2012-05-15T13:40:12-05:00 2011-06-30 DELOITTE TAX LLP 555 E WELLS ST SUITE 1400 MILWAUKEE WI 53202 990 2010-07-01 391834639 COLUMBIA ST MARY'S INC COLU 4143262230 4425 NORTH PORT WASHINGTON ROAD NO 301 GLENDALE WI 53212 RHONDA ANDERSON 4143262230 2012-05-15 1 4142713000 2010 2016-02-24 21:20:13Z MARK R TAYLOR 4425 NORTH PORT WASHINGTON ROAD NO 301 GLENDALE WI 53212 163962443 0 0928 X COLUMBIA-STMARYS.ORG X 2001 WI HEALTH CARE SYSTEM DEDICATED TO MAKING A POSITIVE DIFFERENCE IN INDIVIDUALS AND OUR COMMUNITY. 15 12 645 15 854290 128813 0 376371 13846832 119610361 1332905 3320818 11830452 40555376 27010189 163862926 360000 206484 0 0 8133293 42683203 0 0 0 16101502 104498673 24594795 147388360 2415394 16474566 292829491 276339021 224000083 217760006 68829408 58579015 X COLUMBIA ST. MARY'S, INC. ("CSM") IS A HEALTH CARE PROVIDER FOUNDED IN RESPONSE TO IDENTIFIED COMMUNITY NEEDS, WHICH IS SPONSORED BY ASCENSION HEALTH, A CATHOLIC NATIONAL HEALTH SYSTEM, AND COLUMBIA HEALTH SYSTEM, A NON-SECTARIAN COMMUNITY HEALTH SYSTEM. CSM EXISTS TO MAKE A POSITIVE DIFFERENCE IN THE HEALTH STATUS AND LIVES OF INDIVIDUALS AND OUR COMMUNITY, WITH SPECIAL CONCERN FOR THOSE WHO ARE VULNERABLE. CSM AND ITS AFFILIATES ARE COMMITTED TO PROVIDING HIGH-QUALITY, ACCESSIBLE, VALUES-DRIVEN PROGRAMS AND SERVICES WITH EQUAL ATTENTION TO THE PHYSICIAL, SPIRITUAL, AND EMOTIONAL DIMENSIONS OF HEALTH. 0 0 124211534 206484 155771549 CSM, INC EXISTS AS THE PARENT CORPORATION IN THE CSM SYSTEM, WHICH IS COMPRISED OF THREE HOSPITALS, (COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE INC, COLUMBIA ST. MARY'S HOSPITAL OZAUKEE INC, AND SACRED HEART REHABILITATION INSTITUTE INC.), 65 COMMUNITY CLINICS, THE COLUMBIA COLLEGE OF NURSING, SETON CHILDREN'S SCHOOL, A PARTNERSHIP WITH THE ORTHOPAEDIC HOSPITAL OF WISCONSIN, A NEW PARTNERSHIP IN FY11 WITH THE SLEEP WELLNESS INSTITUTE, AND FOUR URGENT CARE CENTERS. DURING FISCAL 2011, CSM'S HEALTH SYSTEM PROVIDED CARE TO 285,062 PATIENTS. THE ESTIMATED UNREIMBURSED COST OF SERVICES PROVIDED TO THE ELDERLY, UNINSURED AND UNDERINSURED TOTALED $147,274,030. REFER TO THE COMMUNITY BENEFIT INFORMATION IN SCHEDULE H FOR DISCUSSION OF HOW CSM MAKES A POSITIVE DIFFERENCE IN THE HEALTH STATUS OF ITS COMMUNITY, FOCUSING ON THOSE WHO ARE VULNERABLE. 124211534 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 120 0 1 645 1 1 1 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X RHONDA ANDERSON 4143262230 4425 N PORT WASHINGTON ROAD GLENDALE WI 53212 X DAVID HOOGERLAND MD 5.00 X 0 537518 47468 GEORGE H HOFF 1.00 X 0 0 0 KEVIN GONIU MD 5.00 X 0 581431 55819 LEO P BRIDEAU 1.00 X X 1836612 0 78942 MARK R TAYLOR 1.00 X X 0 0 0 MASON G ROSS 1.00 X 0 0 0 MICHAEL GREBE 1.00 X 0 0 0 R BRUCE MCDONALD 1.00 X 0 0 0 RANDALL PERRY 1.00 X 0 0 0 ROBERT LYON MD 1.00 X 0 0 0 ROBERT VENABLE 1.00 X 0 0 0 SISTER THERESA SULLIVAN DC 1.00 X 0 0 0 TINA CHANG 1.00 X 0 0 0 CHRISTINE NUERNBERG 1.00 X 0 0 0 PATRICIA J DOLHUN MD 1.00 X 0 0 0 MICHELLE S NETTLES 1.00 X 0 0 0 RHONDA ANDERSON 5.00 X 467315 0 44961 AMY MARQUARDT 5.00 X 333816 0 36621 CHERYL HILL 5.00 X 313013 0 35052 DAVID H SHAPIRO MD 5.00 X 386542 0 19935 GERRI LIETZ-STAFFILENO 5.00 X 0 312928 30724 KAROL MARCIANO 5.00 X 361072 0 26841 MARY PAUL 5.00 X 0 661504 49257 SUE SANICOLA 5.00 X 231123 0 34778 WILLIAM HART 5.00 X 0 356106 20055 DEBORAH FRIBERG 5.00 X 0 634473 41593 BRUCE MCCARTHY MD 5.00 X 386167 0 29766 CONSTANCE J BRADLEY 5.00 X 0 248016 22826 DAVID OLSON 5.00 X 0 514194 39710 PAUL WESTRICK 5.00 X 228135 0 46031 MITCH QUADE 5.00 X 168055 0 53277 CHRISTOPHER MEYER 5.00 X 163267 0 55869 KIM HODGKINSON 5.00 X 194904 0 41796 JILL WINTERS 5.00 X 181384 0 28141 CHARLES J DREHER 1.00 X 154720 0 27198 5406125 3846170 866660 38 1 1 0 ACCRETIVE 401 NORTH MICHIGAN AVE CHICAGO IL 60611 MANAGEMENT SERVICES 20240962 CG SCHMIDT BARTON MALOW 26500 AMERICAN DRIVE SOUTHFIELD MI 48034 PROJECT MANAGEMENT 6051679 TRIMEDX LLC 6325 DIGITAL WAY INDIANAPOLIS IN 46278 HEALTHCARE EQUIPMENT SERVICES 4728868 HOK GROUP PO BOX 200119 DALLAS TX 753200119 ARCHITECTURAL DESIGN 911872 KAHLER SLATER ARCHITECTS 611 E WISCONSIN AVE MILWAUKEE WI 53202 ARCHITECTURAL DESIGN 656448 18 213543 162828 376371 MANAGEMENT FEE ALLOCAT 561000 119242622 119242622 RENTAL INCOME-PHYSICIA 532000 367739 367739 119610361 3174062 3174062 246273 99517 146756 146756 146756 EXPENSE TRANSFERS 561000 23834711 23834711 JOINT VENTURE INCOME 622110 10265421 10265421 GAIN/LOSS ON INVEST 900099 3385306 3385306 3069938 1203142 854290 1012506 40555376 163862926 155771549 854290 7718630 206484 206484 5201169 5201169 28599647 20007625 8592022 3526699 3438532 88167 3213455 3133119 80336 2142233 2088677 53556 23644475 22028668 1615807 538030 538030 1013769 1013769 48749522 48749522 353117 353117 5758172 5758172 6310025 6310025 38999 38999 175963 129631 46332 5947638 5947638 4845291 4845291 173251 173251 ASCENSION FEES/DUES 4109246 4109246 AFFILIATION EXPENSE 1235666 1235666 IMPAIRMENT WRITE-DOWNS 629212 629212 SPECIAL PROGRAMS 245589 245589 PATIENT CARE SUPPLIES 233313 233313 497395 497395 147388360 124211534 23176826 0 657752 681105 46409397 24138075 4388169 4126738 617320 35483443 662258 899742 2152411 6329014 54240494 21236818 164689308 33003676 39806060 41165054 9029392 19651548 24417424 110860626 292829491 276339021 19869030 21978695 204131053 195781311 224000083 217760006 X 46835982 37574016 15571920 15201690 6421506 5803309 68829408 58579015 292829491 276339021 X 16474566 -26724959 X X 0 1 1 X 0 X X X X 0 0 0 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE 390806315 3 1 1 1 84205713 COLUMBIA ST MARY'S HOSPITAL OZAUKEE 390807063 3 1 1 1 30771839 SACRED HEART REHABILITATION INSTITUTE 390902199 3 1 1 1 2292472 SETON CHILDREN'S SCHOOL 391391245 9 1 1 1 0 COLUMBIA COLLEGE OF NURSING INC 391596986 2 1 1 1 0 5 117270024 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 23814 0 1 8969 32783 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A KEY EMPLOYEE SPENDS 10% OF TIME (AMOUNT REPORTED ON LINE G) RESEARCHING ISSUES AND PREPARING FOR MEETINGS AND PRESENTATIONS FOR: COUNTY OFFICIALS - FUNDING AND OPERATIONAL ISSUES RELATED TO THE GENERAL ASSISTANCE MEDICAL PROGRAM STATE LEGISLATORS, OTHER ELECTED OFFICIALS AND STAFF - LOBBYING ON MEDICAL ASSISTANCE FUNDING, PUBLIC HEALTH INITIATIVES, AND PROVIDER REGULATIONS; FEDERAL ELECTED OFFICIALS AND STAFF - LOBBYING AND MEDICARE AND MEDICAID FUNDING AND PROVIDER REGULATIONS. OTHER ACTIVITIES: AMOUNT PAID TO GOVERNMENT AFFAIRS CONSULTING FIRM PROVIDING LEGISLATIVE, REGULATORY, AND COMMUNICATIONS SERVICES. 890000 890000 24767661 3628456 21139205 2048468 546085 1502383 24559921 16704392 7855529 1974444 357885 1616559 33003676 ORTHOPAEDIC HOSPITAL OF WISC LLC 15525000 C HOME CARE MEDICAL 967055 C CSM STRATEGIC ALLIANCE 42000 C HORIZON HOMECARE 2819000 C WI MEDICAL CYCLOTRON LLC 40000 C CSM FOUNDATION (RESTRICTED FUNDS) 21004999 C SLEEP SERVICES 717000 C ACCOUNTABLE CARE SOLUTIONS 50000 C 41165054 DEFERRED COMPENSATION 473072 ASSETS HELD FOR SALE 4876837 PENSION PREFUNDING 26721622 DUE FROM AFFILIATES 78789095 110860626 INTERCOMPANY DEBT TO ASCENSION HEALTH 164503054 ACCRUED PENSION 24315751 DEFERRED COMPENSATION 473434 MISC NONCURRENT LIABILITIES 2572609 MISC CURRENT LIABILITIES 3916463 195781311 PART X: ASC 740 FOOTNOTE REGARDING UNCERTAIN TAX POSITIONS IN AUDITED FINANCIALS: NOT APPLICABLE. 1 1 1 X 1 X 1 1 0 1 1 228844 0 228844 0.00160 4243543 778871 3464672 0.02360 4472387 778871 3693516 0.02520 4472387 778871 3693516 0.02520 0 137325 3482357 11906248 -8423891 X 1 1 1 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC ORTHOPEDIC SURGERIES 0.50000 0.50000 1 1 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC

475 WEST RIVER WOODS PARKWAY GLENDALE WI 53212

X NA 1 PART I, LINE 3C: THE HOSPITALS OF CSM PROVIDE MEDICALLY NECESSARY CARE TO ALL PATIENTS, REGARDLESS OF RACE, COLOR, CREED, ETHNIC ORIGIN, GENDER, DISABILITY OR ECONOMIC STATUS. OHOW'S SPECIFIC POLICY USES A PERCENTAGE OF FEDERAL POVERTY LEVEL (FPL) TO DETERMINE FREE AND DISCOUNTED CARE. AT A MINIMUM, PATIENTS WITH INCOME LESS THAN OR EQUAL TO 200% OF THE FPL, WHICH MAY BE ADJUSTED FOR COST OF LIVING UTILIZING THE LOCAL WAGE INDEX COMPARED TO NATIONAL WAGE INDEX, WILL BE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF CHARGES FOR SERVICES THAT HAVE BEEN PROVIDED TO THEM. PART I, LINE 6A: OHOW FILES AN ANNUAL COMMUNITY BENEFIT REPORT WITH THE WISCONSIN HOSPITAL ASSOCIATION ("WHA"). CSM DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH THE WHA SINCE CSM DOES NOT HAVE ANY PATIENT CARE REVENUE. HOWEVER, CSM IS THE PARENT ENTITY OF 3 HOSPITALS, COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC., COLUMBIA ST. MARY'S HOSPITAL OZAUKEE, SACRED HEART REHABILITATION, INC., EACH OF WHICH FILE COMMUNITY BENEFIT REPORTS WITH WHA. CSM DOES, HOWEVER, DESCRIBE THE BENEFITS THAT THE CSM ORGANIZATION PROVIDES TO THE COMMUNITY ON ITS WEBSITE. PART I, LINE 7: THE COST OF PROVIDING CHARITY CARE, MEANS TESTED GOVERNMENT PROGRAMS, AND COMMUNITY BENEFIT PROGRAMS IS ESTIMATED USING INTERNAL COST DATA, AND IS CALCULATED IN COMPLIANCE WITH CATHOLIC HEALTH ASSOCIATION ("CHA") GUIDELINES. THE ORGANIZATION USES A COST ACCOUNTING SYSTEM THAT ADDRESSES ALL PATIENT SEGMENTS (FOR EXAMPLE, INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED, OR SELF PAY). THE BEST AVAILABLE DATA WAS USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE. FOR CERTAIN CATEGORIES IN THE TABLE, THIS WAS A COST ACCOUNTING SYSTEM; IN OTHER CATEGORIES, A SPECIFIC COST-TO-CHARGE RATIO WAS APPLIED.PART I, LINE 7G: THE ORGANIZATION HAS NOT INCLUDED COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC AS PART OF SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): CSM'S SHARE OF THE AMOUNT OF BAD DEBT EXPENSE REPORTED BY OHOW IN 2010 BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN (F) IS $460,525. PART II: NO COMMUNITY BUILDING ACTIVITIES HAVE BEEN REPORTED BASED ON THE OHOW JOINT VENTURE; HOWEVER, IN ORDER TO ACCOMPLISH THE COLLABORATIVE WORK IN THE COMMUNITY AND TO OVERSEE ACCESS CLINICS AND OUTREACH PROGRAMS, CSM HAS A COMMUNITY SERVICES DEPARTMENT WHICH OVERSEES THE CSM COMMUNITY BENEFIT PROCESS. PROGRAMS TO PROMOTE THE HEALTH OF THE COMMUNITIES WHICH THE CSM ORGANIZATIONS ARE AFFILIATED WITH INCLUDE:- THE INROADS PROGRAM -- THIS PROGRAM IS A COLLABORATION BETWEEN CSM AND THE MILWAUKEE INROADS COOPERATIVE TO PROVIDE CULTURALLY DIVERSE COLLEGE STUDENTS AN OPPORTUNITY TO EXPERIENCE THE HEALTHCARE WORKPLACE. CSM HAS A STRONG RECORD OF HIRING INROADS GRADUATES AFTER THEIR INTERNSHIP EXPERIENCE. - MILWAUKEE HEALTH CARE PARTNERSHIP (MHCP) -- CSM IS A FOUNDING MEMBER OF THE MILWAUKEE HEALTH CARE PARTNERSHIP (MHCP), WHICH IS A COLLABORATION BETWEEN THE FIVE MILWAUKEE HEALTH SYSTEMS AND FEDERALLY QUALIFIED HEALTH CENTERS TO IMPROVE ACCESS TO HEALTH CARE IN THE COMMUNITY. THE PARTNERSHIP HAS WORKED WITH COUNTY HEALTH OFFICIALS TO IMPROVE BEHAVIORAL ACCESS AND PARTNERSHIP FUNDING SUPPORTS MENTAL HEALTH RESPITE BEDS IN THE COMMUNITY. CSM'S CEO AND MISSION ACCESS VICE PRESIDENT EACH SPEND SIGNIFICANT TIME IN MHCP COLLABORATIVE WORK. - COLLABORATION WITH COMMUNITY CHURCHES -- ACCESS TO HEALTH EDUCATION AND SCREENING IN MANY AREAS OF THE CITY IS BEST ACCOMPLISHED THROUGH CHURCH COLLABORATION. CSM EMPLOYS THREE NURSES TO WORK IN COLLABORATION WITH CHURCHES AND COMMUNITY ORGANIZATIONS TO OFFER HEALTH EDUCATION, HEALTH SCREENING, AND CARE MANAGEMENT SUPPORT TO PARISHIONERS AND COMMUNITY MEMBERS IN A VARIETY OF OUTREACH PROGRAMS AFFILIATED WITH CHURCHES. CSM DEVELOPED THE BEGINNING STAGES OF A COLLABORATION WITH 44 CHURCH OF GOD IN CHRIST CHURCHES IN MILWAUKEE TO ACCOMPLISH BETTER HEALTH AWARENESS AND IMPROVE SCREENING RATES. PART III, LINE 4: OHOW, WHICH FILES FINANCIAL STATEMENTS SEPARATE FROM CSM, INCLUDES THE FOLLOWING FOOTNOTE RELATED TO ACCOUNTS RECEIVABLES: "THE MAJORITY OF THE HOSPITAL'S ACCOUNTS RECEIVABLES ARE DUE FROM THIRD-PARTY PAYORS UNDER REIMBURSEMENT AGREEMENTS AND FROM PATIENTS FOR SERVICES PROVIDED. ACCOUNTS RECEIVABLE ARE DUE UPON RECEIPT OF INVOICE. RECEIVABLES ARE STATED NET OF ANY ALLOWANCE FOR CONTRACTUAL DISCOUNTS AND UNCOLLECTIBLE ACCOUNTS BY CONSIDERING THE NUMBER OF DAYS PAST DUE, COLLECTION HISTORY, AND THE GENERAL ECONOMY AND INDUSTRY AS A WHOLE. CONTRACTUAL ADJUSTMENTS ARE BASED ON EXPECTED PAYMENT RATES IN ACCORDANCE WITH THIRD-PARTY PAYOR AGREEMENTS. THE HOSPITAL WRITES OFF ACCOUNTS RECEIVABLE WHEN THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PAYMENTS SUBSEQUENTLY RECEIVED ARE CREDITED TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS." CSM'S SHARE OF OHOW BAD DEBT EXPENSE IN 2010 WAS $460,525 AT GROSS CHARGES ($137,325 AT COST). PART III, LINE 8: OHOW FOLLOWS THE CATHOLIC HEALTH ASSOCIATION ("CHA") GUIDELINES FOR DETERMINING COMMUNITY BENEFIT. CHA COMMUNITY BENEFIT REPORTING GUIDELINES SUGGEST THAT MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: OHOW HAS A WRITTEN DEBT COLLECTION POLICY THAT ALSO INCLUDES A PROVISION ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. IF A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE CERTAIN COLLECTION PRACTICES DO NOT APPLY. CSM DOES NOT FILE A COMMUNITY BENEFIT REPORT SINCE IT DOES NOT HAVE ANY PATIENT CARE REVENUE. HOWEVER, CSM'S THREE HOSPITAL ORGANIZATIONS, COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC., COLUMBIA ST. MARY'S HOSPITAL OZAUKEE, AND SACRED HEART REHABILITATION, INC. EACH FILE COMMUNITY BENEFIT REPORTS WITH THE WISCONSIN HOSPITAL ASSOCIATION. COLUMBIA ST. MARY'S, INC. AND ITS AFFILIATED HOSPITALS SPONSORS ENVIRONMENTAL INITIATIVES AS PART OF THE NATIONAL PRACTICE GREENHEALTH ENVIRONMENTAL PROGRAM. A CSM GREEN TEAM MEETS MONTHLY TO DEVELOP AND ACCOMPLISH GOALS ACROSS THE INSTITUTIONS. THE TEAM SERVES THE CSM HOSPITALS AND REPORTS THE FOLLOWING ACHIEVEMENTS IN THE PAST YEAR UNDER THE THEMES OF REDUCE, REUSE, AND RECYCLE.REDUCE:AS A HEALTH SYSTEM, CSM WAS AN AWARD RECIPIENT OF THE 2011 PRACTICE GREENHEALTH ENVIRONMENTAL EXCELLENCE AWARD-PARTNER FOR CHANGE WITH DISTINCTION. THIS AWARD DESIGNATION REQUIRES A RECYCLING RATE THROUGH ALL WASTE STREAMS OF GREATER THAN 25%.IN EARLY 2011, CSM HOSPITAL OZAUKEE EARNED AN ENERGY STAR DESIGNATION FROM THE EPA FOR USING 35% LESS ENERGY THAN THE AVERAGE HOSPITAL.REUSE:CSM'S REPROCESSING PRACTICE WITH STERILMED DIVERTED 24,355 UNITS FROM LANDFILLS OR 14,306 POUNDS.RECYCLE:SINGLE SOURCE RECYCLING: 377 TONS RECYCLABLES-EACH TON SAVES 24 GALLONS OF GAS, 4100 KWH OF ELECTRICITY, AND 7,000 GALLONS OF WATER.ADDITIONALLY, CSM HOSPITAL MILWAUKEE, AN AFFILIATED HOSPITAL, IMPLEMENTED A DESIGN OF THE PATIENT CARE TOWER WITH A TOTAL OF 18,800 SQUARE FEET OF GREEN ROOF. THE ROOF REMOVES THE EQUIVALENT OF 282 PASSENGER CARS OF GREENHOUSE GASES ANNUALLY, HOLDS ROUGHLY 25,000 GALLONS OF RAINWATER OUT OF THE SEWAGE SYSTEM, AND REDUCES INDOOR SOUND BY AS MUCH AS 40 DECIBELS LEADING TO A QUIETER PATIENT EXPERIENCE. PART VI, LINE 2: THE HEALTH NEEDS OF THE COMMUNITIES WHICH CSM SERVE ARE ASSESSED THROUGH THE WORK OF THE CSM COMMUNITY BENEFIT COMMITTEES ("CBC"). THE CBCS ARE GUIDED BY THE MISSION STATEMENT OF CSM, AND ARE COMPRISED OF ADMINISTRATIVE LEVEL LEADERSHIP, MANAGERS, AND STAFF INVOLVED IN DIRECT SERVICE TO VULNERABLE PEOPLE. ADDITIONALLY, THE CBCS INCLUDE A REPRESENTATIVE OF THE PATIENT FAMILY ADVISORY COMMITTEE OF CSM AS A STRUCTURED METHOD FOR RECEIVING COMMUNITY INPUT. THE CBC ROLES INCLUDE THE FOLLOWING:- DEVELOP COMMUNITY ASSESSMENT TO DETERMINE NEEDS OVER A TWO YEAR PERIOD TO ADDRESS THROUGH CSM RESOURCES.- CREATE A COMMUNITY BENEFIT PLAN TO DRIVE CSM ACTIVITIES OVER SEVERAL YEARS.- REVIEW AND PROVIDE INPUT TO COMMUNITY BENEFIT REPORTS TO ASCENSION HEALTH, WISCONSIN HEALTH ASSOCIATION AND CHA.- DEVELOP ANNUAL COMMUNITY BENEFIT GOALS TO INCLUDE WITHIN CSM INTEGRATED, STRATEGIC, OPERATIONAL AND FINANCIAL PLAN.- PROVIDE INPUT TO AND ADVOCATE FOR CSM ORGANIZATIONAL POLICIES FOCUSED ON VULNERABLE POPULATIONS (E.G. OUTREACH SCREENING GUIDELINES, TRANSPORTATION, COLLECTION POLICIES).- DEVELOP AND IMPLEMENT COMMUNICATION STRATEGIES TO INFORM MULTIPLE COMMUNITIES ABOUT COMMUNITY BENEFIT ACHIEVEMENTS.- DEVELOP A STRATEGY TO MEASURE AND INCREASE THE IMPACT OF COMMUNITY BENEFIT PROGRAMS.IN FISCAL 2011, THE CBCS PREPARED NEEDS ASSESSMENTS FOR EACH OF THE HOSPITALS TO GUIDE ITS PLANNING. THE ASSESSMENTS WERE DEVELOPED BY GATHERING KEY PUBLIC HEALTH AND DISEASE SPECIFIC ASSESSMENTS FOR EACH COMMUNITY AND SYNTHESIZING THE ASSESSMENTS INTO ONE DOCUMENT FOR MILWAUKEE AND OZAUKEE COUNTIES FROM PUBLIC SOURCES SUCH AS HRSA COMMUNITY HEALTH STATUS REPORT FOR OZAUKEE COUNTY, THE OZAUKEE HEALTH INITIATIVE 2002-2007, CHILDREN'S HEALTH IN WISCONSIN (CENTER FOR HEALTH STATISTICS), START SMART MILWAUKEE STATE OF MILWAUKEE'S CHILDREN HEALTH REPORT, HEALTHIEST WISCONSIN 2010, CITY OF MILWAUKEE HEALTH DEPT. REPORT, CITY OF MILWAUKEE COMMUNITY HEALTH SURVEY, HRSA COMMUNITY HEALTH STATUS REPORT FOR MILWAUKEE COUNTY, WISCONSIN DHFS FAMILY HEALTH SURVEY, WISCONSIN DHFS HEALTH INSURANCE COVERAGE REPORT, RIVERWEST HEALTH INITIATIVES SURVEY REPORT, MILWAUKEE'S COMMITMENT TO ACTION: REPORT FROM THE 2003 URBAN HEALTH FORUM, MILWAUKEE PUBLIC HEALTH REPORT BY ALDERMANIC DISTRICT, WISCONSIN COUNTY HEALTH RANKINGS 2006 AND WISCONSIN NUTRITION AND PHYSICAL ACTIVITY STATE PLAN. SEVERAL OF THESE SURVEYS INCLUDE DIRECT CITIZEN INPUT REGARDING THE STATE OF THEIR HEALTH.THE NEEDS ASSESSMENTS WERE DISCUSSED IN DETAIL BY THE CBC TO GAIN THE INSIGHT OF THOSE AT CSM INVOLVED IN ALL AREAS OF HEALTH AND COMMUNITY HEALTH. THE PLAN THAT WAS SUBSEQUENTLY DEVELOPED FOCUSED ON CARE FOR VULNERABLE PEOPLE CONSISTENT WITH THE CSM MISSION STATEMENT. PART VI, LINE 3: CSM ATTEMPTS TO IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR CHARITY OR DISCOUNTED CARE AS OUTLINED IN THE CHARITY CARE POLICY DURING THE PRE-REGISTRATION, REGISTRATION, ADMISSIONS AND DISCHARGE PROCESSES. A COPY OF THE CHARITY CARE POLICY IS POSTED IN THE EMERGENCY ROOM, AND A SUMMARY OF THE POLICY IS PROVIDED TO PATIENTS WITH ADMISSION AND DISCHARGE PAPERWORK. CSM HAS TRAINED FINANCIAL COUNSELORS AVAILABLE TO DISCUSS PAYMENT OPTIONS TO THE PATIENTS. UPON MAKING AN APPOINTMENT, THE FINANCIAL COUNSELORS WILL MEET WITH THE PATIENT TO DETERMINE WHAT OTHER FINANCIAL ASSISTANCE PROGRAMS THE PATIENT MAY QUALIFY FOR. PART VI, LINE 4: CSM PRIMARILY SERVES THE MILWAUKEE AND OZAUKEE COUNTIES IN SOUTHEASTERN WISCONSIN. OHOW IS LOCATED IN AN URBAN COMMUNITY WITHIN MILWAUKEE COUNTY. THE POPULATION OF MILWAUKEE COUNTY IS APPROXIMATELY 950,000, WITH OVER 19% OF THE HOUSEHOLDS LIVING AT OR BELOW FEDERAL POVERTY GUIDELINES. THE MEDIAN INCOME IS APPROXIMATELY $46,000, OVER 44% OF THE POPULATION IS A MINORITY, AND APPROXIMATELY 15% OF THE POPULATION SPEAK A LANGUAGE OTHER THAN ENGLISH. DISCOUNTS FOR THE UNINSURED AND UNDERINSURED ARE NOT INCLUDED IN PARTS I OR II OF SCHEDULE H. PART VI, LINE 6: COMMUNITY BENEFIT ACTIVITIES OFTEN FOCUS ON ACCESS TO PRIMARY CARE THROUGH FREE OR REDUCED COST CLINICS SPONSORED BY HOSPITAL CSM MILWAUKEE. FOLLOWING ARE SEVERAL EXAMPLES IN WHICH THE HOSPITALS OF CSM FOCUS ON THE CONNECTION BETWEEN COMMUNITY NEEDS AND COMMUNITY BENEFIT PLAN ACTIVITIES. INFANT MORTALITY, PARTICULARLY AMONG THE AFRICAN AMERICAN COMMUNITY IN MILWAUKEE, IS A PARTICULAR HEALTH ISSUE NEEDING IMPROVEMENT. CSM HAS BEEN AN IMPORTANT COLLABORATOR IN CITY AND STATE EFFORTS TO IMPROVE BIRTH OUTCOMES AND REDUCE INFANT MORTALITY RATES IN MILWAUKEE. CSM HAS SUPPORTED THE LIFECOURSE INITIATIVE FOR HEALTHY FAMILIES AS A COMMUNITY/ACADEMIC PARTNERSHIP FOR INITIATION OF A FIVE YEAR FUNDED PLAN FOR MORTALITY IMPROVEMENT. CSM HAS AN INTERNAL COMMITTEE, CSM HEALTHY FAMILIES, THAT MEETS TO PLAN IMPROVEMENTS IN SUPPORT TO FAMILIES. A PARTICULAR FOCUS HAS BEEN THAT OF SAFE SLEEP INITIATIVES TO ASSURE THAT INFANTS HAVE A SAFE PLACE TO SLEEP BY PROVIDING PACK AND PLAY CRIBS FOR MOTHERS WITHOUT A DEDICATED INFANT SLEEP SPACE. ADDITIONALLY, PARENTS ARE EDUCATED ABOUT THE IMPORTANCE OF AN INFANT SLEEPING ON HIS BACK THROUGH A "BACK TO SLEEP" CAMPAIGN OF INFANT APPAREL WITH THAT MESSAGE IMPRINTED. CSM'S COMMUNITY NEEDS ASSESSMENTS HAVE IDENTIFIED THAT ACCESS TO PRIMARY CARE HAS BEEN A COMMUNITY PROBLEM IN MILWAUKEE. CSM HAS RESPONDED TO THAT NEED BY SPONSORING ST. BEN'S CLINIC, THE COMMUNITY-BASED CHRONIC DISEASE MANAGEMENT CLINIC WHICH IS A HYPERTENSION TREATMENT CENTER HOUSED IN A FOOD PANTRY, THE SETON DENTAL CLINIC AND THE SATURDAY CLINIC FOR THE UNINSURED. CSM SPONSORS MEDICAL RESIDENCY EDUCATION PROGRAMS THROUGH THE CSM FAMILY HEALTH CENTER AND THE OB/GYN CLINIC. EACH CENTER OFFERS SLIDING FEE SCALES TO UNINSURED AND UNDERINSURED PATIENTS. LACK OF ACCESS TO ORAL HEALTH CARE HAS ALSO BEEN IDENTIFIED IN THE NEEDS ASSESSMENT. CSM MILWAUKEE SPONSORED THE SMART SMILES PROGRAM OF SCHOOL-BASED ORAL HEALTH CARE TO SERVE CHILDREN. DENTAL ASSESSMENT, ORAL HYGIENE CARE, DENTAL SEALANTS AND FLUORIDE TREATMENTS ARE PROVIDED IN MORE THAN 30 SCHOOLS TO MEET THESE NEEDS. THE ST. ELIZABETH ANN SETON DENTAL CLINIC SERVES AS THE URGENT DENTAL CARE PROVIDER FOR UNINSURED PEOPLE IN MILWAUKEE. DISPARITIES EXIST IN CANCER DIAGNOSIS AND TREATMENT IN THE COMMUNITIES CSM MILWAUKEE SERVES. CSM MILWAUKEE RESPONDED BY PROVIDING A BREAST HEALTH ADVOCATE TO LINK AFRICAN AMERICAN AND HISPANIC WOMEN INTO MAMMOGRAPHY AND FURTHER DIAGNOSTIC TESTING TO FIND DISEASE EARLIER AND TO PROVIDE MORE EFFECTIVE TREATMENT. COLUMBIA COLLEGE OF NURSING STUDENTS AND FACULTY STAFF EL CENTRO DE SALUD NURSING CENTER AT THE UNITED COMMUNITY CENTER, WHICH PROVIDES IMMUNIZATIONS, PHYSICALS, HEALTH EDUCATION, HEALTH PROMOTION, SCREENING AND SUPPORT TO STUDENTS OF UNITED COMMUNITY CENTER PRESCHOOL, ELEMENTARY AND MIDDLE SCHOOLS, AS WELL AS TO ADULTS IN FAMILY PROGRAMS AND OLDER ADULT SERVICES.CSM COLLABORATES WITH THE MEDICAL COLLEGE OF WISCONSIN IN SPONSORING THE FOLLOWING:-THE FAMILY HEALTH CENTER, A RESIDENCY-BASED FAMILY MEDICINE CLINIC THAT PROVIDES PRIMARY CARE TO MORE THAN 9,000 INDIVIDUALS IN THE COMMUNITY.- THE OB/GYN CLINIC, A RESIDENCY-BASED PROGRAM THAT SERVES OVER 150 PATIENTS, 250 OB APPOINTMENTS PER MONTH, AND 325 DELIVERIES PER YEAR.- THE CHRONIC DISEASE MANAGEMENT CLINIC, WHICH SCREENS AND MANAGES HYPERTENSION, DIABETES, OBESITY, AND SMOKING FOR LOW INCOME ADULTS THROUGH A CLINIC BASED IN A FOOD PANTRY. - THE SATURDAY CLINIC FOR THE UNINSURED, WHICH USES MEDICAL STUDENTS AND VOLUNTEER PHYSICIANS TO SERVE HUNDREDS OF UNINSURED PATIENTS EACH YEAR.HOUSECALLS FOR THE HOMEBOUND PROVIDES HIGH-QUALITY PRIMARY CARE TO APPROXIMATELY 90 ELDERLY PATIENTS IN THEIR HOMES WHO ARE TOO FRAIL TO TRAVEL TO PHYSICIANS' OFFICES. ADDITIONAL AREAS OF COMMUNITY SUPPORT INCLUDE CSM'S PARTNERSHIP WITH SIXTEENTH STREET COMMUNITY HEALTH CENTER (SSCHC), A FEDERALLY QUALIFIED HEALTH CENTER (FQHC) THAT SERVES PRIMARILY HISPANIC AND ASIAN PEOPLE IN MILWAUKEE. CSM IS THE PRIMARY HOSPITAL TO ACCEPT ADMISSIONS AND WORK CLOSELY WITH SSCHC TO IMPROVE THE HEALTH OF ITS PATIENTS. MANY OF ITS PATIENTS ARE UNINSURED AND INELIGIBLE FOR COVERAGE. THIS HAS IMPACT ON CSM'S CHARITY CARE FUNDING. CSM ALSO EMPLOYS A CADRE OF SKILLED INTERPRETERS TO ASSURE THAT COMMUNICATION IS EXCELLENT FOR SPANISH-SPEAKING PATIENTS. PART VI, LINE 7: THE CSM HEALTH SYSTEM FOCUSES ON CONTRIBUTING TO THE POSITIVE HEALTH STATUS OF THE COMMUNITIES IT SERVES. CSM IS AN ORGANIZATION COMPRISED OF THREE HOSPITALS, 65 COMMUNITY CLINICS, THE COLUMBIA COLLEGE OF NURSING, SETON CHILDREN'S SCHOOL, A PARTNERSHIP WITH THE ORTHOPAEDIC HOSPITAL OF WISCONSIN, A PARTNERSHIP WITH SLEEP SERVICES OF WISCONSIN, AND FOUR URGENT CARE CENTERS. CSM PROVIDES CARE FOR INDIVIDUALS AND FAMILIES THROUGHOUT MILWAUKEE, OZAUKEE, WASHINGTON, AND SHEBOYGAN COUNTIES - WITH MORE THAN 160 YEARS OF SERVICE TO INDIVIDUALS AND FAMILIES IN THESE COMMUNITIES.OHOW ITSELF IS A SPECIALTY HOSPITAL WHICH PERFORMS MORE THAN 5,000 SURGICAL PROCEDURES EACH YEAR AND OFFERS THE COMPLETE RANGE OF ORTHOPAEDIC SERVICES, INCLUDING JOINT REPLACEMENTS AND SPINE PROCEDURES, REHABILITATION, DIAGNOSTIC TESTING AND PAIN MANAGEMENT SERVICES. AS A MEMBER OF ASCENSION HEALTH, THE NATION'S LARGEST CATHOLIC HEALTHCARE SYSTEM, CSM CONTINUES TO BUILD AND STRENGTHEN SUSTAINABLE COLLABORATIVE EFFORTS THAT BENEFIT THE HEALTH OF INDIVIDUALS, FAMILIES, AND SOCIETY AS A WHOLE. THE GOAL OF CSM IS TO PERPETUATE THE HEALTH MISSION OF THE CHURCH. CSM FURTHERS THIS GOAL THROUGH DELIVERY OF PATIENT SERVICES, CARE TO THE ELDERLY AND INDIGENT, PATIENT EDUCATION AND HEALTH AWARENESS PROGRAMS FOR THE COMMUNITY, AND MEDICAL RESEARCH. OUR CONCERN FOR ALL HUMAN LIFE AND DIGNITY OF EACH PERSON LEADS THE ORGANIZATION TO PROVIDE MEDICAL SERVICES TO ALL PEOPLE IN THE COMMUNITY WITHOUT REGARD TO THE PATIENT'S RACE, CREED, NATIONAL ORIGIN, ECONOMIC STATUS, OR ABILITY TO PAY.CSM EMPLOYS A COMMUNITY BENEFIT PHILOSOPHY IN PROGRAM PLANNING AND IMPLEMENTATION. CSM PROVIDES FOR THE HEALTH OF THE COMMUNITY THROUGH FINANCIAL SUPPORT PROVIDED TO PATIENTS BY FINANCIAL DISCOUNTS AND CONTRACTS, BY DEVELOPING CLINICS AND SERVICES FOR SPECIFIC VULNERABLE GROUPS, BY SPONSORING COMMUNITY EDUCATION AND TRAINING AND BY COLLABORATING WITH GOVERNMENT PROGRAMS.DURING FISCAL 2011, THE CSM SYSTEM PROVIDED MORE THAN $71,859,000 IN UNREIMBURSED SERVICES, INCLUDING $11,270,000 IN TRADITIONAL CHARITY CARE, $7,765,000 IN DISCOUNTS TO THE UNINSURED, $16,078,000 IN COMMUNITY BENEFIT PROGRAMS, AND $36,745,000 IN OTHER UNPAID PUBLIC PROGRAMS, INCLUDING SUBSIDIZED HEALTH CARE, PROFESSIONAL EDUCATION, FINANCIAL CONTRIBUTIONS AND COMMUNITY BUILDING ACTIVITIES.IN ADDITION, THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF LOCAL COMMUNITY LEADERS AND PHYSICIANS, THE MAJORITY OF WHOM RESIDE WITHIN THE COMMUNITIES CSM SERVES AND ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY; HOWEVER, THE CLINICS WITHIN THE ORGANIZATION ARE SERVED BY PHYSICIANS AFFILIATED WITH CSM. 1 WISCONSIN PRIMARY HEALTH CARE ASSOCIATION 4600 AMERICAN PARKWAY SUITE 204 MADISON WI 53718 391407034 501(C)(3) 133334 CONTRIBUTION TO MILWAUKEE HEALTH CENTERS MILWAUKEE DEVELOPMENT CORP 756 N MILWAUKEE ST 4TH FLOOR MILWAUKEE WI 53202 930828687 501(C)(3) 15000 REGIONAL ECONOMIC DEVELOPMENT CAMPAIGN SAINT THOMAS FOUNDATION 4220 HARDING ROAD NASHVILLE TN 37205 581716804 501(C)(3) 10000 DONATION FOR NASHVILLE FLOOD RELIEF CEDARBURG CULTURAL CENTER W62 N546 WASHINGTON AVE CEDARBURG WI 53012 391558200 501(C)(3) 20000 CULTURAL CENTER SPONSORSHIP UNITED WAY 225 W VINE STREET MILWAUKEE WI 53212 390806190 501(C)(3) 14500 2010 UNITED WAY CAMPAIGN CONTRIBUTIONS 5 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: CONTRIBUTIONS TO GOVERNMENTS AND ORGANIZATIONS IN THE UNITED STATES ARE APPROVED BY THE BOARD OF DIRECTORS AND/OR THE PRESIDENT & CEO. ALL RECORDS OF OUTGOING CONTRIBUTIONS ARE RETAINED FOR A PERIOD OF 10 YEARS, PLUS THE CURRENT FISCAL YEAR, AND CAN BE LOCATED AT THE OFFICE CENTER AT 4425 NORTH PORT WASHINGTON RD, GLENDALE, WI 53212. X X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 DAVID HOOGERLAND MD 0 414900 0 101000 0 21618 0 4900 0 42568 0 584986 0 0 KEVIN GONIU MD 0 522609 0 40000 0 18822 0 4900 0 50919 0 637250 0 0 LEO P BRIDEAU 804390 0 857565 0 174657 0 4900 0 74042 0 1915554 0 0 0 RHONDA ANDERSON 353962 0 109478 0 3875 0 3323 0 41638 0 512276 0 0 0 AMY MARQUARDT 234247 0 74208 0 25361 0 19951 0 16670 0 370437 0 0 0 CHERYL HILL 228137 0 61396 0 23480 0 4834 0 30218 0 348065 0 0 0 DAVID H SHAPIRO MD 288246 0 53235 0 45061 0 4900 0 15035 0 406477 0 0 0 GERRI LIETZ-STAFFILENO 0 216241 0 58443 0 38244 0 2141 0 28583 0 343652 0 0 KAROL MARCIANO 246422 0 81198 0 33452 0 4900 0 21941 0 387913 0 0 0 MARY PAUL 0 364297 0 220605 0 76602 0 33825 0 15432 0 710761 0 0 SUE SANICOLA 165577 0 45781 0 19765 0 3825 0 30953 0 265901 0 0 0 WILLIAM HART 0 280195 0 72496 0 3415 0 0 0 20055 0 376161 0 0 DEBORAH FRIBERG 0 432541 0 115466 0 86466 0 361 0 41232 0 676066 0 0 BRUCE MCCARTHY MD 344948 0 0 0 41219 0 0 0 29766 0 415933 0 0 0 CONSTANCE J BRADLEY 0 196027 0 48703 0 3286 0 4740 0 18086 0 270842 0 0 DAVID OLSON 0 348362 0 58277 0 107555 0 0 0 39710 0 553904 0 0 PAUL WESTRICK 174808 0 42690 0 10637 0 12953 0 33078 0 274166 0 0 0 MITCH QUADE 145440 0 22071 0 544 0 22000 0 31277 0 221332 0 0 0 CHRISTOPHER MEYER 140384 0 22616 0 267 0 38500 0 17369 0 219136 0 0 0 KIM HODGKINSON 169950 0 24954 0 0 0 16423 0 25373 0 236700 0 0 0 JILL WINTERS 141952 0 38937 0 495 0 5623 0 22518 0 209525 0 0 0 CHARLES J DREHER 126732 0 10696 0 17292 0 3214 0 23984 0 181918 0 0 0 PART I, LINE 1A CEO RECEIVED SPOUSAL TRAVEL ALLOWANCE OF $1,421 DURING FY11. TAX INDEMNIFICATION PAYMENTS ARE MADE ON THE PERSONAL USE OF EMPLOYER-PROVIDED CELL PHONES. THIS POLICY EXISTS FOR ALL EMPLOYEES ISSUED EMPLOYER-PROVIDED CELL PHONES. GROSS UP PAYMENTS TO COVER TAXES FOR NON-QUALIFIED RELOCATION AND TEMPORARY HOUSING EXPENSES FOR EXECUTIVES WERE PAID IN FY11. PART I, LINE 4B PART I, LINE 4B: ELIGIBLE EXECUTIVES PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. THE FILING ORGANIZATION CONTRIBUTED TO THE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN IN THE AMOUNT AS NOTED BELOW: - A. MARQUARDT $10,400 - P. WESTRICK $6,500 PART I, LINE 7 BOARD MEMBERS, OFFICERS, KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES WHO ARE EMPLOYED BY THE CSM ORGANIZATIONS AND ARE MEDICAL DOCTORS ARE ELIGIBLE TO RECEIVE A PERCENTAGE OF THE REVENUE GENERATED FROM PATIENTS THEY SERVE, BASED ON ESTABLISHED GUIDELINES. OFFICERS AND KEY EMPLOYEES PARTICIPATE IN A MANAGEMENT INCENTIVE PLAN, WHEREBY CERTAIN FINANCIAL TRIGGERS OF THE CSM SYSTEM AS APPROVED BY THE BOARD MUST BE MET BEFORE ANY ELIGIBLE EMPLOYEE MAY RECEIVE PAYMENT OF THE INCENTIVE. ONCE THE TRIGGER IS MET, THE INCENTIVE IS MEASURED BASED ON VARIOUS ESTABLISHED GOALS, INCLUDING OPERATING MARGIN, PATIENT SATISFACTION, QUALITY, AND PRODUCTIVITY. FORM 990, PART VI, SECTION A, LINE 6 CSM HAS TWO CORPORATE MEMBERS: ASCENSION HEALTH AND COLUMBIA HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A ONE OF CSM'S CORPORATE MEMBERS, ASCENSION HEALTH, HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF CSM. FORM 990, PART VI, SECTION A, LINE 7B ASCENSION HEALTH HAS DESIGNED A SYSTEM AUTHORITY MATRIX WHICH ASSIGNS AUTHORITY FOR KEY DECISIONS THAT ARE NECESSARY IN THE OPERATION OF THE SYSTEM. SPECIFIC AREAS THAT ARE IDENTIFIED IN THE AUTHORITY MATRIX ARE: NEW ORGANIZATIONS & MAJOR TRANSACTIONS; GOVERNING DOCUMENTS; APPOINTMENTS/REMOVALS; EVALUATION; DEBT LIMITS; STRATEGIC & FINANCIAL PLANS; ASSETS; SYSTEM POLICIES & PROCEDURES. THESE AREAS ARE SUBJECT TO CERTAIN LEVELS OF APPROVAL BY ASCENSION PER THE SYSTEM AUTHORITY MATRIX. COLUMBIA HEALTH SYSTEM HAS THE AUTHORITY TO APPROVE ANY CHANGES TO THE GOVERNING DOCUMENTS WHICH WOULD AFFECT ITS INTEREST OR RIGHTS IN CSM, THE MISSION AND VISION STATEMENTS OF CSM, AND ANY MAJOR CORPORATE STRUCTURAL TRANSACTIONS OF CSM. FORM 990, PART VI, SECTION B, LINE 11 MANAGEMENT, INCLUDING CERTAIN OFFICERS, WORKS DILIGENTLY TO COMPLETE THE FORM 990 AND ATTACHED SCHEDULES IN A THOROUGH MANNER. MANAGEMENT PRESENTS THE FORM TO THE BOARD, OR A DESIGNATED COMMITTEE, TO REVIEW AND ANSWER ANY QUESTIONS. PRIOR TO FILING THE RETURN, ALL BOARD MEMBERS ARE PROVIDED THE FORM 990 AND MANAGEMENT TEAM MEMBERS ARE AVAILABLE TO ANSWER ANY BOARD MEMBERS QUESTIONS. FORM 990, PART VI, SECTION B, LINE 12C CSM HAS A WRITTEN CONFLICT OF INTEREST POLICY. THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE POLICY IN THAT ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF THE COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING INDIVIDUALS ON THE GOVERNING BOARD OR COMMITTEE MEETING WILL DECIDE IF CONFLICTS OF INTEREST EXIST. EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ITS TAX EXEMPT PURPOSE. FORM 990, PART VI, SECTION B, LINE 15 IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO WAS COMPARED TO OTHER HOSPITALS IN THE AREA THAT HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. THE CEO WAS NOT PRESENT WHEN HIS COMPENSATION WAS DECIDED. IN DETERMINING COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATIONS, THE OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO OTHER HOSPITALS' EMPLOYEES IN THE AREA THAT HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. EMPLOYEE HOURS FORM 990, PART VII, COL (B) THE KEY EMPLOYEES AND OFFICERS LISTED ON FORM 990, PART VII, PROVIDE SERVICES TO THIS ORGANIZATION AS WELL AS OTHER RELATED CSM ORGANIZATIONS. THE HOURS REPORTED IN COLUMN (B) REPRESENT THE ESTIMATED PERCENTAGE OF TIME THESE INDIVIDUALS DEVOTE TO THE REPORTING ORGANIZATION BASED ON AN AVERAGE WEEK. THE TOTAL AVERAGE HOURS PER WEEK THESE INDIVIDUALS SPEND ON ALL CSM ORGANIZATIONS, INCLUDING THIS ORGANIZATION, EXCEED 40 HOURS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: DEFERRED PENSION COSTS -7,622,675. CUMULATIVE EFFECT CHANGE IN ACCOUNTING PRINCIPLE -9,029,392. EQUITY TRANSFERS -10,072,892. TOTAL TO FORM 990, PART XI, LINE 5: -26,724,959. FORM 990, PART XII, LINE 2C NO CHANGES SINCE THE PRIOR YEAR COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390806315 HOSPITAL WI 501(C)(3) 3 COLUMBIA ST MARY'S INC 1 COLUMBIA ST MARY'S HOSPITAL OZAUKEE INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390807063 HOSPITAL WI 501(C)(3) 3 COLUMBIA ST MARY'S INC 1 SACRED HEART REHABILITATION INSTITUTE INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390902199 REHAB FACILITY WI 501(C)(3) 3 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 1 COLUMBIA COLLEGE OF NURSING INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 391596986 COLLEGE WI 501(C)(3) 2 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 1 SETON CHILDREN'S SCHOOL INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 391391245 SCHOOL WI 501(C)(3) 9 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 1 ASCENSION HEALTH 4600 EDMUNDSON ROAD ST LOUIS MO 63136 311662309 HEALTH SYSTEM MO 501(C)(3) 11 N/A 0 HORIZON HOME CARE & HOSPICE INC 8949 N DEERBROOK TRL MILWAUKEE WI 53223 391171298 HOME CARE/HOSPICE WI 501(C)(3) 3 COLUMBIA ST MARY'S INC 0 COLUMBIA HEALTH SYSTEM 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 391494977 HEALTH SYSTEM WI 501(C)(3) 11 N/A 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC 575 RIVERWOODS PKWY GLENDALE WI 53212 392015655 HEALTH CARE WI COLUMBIA ST MARY'S INC RELATED 10732000 15525000 0 1 0.50000 SLEEP SERVICES OF WISCONSIN LLC 111 E KILBOURN AVE STE 1300 MILWAUKEE WI 53202 273148310 SLEEP SERVICES WI COLUMBIA ST MARY'S INC RELATED 267000 450000 0 1 0.50000 CSM STRATEGIC ALLIANCE 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391871856 HEALTHCARE WI COLUMBIA ST MARY'S INC C -1000 42000 0.50000 MADISON MEDICAL AFFILIATES INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391855720 HEALTHCARE WI COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC C -7669593 6643705 1.00000 PROSPECT MEDICAL COMMONS CONDO ASSOCIATION 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 208042108 CONDO ASSOC WI COLUMBIA ST MARY'S INC C 0.70000 0 1 0 0 1 0 0 0 0 0 1 0 0 0 1 1 1 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN O 535778 ASCENSION HEALTH E 164503054 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE K 84205713 COLUMBIA ST MARY'S HOSPITAL OZAUKEE K 30771839 SACRED HEART REHABILITATION INSTITUTE K 2292472 ORTHOPAEDIC HOSPITAL OF WISCONSIN P 24009000 COLUMBIA COLLEGE OF NURSING P 2749000 SETON CHILDREN'S SCHOOL P 1647000 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE P 519688000 COLUMBIA ST MARY'S HOSPITAL OZAUKEE P 82761000 ASCENSION HEALTH Q 11969480 ASCENSION HEALTH Q 4109246 SLEEP SERVICES OF WISCONSIN B 450000 ORTHOPAEDIC HOSPITAL OF WISCONSIN K 1669996