2013-08-13T16:03:05-05:00 2012-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-10-01 390806268 MERCY MEDICAL CENTER OF OSHKOSH INC MERC 9207382000 500 S OAKWOOD RD OSHKOSH WI 54904 JEFF BADGER 9207382000 2013-08-13 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-08-13 2011 2016-02-24 21:20:13Z JEFF BADGER 500 S OAKWOOD RD OSHKOSH WI 54904 120591890 0 0928 X WWW.AFFINITYHEALTH.ORG X X 1891 WI WE PROUDLY SERVE THE OSHKOSH COMMUNITY WITH A HISTORY OF MORE THAN A CENTURY OF QUALITY CARE. THE FACILITY PROVIDES TOTAL HEALTH CARE, INCLUDING EMERGENCY/TRAUMA CARE AND SURGICAL SERVICES AS WELL AS MANY MEDICAL SPECIALTIES SUCH AS CARDIOLOGY, ONCOLOGY, ORTHOPEDICS, INTENSIVE CARE, OBSTETRICS AND NEUROSURGERY. MERCY IS THE HOME OF THE KENNEDY CENTER FOR THE HIP AND KNEE, A NATIONALLY-RECOGNIZED PROGRAM FOR HIP REPLACEMENT. WITH 157 PATIENT BEDS AND MORE THAN 300 MEDICAL STAFF, MERCY MEDICAL CENTER TREATS PATIENTS WITH DIGNITY AND COMPASSION.AVAILABLE SERVICES: CANCER; CARDIAC REHABILITATION; CARDIOVASCULAR SURGERY; DIABETES, NUTRITION AND ENDOCRINOLOGY; ER; GENERAL SURGERY; GYNECOLOGY; HOSPITALIST; LABORATORY; LIFELINE HOME MONITORING; NEPHROLOGY; OBSTETRICS; ORTHOPEDICS; PAIN MANAGEMENT; PALLIATIVE CARE (END OF LIFE CARE); PHARMACY; PSYCHIATRY/PSYCHOLOGY; PULMONOLOGY; RADIOLOGY; REHABILITATION SERVICES; SLEEP LAB; SPIRITUAL SERVICES; SPORTS MEDICINE; VASCULAR MEDICINE; WOUND CARE. 15 9 951 616 100741 -126288 284320 98839 120070923 116127223 4817589 1614302 304534 792104 125477366 118632468 477961 0 0 0 54112272 55562944 0 0 0 54897248 54376008 109487481 109938952 15989885 8693516 265742458 96663540 56327645 66619098 209414813 30044442 X MERCY MEDICAL CENTER HAS ADOPTED THE MISSION STATEMENT OF AFFINITY HEALTH SYSTEM. THE MISSION OF AFFINITY HEALTH SYSTEM IS TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. 0 0 85025823 115521780 MERCY MEDICAL CENTER PROUDLY SERVES THE OSHKOSH COMMUNITY WITH A HISTORY OF MORE THAN A CENTURY OF QUALITY CARE. THE FACILITY PROVIDES TOTAL HEALTH CARE, INCLUDING EMERGENCY/TRAUMA CARE AND SURGICAL SERVICES AS WELL AS MANY MEDICAL SPECIALTIES SUCH AS CARDIOLOGY, ONCOLOGY, ORTHOPEDICS, INTENSIVE CARE, OBSTETRICS AND NEUROSURGERY. MERCY IS THE HOME OF THE KENNEDY CENTER FOR THE HIP AND KNEE, A NATIONALLY-RECOGNIZED PROGRAM FOR HIP REPLACEMENT. WITH 157 PATIENT BEDS AND MORE THAN 300 MEDICAL STAFF, MERCY MEDICAL CENTER TREATS PATIENTS WITH DIGNITY AND COMPASSION. AVAILABLE SERVICES: CANCER; CARDIAC REHABILITATION; CARDIOVASCULAR SURGERY; DIABETES, NUTRITION AND ENDOCRINOLOGY; ER; GENERAL SURGERY; GYNECOLOGY; HOSPITALIST; LABORATORY; LIFELINE HOME MONITORING; NEPHROLOGY; OBSTETRICS; ORTHOPEDICS; PAIN MANAGEMENT; PALLIATIVE CARE (END OF LIFE CARE); PHARMACY; PSYCHIATRY/PSYCHOLOGY; PULMONOLOGY; RADIOLOGY; REHABILITATION SERVICES; SLEEP LAB; SPIRITUAL SERVICES; SPORTS MEDICINE; VASCULAR MEDICINE; WOUND CARE. 85025823 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 84 0 1 951 1 1 1 0 0 0 0 0 0 0 0 0 X 15 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JEFF BADGER 9207201300 1570 MIDWAY PLACE MENASHA WI 54952 X DANIEL E NEUFELDER 10.30 X X 228290 671200 94161 JOHN RUSSO 0.30 X X 0 0 0 STEPHEN C MORTON 0.30 X X 0 0 0 MARK W FAUSTICH MD 0.30 X 0 381831 35392 JOSEPH MCCORMICK MD 0.30 X 0 960725 40487 STACEY SENSOR DO 0.30 X 0 515223 42399 BARBARA J STRAND MD 0.30 X 0 234612 46933 FREDERICK KLEIN MD 0.30 X 0 0 0 MARY HARP-JIRSCHELE 0.30 X 0 0 0 RICHARD WELLS 0.30 X 0 0 0 SUSAN VETTE 0.30 X 0 0 0 THOMAS SCHMIDT 0.30 X 0 0 0 WAYNE TREMBLY 0.30 X 0 0 0 KATHRYN SIEMAN 0.30 X 0 0 0 MONICA VOMASTIC 0.30 X 0 0 0 CHRISTOPHER E ROCKE DO 0.30 X 0 235117 36683 NICHOLAS DESIEN 0.30 X X 0 2017697 58526 JOHN OLIVERIO 0.30 X X 0 2520506 161546 JEFF S BADGER 10.00 X 116823 343471 69379 WILLIAM J CALHOUN 40.00 X 329006 0 44177 LARRY D CROTS 40.00 X 137004 0 8057 KENNETH J HERRERA 40.00 X 130434 0 11607 MICHAEL R MILLER 40.00 X 135062 0 26863 MATTHEW T SCHETTLE 40.00 X 129055 0 30594 NICHOLAS A SYLVIA 40.00 X 161313 0 13020 1366987 7880382 719824 16 0 1 0 KENNEDY CENTER FOR THE HIP & KNEE 2700 W NINTH ST SUITE 100 MILWAUKEE WI 53224 SALARIES, PROFESSIONAL FEES 4168479 AFFINITY HEALTH SYSTEM INC 1570 MIDWAY PL MENASHA WI 54952 SALARIES, LEGAL, CONSULTING, MISC SERV 2507450 MINISTRY HEALTH CARE INC 11925 W LAKE PARK DR SUITE 100 MILWAUKEE WI 53224 MANAGEMENT 1125519 ST ELIZABETH HOSPITAL 1506 S ONEIDA ST APPLETON WI 54915 SALARIES, LAB SERVICES, MED DIR FEES 1063684 NETWORK HEALTH SYSTEM INC 1570 MIDWAY PL MENASHA WI 54952 PHYSICIAN SERVICES, SALARIES, MISC SERV 551862 15 98839 98839 NET PATIENT REVENUE AN 624100 114592173 114592173 CAFETERIA & VENDING 722210 616251 13950 602301 OTHER NON OPERATING RE 624100 298220 298220 NURSE DIRECT SERVICES 900099 248704 248704 GIFT SHOP & AUXILIARY 453220 213991 213991 157884 157884 116127223 1603523 1603523 2070623 1959422 111201 111201 -71093 182294 10779 0 10779 10779 10779 E.H.R. INCENTIVE 900099 628487 628487 P CARD REVENUE 900099 52416 52416 680903 118632468 115521780 100741 2911108 759802 759802 41449743 31449895 9999848 1628680 1235757 392923 9206005 6985035 2220970 2518714 1911068 607646 2267 2267 34071 34071 13949576 7455521 6494055 20629040 19757647 871393 47859 39333 8526 1982425 1449162 533263 210069 26787 183282 2364858 1728722 636136 6639444 4973205 1666239 326518 326518 BAD DEBT EXPENSE 4343028 4343028 MEDICAID ASSESSMENT 2863769 2863769 OTHER EXPENSES 574301 488251 86050 GIFT SHOP & AUXILIARY E 228376 228376 180407 90267 90140 109938952 85025823 24913129 0 5159 5546 2360615 7868248 13640125 15507393 163821638 2429825 2237042 1094674 783639 178831717 116494702 67145127 62337015 1940005 1252313 13305290 6672344 265742458 96663540 11023506 11301489 34886662 44324624 10417477 10992985 56327645 66619098 X 209414813 30044442 209414813 30044442 265742458 96663540 X 8693516 -188063887 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 7633 7633 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: WHA MEMBERSHIP DUES OF $6,425 AND CHA MEMBERSHIP DUES OF $1,208 882258 882258 111309812 59322322 51987490 1021338 884684 136654 61692323 53105331 8586992 3925986 3182365 743621 62337015 OTHER A/R 49988 OTHER ASSET 1815750 RELATED PARTY A/R 4806606 6672344 DUE TO 3RD PARTY - RESERVE 703125 PENSION LIABILITY 9860974 457B PLAN 428886 10992985 118632468 109938952 8693516 282259 -188346146 -188063887 -179370371 120372308 1959422 1959422 118412886 219582 219582 118632468 111669998 1959422 1959422 109710576 228376 228376 109938952 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MINISTRY RECOGNIZES THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. EXAMPLES OF TAX POSITIONS FOR MINISTRY'S NOT-FOR-PROFIT CORPORATIONS INCLUDE THEIR TAX-EXEMPT STATUS AND VARIOUS POSITIONS RELATED TO THE POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). THE TAX BENEFITS RECOGNIZED IN THE FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50 PERCENT LIKELIHOOD OF BEING RECOGNIZED UPON ULTIMATE SETTLEMENT. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION ADJUSTMENT -726,916. TRANSFER OF DEBT TO MINISTRY -182,642,407. WORKERS COMPENSATION ADJUSTMENT -476,823. EQUITY DISTRIBUTION -4,500,000. TOTAL TO SCHEDULE D, PART XI, LINE 8: -188,346,146. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATED TO RENTAL INCOME 1,959,422. PART XII, LINE 4B - OTHER ADJUSTMENTS: RESTRICTED CONTRIBUTIONS IN NET ASSETS 5,591. GIFT SHOP AND AUXILIARY REVENUE 213,991. PART XIII, LINE 2D - OTHER ADJUSTMENTS: EXPENSE ALLOCATED TO RENTAL INCOME 1,959,422. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GIFT SHOP AND AUXILIARY EXPENSES 228,376. 1 1 1 X 1 X 662.000000000000 1 1 0 1 1 408 1083588 0 1083588 0.01030 11052 3333269 0 3333269 0.03160 714 345834 0 345834 0.00330 12174 4762691 4762691 0.04520 4 3522 336548 12375 324173 0.00310 2 232 626870 125718 501152 0.00470 2 2253 5113700 4989720 123980 0.00120 0 0 2 10906 363296 1 363295 0.00340 10 16913 6440414 5127814 1312600 0.01240 10 29087 11203105 5127814 6075291 0.05760 1 2500 1787 0 1787 0.00000 1 0 307 0 307 0.00000 1 156 279 0 279 0.00000 3 2656 2373 2373 0 4343028 41800398 48416451 -6616053 X 1 1 1 1 MERCY MEDICAL CENTER

500 S OAKWOOD RAOD OSHKOSH WI 54904

X X X MERCY MEDICAL CENTER 1 0 1 1 200.000000000000 1 662.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 1 X 0 0 PART I, LINE 3C: IT IS THE POLICY OF MERCY MEDICAL CENTER TO PROVIDE MEDICALLY NECESSARY HEALTH CARE SERVICES TO PEOPLE IN THE COMMUNITIES IT SERVES, REGARDLESS OF THEIR ABILITY TO PAY. AFFINITY CARE FINANCIAL ASSISTANCE IS GRANTED BASED UPON THE PATIENT'S INABILITY TO PAY AND TO INDIVIDUALS WHO ARE UNINSURED, UNDERINSURED OR MEDICALLY INDIGENT. AFFINITY CARE WORKS IN COLLABORATION WITH OTHER FINANCIAL (BOTH PUBLIC AND PRIVATE) ASSISTANCE PROGRAMS. THIS IS TO ENSURE HOLISTIC WELLNESS OF PATIENTS BY FACILITATING KNOWLEDGE OF AVAILABLE SERVICES AND PROGRAMS FOR HEALTH WHILE PRACTICING GOOD STEWARDSHIP OF FUNDS. KEY CRITERIA UTILIZED TO DETERMINE ELIGIBILITY FOR AFFINITY CARE FINANCIAL ASSISTANCE INCLUDES FAMILY SIZE, FEDERAL POVERTY INCOME GUIDELINES AND AVAILABLE ASSETS. THE AVAILABLE ASSET TEST INCLUDES CONSIDERATION OF THE AMOUNT OF EQUITY IN A HOME, AUTOMOBILES, AND SAVINGS ACCOUNTS WHICH ARE CONSIDERED PART OF TOTAL ALLOWABLE INCOME WHEN ASSESSING AGAINST THE FEDERAL POVERTY INCOME GUIDELINES. PART I, LINE 7: AMOUNTS CALCULATED IN PART I, LINE 7 ARE DETERMINED BOTH ON A COST ACCOUNTING SYSTEM AND A COST-TO-CHARGE RATIO. OTHER BENEFITS ARE DETERMINED BASED ON THE DIRECT AND INDIRECT COSTS (WHERE ALLOCATED) ASSOCIATED WITH A PROGRAM NET OF EARNED REVENUE. DETAIL FOR EACH PROGRAM/ACTIVITY IS MAINTAINED AND DETERMINED AT THE DEPARTMENT LEVEL. CHARITY CARE AND MEANS-TESTED PROGRAMS ARE DETERMINED BASED ON A COST-TO-CHARGE RATIO CONSISTENT WITH WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES. PRIOR YEAR COST REPORT SETTLEMENTS ARE EXCLUDED FROM THE SHORTFALL CALCULATION IN ORDER TO GET A TRUE FISCAL YEAR SHORTFALL AMOUNT. PART I, L7 COL(F): BAD DEBT EXPENSE OF $4,343,028 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT OF TOTAL EXPENSES ON SCHEDULE H. PART II: COMMUNITY-BUILDING ACTIVITIES INCLUDE PROGRAMS THAT, WHILE NOT DIRECTLY RELATED TO HEALTH CARE, PROVIDE OPPORTUNITIES TO ADDRESS THE ROOT CAUSES OF HEALTH PROBLEMS, SUCH AS POVERTY, HOMELESSNESS, AND ENVIRONMENTAL PROBLEMS. THESE ACTIVITIES SUPPORT COMMUNITY ASSETS BY OFFERING THE EXPERTISE AND RESOURCES OF THE ORGANIZATION. COSTS FOR THESE ACTIVITIES INCLUDE CASH, IN-KIND DONATIONS, AND EXPENDITURES FOR THE DEVELOPMENT OF A VARIETY OF COMMUNITY HEALTH PROGRAMS AND PARTNERSHIPS. PART III, LINE 4: NO FOOTNOTE EXISTS IN MERCY MEDICAL CENTER'S FINANCIALS STATEMENTS THAT DESCRIBE BAD DEBT EXPENSE. BAD DEBT EXPENSE IS RECORDED IN A CONSISTENT MANNER WITH THE ORGANIZATION'S COLLECTION POLICIES. BAD DEBT EXPENSE INCLUDES ACCOUNTS WHICH ARE WRITTEN OFF AND ESTIMATES MADE ON LIVE ACCOUNTS BASED ON HISTORICAL PAYMENT TRENDS AND ACCOUNT MODELING.A NUMBER OF PATIENTS ARE TRULY UNABLE TO PAY THEIR OUT-OF-POCKET LIABILITY, BUT DO NOT COMPLETE THE PROCESS REQUIRED TO APPLY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S AFFINITY CARE POLICY. THESE PATIENTS WOULD QUALIFY FOR AFFINITY CARE IF THEY COMPLETED THE CHARITY APPLICATION, SO THE BAD DEBT EXPENSE ASSOCIATED WITH TREATING THEM SHOULD BE TREATED AS COMMUNITY BENEFIT. THE ORGANIZATION DOES HAVE A PRESUMPTIVE ELIGIBILITY PROGRAM IN PLACE TO HELP IDENTIFY INDIGENT PATIENTS AND MINIMIZE THE INSTANCES OF WHEN THEY BECOME A BAD DEBT. THE ADMINISTRATIVE REQUIREMENTS TO DETERMINE WHETHER PATIENTS WHO DO NOT COOPERATE WITH THE FINANCIAL ASSISTANCE PROCESS WOULD HAVE QUALIFIED FOR CHARITY CAN BE BURDENSOME, PARTICULARLY FOR SMALL BALANCES. PART III, LINE 8: THE SHORTFALL ASSOCIATED WITH MEDICARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT FOR SEVERAL REASONS. FIRST, IRS REV. RUL. 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NON-PROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. SECOND, FOR-PROFIT SPECIALTY HOSPITALS HAVE BEEN CARVING OUT CERTAIN HIGH-MARGIN SERVICES (I.E. CARDIAC, ORTHOPEDICS, AND ONCOLOGY), LEAVING GENERAL ACUTE CARE HOSPITALS WITH LOWER-MARGIN MEDICARE SERVICES. THIS INDICATES THAT MEDICARE LOSSES CAN BE A RESULT OF RENDERING THESE LOWER-MARGIN SERVICES (WHICH BENEFIT THE COMMUNITY) RATHER THAN INEFFICIENT OPERATIONS. LASTLY, THE COMMUNITY WHICH THE ORGANIZATION SERVES HAS MEDICARE AS THE LARGEST LAYER. THE ORGANIZATION MUST ACCEPT THESE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SUCH SERVICES. IF THE MEDICARE PARTICIPATION IS PREMISED ON THIS FACT, THEN PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A COMMUNITY BENEFIT. THE DEMOGRAPHIC OF THE COMMUNITY IS ALSO AN AGING AND UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE SERVICES, CMS WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY. PART III, LINE 9B: MERCY MEDICAL CENTER HAS A DEBT COLLECTION POLICY WHICH SETS FORTH COLLECTION PRACTICES FOR PATIENTS WHO ARE KNOWN TO QUALIFY OR MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE PROGRAM. SUFFICIENT FINANCIAL COUNSELING SUPPORT IS MADE AVAILABLE TO PATIENTS SO THEY CAN EASILY ACCESS PATIENT FINANCIAL SERVICE REPRESENTATIVES AND HAVE THEIR QUESTIONS ANSWERED, AND GAIN AN UNDERSTANDING OF THE REASONS WHY THEY OWE A BALANCE. ACCOUNTS ARE DESIGNATED AS CHARITY CARE IN THE BUSINESS OFFICES SO NO ADDITIONAL TIME IS SPENT ON COLLECTION EFFORTS. PART VI, LINE 2: MERCY MEDICAL CENTER PERFORMS COMMUNITY HEALTH NEEDS ASSESSMENTS AS NEEDED. PLANNING WORKGROUPS CONSISTING OF COMMUNITY PARTNERS (E.G. COMMUNITY HEALTH IMPROVEMENT PARTNERSHIP (CHIP) ARE FORMED TO DEFINE THE COMMUNITY AND ITS HEALTH NEEDS THROUGH REVIEW OF UNITED WAY LIFE STUDY RESULTS, HEALTHY PEOPLE INITIATIVES, CENSUS DOCUMENTS, AND LOCAL GOVERNMENT HEALTH AND WELFARE AGENCIES. CONSIDERING OTHER COMMUNITY RESOURCES/ASSETS, DATA COLLECTION METHODS ARE USED TO IDENTIFY PARTICULAR PROBLEMS OR SUBGROUPS AND AREAS KNOWN TO HAVE HIGH POVERTY RATES AND TO BE UNDERSERVED. THE DATA IS ANALYZED AND PRIORITIES ARE SET BASED ON TRENDING INFORMATION WHICH MAY TARGET A SPECIFIC NEED. WHEN A NEED IS IDENTIFIED, THE HOSPITAL WILL COLLABORATE THROUGH COMMUNITY PARTNERSHIPS (OR INDIVIDUALLY) TO ADDRESS THE IDENTIFIED NEED. OUTCOMES FROM THE PROGRAMS ARE MEASURED AND CONSIDERED IN SUBSEQUENT COMMUNITY HEALTH NEEDS ASSESSMENTS. THE LEADERSHIP AT AFFINITY TAKES THEIR COMMITMENT TO THE HEALTH AND WELL-BRING OF THE COMMUNITY IT SERVES VERY SERIOUSLY. IN FACT, IT IS CORE TO THE ORGANIZATION'S MISSION, "TO LIVE OUT THE HEALING MINISTRY OF CHRIST BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL-BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR". SENIOR LEADERS AND MANAGEMENT ARE ALSO HIGHLY ENCOURAGED TO PROVIDE DIRECT SERVICE TO THE POOR IN THEIR COMMUNITIES. MERCY MEDICAL CENTER AND THE LEADERSHIP ALSO SUBSCRIBE TO PUBLICATIONS LIKE THE ADVISORY BOARD TO COMPARE NATIONAL TRENDS TO LOCAL TRENDS TO ENSURE THE HOSPITAL IS RESOURCING AREAS TO MEET PATIENT NEEDS. PART VI, LINE 3: MERCY MEDICAL CENTER GOES TO GREAT LENGTHS IN ORDER TO INFORM AND EDUCATE PATIENTS/PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATION'S AFFINITY CARE POLICY. THE AFFINITY CARE POLICY AND APPLICATION IS POSTED ON THE ORGANIZATION'S WEBSITE. ADMISSIONS AND OTHER KEY AREAS CONTAIN SUMMARY INFORMATION OF THE AFFINITY CARE POLICY. AS PART OF THE INTAKE/DISCHARGE PROCESS, PATIENTS ARE PROVIDED WITH A COPY OF THE POLICY AND OTHER INFORMATION FOR FINANCIAL ASSISTANCE. IF DURING THE COURSE OF THE PATIENT REGISTRATION PROCESS, CARE ENCOUNTER, TREATMENT, OR UPON DISCHARGE IT BECOMES EVIDENT THAT A PATIENT MAY NEED FINANCIAL ASSISTANCE, THE PATIENT SHALL BE REFERRED TO MERCY MEDICAL CENTER'S AFFINITY CARE PROGRAM. PATIENTS MAY BE IDENTIFIED AS NEEDING FINANCIAL ASSISTANCE AT ANY TIME DURING THE COURSE OF AN ENCOUNTER. A REFERRAL FOR CONSIDERATION OF AFFINITY CARE FINANCIAL ASSISTANCE CAN BE INITIATED BY ANY MEMBER OF THE HOSPITAL'S WORKFORCE, INCLUDING MEDICAL STAFF MEMBERS, WHO BECOME AWARE OF THE PATIENT'S POTENTIAL NEED FOR AFFINITY CARE FINANCIAL ASSISTANCE. THE AFFINITY CARE BROCHURE WAS ALSO TRANSLATED INTO DIALECTS PREVALENT IN THE COMMUNITY IN ORDER TO REACH OUT TO THOSE THAT MAY SPEAK ANOTHER LANGUAGE (SPANISH AND HMONG). PATIENT REGISTRATION STAFF AND FINANCIAL COUNSELORS ARE PROVIDED WITH GUIDELINES TO FOLLOW WHEN INTERACTING WITH PATIENTS. AS PART OF THE AFFINITY CARE PROCESS, PATIENTS MUST REGISTER WITH THE COUNTY PUBLIC ASSISTANCE TO SEE IF THEY MAY QUALIFY UNDER ANY OTHER FEDERAL OR STATE PROGRAMS. PART VI, LINE 4: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S 'COMMUNITY BENEFIT', THIS IS A WORK IN PROGRESS. THE ORGANIZATION PROVIDED SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT, WHICH IS NOT QUANTIFIED. MERCY MEDICAL CENTER, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY-CARE THAT WITHOUT OUR HOSPITAL, MAY NOT BE AVAILABLE LOCALLY.CERTAIN SPECIALIZED SERVICES AVAILABLE INCLUDE: I/P ADULT BEHAVIORAL HEALTH SERVICES, I/P REHABILITATION SERVICES, I/P SUB-ACUTE(SNF) SERVICES. PART VI, LINE 5: MERCY MEDICAL CENTER'S GOVERNING BOARD CONSISTS PRIMARILY OF PERSONS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. THEY ARE NOT EMPLOYEES OF THE ORGANIZATION.THE ORGANIZATION STRIVES TO FURTHER ITS EXEMPT PURPOSES BY THE FOLLOWING:- MERCY MEDICAL CENTER PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH PROGRAMS (MEDICARE, MEDICAID, CHAMPUS, GENERAL RELIEF, SPECIALIZED COUNTY PROGRAMS AND AREA PRISONS)- MERCY MEDICAL CENTER DONATES FOOD TO AREA SHELTERS.- MERCY HEALTH FOUNDATION DONATED FUNDS TO SUPPORT AREA ORGANIZATIONS THAT PROVIDE SERVICES TO THE FOLLOWING SECTORS OF OUR POPULATION: LOW-INCOME, PHYSICALLY AND MENTALLY CHALLENGED AND CHRONICALLY ILL. - MERCY MEDICAL CENTER WORKS WITH LOCAL POLICE DEPARTMENTS IN THE PERFORMANCE OF SEXUAL ASSAULT EXAMS. THE PATIENT DOES NOT INCUR A BILL FOR THE EXAM AND THE CHARGES ARE WRITTEN OFF. - MERCY MEDICAL CENTER PROVIDES COMMUNITY HEALTH IMPROVEMENT SERVICES THROUGH HEALTH EDUCATION LECTURES, HEALTH FAIRS AND SUPPORT GROUPS.- MERCY MEDICAL CENTER CONDUCTS CARDIAC AND PULMONARY REHABILITATION FAMILY EDUCATION SESSIONS.- DISCOUNTED CARE IS PROVIDED TO LOW INCOME FAMILIES UP TO 662% OF FEDERAL POVERTY GUIDELINES.- MERCY MEDICAL CENTER IS A DISPROPORTIONATE SHARE HOSPITAL WITH A COMBINED MEDICAID AND SSI UTILIZATION OF OVER 21.19%.- MERCY MEDICAL CENTER PROVIDES A SUBSIDY TO A SCHOOL OF RADIOLOGIC TECHNOLOGY PROGRAM.- MERCY MEDICAL CENTER SERVES AS A SPONSOR SITE FOR CLINICAL TRAINING OF COLLEGE STUDENTS IN VARIOUS HEALTH CARE PROGRAMS.- MERCY MEDICAL CENTER HELPS TO SUBSIDIZE AN AREA COMMUNITY CLINIC THAT SERVES THE UNINSURED AND LOW INCOME MEMBERS OF THE COMMUNITY. SUPPORT CONSISTS OF CASH DONATIONS FOR OPERATIONS, USE OF CLINIC BUILDING AND LAB AND X-RAY SERVICES. PART VI, LINE 6: MERCY MEDICAL CENTER, OF OSHKOSH, WISCONSIN IS PART OF AN AFFILIATED HEALTH CARE SYSTEM CALLED AFFINITY HEALTH SYSTEM. AFFINITY HEALTH SYSTEM ALSO HAS TWO OTHER HOSPITALS, ST. ELIZABETH HOSPITAL, IN APPLETON, WI AND CALUMET MEDICAL CENTER, IN CHILTON, WI. THE LATTER HOSPITAL QUALIFIES AS A CRITICAL ACCESS HOSPITAL. IN ADDITION TO THE HOSPITALS, AFFINITY HEALTH SYSTEM ALSO HAS 25 AREA CLINICS UNDER THE CONTROL OF AFFINITY MEDICAL GROUP. THE MISSION OF AFFINITY, AS A CATHOLIC HEALTH CARE SYSTEM, IS TO LIVE OUT THE HEALING MINISTRY OF BY PROVIDING SERVICES THAT PROMOTE THE HEALTH AND WELL BEING OF THE COMMUNITIES WE SERVE, ESPECIALLY THE POOR. UNTIL FEBRUARY 7, 2012, AFFINITY HEALTH SYSTEM WAS SPONSORED EQUALLY BY TWO CATHOLIC HEALTH SYSTEMS, MINISTRY HEALTH CARE, HEADQUARTERED IN MILWAUKEE, WI AND WHEATON FRANCISCAN HEALTH CARE, ALSO HEADQUARTERED IN MILWAUKEE, WI. AS OF FEBRUARY 8, 2012 AFFINITY HEALTH SYSTEM IS SOLELY SPONSORED BY MINISTRY HEALTH CARE. MERCY MEDICAL CENTER AND ST. ELIZABETH HOSPITAL BOTH SUBSIDIZE AREA COMMUNITY MEDICAL CLINICS AS WELL AS COMMUNITY DENTAL CLINICS. THE 3 HOSPITALS AND THE 25 CLINICS PROVIDE FREE OR MINIMAL COST HEALTH EDUCATION, SUPPORT AND SCREENING SERVICES FOR THE POPULATIONS THEY SERVE. MERCY MEDICAL CENTER AND ST. ELIZABETH HOSPITAL BOTH PROVIDE SUPPORT FOR EDUCATIONAL PROGRAMS TO EDUCATE FUTURE HEALTH CARE PROFESSIONALS. THERE IS ALSO AN EXPECTATION THAT ALL PEOPLE IN MANAGEMENT SERVICES AT AFFINITY HEALTH SYSTEM WILL PROVIDE DIRECT SERVICES TO THE POOR. MERCY MEDICAL CENTER HAS A FOUNDATION WHICH IS NOT INCLUDED WITHIN THE OPERATIONS OF THE ORGANIZATION. THE FOUNDATION PROVIDES CASH DONATIONS WHICH HELP SUPPORT THE MISSION OF THE ORGANIZATION AND THE AFFILIATED HEALTH CARE SYSTEM. EXAMPLES OF THE DONATIONS ARE INCLUDED IN ITEM #5 (PART VI, LINE 5) ABOVE. REPORTS FILED WITH STATES PART VI, LINE 7 WI PART VI, LINE 7: MERCY MEDICAL CENTER OF OSHOKSH, INC. FILES THEIR COMMUNITY BENEFIT RESULTS IN THE STATE OF WISCONSIN. THEIR DATA IS INCORPORATED INTO A REPORT FOR ALL AFFINITY HEALTH SYSTEM THAT ULTIMATELY IS PUBLISHED IN THE AREA NEWSPAPERS. X X X 1 1 X X X X X 0 0 0 0 0 1 0 0 0 DANIEL E NEUFELDER 165407 486315 57455 168925 5428 15960 18232 53604 5666 16659 252188 741463 0 0 MARK W FAUSTICH MD 0 378875 0 0 0 2956 0 28478 0 6914 0 417223 0 0 JOSEPH MCCORMICK MD 0 959585 0 0 0 1140 0 18827 0 21660 0 1001212 0 0 STACEY SENSOR DO 0 512804 0 0 0 2419 0 22598 0 19801 0 557622 0 0 BARBARA J STRAND MD 0 233200 0 0 0 1412 0 22117 0 24816 0 281545 0 0 CHRISTOPHER E ROCKE DO 0 234764 0 0 0 353 0 18046 0 18637 0 271800 0 0 NICHOLAS DESIEN 0 923911 0 362645 0 731141 0 39630 0 18896 0 2076223 0 0 JOHN OLIVERIO 0 952774 0 662500 0 905232 0 99519 0 62027 0 2682052 0 0 JEFF S BADGER 86927 255575 22891 67302 7005 20594 11280 33165 6328 18606 134431 395242 0 0 WILLIAM J CALHOUN 242790 0 73696 0 12520 0 18827 0 25350 0 373183 0 0 0 MICHAEL R MILLER 134965 0 0 0 97 0 10631 0 16232 0 161925 0 0 0 MATTHEW T SCHETTLE 128664 0 0 0 391 0 11696 0 18898 0 159649 0 0 0 NICHOLAS A SYLVIA 161128 0 0 0 185 0 11554 0 1466 0 174333 0 0 0 PART I, LINE 1B BUSINESS TRAVEL EXPENSES FOR SPOUSES OF EXECUTIVES AND COUNTRY CLUB MEMBERSHIP FOR EXECUTIVES ARE REIMBURSED AS PART OF THEIR EXECUTIVE FLEX CREDIT ACCOUNT. RECEIPTS ARE PROVIDED TO SR. ADMINISTRATIVE ASSISTANT IN HR WHO REVIEWS FOR ACCURACY, COMPLETES A REIMBURSEMENT FORM WITH SUBSTANTIATION TO PAYROLL FOR REIMBURSEMENT. THESE REIMBURSEMENTS ARE TAXABLE AND, WHEN ADDED TO THE COMPENSATION PACKAGE TAKEN AS A WHOLE, HAVE BEEN INCLUDED WHEN COMPARED TO THE COMPENSATION STUDIES. PART I, LINE 6 EXECUTIVE INCENTIVE PLAN WAS ACCRUED FOR HOWEVER NO PAYMENTS WERE MADE FOR FY 2012. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATE MEMBERS OF MERCY MEDICAL CENTER OF OSHKOSH, INC. ARE MINISTRY HEALTH CARE, INC. AND AFFINITY HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A MINISTRY HEALTH CARE HAS THE POWER TO APPROVE AND REMOVE DIRECTORS FROM MERCY MEDICAL CENTER OF OSHKOSH, INC. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS OF THE ARTICLES OF INCORPORATION AND BYLAWS MUST BE APPROVED BY MINISTRY HEALTH CARE, INC. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND CFO OF AFFINITY HEALTH SYSTEM PERFORM A DETAIL REVIEW OF THE 990. AFTER MANAGEMENT'S REVIEW, A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS RECEIVES A CONFLICT OF INTEREST QUESTIONNAIRE EVERY YEAR. FORM 990, PART VI, SECTION B, LINE 15 EACH YEAR THE ORGANIZATION ENGAGES AN INDEPENDENT COMPENSATION FIRM TO PROVIDE MARKET DATA FOR CEO, EXECUTIVES AND KEY EMPLOYEE POSITIONS. THIS STUDY IS SHARED WITH THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR REVIEW AND RECOMMENDATIONS REGARDING ANY COMPENSATION CHANGES. THE COMPENSATION COMMITTEE IS COMPRISED OF INDEPENDENT MEMBERS. THE CEO REVIEWS EACH EXECUTIVE AND KEY EMPLOYEE'S ANNUAL PERFORMANCE APPRAISAL RATINGS IN MAKING HIS COMPENSATION RECOMMENDATIONS TO THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE HAS THE FINAL AUTHORITY TO APPROVE ANY AND ALL AMOUNTS OF COMPENSATION FOR MEMBERS OF THE EXECUTIVE TEAM. THE FINAL APPROVAL OF COMPENSATION AMOUNTS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. HOURS WORKED FOR RELATED ORGANIZATIONS FORM 990, PART VII MARK FAUSTICH, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. JOSEPH MCCORMICK, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. CHRISTOPHER ROCKE, DO WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. STACEY SENSOR, DO WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. BARBARA STRAND, MD WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. DANIEL NEUFELDER WORKED AN AVERAGE OF 30 HOURS PER WEEK FOR RELATED ORGANIZATIONS. JEFF BADGER WORKED AN AVERAGE OF 30 HOURS PER WEEK FOR RELATED ORGANIZATIONS. JOHN OLIVERIO WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATION. NICHOLAS DESIEN WORKED AN AVERAGE OF 40 HOURS PER WEEK FOR A RELATED ORGANIZATON. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 282,259. PENSION ADJUSTMENT -726,916. TRANSFER OF DEBT TO MINISTRY -182,642,407. WORKERS COMPENSATION ADJUSTMENT -476,823. EQUITY DISTRIBUTION -4,500,000. TOTAL TO FORM 990, PART XI, LINE 5: -188,063,887. FORM 990, PART XII, LINE 2C PROCESS FOR OVERSIGHT OF AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT: MERCY MEDICAL CENTER OF OSHKOSH, INC. (ORGANIZATION) DOES NOT RECEIVE SEPARATELY AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION IS AUDITED AND REPORTED THROUGH CONSOLIDATED FINANCIAL STATEMENTS. THE AUDIT COMMITTEE IS RESPONSIBLE FOR THE AUDITOR SELECTION. THE AUDIT STATEMENTS ARE REVIEWED BY THE CONTROLLER, CFO, MINISTRY HEALTH CFO, AND THE AUDIT COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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