2012-10-15T07:18:20-05:00 2011-12-31 010494526 Baker Newman & Noyes LLC PO Box 507 Portland ME 04112 990 2011-01-01 020497927 Wentworth-Douglass Physician Corporation WENT 6037425252 789 Central Avenue Dover NH 038202526 Peter E Walcek 6037422804 2012-10-05 1 Timothy R Hepburn CPA P00182393 2078792100 2012-10-05 2011 2016-02-24 21:20:13Z Wentworth Health Partners Gregory J Walker 789 Central Avenue Dover NH 038202526 26389308 0 X N/A X 1998 NH Improve the health of the community by providing high quality healthcare. 11 4 335 0 52234 -3123 0 0 23560980 26288431 27938 0 67768 70426 23656686 26358857 0 0 0 0 29934723 30879639 0 0 0 11388085 13569483 41322808 44449122 -17666122 -18090265 3962487 4589855 4079036 4976680 -116549 -386825 X Improve the health of the community by providing high quality health care that exceeds expectations through an integrated network of highly qualified professionals. 0 0 39385282 25165217 Wentworth-Douglass Physician Corporation (WDPC) was formed in response to a community needs assessment that identified a lack of primary care and specialty services in the community. The formation of the Physician Corporation and recruitment of primary care and specialty physicians closed the gap by improving access to medical services in Dover, NH and surrounding areas. (See Schedule O for a list of facilities operated by WDPC.)In 2011, the Corporation provided for a total of 198,259 patient visits. 1589125 1141406 The Wentworth-Douglass Community Dental Center is open to low-income, uninsured adults and children living in Wentworth-Douglass Hospital's primary service area (Dover, Durham, Madbury, Lee, Barrington, Somersworth, Rollinsford, NH and Berwick and So. Berwick, ME) or patients of the physician practices who have a family income at or below 300% of the federal poverty guidelines. In 2011, a total of 4,416 patient visits were recorded, with total revenue of $1,141,406 and expenses of $1,589,125 resulting in a net community benefit cost of $447,719.In addition, WDPC provided community benefits totaling nearly $400,000 in 2011. The Corporation supports numerous community based programs, including the Community Dental Center.WDPC provides financial aid information and resources to assist patients with their healthcare bills. Medical care is provided at no charge for eligible patients at 300% of the federal poverty level, reduced to 200% effective 10/1/11. In 2011 WDPC provided $1,089,174 of financial aid (stated at cost). Medicaid Costs Exceeding Reimbursement totaled $459,184 for the Corporation in 2011. 40974407 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 1 335 1 1 1 0 0 0 0 0 0 0 0 0 X 11 4 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Peter E Walcek CFOVP of Finance 6037402804 789 Central Avenue Dover NH 038202526 X Neil Garvey 1.00 X X 0 0 0 Roger Hamel 1.00 X X 0 0 0 Michael Steinberg 1.00 X X 0 0 0 Carol Bailey 1.00 X X 0 0 0 Mark R Blackwood MD 65.00 X 199458 0 15447 William Boc 0.50 X 0 0 0 William R Brandon MD 65.00 X 268637 0 7437 Ellen L Caille 2.00 X 0 290088 77688 Barbara F Civiello MD 65.00 X 475884 0 27624 Girish C Joshi MD 65.00 X 500974 0 25401 Nancy J Pettinari MD 65.00 X 150952 0 7232 Theodore Ristaino 1.00 X 0 0 0 Peter E Walcek 2.00 X X 0 326016 75307 Gregory J Walker 2.00 X X 0 645708 148296 Roger Evans MD 65.00 X 481303 0 27060 Shubhra Ray MD 65.00 X 341434 0 29476 Taylor M Ortiz 65.00 X 362657 0 6076 Patricia A Auty MD 65.00 X 348816 0 21652 Cecil W Bean MD 65.00 X 342827 0 16626 3472942 1261812 485322 81 0 1 0 0 Patient service revenu 621110 25962890 25962890 Other related function 621990 227923 175689 52234 Other - UNH 621990 97618 97618 26288431 100877 30451 70426 70426 70426 26358857 26306623 52234 0 1679063 1679063 24086293 22573674 1512619 275139 257860 17279 2781955 2607248 174707 2057189 1927998 129191 23034 23034 20830 20830 5544976 4509145 1035831 123184 25059 98125 565273 349051 216222 3368832 3155357 213475 231700 198298 33402 534083 534083 582471 582471 Provision for bad debt 1212065 1212065 Pharmacy expense 623002 623002 Dental community benefi 447719 447719 Transcription 284127 284127 8187 8187 44449122 40974407 3474715 0 68715 279189 2112888 2555850 7423884 5672765 1777187 1751119 3697 3697 3962487 4589855 4079036 4976680 4079036 4976680 X -116549 -386825 -116549 -386825 3962487 4589855 X -18090265 17819989 X X 0 1 1 X 0 X 2642982 1974361 668621 4779539 3698404 1081135 1363 1363 1751119 26358857 44449122 -18090265 17819989 17819989 -270276 26389308 30451 30451 26358857 0 26358857 44479573 30451 30451 44449122 0 44449122 Description of Uncertain Tax Positions Under FIN 48: Part X: The audited financial statements contain the following paragraph in Footnote 1 pertaining to uncertain tax positions: "The Hospital, WDPC and the Foundation are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes pursuant to Section 501(a) of the Code. Management evaluated these not-for-profit corporations' tax positions and concluded theses not-for-profit corporations have maintained their tax-exempt status, do not have any significant unrelated business income and have taken no uncertain tax positions that require adjustment to or disclosure in the accompanying consolidated financial statements. With few exceptions, these not-for-profit corporations are no longer subject to tax examination by the U.S. federal or state tax authorities for years prior to 2008." Part XI, Line 8 - Other Adjustments: Equity transfer from Wentworth-Douglass Hospital 17,819,989. Part XII, Line 2d - Other Adjustments: Occupancy expenses allocated to building rental 30,451. Part XIII, Line 2d - Other Adjustments: Occupancy expenses allocated to building rental 30,451. X X X X 0 1 0 0 0 0 0 1 0 Mark R Blackwood MD 151022 0 43716 0 4720 0 9310 0 6137 0 214905 0 0 0 William R Brandon MD 241197 0 13417 0 14023 0 0 0 7437 0 276074 0 0 0 Ellen L Caille 0 244925 0 35143 0 10020 0 51616 0 26072 0 367776 0 0 Barbara F Civiello MD 356469 0 114695 0 4720 0 6370 0 21254 0 503508 0 0 0 Girish C Joshi MD 186607 0 309647 0 4720 0 8729 0 16672 0 526375 0 0 0 Nancy J Pettinari MD 125305 0 22527 0 3120 0 6081 0 1151 0 158184 0 0 0 Peter E Walcek 0 279133 0 37192 0 9691 0 56035 0 19272 0 401323 0 0 Gregory J Walker 0 416504 0 88826 0 140378 0 127804 0 20492 0 794004 0 0 Roger Evans MD 476583 0 0 0 4720 0 9800 0 17260 0 508363 0 0 0 Shubhra Ray MD 311615 0 24500 0 5319 0 12250 0 17226 0 370910 0 0 0 Taylor M Ortiz 356691 0 3625 0 2341 0 0 0 6076 0 368733 0 0 0 Patricia A Auty MD 334896 0 9200 0 4720 0 9800 0 11852 0 370468 0 0 0 Cecil W Bean MD 338827 0 0 0 4000 0 0 0 16626 0 359453 0 0 0 Part I, Line 4b Gregory J. Walker (President/CEO) - 2011 total contributions to the 457(f) plan = $113,104. This supplemental retirement plan contribution is intended to fund benefits accruing and payable at retirement for multiple years of service that began in calendar year 1997. In 2011, the Hospital funded a supplemental executive retirement plan which provides benefits to other qualifying executives. The contributions are intended to provide a forfeitable supplemental retirement benefit and are being provided in consideration for many years of service to the Hospital. The respective contributions for the 2011 plan year, for those individuals identified in Schedule J - Part II, are as follows: Peter E. Walcek = $42,466, and, Ellen L. Caille =$40,126. Part I, Line 7 At-risk compensation for Wentworth-Douglass executives, which is subject to review and paid annually. Wentworth-Douglass Physician Corporation has an incentive-based compensation model that uses relative value units (RVUs) as a measure for determining physician compensation within the Medical Group Management Association published salary ranges. The model includes a base salary plus incentive compensation that has both productivity and performance components inclusive of patient satisfaction, quality, and community citizenship metrics. Both budgeted performance and actual performance are measured. Granite Shield Insurance Exchange Current officer serves both organizations 1172063 Wentworth-Douglass Hospital made a capital contribution of $250,000 to Granite Shield Insurance Exchange (GSIE) in February of 2011 bringing the Hospital's ownership interest in GSIE to approximately 11%. WDH also made captive insurance payments totaling $1,172,063 to GSIE in 2011. Insurance payments for Wentworth-Douglass Physician Corp. are included in that total. 0 Form 990, Part VI, Section B, line 11 A draft of the Form 990 is initially reviewed in detail by key Wentworth-Douglass Hospital finance employees. Thereafter, the final draft is presented to the full board prior to filing with the IRS. Each member of the Board and Finance Committee is provided with a draft of the Form 990 in advance of each meeting. Form 990, Part VI, Section B, line 12c A copy of WDPC'S Conflict Of Interest Policy is distributed annually to all officers, trustees, medical staff officers and committee members, and the management team. All are required to report any conflicts and sign, date, and return the policy, whether or not a conflict exists, to confirm compliance. Conflicts are disclosed in accordance with State of New Hampshire RSA 7:19-a, in the local newspaper and submitted to the New Hampshire Attorney General. Form 990, Part VI, Section B, line 15 CEO's Compensation: The compensation and benefits of Wentworth-Douglass Hospital's CEO are reviewed, adjusted and voted on by the full Wentworth-Douglass Hospital (WDH) board annually. See WDH's separate Form 990 for further details. Compensation of Key Employees: The WDH CEO reviews the salaries of Wentworth-Douglass Physician Corporation's Key Employees annually and determines compensation based on performance, salary ranges and market competitive data. Compensation data is provided by an independent national consulting firm every other year. Using the Board approved salary range data, the CEO recommends salary increases. Physician salary ranges are established every other year using the Medical Group Management Association (MGMA) published salary survey data. Form 990, Part VI, Section C, line 19 Wentworth-Douglass Physician Corporation (WDPC) files audited financial statements annually with the New Hampshire Attorney General's Charitable Trust Unit and informs the Director of Charitable Trusts of pecuniary benefit transactions that have occurred between the Foundation and a board member or officer. Notices of such transactions of $5,000 or more are also published in the local newspaper in accordance with NH RSA 7:19-a, II(d). Current copies of the Bylaws, Conflict Of Interest Policy and Form 990 are on file with the Charitable Trust Unit. Reportable Compensation from Related Organizations Form 990, Part VII, Section A, Column E The 2011 compensation reported for Gregory Walker, Peter Walcek, and Ellen Caille was paid by Wentworth-Douglass Hospital for their services as full-time executives. Gregory Walker and Peter Walcek each worked an average of 55 hours per week and Ellen Caille 50 hours per week. Of the respective hours worked by each, an average of 2 hours per week was dedicated to Wentworth-Douglass Physician Corporation. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Equity transfer from Wentworth-Douglass Hospital 17,819,989. Total to Form 990, Part XI, Line 5: 17,819,989. Audit Review Process Form 990, Part XII, Line 2c The audit process for WDPC is overseen by the Finance Committee, in conjunction with that for Wentworth-Douglass Hospital. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2010 and 2011. Consolidated financial statements were prepared for 2011. WDPC'S Facilities Form 990, Part III, Line 4a Wentworth-Douglass Physician Corporation does not file a separate annual community benefits report. Rather, Wentworth-Douglass Hospital (WDH) includes WDPC data with its community benefits report that is filed annually with the State of New Hampshire. WDH owns 100% of WDPC, and oversees all of WDPC's primary care and specialty practices, outpatient physician clinics and its dental clinic, which are located as follows: Adult & Children's Medicine, 10 Members Way, Suite 201, Dover, NH Barrington Health Center, 2 Century Pines Drive, Barrington, NH Bellamy Health Center, 15 Old Rollinsford Road, Dover, NH Dover Family Practice, 10 Members Way, Suite 203, Dover, NH Dover Internal and Geriatric Medicine, 10 Members Way, Suite 301, Dover, NH Durham Health Center, 36 Madbury Road, Durham, NH Great Bay Family Practice, 60 Exeter Road, Unit 3, Newmarket, NH Hilltop Family Practice, 85 Main Street, Somersworth, NH Lee Family Practice, 65 Calef Highway, Suite 200, Lee, NH Marshwood Family Care, 19 Levesque Drive, Suite 2, Eliot, ME Primary Care Of Dover, 10 Members Way, Suite 300, Dover, NH South Berwick Family Practice, 31 Colcord Street, South Berwick, ME Strafford Medical Associates, 10 Members Way, Suite 302, Dover, NH Endocrinology & Diabetes, 19 Webb Place, Dover, NH Hospitalists, 789 Central Avenue, Level 2, Dover, NH Palliative Care, 789 Central Avenue, Level 3, Dover, NH Seacoast Arthritis & Osteoporosis, 15 Old Rollinsford Road, Suite 204, Dover, NH Seacoast Pulmonary (Intensivists), 789 Central Avenue, Level 3, Dover, NH Summit Infectious Disease, 15 Old Rollinsford Road, Dover, NH Wentworth Community Dental Care Center, 668 Central Avenue, Dover, NH Seacoast Integrative Medicine, 15 Old Rollinsford Road, Dover, NH Center for Medical Genetics, 17 Old Rollinsford Road, Suite 6, Dover, NH WHP After Hours, 10 Members Way, Suite 203, Dover, NH WHP Cardiovascular Group, 19 Old Rollinsford Road, Dover, NH WHP Thoracic Specialists, 789 Central Avenue, Dover, NH Plastic Surgery Specialists, 10 Members Way, Suite 303, Dover, NH Wentworth-Douglass Hospital 789 Central Avenue Dover NH 03820 020260334 Health care NH 501(c)(3) 170(b)(1) (A)(iii) N/A 0 Wentworth-Douglass Hospital & Health Foundation 789 Central Avenue Dover NH 03820 510491062 Philanthropic fund raising & stewardship NH 501(c)(3) 509(a)(3) N/A 0 Wentworth-Douglass Community Health Corporation 789 Central Avenue Dover NH 03820 020399963 Health fitness center NH N/A C 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 Wentworth-Douglass Hospital C 17819989 Actual per books Wentworth-Douglass Hospital O 284127 Actual per books Wentworth-Douglass Hospital J 2296957 Actual per books