2012-05-15T13:40:12-05:00 2011-06-30 DELOITTE TAX LLP 555 E WELLS SUITE 1400 MILWAUKEE WI 53202 990 2010-07-01 390806315 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE COLU 4143262230 4425 N PORT WASHINGTON ROAD GLENDALE WI 53212 RHONDA ANDERSON 4143262230 2012-05-15 1 4142713000 2010 2016-02-24 21:20:13Z MARK TAYLOR 4425 N PORT WASHINGTON ROAD GLENDALE WI 53212 512087964 0 0928 X COLUMBIA-STMARYS.ORG X 1859 WI FULL-SERVICE HOSPITAL WITH MEDICAL, SURGICAL, ADVANCED CLINICAL AND OTHER COMMUNITY SERVICES. 15 12 3497 419 6770264 -1324307 1658641 1419275 532590776 480834242 164407 1563302 13954930 10115718 548368754 493932537 0 0 0 0 263906425 227704214 0 0 0 284873511 296036320 548779936 523740534 -411182 -29807997 540593519 681031989 365970737 454426496 174622782 226605493 X COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE ("CSM-M") IS PART OF COLUMBIA ST. MARY'S INC. ("CSM"), A HEALTHCARE 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-M'S GOVERNING BODY HAS ADOPTED THE MISSION OF CSM. 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 428831107 0 482432005 CSM-M OPERATED 2 FULL-SERVICE HOSPITALS THROUGH OCTOBER 2010, COLUMBIA HOSPITAL, A 370-BED HOSPITAL, AND COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, A 294-BED HOSPITAL, WHICH OFFER A COMPLETE RANGE OF MEDICAL, SURGICAL AND ADVANCED CLINICAL SPECIALITIES. BOTH HOSPITALS OPERATED EMERGENCY DEPARTMENTS THAT ARE OPEN TO ALL PERSONS, REGARDLESS OF ABILITY TO PAY. IN OCTOBER 2010, CSM COMBINED OPERATIONS OF BOTH HOSPITALS INTO ONE LOCATION WITH 336 BEDS ON LAKE DRIVE IN MILWAUKEE. DURING FISCAL 2011, CSM-M'S HOSPITALS AND CLINICS PROVIDED CARE TO 14,199 INPATIENTS AND 186,993 OUTPATIENTS. CSM-M'S ESTIMATED UNREIMBURSED COSTS OF SERVICES TO THE ELDERLY, UNINSURED, AND UNDERINSURED TOTALED $104,023,119. CSM-M ALSO SPONSORS A NUMBER OF PROGRAMS DESIGNED TO IMPROVE THE HEALTH CARE IN ITS COMMUNITY. REFER TO THE COMMUNITY BENEFIT INFORMATION IN SCHEDULE H FOR DISCUSSION OF HOW CSM-M MAKES A POSITIVE DIFFERENCE IN THE HEALTH STATUS OF ITS COMMUNITY, FOCUSING ON THOSE WHO ARE VULNERABLE 428831107 1 1 0 1 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 177 0 1 3497 1 1 1 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 0 X RHONDA ANDERSON 4143262230 4425 N PORT WASHINGTON ROAD GLENDALE WI 53212 X MICHELLES NETTLES 1.00 X 0 0 0 DAVID HOOGERLAND MD 35.00 X 537518 0 47468 GEORGE H HOFF 1.00 X 0 0 0 PATRICIA J DOLHUN MD 1.00 X 0 0 0 KEVIN GONIU MD 1.00 X 0 581431 55819 LEO P BRIDEAU 15.00 X X 0 1836612 78942 MARK TAYLOR 15.00 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 RHONDA ANDERSON 15.00 X 0 467315 44961 AMY MARQUARDT 15.00 X 0 333816 36621 CHERYL HILL 15.00 X 0 313013 35052 DAVID H SHAPIRO MD 15.00 X 0 386542 19935 GERRI LIETZ-STAFFILENO 1.00 X 0 312928 30724 KAROL MARCIANO 30.00 X 0 361072 26841 MARY PAUL 20.00 X 0 661504 49257 SUE SANICOLA 20.00 X 0 231123 34778 WILLIAM HART 20.00 X 356106 0 20055 DEBORAH FRIBERG 20.00 X 634473 0 41593 BRUCE MCCARTHY 20.00 X 0 386167 29766 CONSTANCE J BRADLEY 35.00 X 248016 0 22826 DAVID OLSON 1.00 X 0 514194 39710 ROBERT B ROTH MD 40.00 X 1695121 0 89927 ROBERT L HUXLEY MD 40.00 X 1493608 0 89090 DAVID W GRAMBOW MD 40.00 X 1321296 0 84125 SANJAY S DESHPANDE MD 40.00 X 1519956 0 79954 RICHARD A PIRCON MD 40.00 X 1150455 0 71224 CHARLES J DREHER 1.00 X 0 154720 27198 8956549 6540437 1055866 242 1 1 0 CG SCHMIDT-BARTON MALOW 26500 AMERICAN DRIVE SOUTHFIELD MI 48034 PROJECT MGMT 52517224 FW MADISON MEDICAL ASSO SC 788 N JEFFERSON ST SUITE 300 MILWAUKEE WI 53202 THIRD PARTY MED SERVICE 6082312 MEDICAL COLLEGE OF WISCONSIN 8701 WATERTOWN PLANK ROAD MILWAUKEE WI 53226 RESIDENT & INTERN PROGRAM 2863577 METROPOLITAN ANESTHESIOLOGY 4225 N DOWNER AVE SHOREWOOD WI 53211 ANESTHESIOLOGY SERVICES 2627286 TRIMEDX LLC 6325 DIGITAL WAY 400 INDIANAPOLIS IN 46278 EQUIPMENT REPAIR & MAINT 2342676 93 1419275 1419275 NET PATIENT SERVICES 621990 468210673 468210673 RETAIL PHARMACY REVENU 446110 5377424 3870149 1507275 DIAGNOSTIC LAB REVENUE 621500 5202166 5202166 FOOD & NUTRITION 722210 1312785 1312785 RENTAL INCOME 531120 731194 731194 480834242 19718729 18155427 1563302 1563302 1563302 SALES TO OUTSIDE ORGS 900099 3473296 3473296 CAPITALIZED INTEREST 900099 1998208 1998208 EXPENSE TRANSFERS 900099 1611710 1611710 3032504 2971681 60823 10115718 493932537 482432005 6770264 3310993 1854444 1854444 181791805 173271633 8520172 13608049 12941255 666794 17495937 16638636 857301 12953979 12319234 634745 1957862 1957862 1408 1408 2350 2350 34438521 34438521 1954115 1954115 6307770 5992381 315389 300751 300751 16810813 16810813 70951 70951 311589 311589 4465035 4465035 26254797 26254797 2971574 2971574 CSM MANAGEMENT FEE 82056824 82056824 PATIENT CARE SUPPLIES 57280584 57280584 BAD DEBT EXPENSE 27044182 27044182 EXPENSE TRANSFERS 18070191 18070191 HOSPITAL TAX ASSESSMENT 15282467 15282467 454536 454536 523740534 428831107 94909427 0 9116988 7025474 16184357 25218862 68058676 67039777 862356 142526 5833813 6015646 13189549 7873310 741173224 198064323 420023222 543108901 82500 14760205 7242058 9847288 540593519 681031989 43187012 39083856 322783725 415342640 365970737 454426496 X 174622782 226605493 174622782 226605493 540593519 681031989 X -29807997 81790708 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 26378 26378 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LOBBYING EXPENSES REPRESENT THE PORTION OF DUES PAID TO NATIONAL AND STATE HOSPITAL ASSOCIATIONS THAT IS SPECIFICALLY ALLOCABLE TO LOBBYING. 10038037 10038037 440321777 75688487 364633290 4080964 1889103 2191861 267919294 118776645 149142649 18813152 1710088 17103064 543108901 CUSTODIAL 529426 PENSION/DEFERRED COMPENSATION 9185827 PAYABLE TO THIRD PARTIES 1782629 PAYABLE TO AFFILIATES 287365264 OTHER LONG TERM LIABILITY 4221029 INTERCOMPANY DEBT TO ASCENSION HEALTH 112258465 415342640 PART X: ASC 740 FOOTNOTE REGARDING UNCERTAIN TAX POSITIONS IN AUDITED FINANCIALS: NOT APPLICABLE. 1 1 X 1 X 1 X 1 1 1 0 1 1 8546264 0 8546264 0.01720 107947411 77372105 30575306 0.06160 0 0 116493675 77372105 39121570 0.07880 4916814 1124159 3792655 0.00760 15674626 4969950 10704676 0.02160 0 0 0 0 654432 0 654432 0.00130 21245872 6094109 15151763 0.03050 137739547 83466214 54273333 0.10930 0 0 0 0 2831 0 2831 0.00000 0 0 0 0 13495 0 13495 0.00000 37075 0 37075 0.00010 121895 0 121895 0.00020 0 0 175296 175296 0.00030 0 14304854 286097 416772261 432240653 -15468392 X 1 1 2 1 COLUMBIA ST MARYS HOSPITAL COLUMBIA

2025 E NEWPORT AVENUE MILWAUKEE WI 53211

X X X 2 COLUMBIA ST MARYS HOSPITAL MILWAUKEE

2323 N LAKE DRIVE MILWAUKEE WI 53211

X X X NA 1 37 AIRPORT MEDICAL CLINIC

4848 S 6TH STREET MILWAUKEE WI 53221

CLINIC BABBITZ BURSTEIN & NASH

2350 N LAKE DR SUITE 201 MILWAUKEE WI 53221

CLINIC BAY VIEW FAMILY HEALTH CENTER

3056 S KINNICKINNIC AVE MILWAUKEE WI 53207

CLINIC CSMCP PULMONOLOGY

2311 N PROSPECT AVE 2B MILWAUKEE WI 53211

CLINIC CARDIAC RHYTHM SPECIALISTS

2350 N LAKE DR SUITE 206 MILWAUKEE WI 53211

CLINIC CARDIAC & VASCULAR INTERVENTIONAL SPECIA

2350 N LAKE DR SUITE 303 MILWAUKEE WI 53211

CLINIC CATHEDRAL SQUARE URGENT CARE CENTER

734 N JACKSON ST MILWAUKEE WI 53202

CLINIC COLUMBIA WEST

10950 W CAPITOL DR WAUWATOSA 53222 WAUWATOSA WI 53222

CLINIC ENT ASSOCIATES

2350 N LAKE DRIVE SUITE 406 MILWAUKEE WI 53211

CLINIC FAMILY HEALTH CENTER

1121 E NORTH AVE MILWAUKEE WI 53212

CLINIC PMC NEUROLOGY

2311 N PROSPECT AVE MILWAUKEE WI 53211

CLINIC GATEWAY MEDICAL CLINIC

801 S 70TH ST WEST ALLIS WI 53214

CLINIC GLENDALE CLINIC GREEN BAY ROAD

9233 N GREEN BAY RD BROWN DEER WI 53209

CLINIC GLENDALE CLINIC PORT WASH ROAD

6900 N PORT WASHINGTON RD GLENDALE WI 53217

CLINIC GYN ONCOLOGY

2350 N LAKE DR SUITE 501 MILWAUKEE WI 53211

CLINIC MEDICAL ONCOLOGY

2350 N LAKE DR SUITE 100 MILWAUKEE WI 53211

CLINIC NORTHSHORE MEDICAL CLINIC

7080 N PORT WASHINGTON RD GLENDALE WI 53217

CLINIC OBGYN RESIDENCY CLINIC

2320 N LAKE DRIVE MILWAUKEE WI 53211

CLINIC CSM PERINATOLOGY

2388 N LAKE DRIVE MILWAUKEE WI 53211

CLINIC PROSPECT MEDICAL COMMONS

2311 N PROSPECT AVE MILWAUKEE WI 53211

CLINIC RADIATION ONCOLOGY

2350 N LAKE DR SUITE 100 MILWAUKEE WI 53211

CLINIC RIVER GLEN MEDICAL CLINIC

375 W RIVERWOODS PKWY GLENDALE WI 53212

CLINIC RIVER WOODS URGENT CARE

375 W RIVERWOODS PKWY GLENDALE WI 53212

CLINIC SHOREWOOD FAMILY PHYSICIANS

1901 E CAPITOL DR SHOREWOOD WI 53211

CLINIC WEST ALLIS MEDICAL CLINIC

2323 SOUTH 102ND STREET WEST ALLIS WI 53227

CLINIC WESTGATE MEDICAL GROUP

2727 N MAYFAIR RD WAUWATOSA WI 53222

CLINIC PLASTIC SURGERY

2350 N LAKE DR SUITE 501 MILWAUKEE WI 53211

CLINIC WISCONSIN CARDIOVASCULAR GROUP MILWAUKEE

2350 N LAKE DR SUITE 400 MILWAUKEE WI 53211

CLINIC CSM CANCER CENTER - ONCOLOGYHEMATOLOGY

2350 N LAKE DR SUITE 100 MILWAUKEE WI 53211

CLINIC NORTH SHORE CARDIOLOGY EAST

2350 N LAKE DR SUITE 400 MILWAUKEE WI 53211

CLINIC PERINATAL ASSESSMENT CENTER

2323 N LAKE DR 4TH FLOOR MILWAUKEE WI 53211

CLINIC MADISON MEDICAL AFFILIATES - MAYFAIR

201 N MAYFAIR RD SUITE 550 WAUWATOSA WI 53226

CLINIC CARDIAC RHYTHM SPECIALISTS - WAUWATOSA

2727 N MAYFAIR RD SUITE I WAUWATOSA WI 53222

CLINIC CENTER FOR PAIN MANAGEMENT

2323 N LAKE DR MILWAUKEE WI 53211

CLINIC MMA CATHEDRAL SQUARE SUITE 201

788 N JEFFERSON ST MILWAUKEE WI 53202

CLINIC MMA CATHEDRAL SQUARE SUITE 300

788 N JEFFERSON ST MILWAUKEE WI 53202

CLINIC MMA CATHEDRAL SQUARE SUITE 401

788 N JEFFERSON ST MILWAUKEE WI 53202

CLINIC PART I, LINE 6A: CSM HOSPITAL MILWAUKEE PREPARES AND FILES AN ANNUAL COMMUNITY BENEFIT PLAN REPORT WITH THE WISCONSIN HOSPITAL ASSOCIATION ("WHA"). THE INFORMATION ON THIS REPORT INCLUDES INFORMATION ONLY FOR CSM MILWAUKEE AND NOT ANY OF ITS AFFILIATED HOSPITALS. 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 7: THE TOTAL AMOUNT OF CHARITY CARE AND OTHER COMMUNITY BENEFITS IN PART I, LINE 7 IS DIFFERENT FROM THE COMMUNITY BENEFIT AS REPORTED IN THE ANNUAL COMMUNITY BENEFIT REPORT BY THE AMOUNT OF COMMUNITY BUILDING ACTIVITIES REPORTED ON PART II OF SCHEDULE H. THE IRS DOES NOT CONSIDER COMMUNITY BUILDING ACTIVITIES TO BE COMMUNITY BENEFIT; HOWEVER, THESE COSTS ARE INCLUDED IN THE TOTAL COMMUNITY BENEFIT AMOUNT AS REPORTED IN THE ANNUAL COMMUNITY BENEFIT REPORT.PART I, LINE 7G: THE ORGANIZATION EMPLOYS ITS PHYSICIANS AT ITS HOSPITALS AND PHYSICIAN CLINICS, SO THE ASSOCIATED COSTS AND CHARGES RELATING TO THOSE PHYSICIAN SERVICES ARE INCLUDED IN ALL RELEVANT CATEGORIES IN PART I. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN (F) IS $27,044,182. PART II: CSM HOSPITAL MILWAUKEE PROVIDED THE FOLLOWING COMMUNITY BUILDING ACTIVITIES IN FISCAL 2011:- 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. IN ORDER TO ACCOMPLISH THE COLLABORATIVE WORK IN THE COMMUNITY AND TO OVERSEE ACCESS CLINICS AND OUTREACH PROGRAMS, A COMMUNITY SERVICES DEPARTMENT EXISTS. THE DEPARTMENT ALSO OVERSEES THE COMMUNITY BENEFIT PROCESS. THE EXPENSE OF DEPARTMENTAL SUPPORT IS INCLUDED IN THE REPORTING OF COMMUNITY BENEFIT. PART III, LINE 4: THE ORGANIZATION IS A PART OF THE COLUMBIA ST. MARY'S, INC. CONSOLIDATED AUDIT AND FURTHER INCLUDED AS PART OF THE ASCENSION HEALTH CONSOLIDATED AUDITED FINANCIALS. THE FOOTNOTE THAT REFERENCES BAD DEBT EXPENSE IN THE FISCAL 2011 CONSOLIDATED AUDIT IS AS FOLLOWS: "THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF EXPECTED NET COLLECTIONS CONSIDERING ECONOMIC CONDITIONS, HISTORICAL EXPERIENCE, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE OFF EXPERIENCE BY PAYOR CATEGORY, INCLUDING THOSE AMOUNTS NO COVERED BY INSURANCE. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE AND REASONABLE EFFORTS TO COLLECT FROM THE PATIENT HAVE BEEN EXHAUSTED, THE ORGANIZATION FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY THE ORGANIZATION. ACCOUNTS RECEIVABLE ARE WRITTEN OFF AFTER COLLECTION EFFORTS HAVE BEEN FOLLOWED IN ACCORDANCE WITH THE ORGANIZATION'S POLICIES." CSM HOSPITAL MILWAUKEE'S SHARE OF BAD DEBT EXPENSE IN FISCAL 2011 WAS $27,044,182 AT CHARGES ($14,304,854 AT COST). NO BAD DEBT AMOUNTS ARE INCLUDED IN COMMUNITY BENEFIT. PART III, LINE 8: ASCENSION HEALTH AND RELATED HEALTH MINISTRIES FOLLOW 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: THE ORGANIZATION 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. PART VI, LINE 8: CSM HOSPITAL MILWAUKEE FILES A COMMUNITY BENEFIT REPORT WITH THE WHA IN WISCONSIN WHICH INCLUDES THE DATA ONLY FOR CSM HOSPITAL MILWAUKEE. THE AFFILIATE HOSPITALS OF CSM, INCLUDING CSM HOSPITAL OZAUKEE, INC. AND SACRED HEART REHABILITATION INSTITUTE, INC. ALSO FILE SEPARATE COMMUNITY BENEFIT REPORTS WITH WHA. 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 HOSPITAL MILWAUKEE SERVES ARE ASSESSED THROUGH THE WORK OF THE COMMUNITY BENEFIT COMMITTEE ("CBC"). THE CBC IS GUIDED BY THE MISSION STATEMENT OF CSM, AND IS COMPRISED OF ADMINISTRATIVE LEVEL LEADERSHIP, MANAGERS, AND STAFF INVOLVED IN DIRECT SERVICE TO VULNERABLE PEOPLE. ADDITIONALLY, CBC INCLUDES 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, WHA 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 CBC PREPARED A NEEDS ASSESSMENT WHICH ADDRESSES THE COMMUNITIES IN WHICH THE HOSPITAL SERVES TO GUIDE THE CSMM PLANNING. THE ASSESSMENT WAS DEVELOPED BY GATHERING KEY PUBLIC HEALTH AND DISEASE SPECIFIC ASSESSMENTS FOR EACH COMMUNITY AND SYNTHESIZING THE ASSESSMENTS INTO ONE DOCUMENT 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 ASSESSMENT WAS 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 HOSPITAL MILWAUKEE 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 HOSPITAL MILWAUKEE 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 FOR WHICH THE PATIENT MAY QUALIFY. PART VI, LINE 4: CSM HOSPITAL MILWAUKEE SERVES A PRIMARY SERVICE AREA OF EASTERN MILWAUKEE COUNTY, FROM THE NEAR SOUTH SIDE OF MILWAUKEE NORTH THROUGH OZAUKEE COUNTY. CSM HOSPITAL MILWAUKEE 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. THE SERVICE AREA IS VARIED, WITH SOME SECTORS HAVING HIGH INCOMES AND MANY HEALTH RESOURCES WHILE OTHER HIGH ADMISSION ZIP CODES ARE LOCATED IN THE IMPOVERISHED CENTRAL CITY AND IN MEDICALLY UNDERSERVED AREAS. SEVERAL HIGH ADMITTING ZIP CODES FOR CSM HAVE A HIGH PROPORTION OF AFRICAN AMERICAN PEOPLE AND TWO HIGH ADMITTING ZIP CODES HAVE HIGH PROPORTIONS OF PEOPLE OF HISPANIC BACKGROUND. ADDRESSING THE HEALTH DISPARITY ISSUES OF THESE POPULATIONS IS AN IMPORTANT PART OF THE COMMUNITY BENEFIT SERVICE OF CSM HOSPITAL MILWAUKEE. IN FISCAL 2011, CSM HOSPITAL MILWAUKEE SERVED 201,192 PATIENTS AND PROVIDED $8,546,264 IN TRADITIONAL CHARITY CARE, $30,575,336 IN UNPAID COSTS OF PUBLIC PROGRAMS, $6,001,281 IN UNINSURED DISCOUNTS AND $15,327,060 IN OTHER COMMUNITY PROGRAMS AND SERVICES, WHICH ARE REPORTED ON PART I, LINE 7J AND PART II. 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 CSM HOSPITAL MILWAUKEE FOCUSES 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. CSMM'S COMMUNITY NEEDS ASSESSMENT HAS IDENTIFIED 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: CSM HOSPITAL MILWAUKEE IS PART OF THE CSM HEALTH SYSTEM, WHICH CONTRIBUTES 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 WELLNESS INSTITUTE, 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.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 COMMUNITY HEALTH BENEFIT SERVICES, 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. X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 DAVID HOOGERLAND MD 414900 0 101000 0 21618 0 4900 0 42568 0 584986 0 0 0 KEVIN GONIU MD 0 522609 0 40000 0 18822 0 4900 0 50919 0 637250 0 0 LEO P BRIDEAU 0 804390 0 857565 0 174657 0 4900 0 74042 0 1915554 0 0 RHONDA ANDERSON 0 353962 0 109478 0 3875 0 3323 0 41638 0 512276 0 0 AMY MARQUARDT 0 234247 0 74208 0 25361 0 19951 0 16670 0 370437 0 0 CHERYL HILL 0 228137 0 61396 0 23480 0 4834 0 30218 0 348065 0 0 DAVID H SHAPIRO MD 0 288246 0 53235 0 45061 0 4900 0 15035 0 406477 0 0 GERRI LIETZ-STAFFILENO 0 216241 0 58443 0 38244 0 2141 0 28583 0 343652 0 0 KAROL MARCIANO 0 246422 0 81198 0 33452 0 4900 0 21941 0 387913 0 0 MARY PAUL 0 364297 0 220605 0 76602 0 33825 0 15432 0 710761 0 0 SUE SANICOLA 0 165577 0 45781 0 19765 0 3825 0 30953 0 265901 0 0 WILLIAM HART 280195 0 72496 0 3415 0 0 0 20055 0 376161 0 0 0 DEBORAH FRIBERG 432541 0 115466 0 86466 0 361 0 41232 0 676066 0 0 0 BRUCE MCCARTHY 0 344948 0 0 0 41219 0 0 0 29766 0 415933 0 0 CONSTANCE J BRADLEY 196027 0 48703 0 3286 0 4740 0 18086 0 270842 0 0 0 DAVID OLSON 0 348362 0 58277 0 107555 0 0 0 39710 0 553904 0 0 ROBERT B ROTH MD 1618299 0 58000 0 18822 0 4900 0 85027 0 1785048 0 0 0 ROBERT L HUXLEY MD 1486286 0 5000 0 2322 0 4900 0 84190 0 1582698 0 0 0 DAVID W GRAMBOW MD 1283767 0 36287 0 1242 0 4450 0 79675 0 1405421 0 0 0 SANJAY S DESHPANDE MD 1345384 0 156830 0 17742 0 4900 0 75054 0 1599910 0 0 0 RICHARD A PIRCON MD 960213 0 189000 0 1242 0 4900 0 66324 0 1221679 0 0 0 CHARLES J DREHER 0 126732 0 10696 0 17292 0 3214 0 23984 0 181918 0 0 PART I, LINE 1A 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 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 (CSMM) DID NOT CONTRIBUTE ANY AMOUNT TO THIS PLAN THIS YEAR. 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. R BRUCE MCDONALD BOARD CHAIR 711553 CFO OF JOHNSON CONTROLS, INC., A PUBLIC COMPANY WHICH PROVIDES SERVICES TO CSM AND ITS AFFILIATES. ALL TRANSACTIONS ARE CONDUCTED AT ARMS' LENGTH. 0 DAVID SHAPIRO MD KEY EMPLOYEE 167371 SPOUSE IS ALSO EMPLOYED BY CSM SYSTEM. ALL COMPENSATION IS DETERMINED IN ACCORDANCE WITH PAYROLL POLICY GUIDELINES. 0 FORM 990, PART VI, SECTION A, LINE 6 CSM-M HAS A SINGLE CORPORATE MEMBER, CSM. FORM 990, PART VI, SECTION A, LINE 7A CSM-M HAS A SINGLE CORPORATE MEMBER, CSM, WHO HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF CSM-M. FORM 990, PART VI, SECTION A, LINE 7B ALL DECISIONS THAT HAVE A MATERIAL IMPACT TO CSM-M'S FINANCIAL INFORMATION OR CORPORATION AS A WHOLE ARE SUBJECT TO APPROVAL BY ITS SOLE CORPORATE MEMBER, CSM. FORM 990, PART VI, SECTION B, LINE 11 MANAGEMENT, INCLUDING CERTAIN KEY EMPLOYEES, 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 15A. 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. 15B. 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. CSM DOES PUBLISH AN ANNUAL REPORT AND FACT SHEETS ON THE EXTERNAL WEBSITE, WHICH IS AVAILABLE FOR PUBLIC VIEWING. 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: OTHER ADJUSTMENTS 81,790,708. TOTAL TO FORM 990, PART XI, LINE 5: 81,790,708. FORM 990, PART XII, LINE 2C NO CHANGES SINCE THE PRIOR YEAR ST MARY'S HOSPITAL OZAUKEE 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390807063 HOSPITAL WI 501(C)(3) 3 N/A 0 SACRED HEART REHABILITATION INSTITUTE 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 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 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 N/A 0 COLUMBIA ST MARY'S INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391834639 HEALTH SYSTEM WI 501(C)(3) 11 N/A 0 COLUMBIA HEALTH SYSTEM 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391494977 HEALTH SYSTEM WI 501(C)(3) 11 N/A 0 COLUMBIA ST MARY'S FOUNDATION INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391494981 FOUNDATION WI 501(C)(3) 7 N/A 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC 575 RIVERWOODS PKWY GLENDALE WI 53212 392015655 HEALTHCARE WI N/A SLEEP SERVICES OF WISCONSIN 111 E KILBOURN AVE STE 1300 MILWAUKEE WI 53202 273148310 SLEEP SERVICES WI N/A CSM STRATEGIC ALLIANCE 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391871856 HEALTH CARE WI N/A C MADISON MEDICAL AFFILIATES INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391855720 HEALTH CARE WI COLUMBIA ST MARY'S HOSPITAL INC C 0.72000 PROSPECT MEDICAL COMMONS CONDO ASSOCIATION 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 208042108 CONDO ASSOCIATION WI N/A C 0 0 0 0 1 0 0 0 1 0 1 1 0 0 1 0 1 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN K 121645 SACRED HEART REHABILITATION INSTITUTE K 1414537 ASCENSION HEALTH E 112258465 COLUMBIA ST MARY'S INC L 84205713 COLUMBIA ST MARY'S HOSPITAL OZAUKEE L 1992036 SACRED HEART REHABILITATION INSTITUTE L 144507 COLUMBIA HEALTH SYSTEM Q 320016 COLUMBIA ST MARY'S INC O 519688000