHER NON-PROFIT ORGANIZATIONS, ST. LUKE'S IS ABLE TO MOVE ONE STEP CLOSER TO FULFILLING ITS MISSION TO IMPROVE THE HEALTH OF THE PEOPLE OF SIOUXLAND. PART III, LINE 4: THE HEALTH SYSTEM PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HEALTH SYSTEM BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE AMOUNT REPORTED ON LINE 2 WAS CALCULATED USING IRS WORKSHEET 2 'RATIO OF PATIENT CARE COST TO CHARGES' TO CALCULATE THE COST TO CHARGE RATIO FOR NIHC. THIS RATIO WAS THEN APPLIED AGAINST THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS USING IRS WORKSHEET A TO ARRIVE AT THE BAD DEBT EXPENSE AT COST REPORTED ON LINE 2. PART III, LINE 8: AMOUNTS ON LINE 6 WERE CALCULATED USING IRS WORKSHEET B 'TOTAL MEDICARE ALLOWABLE COSTS.' THE MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORTS AND THEN REDUCED BY ANY AMOUNTS ALREADY CAPTURED IN COMMUNITY BENEFIT EXPENSE IN PART I ABOVE.THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE MEDICARE SURPLUS REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT. HOWEVER THE MEDICARE COST REPORT DISALLOWS CERTAIN ITEMS THAT WE BELIEVE ARE LEGITIMATE EXPENSES INCURRED IN THE PROCESS OF CARING FOR OUR MEDICARE PATIENTS. EXAMPLES OF THESE ITEMS INCLUDE PROVIDER BASED PHYSICIAN EXPENSE, SELF INSURANCE EXPENSE, HOME OFFICE EXPENSE AND THE SHORTFALL FROM FEE SCHEDULE PAYMENTS. THE ORGANIZATION'S COST ACCOUNTING SYSTEM CALCULATES A MEDICARE SHORTFALL OF $6,200,660. IN ADDITION TO THESE ITEMS THE MEDICARE COST REPORT AND THE COST ACCOUNTING SYSTEM DO NOT INCLUDE MEDICARE PHYSICIAN FEE SCHEDULE EXPENSE OF $1,089,985 AND REVENUE OF $892,575. AFTER TAKING THESE ITEMS INTO ACCOUNT WE CALCULATE AN ACTUAL MEDICARE SHORTFALL OF $6,398,070.THE HOSPITAL BELIEVES THE ENTIRE AMOUNT OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT, MORE SPECIFICALLY, AS CHARITY CARE. THE ELDERLY CONSTITUTE A CLEARLY-RECOGNIZED CHARITABLE CLASS, AND MANY MEDICARE BENEFICIARIES, LIKE THEIR MEDICAID COUNTERPARTS, ARE POOR AND THUS WOULD HAVE QUALIFIED FOR THE HOSPITAL'S CHARITY CARE PROGRAM, MEDICAID OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS ABSENT THE MEDICARE PROGRAM. BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS. ADDITIONALLY, THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS. FINALLY, THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER CHARITY CARE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: AFTER THE PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS PARTIALLY OR ENTIRELY WRITTEN OFF, AS APPROPRIATE. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. PART VI, LINE 2: NORTHWEST IOWA HOSPITAL CORPORATION D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER (ST. LUKE'S) CONTINUALLY WORKS WITH COMMUNITY PARTNERS TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY AND THEN ENGAGES IN PRIORITIES THAT MATCH ITS MISSION AND CAPACITY. SIOUXLAND DISTRICT HEALTH, LOCATED IN SIOUX CITY, ASSESSES THE COMMUNITY'S HEALTHCARE NEEDS AT LEAST ONCE EVERY FIVE YEARS. THROUGH A PLANNED AND ORGANIZED EFFORT, SIOUXLAND DISTRICT HEALTH DEVELOPS A HEALTH AGENDA BY IDENTIFYING SPECIFIC HEALTH PRIORITIES AND SHARES THAT INFORMATION THROUGH A COMPREHENSIVE REPORT TO THE COMMUNITY. IN COLLABORATION WITH THIS AGENCY, ST. LUKE'S UTILIZES THIS INFORMATION TO MONITOR LOCAL HEALTH, ENSURING THE HOSPITAL'S PROGRAMS, SERVICES AND HEALTH EDUCATION SUPPORTS PRIORITIES IDENTIFIED BY SIOUXLAND DISTRICT HEALTH. ST. LUKE'S ALSO PARTICIPATES IN HEALTHY SIOUXLAND INITIATIVE, A COLLECTION OF PUBLIC HEALTH PARTNERS THAT CONVENES MONTHLY, AND OTHER COMMUNITY HEALTH COLLABORATIONS, DESIGNED TO BUILD PARTNERSHIPS AMONG COMMUNITY HEALTHCARE ORGANIZATIONS TO BUILD A HEALTHY AND SAFE COMMUNITY. UNITED WAY IS ANOTHER PROGRAM ST. LUKE'S PARTICIPATES IN THROUGH THE UNITED WAY COMMUNITY IMPACT TEAMS. THIS GROUP ACTIVELY ADDRESSES NEED AND STRATEGIES ASSOCIATED WITH HEALTH. MORE SPECIFICALLY, THE SOCIAL DETERMINANTS OF HEALTH AND HOW TO IMPACT THEM IN THE EFFORT TO RAISE COMMUNITY HEALTH STATUS IS THE FOCUS OF THIS GROUP. THIS WIDE BASED COLLABORATIVE PROVIDES OPPORTUNITIES FOR ST. LUKE'S TO ENGAGE IN VARIOUS AREAS OF SERVICE TO THE COMMUNITY THAT MAY BE OUTSIDE OF ITS TYPICAL EXPERTISE BUT WITHIN ITS EXISTING RESOURCES. IN ADDITION TO THESE EFFORTS, ST. LUKE'S CONTINUALLY MONITORS COMMUNITY NEEDS SPECIFIC TO ITS SERVICE LINES AND THE RESOURCES IT CAN LEVERAGE TO ADDRESS THEM. INDIVIDUAL DEPARTMENTS ALSO WORK TO IDENTIFY SPECIFIC NEEDS RELATED TO THEIR SERVICES AND THE POPULATIONS THEY AFFECT. PART VI, LINE 3: NORTHWEST IOWA HOSPITAL CORPORATION D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER (ST. LUKE'S) CARES FOR ALL PERSONS REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES. TO ACCOMPLISH THIS, ST. LUKE'S PROVIDES EFFECTIVE COMMUNICATIONS FOR PATIENTS REGARDING THEIR HOSPITAL BILLS, MAKES EFFORTS TO HELP PATIENTS APPLY FOR PUBLIC AND PRIVATE FINANCIAL SUPPORT PROGRAMS, AND OFFERS FINANCIAL SUPPORT TO PATIENTS WITH LIMITED MEANS.ST. LUKE'S COMMUNICATES THE AVAILABILITY OF CHARITY CARE AND FINANCIAL ASSISTANCE TO ALL PATIENTS BY PLACING SIGNAGE AND EDUCATIONAL INFORMATION IN HIGH TRAFFIC AREAS OF THE HOSPITAL AND ITS CAMPUS INCLUDING ADMITTING, EMERGENCY AND OUTPATIENT AREAS AND PROVIDER OFFICES. IN ADDITION, DETAILED INFORMATION ABOUT ST. LUKE'S FINANCIAL ASSISTANCE PROGRAMS INCLUDING CHARITY CARE AND HOW TO OBTAIN MORE INFORMATION IS AVAILABLE ON THE HOSPITAL'S WEBSITE AT WWW.STLUKES.ORG. ST. LUKE'S ALSO PROVIDES INFORMATION ABOUT FINANCIAL ASSISTANCE AT REGISTRATION, AND AGAIN, ON THE PATIENT'S HEALTHCARE BILLING STATEMENT. STAFF HAS BEEN EDUCATED TO DIRECT INPATIENTS TO APPROPRIATE CONTACTS UPON ADMISSION IF FINANCIAL ASSISTANCE IS NEEDED. DESIGNATED INDIVIDUALS ARE AVAILABLE TO ANSWER QUESTIONS REGARDING ST. LUKE'S CHARITY CARE AND FINANCIAL ASSISTANCE PROGRAMS. TRANSLATION SERVICES ARE AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK TO ENSURE CLARITY OF ASSISTANCE.ST. LUKE'S ALSO WORKS WITH THE MISSION HEALTH PROGRAM, A COLLABORATION BETWEEN THE SIOUXLAND COMMUNITY HEALTH CENTER, MERCY MEDICAL CENTER SIOUX CITY AND ST. LUKE'S. INFORMATION IN THIS PROGRAM IS ALSO AVAILABLE IN SPANISH. THIS COMMUNITY OUTREACH PROGRAM PRE-QUALIFIES PARTICIPANTS FOR FINANCIAL ASSISTANCE AT BOTH LOCAL HOSPITALS, AND PARTICIPANTS ARE INVITED TO SELECT A MEDICAL HOME.EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY PRIOR TO OR AT THE TIME OF ADMISSION OR SERVICE. HOWEVER, FINANCIAL SUPPORT DETERMINATION MAY BE MADE DURING ANY STAGE OF A PATIENT'S STAY AFTER STABILIZATION OR COLLECTION CYCLE. PART VI, LINE 4: NORTHWEST IOWA HOSPITAL CORPORATION D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER (ST. LUKE'S) IS AN URBAN, ACUTE-CARE COMMUNITY HOSPITAL LICENSED FOR 346 BEDS AND STAFFED FOR 158 BEDS SERVING THE SIOUXLAND AREA. THE SIOUXLAND AREA IS A TRI-STATE AREA CONSISTING OF NORTHWEST IOWA, NORTHEAST NEBRASKA, AND SOUTHEAST SOUTH DAKOTA. ST. LUKE'S IS NONDENOMINATIONAL AND SERVES ALL WHO COME HERE, REGARDLESS OF REASON OR CIRCUMSTANCE. ST. LUKE'S DISCHARGES JUST OVER 11,000 INPATIENTS AND OVERSEES OVER 66,000 OUTPATIENTS VISITS PER YEAR INCLUDING EMERGENCY PATIENTS. WITHIN THE SIOUXLAND AREA, ST. LUKE'S SERVES A PRIMARY AND SECONDARY MARKET DEFINED BY COUNTIES. THE PRIMARY MARKETS ARE PLYMOUTH AND WOODBURY COUNTIES IN IOWA, DAKOTA COUNTY IN NEBRASKA AND UNION COUNTY IN SOUTH DAKOTA. THE PRIMARY COUNTIES ACCOUNT FOR 85% OF ST. LUKE'S INPATIENT DISCHARGES. WITHIN THE PRIMARY MARKET, TWO COMMUNITY HOSPITALS ARE LOCATED IN WOODBURY COUNTY, IOWA, AND ONE SURGICAL SPECIALTY HOSPITAL THAT IS PHYSICIAN-OWNED IS LOCATED IN UNION COUNTY, SOUTH DAKOTA. WOODBURY COUNTY IS THE LARGEST COUNTY IN THE SIOUXLAND AREA WITH APPROXIMATELY 102,000 RESIDENTS, WITH SIOUX CITY AS THE LARGEST CITY IN THE AREA WITH A 2011 ESTIMATED POPULATION OF 82,600. THE SECONDARY MARKETS ARE CHEROKEE, MONONA AND SIOUX COUNTIES IN IOWA AND THURSTON COUNTY IN NEBRASKA. WITH THE EXCEPTION OF THURSTON, A SEPARATE CRITICAL ACCESS HOSPITAL IS HOUSED IN EACH OF THESE COUNTIES.FOCUSING ON THE PRIMARY MARKET, THE HISPANIC POPULATION HAS THE LARGEST IMPACT IN TWO OF THE FOUR PRIMARY COUNTIES WITH DAKOTA COUNTY'S POPULATION HAVING 34% HISPANIC ETHNICITY AND WOODBURY COUNTY WITH 13%. DAKOTA COUNTY AND WOODBURY COUNTY ALSO HAVE THE HIGHEST PERCENTAGE OF FAMILIES BELOW THE FEDERAL POVERTY LEVEL AT 12% AND 11% RESPECTIVELY. PART VI, LINE 5: NORTHWEST IOWA HOSPITAL CORPORATION D/B/A ST. LUKE'S REGIONAL MEDICAL CENTER (ST. LUKE'S) IS ORGANIZED AND OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITH THE GOAL OF PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. ST. LUKE'S SUPPORTS THIS MISSION WITH A COMMUNITY BOARD, OPEN MEDICAL STAFF, AND AN EMERGENCY ROOM AVAILABLE TO PATIENTS REGARDLESS OF ABILITY TO PAY. ST. LUKE'S IS THE REGION'S ONLY IOWA LEVEL II REGIONAL OBSTETRICAL TRANSPORT CENTER FOR HIGH-RISK OBSTETRICS AND IOWA LEVEL II NEONATOLOGY CENTER.ST. LUKE'S IS ALSO INVOLVED IN THE NW IOWA'S AMERICAN HEART TASK FORCE, TRI-STATE DISASTER COMMITTEE, IOWA'S DISASTER MEDICAL ASSISTANCE TEAM AND EMERGENCY CONFERENCE COMMITTEE. ST. LUKE'S SUPPORTS THE SIOUXLAND MEDICAL EDUCATION FOUNDATION, A FAMILY PRACTICE RESIDENCY AS WELL AS ST. LUKE'S COLLEGE, WHICH IS THE REGION'S ONLY MEDICAL CENTER BASED HEALTH SCIENCES COLLEGE. THE COLLEGE OFFERS ASSOCIATE OF SCIENCE DEGREES IN NURSING, RADIOLOGY, AND RESPIRATORY CARE AS WELL AS CERTIFICATES IN MEDICAL LABORATORY SCIENCES AND PHLEBOTOMY.THE BOARD OF DIRECTORS OF ST. LUKE'S IS COMPOSED OF CIVIC LEADERS WHO RESIDE IN THE SERVICE AREA OF THE HOSPITAL. THE BOARD ACTIVELY DEBATES AND SETS POLICY AND STRATEGIC DIRECTION FOR THE HOSPITAL BUT DOES NOT GET INVOLVED IN ISSUES RELATED TO THE DIRECT OPERATIONS OF THE HOSPITAL. THE BOARD TAKES A BALANCED APPROACH WHEN ADDRESSING COMMUNITY AND BUSINESS/FINANCIAL CONCERNS. THE BOARD IS ALSO THE PRIMARY GROUP FOR DETERMINING THE USE OF HOSPITAL SURPLUS FUNDS, WHICH ARE ALL USED TO FURTHER OUR CHARITABLE PURPOSE. PART VI, LINE 6: THE HOSPITAL IS PART OF IOWA HEALTH SYSTEM. INITIALLY FORMED IN 1995, IOWA HEALTH SYSTEM IS THE STATE'S FIRST AND LARGEST INTEGRATED HEALTH SYSTEM, SERVING NEARLY ONE OF EVERY THREE PATIENTS IN IOWA. THROUGH RELATIONSHIPS WITH 29 HOSPITALS IN METROPOLITAN AND RURAL COMMUNITIES AND 280 PHYSICIAN CLINICS, IOWA HEALTH SYSTEM PROVIDES CARE THROUGHOUT IOWA AND ILLINOIS.IOWA HEALTH SYSTEM ENTITIES EMPLOY THE STATE'S LARGEST NONPROFIT WORKFORCE, WITH MORE THAN 24,000 EMPLOYEES WORKING TOWARD INNOVATIVE ADVANCEMENTS TO DELIVER THE BEST OUTCOME FOR EVERY PATIENT EVERY TIME. EACH YEAR, THROUGH MORE THAN 4 MILLION PATIENT VISITS, IOWA HEALTH SYSTEM HOSPITALS AND CLINICS PROVIDE A FULL RANGE OF CARE TO PATIENTS AND FAMILIES. WITH ANNUAL REVENUES OF $2.7 BILLION, IOWA HEALTH SYSTEM IS THE FOURTH LARGEST NONDENOMINATIONAL HEALTH SYSTEM IN AMERICA AND PROVIDES COMMUNITY BENEFIT PROGRAMS AND SERVICES TO IMPROVE THE HEALTH OF PEOPLE IN ITS COMMUNITIES. IOWA HEALTH SYSTEM AND ITS AFFILIATES ENGAGE IN COMMUNITY HEALTH PROGRAMS AND SERVICES THROUGHOUT IOWA, AND WORK WITH VOLUNTEER AND CIVIC ORGANIZATIONS, SCHOOLS, BUSINESSES, INSURERS AND INDIVIDUALS TO SUPPORT ACTIVITIES THAT BENEFIT PEOPLE THROUGHOUT THE STATE. IN 2012, IOWA HEALTH SYSTEM AND ITS AFFILIATES PROVIDED $421 MILLION OF COMMUNITY BENEFIT. THE CONTRIBUTIONS TO THEIR COMMUNITIES BY IOWA HEALTH SYSTEM AND ITS AFFILIATES ARE REPORTED IN DETAIL IN STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS (PART III) OF THE IRS FORM 990 OF THOSE AFFILIATES. REPORTS FILED WITH STATES PART VI, LINE 7 IA 1 BUY FRESH LOCAL - SIOUXLAND INC 505 FIFTH STREET SUITE 200 SIOUX CITY IA 51101 263295404 501(C)(3) 5000 PROGRAM SUPPORT COUNCIL ON SEXUAL ASSAULT & DOMESTIC VIOLENCE INC PO BOX 1565 SIOUX CITY IA 51102 421104234 501(C)(3) 5160 EVENT SPONSOR SIOUX CITY SYMPHONY ORCHESTRA 375 ORPHEUM ELECTRIC BUILDING SIOUX CITY IA 51102 426006580 501(C)(3) 5000 EVENT SPONSOR SIOUXLAND INITIATIVE 101 PIERCE STREET SIOUX CITY IA 51101 421328697 501(C)(6) 10000 PROGRAM SUPPORT SIOUXLAND MEDICAL EDUCATION FOUNDATION 2501 PIERCE STREET SIOUX CITY IA 51104 421036971 501(C)(3) 1139000 PROGRAM SUPPORT ST LUKE'S HEALTH FOUNDATION OF SIOUX CITY IOWA 2720 STONE PARK BLVD SIOUX CITY IA 51104 421301885 501(C)(3) 66415 PROGRAM SUPPORT THE SIOUXLAND Y (YMCA) 601 RIVERVIEW DRIVE SOUTH SIOUX CITY NE 68776 420738980 501(C)(3) 5000 PROGRAM SUPPORT UNITED WAY OF SIOUXLAND 701 STEUBEN STREET SIOUX CITY IA 51101 420680395 501(C)(3) 15000 PROGRAM SUPPORT 7 1 SCHOLARSHIPS 75 12392 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: NORTHWEST IOWA HOSPITAL CORPORATION REQUIRES EACH RECIPIENT OF THE GRANTS MENTIONED IN PART II (OTHER THAN ASSISTANCE TO RELATED ORGANIZATIONS IN THE FORM OF WORKING CAPITAL) TO APPLY FOR THE GRANT AND OUTLINE A SERIES OF ELIGIBILITY STANDARDS THAT ARE REQUIRED TO BE MET. NORTHWEST IOWA HOSPITAL CORPORATION THEN REVIEWS THESE APPLICATIONS, AND BASED ON NEED & ELIGIBILITY, MANAGEMENT MAKES THE FINAL DECISION ON ALL GRANT RECIPIENTS. NORTHWEST IOWA HOSPITAL CORPORATION MINIMIZES THE THREAT OF DIVERSION FOR INTENDED PURPOSE BY SENDING THE FUNDS DIRECTLY TO THE ORGANIZATION, WHERE POSSIBLE, ETC. X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 JAMES GOBELL 160079 0 21549 0 8673 0 23025 0 21127 0 234453 0 0 0 RICHARD HILDEBRAND MD 264161 0 83172 0 28389 0 86471 0 24878 0 487071 0 0 0 CHAD MARKHAM 112093 0 34199 0 8560 0 7666 0 20524 0 183042 0 0 0 PRISCILLA STOKES 134345 0 42830 0 8758 0 9049 0 13023 0 208005 0 0 0 PETER THOREEN 320456 0 112281 0 58318 0 192446 0 21408 0 704909 0 0 0 SUSAN UNGER 118947 0 30092 0 7800 0 7537 0 1974 0 166350 0 0 0 LYNN WOLD 200149 0 56337 0 12855 0 52210 0 22508 0 344059 0 0 0 GARY JOHNSON 126766 0 24204 0 0 0 15481 0 9691 0 176142 0 0 0 ALFRED FLEMING MD 451617 0 0 0 12102 0 12500 0 20243 0 496462 0 0 0 JOHN GOEBEL 438894 0 0 0 2622 0 12500 0 20243 0 474259 0 0 0 FADY JABRE MD 484485 0 0 0 1710 0 12725 0 20243 0 519163 0 0 0 LUIS LEBREDO MD 586614 0 0 0 34594 0 17548 0 13871 0 652627 0 0 0 JEFFREY O'TOOL 513660 0 0 0 1026 0 12500 0 20516 0 547702 0 0 0 MARK JOHNSON TO 1211 8579 244459 75600 0 407 65076 556 93581 45 19495 85187 422611 0 0 PART I, LINE 1A FIRST-CLASS OR CHARTER TRAVEL: CEO AND BOARD MEMBERS USE PRIVATE CHARTER FOR BUSINESS TRAVEL BETWEEN AFFILIATE CITIES AND FOR BOARD OF DIRECTOR MEETINGS. THIS TRAVEL IS FOR BUSINESS PURPOSES ONLY. NO FIRST CLASS COMMERCIAL TRAVEL IS REIMBURSED. TRAVEL FOR COMPANIONS: SPOUSES SOMETIMES ACCOMPANY BOARD MEMBERS AND/OR OFFICERS ON ORGANIZATIONAL ACTIVITIES, INCLUDING BOARD RELATED TRAVEL. THE ADDITIONAL COST ATTRIBUTABLE TO THE SPOUSE IS TREATED AS TAXABLE COMPENSATION TO THE BOARD MEMBER OR OFFICER AND REPORTED AS APPROPRIATE TO THE IRS. PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN WITH THE FOLLOWING CHANGES TO THEIR ACCOUNTS: JAMES GOBELL $12,659, RICHARD HILDEBRAND, MD $73,846, MARK JOHNSON $79,901, PETER THOREEN $178,218, AND LYNN WOLD $39,710. IOWA HEALTH SYSTEM CONTRACTING SERVICES LC COMMON BOARD MEMBER/OFFICER 153386 PERFORMANCE OF SERVICES 0 PIERCE STREET SAME DAY SURGERY CENTER LC COMMON BOARD MEMBER/OFFICER 3187203 LEASE STAFF, RENT SPACE AND EQUIPMENT, AND DIVIDENDS 0 FORM 990, PART VI, SECTION A, LINE 6 IOWA HEALTH SYSTEM, A TAX-EXEMPT IOWA NOT-FOR-PROFIT CORPORATION, IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B IOWA HEALTH SYSTEM, AS SOLE MEMBER, APPROVES AMENDMENTS TO ARTICLES AND BYLAWS, APPOINTS AND REMOVES CEO, APPROVES LIQUIDATION OR DISSOLUTION, AND APPROVES INDEBTEDNESS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED INTERNALLY BY THE TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY FUNCTIONAL AREA WITH RESPONSIBILITY ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS ("COMMITTEE") CONDUCTS A COMPREHENSIVE ANNUAL REVIEW OF ALL COMPENSATION AND BENEFITS PROVIDED TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES, INCLUDING THE IHS CHIEF EXECUTIVE OFFICER (THE "CEO"). THIS ANNUAL REVIEW COMPARES THE TOTAL COMPENSATION AND VALUE OF BENEFITS PROVIDED TO EACH EXECUTIVE, ON A POSITION BY POSITION BASIS, TO THAT PROVIDED TO FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED ORGANIZATIONS. THIS REVIEW IS CONDUCTED BY THE COMMITTEE WITH THE ASSISTANCE OF A NATIONAL, INDEPENDENT COMPENSATION CONSULTANT REPORTING DIRECTLY TO THE COMMITTEE. THE COMMITTEE HAS BEEN DELEGATED THE RESPONSIBILITY FOR OVERSIGHT OF EXECUTIVE COMPENSATION AND IS MADE UP ENTIRELY OF INDEPENDENT DIRECTORS WITHIN THE MEANING OF THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER THE FEDERAL INCOME TAX INTERMEDIATE SANCTIONS RULES. THE COMPENSATION CONSULTANT HOLDS ITSELF OUT TO THE PUBLIC AS A COMPENSATION CONSULTANT, PERFORMS THESE VALUATIONS ON A REGULAR BASIS, IS QUALIFIED TO MAKE THE VALUATIONS OF THE SERVICES INVOLVED, AND HAS SO INDICATED IN A WRITTEN CERTIFICATION TO THE COMMITTEE. BASED UPON THE ADVICE OF THE COMPENSATION CONSULTANT, AND APPLYING THE BOARD'S COMPENSATION PHILOSOPHY, THE COMMITTEE ESTABLISHES THE OVERALL ADJUSTMENT IN COMPENSATION AND BENEFITS FOR APPROXIMATELY THE TOP FIFTY EXECUTIVES IN THE ENTIRE HEALTH SYSTEM (SEVERAL OF WHICH ARE EMPLOYEES OF THE FILING ORGANIZATION) AND DELEGATES TO THE CEO THE AUTHORITY TO MAKE ADJUSTMENTS, CONSISTENT WITH THE COMMITTEE'S DIRECTION, FOR THE OTHER EXECUTIVES. THE COMMITTEE DETERMINES ALL ASPECTS OF THE COMPENSATION AND BENEFITS OF THE CEO. THE COMMITTEE INTENTIONALLY TAKES ALL THE STEPS NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE FEDERAL INCOME TAX LAW INTERMEDIATE SANCTIONS RULES, INCLUDING CONTEMPORANEOUS SUBSTANTIATION OF ALL COMMITTEE MEETINGS AND ACTIONS. THE ORGANIZATION BELIEVES IT IS IN FULL COMPLIANCE WITH SECTION 4958 OF THE IRC, PROVIDES NO MORE THAN REASONABLE AND FAIR MARKET VALUE COMPENSATION AND BENEFITS FOR ITS EMPLOYEES AND DOES NOT PROVIDE ANY EXCESS COMPENSATION OR BENEFITS AS PROHIBITED BY SECTION 4958. THE ANNUAL REVIEW OF COMPENSATION AND BENEFITS WAS LAST PERFORMED IN NOVEMBER 2012 FOR THE FOLLOWING INDIVIDUALS: JAMES GOBELL, RICHARD HILDEBRAND, MD, MARK JOHNSON, PETER THOREEN, AND LYNN WOLD. THE COMPENSATION AND BENEFITS OF THE OTHER PERSONS LISTED ON FORM 990, PART VII WAS ESTABLISHED BY AN INDEPENDENT PERSON/COMMITTEE USING AN INDEPENDENT COMPENSATION CONSULTANT AND/OR COMPENSATION SURVEY OR STUDY FOR SIMILARLY QUALIFED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. COMPENSATION AND BENEFITS ARE BASED ON THE FAIR MARKET VALUE OF THE SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, HAS VOLUNTARILY ADOPTED MANY OF OUR INDUSTRY'S GOVERNANCE "BEST PRACTICES." IOWA HEALTH SYSTEM HAS DONE SO TO FURTHER ASSURE OUR STAKEHOLDERS THAT OUR GOVERNANCE AND MANAGEMENT IS CONDUCTED RESPONSIBLY AND WARRANTS THE TRUST YOU PLACE IN US. IN SEPTEMBER 2003, THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS VOLUNTARILY ADOPTED OVER 40 CHANGES TO ITS GOVERNANCE STRUCTURE TO BETTER COMPLY WITH GOVERNANCE BEST PRACTICES AND THE INTENT AND APPLICABLE REQUIREMENTS OF THE SARBANES-OXLEY ACT OF 2003. IN ADDITION, GOVERNANCE POLICIES AND RELATED INFORMATION HAS BEEN ADDED TO THE IOWA HEALTH SYSTEM WEBSITE, WWW.IHS.ORG, INCLUDING BUT NOT LIMITED TO: OVER 130 CORPORATE COMPLIANCE POLICIES, INCLUDING CHARITY CARE AND CONFLICTS OF INTEREST POLICIES; GOVERNANCE BEST PRACTICE POLICIES; THE IDENTIFICATION OF BOARD MEMBERS AND BOARD COMMITTEES; COMPENSATION FOR HOSPITAL CEO'S; AND FINANCIAL INFORMATION FOR THE PAST SEVEN YEARS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: FUND BALANCE TRANSFERS 251,495. CHANGE IN BENEFICIAL INTEREST OF ST. LUKE'S HEALTH FOUNDATION OF SC, IA -406,747. ALLEN COLLEGE 1825 LOGAN AVENUE WATERLOO IA 50703 421351526 EDUCATE AND DEVELOP HEALTHCARE PROFESSIONALS IA 501(C)(3) 170(B)(1) (A)(II) ALLEN HEALTH SYSTEMS INC 0 ALLEN HEALTH SYSTEMS INC 1825 LOGAN AVENUE WATERLOO IA 50703 421201924 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 0 ALLEN MEMORIAL HOSPITAL CORPORATION 1825 LOGAN AVENUE WATERLOO IA 50703 420698265 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ALLEN HEALTH SYSTEMS INC 0 ANAMOSA AREA AMBULANCE SERVICE 101 GRANT WOOD DRIVE ANAMOSA IA 52205 421466284 PROVIDE AMBULANCE SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'SJONES REGIONAL MEDICAL CENTER 0 CENTRAL IOWA HEALTH PROPERTIES CORPORATION 1200 PLEASANT STREET DES MOINES IA 50309 421233759 PROPERTY HOLDING COMPANY IA 501(C)(2) CENTRAL IOWA HEALTH SYSTEM 0 CENTRAL IOWA HEALTH SYSTEM 1200 PLEASANT STREET DES MOINES IA 50309 421189791 SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM 0 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1026 A AVENUE NE CEDAR RAPIDS IA 52402 426061621 PAY MEDICAL BILLS OF RETIRED TEACHERS UNABLE TO PAY IA 501(C)(3) 509(A)(3), TYPE I ST LUKE'S METHODIST HOSPITAL 0 NORTH CENTRAL IOWA MENTAL HEALTH CENTER INCORPORATED 720 KENYON DRIVE FORT DODGE IA 50501 420937390 MENTAL HEALTH CARE IA 501(C)(3) 170(B)(1) (A)(III) TRINITY HEALTH SYSTEMS INC 0 NORTHWEST IOWA HOSPITAL CORPORATION 2720 STONE PARK BLVD SIOUX CITY IA 51104 421019872 HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) IOWA HEALTH SYSTEM 0 SELF INSURANCE TRUST AGREEMENT EST BY METHODIST MEDICAL CENTER OF ILLINOIS 221 NORTHEAST GLEN OAK AVENUE PEORIA IL 61636 376181831 FUND SELF-INSURANCE PLAN IL 501(C)(3) 509(A)(3), TYPE I METHODIST MEDICAL CENER OF ILLINOIS 0 SIOUXLAND PACE INC 313 COOK STREET SIOUX CITY IA 51103 261120134 ALL-INCLUSIVE CARE FOR THE ELDERLY IA 501(C)(3) 170(B)(1) (A)(III) ST LUKE'S HEALTH SYSTEM INC 0 ST LUKE'S HEALTH RESOURCES 2720 STONE PARK BLVD SIOUX CITY IA 51104 421059182 OUTPATIENT CLINICS AND HEALTHCARE SERVICES 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IA N/A C 0 DELHI POINT CONDO ASSOCIATION 350 N GRANDVIEW DUBUQUE IA 52001 421467002 REAL ESTATE MANAGEMENT IA N/A C 0 INTEGRATED CARE ORGANIZATION 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 274665007 INTEGRATED AFFILIATE CARE IA N/A C 0 IOWA HEALTH SYSTEM 457 DEF COMP PLAN 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 421435199 INVESTMENT IA N/A T 0 MEDIMORE INC 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 421414390 MANAGED CARE IA N/A C 0 METHODIST HEALTH VENTURES INC PO BOX 87 PEORIA IL 61650 371140939 PHARMACY/OFFICE STAFFING IL N/A C 0 METHODIST PHYSICIAN SERVICES INC PO BOX 87 PEORIA IL 61650 363858550 MEDICAL SERVICES IL N/A C 0 PRECEDENCE INC 4622 PROGRESS DRIVE STE A DAVENPORT IA 52807 371288604 MANAGED MENTAL CARE IA N/A C 0 PROVIDER RESOURCE MANAGEMENT INC PO BOX 87 PEORIA IL 61650 371223550 RESOURCE MANAGEMENT IL N/A C 0 RURAL IOWA SPECIALTY PHYSICIAN CONSORTIUM INC 700 E UNIVERSITY AVE DES MOINES IA 50316 261271143 SPECIALTY PHYSICIANS MEDICAL CARE IA N/A C 0 STL HEALTH RESOURCES CO 1026 A AVE NE CEDAR RAPIDS IA 52402 421193499 PHYSICIAN OFFICE RENTAL IA N/A C 0 TRINITY HEALTH ENTERPRISES INC 2701 17TH ST ROCK ISLAND IL 61201 363320141 RETAIL DURABLE MEDICAL EQUIPMENT & PHARMACY IL N/A C 0 TRINITY PHYSICIAN HOSPITAL ORGANIZATION LTD 4622 PROGRESS DRIVE STE A DAVENPORT IA 52807 363924720 MANAGED HEALTH CARE IA N/A C 0 0 0 1 0 0 0 1 0 0 1 0 1 1 0 1 0 1 0 0