2012-11-14T15:42:29-06:00 2011-12-31 450250958 EIDE BAILLY LLP PO BOX 1914 BISMARCK ND 58502 990 2011-01-01 450226700 MEDCENTER ONE INC MEDC 7013236000 300 NORTH 7TH STREET BISMARCK ND 58501 DR CRAIG LAMBRECHT 7013236000 2012-11-14 1 LISA CHAFFEE CPA P00193453 7012551091 2012-11-14 2011 2016-02-24 21:20:13Z DR CRAIG LAMBRECHT 300 NORTH 7TH STREET BISMARCK ND 58501 327492602 0 X WWW.MEDCENTERONE.COM X 1907 ND COMMITTED TO CARING-ONE LIFE AT A TIME. 32 16 3592 200 1621625 132763 1945656 1091920 278162119 325884492 481269 339133 152184 153091 280741228 327468636 21400 81529 0 0 165107106 186400824 0 0 0 100349209 121932553 265477715 308414906 15263513 19053730 165804928 167774518 85681184 80393032 80123744 87381486 X "COMMITTED TO CARING-ONE LIFE AT A TIME." MEDCENTER ONE IS AN ACCLAIMED LEADER IN DEVELOPING AND PROVIDING SCIENTIFIC AND INNOVATIVE HEALTHCARE. WE ARE RECOGNIZED FOR EASY ACCESS AND COORDINATION OF CARE. A PRIMARY MEASURE OF OUR SUCCESS IS HIGH PATIENT SATISFACTION. WE DRIVE QUALITY THROUGH SYSTEM INTEGRATION AND EFFICIENT UTILIZATION OF RESOURCES. THROUGH THESE EFFORTS PERFORMED BY KNOWLEDGEABLE, SKILLED AND CARING MEDICAL AND ASSOCIATE STAFF, MEDCENTER ONE IS THE REGIONAL HEALTH SYSTEM OF CHOICE. 0 0 242657741 81529 309254743 INTEGRATED HEALTHCARE SYSTEMMEDCENTER ONE IS A FULLY INTEGRATED HEALTHCARE SYSTEM THAT CONSISTS OF SIX PRIMARY CARE CLINICS COVERING WESTERN AND CENTRAL NORTH DAKOTA; A HOME HEALTH/HOSPICE AGENCY, IN- AND OUT-PATIENT REHABILITATION SERVICES, SUB-ACUTE HOSPITAL, IN- AND OUT-PATIENT PSYCHIATRIC SERVICES, TWO URGENT CARE CLINICS, THREE KIDNEY DIALYSIS CENTERS, A MRI CENTER, A WOMEN'S HEATH/FITNESS CENTER, A MULTI-SPECIALTY CLINIC, A COLLEGE OF NURSING AND A HOSPITAL.THE MEDCENTER ONE MAIN CAMPUS IS LOCATED IN BISMARCK, N.D. WITH ADDITIONAL CLINICS IN BISMARCK, DICKINSON, JAMESTOWN, MANDAN, AND MINOT, N.D. MEDCENTER ONE IS COMMITTED TO PROVIDING PROFESSIONAL AND PERSONAL HEALTHCARE. WE FOCUS ON THE RELATIONSHIP BETWEEN THE PHYSICIAN AND THE PATIENT: THE ONE-TO-ONE RELATIONSHIP THAT IS CENTRAL TO OUR PHILOSOPHY OF HEALTHCARE DELIVERY AND MISSION: COMMITTED TO CARING--ONE LIFE AT A TIME. MEDCENTER ONE INCLUDES A 210-BED HOSPITAL, 22-SKILLED NURSING BEDS, AND PRIMARY AND PHYSICIAN MULTI-SPECIALTY CLINIC. MEDCENTER ONE HAS 432 CREDENTIALED PROVIDERS INCLUDING 295 PHYSICIANS. IN 2011, MEDCENTER ONE HAD 10,762 HOSPITAL ADMISSIONS, 771 BIRTHS, 25,948 EMERGENCY DEPARTMENT VISITS, AND 464,219 TOTAL OUTPATIENT VISITS. 9283636 12811000 CHARITY CARE AND CARE UNDER PUBLIC INSURANCE PROGRAMSCHARITY CARE:MEDCENTER ONE'S COMMUNITY CARE BROCHURES ARE AVAILABLE AT EACH REGISTRATION DESK INCLUDING THE EMERGENCY ROOM REGISTRATION AREA. PATIENTS WHO MAY NOT HAVE THE ABILITY TO PAY CAN ALSO MEET DIRECTLY WITH A FINANCIAL COUNSELOR TO DETERMINE WHETHER THEY WILL QUALIFY FOR THE CHARITY CARE PROGRAM. MEDCENTER ONE'S CHARITY CARE POLICY ALLOWS PATIENTS AT 200% FPL TO RECEIVE FREE CARE AND PATIENTS UP TO 275% FPL ARE ELIGIBLE FOR DISCOUNTED CARE. FINANCIAL COUNSELORS ALSO MEET DIRECTLY WITH PATIENTS DURING THEIR IN-PATIENT STAY TO INFORM THEM OF THE CHARITY CARE PROGRAM. THE PROGRAM IS HIGHLIGHTED ON THE MEDCENTER ONE WEBSITE.IN 2011, MEDCENTER ONE PROVIDED $12,811,000 IN CHARITY CARE (CHARGES FOREGONE). MEDCENTER ONE ALSO PROVIDED CARE TO PATIENTS WHO DID NOT PAY THEIR BILL. IN 2011, MEDCENTER ONE PROVIDED $9,283,636 OF CARE IN BAD DEBT. IT IS ESTIMATED THAT 15% OF THE CARE PROVIDED WAS TO PATIENTS WHO WOULD HAVE BEEN ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY . 3358475 2197124 EDUCATION:MEDCENTER ONE PROVIDES LEARNING ENVIRONMENTS AND FINANCIAL SUPPORT FOR MANY PROGRAMS THAT TRAIN HEALTHCARE PROFESSIONALS AND ENSURE ADEQUATE WORKFORCE FOR OUR COMMUNITY IN THE FUTURE.PHYSICIAN/MEDICAL STUDENTS:MEDCENTER ONE CONTRACTED A TOTAL OF $553,835 OF IME PAYMENTS TO THE UNIVERSITY OF NORTH DAKOTA SCHOOL OF MEDICINE AT BISMARCK.STIPEND AGREEMENTS WITH PHYSICIAN RESIDENTS: PHYSICIAN STIPENDS ARE OFFERED TO INDIVIDUALS WHO HAVE COMPLETED MEDICAL SCHOOL, DECLARED A SPECIALTY AND HAVE COMMITTED TO WORKING FOR MEDCENTER ONE FOLLOWING THEIR RESIDENCY OR FELLOWSHIP EXPERIENCES. IN 2011, $491,425 WAS PAID TO PHYSICIAN RESIDENTS TO FURTHER THEIR EDUCATION AS PART OF THIS PROGRAM. 255299852 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 1 0 0 0 0 1 170 0 1 3592 1 1 1 0 0 0 0 0 0 0 0 0 X 32 16 0 1 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X MICHAEL SCHUMACHER CFO 7013236130 300 N 7TH STREET BISMARCK ND 58501 PATRICK DURICK 1.00 X X 0 0 0 DR ALAN VANNORMAN 40.00 X X 688030 0 25513 GERALD WILLER 1.00 X X 0 0 0 DR CRAIG LAMBRECHT 40.00 X X 753997 0 45523 DR GRETCHEN BELZER-CURL 40.00 X 216661 0 26513 DR KIMBER BOYKO 40.00 X 691403 0 54913 DR WILLIAM CANHAM 40.00 X 524569 0 28942 WES ENGBRECHT 1.00 X 0 0 0 DAVE GOODIN 1.00 X 0 0 0 DICK HEDAHL 1.00 X 0 0 0 CLAIRE ANN HOLMBERG 1.00 X 0 0 0 ELLEN HUBER 1.00 X 0 0 0 NILES HUSHKA 1.00 X 0 0 0 PETE JAHNER 1.00 X 0 0 0 LOWELL JENSEN 1.00 X 0 0 0 GEORGE KEISER 1.00 X 0 0 0 JAMES LADUCER 1.00 X 0 0 0 SISTER PAULA LARSON 1.00 X 0 0 0 SUSAN LUNDBERG 1.00 X 0 0 0 DR C KENT MARTIN 40.00 X 304069 0 25088 DR MICHAEL MCINTEE 40.00 X 887511 0 25513 DR CHRISTOPHER MEEKER 40.00 X 438060 0 26671 DR DAVID PENGILLY 40.00 X 365729 0 21429 DR SEAN RUSSELL 40.00 X 719847 0 58106 JON SANSTEAD 1.00 X 0 0 0 GENERAL ROBERT SCHULTE 1.00 X 0 0 0 DR LARRY SKOGEN 1.00 X 0 0 0 DUWAYNE TERNES 1.00 X 0 0 0 DR MICHELLE TINCHER 40.00 X 338320 0 25088 JAMES VOLK 1.00 X 0 0 0 IRENE WENTZ 1.00 X 0 0 0 DR JAMES WHEELER 1.00 X 0 0 0 PAUL MORTH 40.00 X 255052 0 40132 KAREN PAUL 40.00 X 174372 0 21684 JAN KAMPHUIS 40.00 X 227283 0 25871 SCOTT BOEHM 40.00 X 223209 0 33146 DR ANTHONY TELLO 40.00 X 468953 0 25513 JOHN MILLER 40.00 X 277796 0 0 DR DOUGLAS BERGLUND 40.00 X 1185895 0 53120 DR JOHN WATKINS 40.00 X 1243857 0 23720 DR MICHAEL QUAST 40.00 X 1000401 0 59488 DR TED FOGARTY 40.00 X 895059 0 62095 DR TAREK DUFAN 40.00 X 1306051 0 45863 EVY OLSON 40.00 X 133561 0 16434 PAM HOPKINS 40.00 X 129748 0 9611 13449433 0 779976 209 1 1 0 CAPITAL CITY CONSTRUCTION PO BOX 7337 BISMARCK ND 58507 CONSTRUCTION SERVICES 2325328 MCKESSON PO BOX 98347 CHICAGO IL 606938347 TECHNOLOGY SERVICES 1692813 UNITED BLOOD SERVICES PO BOX 53022 PHOENIX AZ 85072 BLOOD PRODUCTS 1181560 WEATHERBY LOCUMS PO BOX 972633 DALLAS TX 753972633 PHYSICIAN SERVICES 1069243 US TRANSCRIPTION INC 1880 RADFORD RD DUBUQUE IA 52002 TRANSCRIPTION SERVICES 885332 50 409929 23875 658116 1091920 NET PATIENT SERVICE RE 621400 305247595 305247595 PHARMACY SALES 446110 10817286 10162750 654536 CONTRACTUAL ANCILLARY 621400 5857614 5857614 EDUCATION REVENUE 611710 817833 817833 CAFETERIA REVENUE 722320 816688 712992 103696 2327476 1464083 863393 325884492 342047 342047 161143 8052 153091 153091 153091 13000 15914 -2914 -2914 -2914 327468636 324262867 1621625 492224 81529 81529 8017074 5423429 2593645 1505744 1210151 295593 149149747 131161642 17988105 5223802 3652103 1571699 12942880 10225453 2717427 9561577 7943334 1618243 411793 411793 121919 121919 19074612 13283625 5790987 870152 1473 868679 59904722 56238238 3666484 2899563 327383 2572180 6114362 4887671 1226691 142078 134759 7319 1274865 970371 304494 894094 894094 8740654 4522521 4218133 3014417 3014417 PROVISION FOR BAD DEBTS 9283636 9283636 EQUIPMENT RENTAL & MAIN 3705519 3417995 287524 REPAIRS AND MAINTENANCE 2870956 2133597 737359 2609211 400942 2208269 308414906 255299852 53115054 0 48330920 40606014 36934689 43490906 4582145 5283555 1697942 2125079 182049841 116312993 56889017 65736848 11719996 4995283 3007761 3502385 2642458 2034448 165804928 167774518 31385217 38531266 704746 508277 16748072 0 446666 344749 6702565 1716982 29693918 39291758 85681184 80393032 X 78703635 86049420 1420109 1332066 80123744 87381486 165804928 167774518 X 19053730 -11795988 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 1 50582 1 8618 0 0 59200 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: MEMBERSHIP DUES TO AHA, NDHA, MGMA FOR WHICH THOSE ORGANIZATIONS SPEND A PORTION ON LOBBYING ACTIVITIES. SOME STAFF TIME TESTIFYING FOR BILLS OR CONTACT WITH STATE LEGISLATORS. 1547510 7038321 8585831 86738553 62895671 23842882 75747961 51789845 23958116 10977496 1627477 9350019 65736848 PENSION PLANS 20358572 ADVANCES FOR STUDENT LOANS 222784 ESTIMATED THIRD PARTY SETTLEMENTS 10148181 DUE TO RELATED PARTIES 136469 CAPITALIZED LEASE OBLIGATION 8425752 39291758 327468636 308414906 19053730 6178 -145198 -11656968 -11795988 7257742 327411612 6178 -63202 -57024 327468636 0 327468636 308351704 0 308351704 63202 63202 308414906 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MCO IS ORGANIZED AS A NORTH DAKOTA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). MCO IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, MCO IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. MCO FILES AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT ITS UNRELATED BUSINESS TAXABLE INCOME. MCO BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. MCO WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. MCO'S FEDERAL FORM 990T FILINGS ARE NO LONGER SUBJECT TO FEDERAL AND STATE TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE 2009. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION-RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -11,568,925. CHANGE IN INTEREST IN NET ASSETS OF MEDCENTER ONE FOUNDATION -88,043. TOTAL TO SCHEDULE D, PART XI, LINE 8: -11,656,968. PART XII, LINE 2D - OTHER ADJUSTMENTS: RELATED PARTY RENTAL EXPENSES RECORDED IN REVENUES FOR FINANCIAL STATEMENTS -63,202. PART XIII, LINE 4B - OTHER ADJUSTMENTS: RELATED PARTY RENTAL EXPENSES RECORDED IN REVENUES FOR FINANCIAL STATEMENTS 63,202. 1 1 X 1 X 1 X 275.000000000000 0 1 1 0 0 8092522 8092522 0.02730 25185039 21869852 3315187 0.01120 33277561 21869852 11407709 0.03850 2104747 956991 1147756 0.00370 39182130 36846520 2335610 0.00790 306168 306168 0.00100 41593045 37803511 3789534 0.01260 74870606 59673363 15197243 0.05110 73577 73577 0.00020 42500 42500 0.00010 116077 116077 0.00030 0 9283636 1485382 74044213 73633732 410481 X 1 1 1 1 MEDCENTER ONE INC

300 N 7TH ST BISMARCK ND 58501

X X X X X MEDCENTER ONE INC 1 1 1 200.000000000000 1 275.000000000000 1 X X X 1 1 X X 1 0 1 X 1 1 22 MCO - Q&R CLINIC

222 N 7TH ST BISMARCK ND 58501

PROVIDER-BASED CLINIC MCO - BONE SPINE SPORTS CLINIC

225 N 7TH ST BISMARCK ND 58501

HOSPITAL OUTPATIENT PHYSICAL THERAPY AND PROVIDER-BASED CLINICS MCO - OP SURGERY CENTER

414 N 7TH ST BISMARCK ND 58501

PROVIDER-BASED CLINICS, PRE-OP AND POST-OP SURGICAL CARE MCO - COLLEGE OF NURSING

512 N 7TH ST BISMARCK ND 58501

COLLEGE OF NURSING AND SUPPORT MCO - BISMARCK FAMILY CLINIC NORTH

2830 N WASHINGTON ST BISMARCK ND 58501

PROVIDER-BASED CLINIC MCO - TOM & FRANCES LEACH DIALYSIS CENTE

201 N 7TH ST BISMARCK ND 58501

OUTPATIENT DIALYSIS SERVICES & SUPPORT SERVICES MCO - DICKINSON CLINIC

938 2ND AVE W DICKINSON ND 58601

AMBULATORY PHYSICIAN OFFICE BASED CLINIC MCO - MRI CENTER

500 E BROADWAY AVE BISMARCK ND 58501

MRI SERVICES FOR INPATIENTS AND OUTPATIENTS MCO - WALK-IN CLINIC NORTH

3318 N 14TH ST BISMARCK ND 58501

PROVIDER-BASED CLINIC MCO - JAMESTOWN CLINIC

300 2ND AVE NE JAMESTOWN ND 58401

AMBULATORY PHYSICIAN OFFICE BASED CLINIC MCO - NORTHBROOK HEARING CENTER

1929 N WASHINGTON ST BISMARCK ND 58501

AUDIOLOGY SERVICES MCO - BISMARCK FAMILY CLINIC SOUTH

1040 TACOMA AVE BISMARCK ND 58504

PROVIDER-BASED CLINIC MCO - WOMEN'S HEALTH CENTER

1100 COLLEGE DRIVE BISMARCK ND 58501

PHYSICAL THERAPY & FITNESS FACILITY MCO - MANDAN FAMILY CLINIC EAST

102 MANDAN AVE MANDAN ND 58554

PROVIDER-BASED CLINIC MCO - MANDAN FAMILY CLINIC NORTH

910 N 18TH ST NW MANDAN ND 58554

PROVIDER-BASED CLINIC & ADMINISTRATIVE SUPPORT FOR HOME HEALTH AND HOSPICE S MCO - OCCUPATIONAL HEALTH CLINIC

1833 EAST BISMARCK EXPRESSWAY BISMARCK ND 58504

EMPLOYER BASED OCCUPATIONAL HEALTH SERVICES & CHIROPRACTIC SERVICES MCO - OCCUPATIONAL HEALTH CLINIC

1531 W VILLARD ST DICKINSON ND 58601

EMPLOYER BASED OCCUPATIONAL HEALTH SERVICES MCO - WALK-IN CLINIC DOWNTOWN

715 E BROADWAY AVE BISMARCK ND 58501

PROVIDER-BASED CLINIC MCO - DIALYSIS - FT YATES

10 N RIVER RD FT YATES ND 58538

OUTPATIENT DIALYSIS SERVICES DIALYSIS - JAMESTOWN

419 5TH ST NE JAMESTOWN ND 58401

OUTPATIENT DIALYSIS SERVICES MCO - OCCUPATIONAL MEDICINE CLINIC

801 21ST AVE SE MINOT ND 58701

EMPLOYER BASED OCCUPATIONAL HEALTH SERVICES MCO - WALK-IN CLINIC MINOT

801 21ST AVE SE MINOT ND 58701

EMPLOYER BASED OCCUPATIONAL HEALTH SERVICES PART I, LINE 3C: MEDCENTER ONE DOES USE THE FPG TO HELP DETERMINE FINANCIAL ASSISTANCE ELIGIBILITY IF THE INFORMATION IS AVAILABLE. HOWEVER, IF AN APPLICATION IS NOT COMPLETED AND THE GUARANTOR/PATIENT HAS A RECOVERY CREDIT SCORE OF 500 OR LESS WITH NO AVAILABLE CREDIT THEY MAY BE ELIGIBLE FOR A DISCOUNT UP TO 100%. THE RECOVERY SCORE IS THE MEASUREMENT OF THE ABILITY OF THE GUARANTOR/PATIENT'S ABILITY TO REPAY CURRENT AND PAST DUE BALANCES. PART I, LINE 7: COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS AS WELL AS CASH AND IN-KIND CONTRIBUTIONS WERE DETERMINED USING ACTUAL COSTS IN THE GENERAL LEDGER OR SPECIFIC DETAIL IN SUBLEDGERS. HEALTH PROFESSIONS EDUCATION WAS DETERMINED USING THE MEDICARE COST REPORT TOTAL COST OF THESE PROGRAMS AND OFFSETTING REIMBURSEMENT FROM THE MEDICARE COST REPORT.THE COST TO CHARGE RATIO USED FOR BAD DEBT, CHARITY CARE, AND PUBLIC PROGRAMS WAS BASED ON THE RATIO OF OPERATING COSTS FOR THE CLINIC AND HOSPITAL OPERATIONS BASED ON THE 2011 AUDITED FINANCIAL STATEMENTS DIVIDED BY THE GROSS PATIENT CHARGES POSTED DURING THE YEAR TO OUR FOUR PATIENT ACCOUNT RECEIVABLE SYSTEMS FOR THE HOSPITAL, CLINIC, HOME HEALTH, AND OCCUPATIONAL HEALTH. OPERATING COSTS WERE REDUCED BY NON-OPERATING REVENUE AND THE COMMUNITY HEALTH IMPROVEMENT, COMMUNITY BENEFIT OPERATIONS, AND HEALTH PROFESSIONAL EDUCATION COSTS REPORTED ABOVE.THE COSTS AND NET PATIENT CARE REVENUES ASSOCIATED WITH SUBSIDIZED HEALTH SERVICES WERE CALCULATED BASED ON A STUDY OF INPATIENT AND OUTPATIENT (INCLUDING CLINIC SERVICES) COSTS AND REIMBURSEMENTS ATTRIBUTED TO THE PERFORMING OR ATTENDING PHYSICIAN AT THE PATIENT ACCOUNT LEVEL. PHYSICIANS AND NON-PHYSICIAN PROVIDERS WERE CATEGORIZED INTO SERVICE CATEGORIES, I.E. INFECTIOUS DISEASE, BASED ON THEIR PRIMARY SPECIALTY AREA.DIRECT PATIENT CARE COSTS FOR HOSPITAL INPATIENT AND OUTPATIENT CARE WERE ALLOCATED TO THE PHYSICIAN BASED ON SEPARATE COST TO CHARGE RATIOS FOR SUPPLY AND NON-SUPPLY CHARGES ON THE PATIENT ACCOUNT. OVERHEAD COSTS WERE STEPPED DOWN TO THE REVENUE PRODUCING DEPARTMENTS BASED ON THE STATISTICS USED FOR THE MEDICARE COST REPORT.DIRECT PATIENT CARE COSTS FOR PHYSICIAN CLINIC SERVICES ARE MAINTAINED IN THE PHYSICIANS COST CENTER IN THE GENERAL LEDGER. DEPARTMENTAL EXPENSES WERE ALLOCATED TO THE INDIVIDUAL PHYSICIANS BASED ON VARIOUS STATISTICS DEPENDING ON THE TYPE OF EXPENSE. STATISTICS USED INCLUDED CLINIC VISITS, WORK RVU'S, MALPRACTICE RVU'S, LINES TRANSCRIBED, FTE STATUS, AND SALARY EXPENSE. OVERHEAD EXPENSES WERE ALSO ALLOCATED TO THE INDIVIDUAL PHYSICIANS BASED ON THESE STATISTICS.OFFSETTING INPATIENT AND OUTPATIENT PATIENT CARE REVENUE WERE THOSE REIMBURSEMENTS FOR THE ACCOUNT ATTRIBUTED TO THE ATTENDING PHYSICIAN. OFFSETTING PROFESSIONAL REIMBURSEMENTS WERE THOSE REIMBURSEMENTS FOR WHICH THE PHYSICIAN OR NON-PHYSICIAN PROVIDER WAS THE BILLING PROVIDER. PART I, LINE 7G: THE ORGANIZATION INCLUDED $15,171,099 OF COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS AS PART OF SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX, LINE 25, COLUMN (A) OF $9,283,636 WAS REMOVED FROM THE DENOMINATOR PRIOR TO THE CALCULATION. PART II: COMMUNITY SUPPORT:MEDCENTER ONE OPERATES THE DAKOTA CHILDREN'S ADVOCACY CENTER, WHICH IS A PROGRAM THAT IS COMMITTED TO IMPROVING THE RESPONSE TO CHILD ABUSE. THE ADVOCACY CENTER IS A COMMUNITY PARTNERSHIP THAT UTILIZES A COMPREHENSIVE MULTIDISCIPLINARY TEAM APPROACH TO INVESTIGATING CHILD ABUSE. PROFESSIONALS FROM SOCIAL SERVICES, LAW ENFORCEMENT, PROSECUTION, VICTIM ADVOCACY AND THE MEDICAL AND MENTAL HEALTH COMMUNITIES COME TOGETHER UNDER ONE ROOF, SO THAT A CHILD ONLY HAS TO TELL OF HIS OR HER ABUSE ONE TIME.MEDCENTER ONE STAFF MEMBERS ALSO PARTICIPATE ON LOCAL VIOLENCE PREVENTION COUNCILS, PROMOTE AND TRAIN COMMUNITY MEMBERS IN SELF-DEFENSE AND WORK CLOSELY WITH LOCAL LAW ENFORCEMENT TO ENSURE VICTIM RIGHTS. COALITION BUILDING:MEDCENTER ONE IS ACTIVE IN THE LOCAL CHAMBER OF COMMERCE, NORTH DAKOTA CHAMBER OF COMMERCE, BISMARCK-MANDAN DEVELOPMENT ASSOCIATION, YMCA, NORTH DAKOTA DEPARTMENT OF HEALTH PROGRAMS, UNIVERSITY OF NORTH DAKOTA MEDICAL SCHOOL, LOCAL AND STATEWIDE DISASTER AND FLU RESPONSE PLANNING, BIS-MAN TRANSIT AND OTHER HEALTH ADVISORY COUNCILS.MEDCENTER ONE IS THE LOCAL MEALS ON WHEELS PROVIDER AND IS ACTIVE ON ITS BOARD OF DIRECTORS.DISASTER READINESS: MEDCENTER ONE TAKES DISASTER READINESS VERY SERIOUSLY AND HAS RESPONDED TO THIS CALL BEYOND WHAT IS REQUIRED FOR LICENSURE. OUR STAFF ACTIVELY PARTICIPATES IN LOCAL, REGIONAL AND STATEWIDE READINESS PLANNING AND ACTIVITIES. WE HAVE MADE THE FOLLOWING CHANGES RELATED TO PROSPECTIVE DISASTERS: * PROVIDED MAN HOURS FOR EMERGENCY PLANNING * IMPROVED LOCKDOWN CAPABILITIES, ENHANCED SECURITY MEASURES * ADDED DISASTER-RELATED COMMUNICATION EQUIPMENT * PURCHASED ADDITIONAL PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR STOCKPILES * PARTICIPATED IN COMMUNITY PREPAREDNESS DRILLS AND EXERCISES * PURCHASED MEDICAL, SURGICAL AND PHARMACEUTICAL SUPPLIES * CONDUCTED SPECIALIZED EMERGENCY TRAINING FOR STAFF * VOLUNTEERED STORAGE SPACE FOR STATEWIDE STOCKPILED SUPPLIESCOMMUNITY HEALTH IMPROVEMENT ADVOCACY:MEDCENTER ONE WORKS WITH THE NORTH DAKOTA DEPARTMENT OF HEALTH, NORTH DAKOTA RURAL HEALTHCARE ASSOCIATION, NORTH DAKOTA NURSES ASSOCIATION, NORTH DAKOTA MEDICAL ASSOCIATION AND OTHER NORTH DAKOTA HEALTH ADVOCACY GROUPS TO IMPACT PUBLIC POLICY TO IMPROVE THE HEALTH OF THE COMMUNITY. MEDCENTER ONE WILL ALSO PROVIDE VOUCHERS AND FINANCIAL ASSISTANCE TO LOW-INCOME FAMILIES FOR TRANSPORTATION AND LODGING EXPENSE TO FACILITATE MEDICAL TREATMENT AND SAFE TRAVEL CONDITIONS HOME WHEN NECESSARY.DUE TO SMALL OPERATING MARGINS, MEDCENTER ONE HAS LIMITED REINVESTMENT EVEN IN ITS OWN PLANT AND EQUIPMENT. THE AVERAGE AGE OF PLANT FOR MEDCENTER ONE IS 17.1 YEARS AS COMPARED TO 11.93 FOR NORTH DAKOTA HOSPITALS. THIS REDUCED MARGIN HAS ALSO LIMITED FINANCIAL SUPPORT OF COMMUNITY BUILDING ACTIVITIES OVER THE LAST 10 YEARS.OTHERMEDCENTER ONE IS LEASING LAND WITH A FAIR MARKET VALUE OF $768,000 TO UND FAMILY PRACTICE CENTER (UND FPC). UND FPC IS CONSTRUCTING, AND WILL OWN, A BUILDING ON THE LAND. THE LEASE IS FOR 50 YEARS WITH A TOTAL LEASE PAYMENT OF $1.00. THE LAND SIZE IS LOTS 1-24 OF BLOCK 98, WHICH EQUALS 34,000 SQUARE FEET. USING A COMPARATIVE LEASE VALUE FOR SIMILAR LAND IN THE THE LOCAL BISMARCK MARKET THE COMPARATIVE LEASE VALUE EQUALED $42,500 FOR THE ANNUAL LEASE THAT MEDCENTER ONE IS PROVIDING TO UND FPC. PART III, LINE 4: MEDCENTER ONE POSTS PAYMENTS AND DISCOUNTS TO INDIVIDUAL PATIENT ACCOUNTS. FOR EVERY PATIENT ACCOUNT, A GUARANTOR OR FINANCIALLY RESPONSIBLE PARTY IS DETERMINED. ACCOUNTS WITH THE SAME GUARANTOR ARE AGGREGATED WHEN DETERMINING BAD DEBT EXPENSE.WORKSHEET 2 WAS USED TO DETERMINE LINE 2.TO DETERMINE IF THE AMOUNT OF BAD DEBT EXPENSE THAT WE REASONABLY BELIEVE WOULD QUALIFY AS CHARITY CARE IF WE HAD RECEIVED THE PROPER DOCUMENTATION, WE PERFORMED THE FOLLOWING CALCULATION. FOR ACCOUNTS SENT TO COLLECTION AGENCY AND THEREFORE INITIALLY DETERMINED TO BE BAD DEBT, WE CALCULATED THE RATIO OF THE COLLECTION AGENCY'S AVERAGE COLLECTION RECOVERY PERCENTAGE AND THE NUMBER OF ACCOUNTS WITH PAYMENT ARRANGEMENTS AND/OR IN LEGAL COMPARED TO THE TOTAL. ACCOUNTS WITHOUT RECOVERY OR WITHOUT PAYMENT ARRANGEMENTS WE FELT WOULD HAVE QUALIFIED FOR COMMUNITY CARE. ALSO FACTORED IN WAS THE INCREASE OF BAD DEBT WRITE OFFS OF 8%. SO FOR 2011 THE ESTIMATE OF THE PERCENTAGE OF BAD DEBT THAT COULD HAVE BEEN CLASSIFIED AS CHARITY CARE IS 16%. THIS 16% WAS APPLIED TO LINE 2 TO CALCULATE LINE 3.FOOTNOTE TO FINANCIAL STATEMENTS:PATIENT RECEIVABLES ARE UNCOLLATERALIZED PATIENT AND THIRD-PARTY PAYOR OBLIGATIONS. PAYMENTS OF PATIENT RECEIVABLES ARE ALLOCATED TO THE SPECIFIC CLAIMS IDENTIFIED ON THE REMITTANCE ADVICE OR, IF UNSPECIFIED, ARE APPLIED TO THE EARLIEST UNPAID CLAIM.THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. PART III, LINE 8: MEDICARE COST REPORT STEP-DOWN METHODOLOGY RESULTING IN COST TO CHARGE RATIO APPLIED TO APPROPRIATE REVENUE CODES. PART III, LINE 9B: STATEMENTS FOR PATIENT BALANCES DUE ARE SENT TO PATIENTS ON A MONTHLY BASIS. IF THE INDIVIDUAL CONTACTS MEDCENTER ONE AND PROVIDES INFORMATION THAT THEY ARE ELIGIBLE FOR CHARITY CARE, THE ACCOUNT BALANCE IS WRITTEN OFF IMMEDIATELY AND NO FURTHER COLLECTION ACTION IS TAKEN. IF THE ACCOUNT WAS ALREADY TURNED OVER TO A THIRD PARTY COLLECTION AGENCY, THE AGENCY IS NOTIFIED, THE ACCOUNT IS WRITTEN OFF AND NO FURTHER COLLECTION ACTION IS TAKEN. PATIENT CONTACT AND COMMUNICATION IS RECORDED IN THE PATIENT ACCOUNTING SYSTEM FOR CUSTOMER ACCOUNT REPRESENTATIVES AND COLLECTION REPRESENTATIVES TO VIEW AND KEEP CURRENT. MEDCENTER ONE, INC. PART V, SECTION B, LINE 11H: CREDIT SCORING IS ALSO USED AS A TOOL IN THE ASSESSMENT. IF A PATIENT IS UNABLE TO PAY FOR SERVICES AND HAS A CREDIT SCORE OF LESS THAN 500 THE BALANCE IS WRITTEN OFF TO CHARITY CARE AND NO ADDITIONAL COLLECTION EFFORTS ARE TAKEN. MEDCENTER ONE, INC. PART V, SECTION B, LINE 13G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS PROVIDED IN THE EMERGENCY ROOM AND THE WAITING ROOMS. MEDCENTER ONE, INC. PART V, SECTION B, LINE 19D: THE HOSPITAL OFFERS A 10% DISCOUNT TO SELF-PAY PATIENTS. THE HOSPITAL BILLING POLICY IS PAYMENT IN FULL IN 30 DAYS OR THE BALANCE PAID IN FULL IN FOUR EQUAL INSTALLMENTS OVER 4 MONTHS. IF A PATIENT IS UNABLE TO MEET THESE BILLING GUIDELINES THEY CAN CONTACT THE FACILITY FOR ALTERNATIVE PAYMENT OPTIONS. THE HOSPITAL CURRENTLY APPLIES THE FINANCIAL ASSISTANCE POLICY DISCOUNT DIRECTLY TO GROSS CHARGES FOR THOSE THAT DO NOT HAVE INSURANCE.ALTHOUGH THE FACILITY IS NOT CURRENTLY USING ONE OF THE TWO IRS APPROVED METHODOLOGIES THEY ARE WORKING ON DEVELOPING THEIR POLICIES TO ENSURE THEY ARE IN COMPLIANCE WITH IRS REQUIREMENTS. MEDCENTER ONE, INC. PART V, SECTION B, LINE 20: THE HOSPITAL CURRENTLY APPLIES THEIR FINANCIAL ASSISTANCE DISCOUNT PERCENTAGE DIRECTLY TO THE GROSS CHARGES FOR AN EMERGENCY OR MEDICALLY NECESSARY SERVICE THAT WAS PROVIDED TO ELIGIBLE PATIENTS UNDER THEIR FINANCIAL ASSISTANCE POLICY. MEDCENTER ONE, INC. PART V, SECTION B, LINE 21: THE HOSPITAL CURRENTLY APPLIES THEIR FINANCIAL ASSISTANCE DISCOUNT PERCENTAGE DIRECTLY TO THE GROSS CHARGES FOR ANY SERVICE THAT WAS PROVIDED TO ELIGIBLE PATIENTS UNDER THEIR FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: MEDCENTER ONE EMPLOYS A VARIETY OF TOOLS AND VEHICLES TO ASSESS THE HEALTHCARE NEEDS OF THE COMMUNITIES IT SERVES. MEDCENTER ONE'S BOARD OF DIRECTORS AND STRATEGIC PLANNING COMMITTEE CONTINUALLY REVIEW THE ORGANIZATION'S SUBSIDIZED PROGRAMS AND THE NEEDS OF THE COMMUNITY. INFORMATION IS GATHERED FROM MEDCENTER ONE DATA AS WELL AS EXTERNAL DATA SOURCES INCLUDING NORTH DAKOTA DEPARTMENT OF HEALTH, NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES, NORTH DAKOTA COURTS AND LAW ENFORCEMENT, NORTH DAKOTA STATE DATA CENTER, NORTH DAKOTA VITAL STATISTICS, NORTH DAKOTA CENTER FOR RURAL HEALTH, UNITED WAY, UNITED STATES CENSUS BUREAU AND THE CENTERS FOR DISEASE CONTROL AND PREVENTION. DATA FROM EACH AGENCY IS USED TO DETERMINE THE HEALTHCARE-RELATED NEEDS AND CHANGES IN THE COMMUNITY. INFORMATION FROM THESE VARIOUS SOURCES IS COMPILED AND SHARED WITH THE SENIOR MANAGEMENT TEAM AND THE STRATEGIC PLANNING COMMITTEE. THE SENIOR MANAGEMENT TEAM REVIEWS THE VOLUME OF SERVICES PROVIDED TO DETERMINE IF THERE ARE CHANGES IN VOLUME THAT IMPACT ACCESS. TO ENSURE ACCESS TO HEALTHCARE SERVICES THAT EXPERIENCE INCREASED DEMAND, MEDCENTER ONE STRIVES TO ADD NEW ACCESS POINTS AND INCREASED STAFFING. PART VI, LINE 3: THE MEDCENTER ONE COMMUNITY CARE BROCHURES ARE DISTRIBUTED AT EACH MEDCENTER ONE REGISTRATION DESK INCLUDING THE EMERGENCY AND TRAUMA CENTER REGISTRATION AREA. PATIENTS WHO MAY NOT HAVE THE ABILITY TO PAY MAY ALSO MEET DIRECTLY WITH A FINANCIAL COUNSELOR TO DETERMINE WHETHER THEY WILL QUALIFY FOR THE CHARITY CARE PROGRAM. ADDITIONALLY, FINANCIAL COUNSELORS MEET DIRECTLY WITH PATIENTS DURING THEIR IN-PATIENT STAY TO INFORM THEM OF THE CHARITY CARE PROGRAM. AN ONLINE CREDIT SCORING PROCESS INITIATED IN 2010 TO DETERMINE ELIGIBILITY HAS ALLOWED MEDCENTER ONE TO BETTER CAPTURE ELIGIBLE CHARGES THAT PATIENTS ARE UNABLE TO PAY. INTAKE AND FINANCIAL STAFF ALSO DISCUSS THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS SUCH AS MEDICAID, SCHIP AND STATE HIGH-RISK INSURANCE PROGRAMS. MEDCENTER ONE CONTRACTS WITH AN EXTERNAL AGENCY TO PROVIDE ASSISTANCE FOR PATIENTS WHEN COMPLETING ELIGIBILITY FORMS; THIS SERVICE HELPS LOW-INCOME PATIENTS QUALIFY FOR GOVERNMENT MEDICAL AID PROGRAMS, A PROCESS WHICH IS OFTEN TIMES INTIMIDATING TO PATIENTS. PART VI, LINE 4: POPULATION SERVED: MEDCENTER ONE SERVES RESIDENTS OF CENTRAL AND WESTERN NORTH DAKOTA. THE SERVICE AREA IS APPROXIMATELY 60 PERCENT OF THE 68,976 SQUARE MILES OF THE STATE'S GEOGRAPHIC AREA. THE SERVICE AREA INCLUDES 35 COUNTIES OF WHICH 28 HAVE A FRONTIER DESIGNATION (LESS THAN 6 PEOPLE PER SQUARE MILE). THE POPULATION IS 90.4 PERCENT WHITE, 5.5 PERCENT NATIVE AMERICAN, 2.2 PERCENT HISPANIC OR LATINO, 1.3 PERCENT BLACK AND 1.1 PERCENT ASIAN (NOTE: SOME PEOPLE SELECTED MORE THAN ONE RACE.) THE LEADING CAUSES OF DEATH ARE HEART DISEASE AND CANCER. NATIVE AMERICANS EXPERIENCE HEALTH DISPARITIES ESPECIALLY RELATED TO DIABETES, OBESITY AND SUBSTANCE ABUSE. ACCORDING TO COUNTY-SPECIFIC DATA AVAILABLE THROUGH THE NORTH DAKOTA DATA CENSUS CENTER, THE POPULATION IN MEDCENTER ONE'S PRIMARY SERVICE AREA EXPERIENCED MODEST GROWTH IN 2011, JUMPING 1.7 PERCENT FROM 672,591 IN 2010 TO 683,932 IN 2011. CENSUS DATA, HOWEVER, DOES NOT ACCOUNT FOR THE THOUSANDS OF WORKERS MIGRATING TO WESTERN NORTH DAKOTA AS A RESULT OF THE STATE'S GROWING ENERGY INDUSTRY. POPULATION ESTIMATES PROVIDED BY COMMUNITY LEADERS IN OIL-PRODUCING COMMUNITIES SUGGEST POPULATIONS HAVE GROWN FAR BEYOND U.S. CENSUS ESTIMATES. FOR EXAMPLE, WHILE U.S. CENSUS DATA ESTIMATES THE POPULATION OF DICKINSON, N.D. TO BE 18,499 (A THREE PERCENT INCREASE FROM 2010'S 17,897 RESIDENTS) CITY LEADERS ESTIMATE THE POPULATION ACTUALLY TOPPED 22,000 IN 2011. POPULATIONS IN WESTERN NORTH DAKOTA'S HUB HEALTH CARE COMMUNITIES-WILLISTON, DICKINSON, WATFORD CITY AND MINOT-ARE PROJECTED TO INCREASE BY NEARLY 60 PERCENT BETWEEN NOW AND 2020. COLLECTIVELY, THESE FOUR COMMUNITIES ARE ESTIMATED TO HAVE NEARLY 100,000 RESIDENTS (TEMPORARY HOUSING INCLUDED); CITY PLANNERS ESTIMATE THAT NUMBER WILL JUMP TO 155,000 RESIDENTS BY 2020.MIGRATION TO URBAN AREAS, LOSS OF POPULATION IN RURAL AREAS: UP UNTIL 2010, THE TREND IN NORTH DAKOTA WAS LARGELY MIGRATION FROM SMALLER COMMUNITIES TO THE STATE'S URBAN CENTERS. THIS TREND CONTINUES THROUGHOUT THE STATE WITH THE EXCEPTION OF WESTERN NORTH DAKOTA'S OIL PRODUCING COUNTIES. THESE COUNTIES HAVE EXPERIENCED UNPRECEDENTED GROWTH IN THE LAST YEAR AND ARE PROJECTED TO CONTINUE GROWING FOR ANOTHER 10-20 YEARS. THE DOMINO IMPACT ON BISMARCK-BASED SERVICES IS INCREASED LIMITATIONS ON ACCESS TO PRIMARY CARE AND HOSPITAL SERVICES. AGE: THE NORTH DAKOTA DATA CENSUS CENTER POPULATION ESTIMATES SHOW AN AGING OF THE POPULATION IN MEDCENTER ONE'S SERVICE AREA. FROM 2005 TO 2020, IT IS ESTIMATED THAT THE MEDCENTER ONE SERVICE AREA WILL SEE A DECREASE OF 12 PERCENT IN THE NUMBER OF RESIDENTS AGE ZERO TO 64 AND A 32 PERCENT INCREASE IN THOSE PEOPLE 65 YEARS OF AGE AND OLDER. NORTH DAKOTA'S 65-AND-OVER POPULATION GREW TO 14.5 PERCENT IN 2011. THIS SHIFTING HAS A SIGNIFICANT IMPACT ON THE HEALTHCARE NEEDS OF THE POPULATION. IT IS ANTICIPATED THAT THE TYPES OF SERVICES AND THE VOLUME OF SERVICES REQUIRED BY THE POPULATION WILL CHANGE WITH THE AGING OF THE ELDERLY PATIENTS EXPERIENCE MORE HEALTHCARE ISSUES AND HAVE STATISTICALLY HIGHER HEALTHCARE SPENDING THAN OTHER AGE CATEGORIES. WHEN AGE CATEGORIES ARE COMPARED IN A RELATIVE SPENDING GRID, PEOPLE AGES 0-24 HAVE A RELATIVE SPENDING OF 0.5, WHEREAS, ELDERLY AGED 75 YEARS AND OLDER HAVE A RELATIVE SPENDING OF 5.5. SO AS A POPULATION AGES, THERE IS A STATISTICALLY SIGNIFICANT INCREASE IN THE AMOUNT OF HEALTHCARE SERVICES DEMANDED, INCLUDING INTENSIVE CARE SERVICES.RACE: NATIVE AMERICANS COMPRISE 4.5 PERCENT OF THE POPULATION OF NORTH DAKOTA, BUT MEDCENTER ONE HAS A HIGHER PERCENT OF HOSPITALIZED PATIENTS FROM THE NATIVE AMERICAN RACE THAN IS SEEN IN THE GENERAL POPULATION. BECAUSE NATIVE AMERICANS EXPERIENCE HEALTH DISPARITIES, THIS RACE MAKES UP MORE THAN 15 PERCENT OF MEDCENTER ONE'S INPATIENT STAYS AND ICU ADMISSIONS.SOCIO-ECONOMIC STATUS: THE SOCIOECONOMIC STATUS OF THE SERVICE AREA WAS POSITIVELY IMPACTED BY THE WESTERN NORTH DAKOTA ENERGY INDUSTRY. ACCORDING TO DATA FROM THE U.S. CENSUS BUREAU, THE MEDIAN ANNUAL INCOME IN NORTH DAKOTA IN 2011 WAS $53,827, UP FROM $51,005 IN 2010. FOURTEEN PERCENT OF NORTH DAKOTA RESIDENTS LIVE BELOW THE FEDERAL POVERTY LEVEL (FPL); AN ADDITIONAL FIVE PERCENT HAVE INCOMES THAT FALL BELOW THE 138 PERCENT FPL. INSURANCE COVERAGE:STATEWIDE, IT IS ESTIMATED THAT 55 PERCENT OF NORTH DAKOTANS HAVE EMPLOYER-PROVIDED HEALTH INSURANCE COVERAGE, 14 PERCENT HAVE MEDICARE, 9 PERCENT HAVE MEDICAID, 9 PERCENT HAVE INDIVIDUAL PRIVATE INSURANCE, 1 PERCENT HAVE OTHER PUBLIC-PROVIDED INSURANCE AND 11 PERCENT ARE UNINSURED. PAYER MIX:THE LARGEST SEGMENT OF MEDCENTER ONE'S PAYER MIX IS MEDICARE WITH 40.6 PERCENT, BLUE CROSS BLUE SHIELD IS AT 33.6 PERCENT AND COMMERCIAL AND OTHER GOVERNMENTAL PAYERS (WORKFORCE SAFETY AND INSURANCE, CHAMPUS-NORTH DAKOTA HIGH RISK INSURANCE PROGRAM, AND PUBLIC HEALTH SYSTEM) AT 12.9 PERCENT. MEDICAID MAKES UP 8.5 PERCENT, AND SELF-PAY ACCOUNTS FOR ONLY 4.4 PERCENT.PRESENCE OF FEDERALLY-DESIGNATATED UNDERSERVED AREAS: ALL BUT THREE COUNTIES IN MEDCENTER ONE'S SERVICE AREA ARE DESIGNATED AS HEALTH PROFESSIONAL SHORTAGE AREAS (HPSAS). THE ONLY AREAS NOT DESIGNATED AS HPSAS ARE PARTS OF MORTON AND BURLEIGH COUNTIES-WHERE THE MEDCENTER ONE HUB RESIDES-AND PORTIONS OF STUTSMAN COUNTY. PRIMARY CARE PHYSICIANS ARE IN SHORT SUPPLY THROUGHOUT THE STATE; SPECIALTY CARE PHYSICIANS INCLUDING PSYCHIATRISTS, UROLOGISTS AND NEUROLOGISTS ARE IN SHORT SUPPLY ACROSS THE STATE INCLUDING THE COMMUNITIES WITH THE STATE'S LARGEST HEALTHCARE SYSTEMS.OTHER HOSPITALS:THERE IS ONLY ONE OTHER LEVEL II TRAUMA CENTER THAT SERVES THE SAME SERVICE AREA. MEDCENTER ONE AND THE OTHER FACILITY SERVE AS TERTIARY CARE CENTERS FOR 13 CRITICAL ACCESS HOSPITALS IN THE SERVICE AREA. PART VI, LINE 5: MEDCENTER ONE FURTHERS ITS EXEMPT STATUS PURPOSE BY WORKING TO PROMOTE THE HEALTH AND WELL-BEING OF THE PATIENTS IT SERVES. MEDCENTER ONE'S BROAD BASED, VOLUNTEER BOARD OF DIRECTORS CONSISTS OF 32 MEMBERS. MEMBERSHIP INCLUDES 11 EMPLOYEES (THE MEDCENTER ONE CEO AND 10 PHYSICIANS) AND 21 COMMUNITY MEMBERS WHO ARE NOT EMPLOYED BY MEDCENTER ONE. ALL 32 BOARD MEMBERS RESIDE IN THE MEDCENTER ONE SERVICE AREA. THE BOARD'S SIZE, DIVERSITY AND GEOGRAPHIC REPRESENTATION ENABLE MEDCENTER ONE TO STAY IN TOUCH WITH THE NEEDS OF THE VAST SERVICE AREA. THE VOLUNTEER BOARD IS ALSO EFFECTIVE IN MONITORING THE CHANGING NEEDS OF THE POPULATION AND WORKING TO ENSURE THAT HEALTH NEEDS ARE MET. MEDCENTER ONE REINVESTS ANY PROFIT BACK INTO THE CORPORATION, SO MEDCENTER ONE CAN CONTINUE TO PROVIDE THE HIGHEST QUALITY AND BROADEST ARRAY OF SERVICES AVAILABLE IN WESTERN AND CENTRAL NORTH DAKOTA.SAFETY NET SERVICES PROVIDED BY MEDCENTER ONE INCLUDE: -LEVEL II TRAUMA SERVICES AND EMERGENCY CARE-NEONATAL INTENSIVE CARE UNIT-ONLY PEDIATRIC INTENSIVE CARE UNIT AND ONCOLOGY SERVICES IN WESTERN NORTH DAKOTA-CHILDREN'S ADVOCACY CENTER-HOME CARE/HOSPICE-KIDNEY DIALYSIS (3 SITES)-ONLY KIDNEY TRANSPLANT PROGRAM IN WESTERN NORTH DAKOTA-MENTAL HEALTH (OUTPATIENT AND INPATIENT)-COLLEGE OF NURSING-OUTPATIENT AUDIOLOGY-DIABETES CARE-REHABILITATION SERVICES-WOUND CARE SERVICESMANY OF THE SAFETY NET SERVICES LISTED ABOVE NEED TO BE SUBSIDIZED TO CONTINUE THEIR EXISTENCE. SUBSIDIZED HEALTH SERVICES THAT ARE A SUBSTANTIAL COST TO MEDCENTER ONE INCLUDE: NEPHROLOGY/DIABETES CARE CENTER, MENTAL HEALTH, TRAUMA AND CRITICAL CARE SERVICES, ACUTE REHABILITATION, INFECTIOUS DISEASE, AND WOUND CARE.NURSING/NURSING STUDENTS:MEDCENTER ONE COLLEGE OF NURSING: MEDCENTER ONE WAS ONE OF THE FIRST HEALTHCARE ORGANIZATIONS IN THE COUNTRY TO OPERATE A SINGLE PURPOSE SCHOOL. IT HAS OWNED, OPERATED AND FINANCIALLY SUPPORTED ITS OWN COLLEGE OF NURSING SINCE 1908. MEDCENTER ONE'S COLLEGE OF NURSING IS A FULLY ACCREDITED, UPPER-DIVISION INSTITUTION AWARDING ITS GRADUATES A FOUR-YEAR BACHELOR OF SCIENCE DEGREE IN NURSING. FORTY-THREE STUDENTS GRADUATED FROM THE MEDCENTER ONE COLLEGE OF NURSING IN SPRING 2011. THE NET COST OF THIS PROGRAM IN 2011 WAS $1.3 MILLION. OTHER HEALTH PROFESSION EDUCATION:RADIOLOGIC TECHNOLOGY PROGRAM SUBSIDY: MEDCENTER ONE OPERATES A SCHOOL OF RADIOGRAPHY. THE NET LOSS OF THIS PROGRAM IS ESTIMATED AT $73,739 IN 2011. PROFESSIONAL HEALTHCARE TRAINING: MEDCENTER ONE SUPPORTS MEDICAL EDUCATION PROGRAMS FOR PHARMACISTS, RADIOLOGISTS AND LABORATORY TECHNICIANS. MEDCENTER ONE WORKS IN COORDINATION WITH OTHER STATE INSTITUTIONS TO OFFER LABORATORY TRAINING FOR NORTH DAKOTA STUDENTS. MEDCENTER ONE HAS MANY CLINICAL AFFILIATION AGREEMENTS WITH ND COLLEGES/UNIVERSITIES AND SEVERAL AGREEMENTS WITH OUT-OF-STATE PROGRAMS. EMERGENCY MEDICAL SERVICES (EMS) EDUCATION: MEDCENTER ONE EMS EDUCATION IS RESPONSIBLE FOR TRAINING EMERGENCY PERSONNEL FROM WESTERN AND CENTRAL NORTH DAKOTA. CLASSES IN CPR (CERTIFICATION AND RECERTIFICATION), USE OF AUTOMATIC EXTERNAL DEFIBRILLATORS (AED), FIRST AID, PEDIATRIC FIRST AID, ADVANCED CARDIAC LIFE SUPPORT, PEDIATRIC ADVANCED LIFE SUPPORT, AMERICAN HEART ASSOCIATION INSTRUCTOR, FIRST RESPONDER, EMERGENCY MEDICAL TECHNICIAN-BASIC/INTERMEDIATE, PARAMEDIC, INTERNATIONAL TRAUMA LIFE SUPPORT, NEBULIZER AND EPI-PEN TRAINING ARE OFFERED. COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, DONATIONS/SPONSORSHIPS AND IN-KIND SUPPORTHEALTH INFORMATION AND SCREENING PROGRAMS ARE PROMOTED THROUGH A MONTHLY PUBLICATION SENT TO 150,000 HOUSEHOLDS WITHIN MEDCENTER ONE'S COMMUNITY AREA. THE PUBLICATION INCLUDES A CALENDAR THAT HIGHLIGHTS HEALTH INFORMATION AND SCREENING PROGRAMS AVAILABLE FOR THE COMING MONTH AND FEATURE STORIES THAT FOCUS ON NEW TREATMENTS AVAILABLE IN OUR SERVICE AREA. MEDCENTER ONE ALSO PRODUCES AND DISTRIBUTES TRAUMA TIMES TO SERVICE AREA EMERGENCY PERSONNEL AND CRITICAL ACCESS HOSPITAL STAFF YEARLY. HEALTH PROMOTIONAL EVENTS SUCH AS PRESENTATIONS, HEALTH FAIRS AND EDUCATIONAL EVENTS ARE OFFERED ON A REGULAR BASIS. ONE PROGRAM CALLED DOC TALK FEATURES A FREE EDUCATIONAL SESSION FOR THE GENERAL PUBLIC LED BY A MEDCENTER ONE PHYSICIAN. PARTICIPANTS ARE ENCOURAGED TO ASK HEALTH QUESTIONS FOLLOWING THE PRESENTATION. IN 2011, MEDCENTER ONE HOSTED 10 DOC TALKS WITH A TOTAL OF 415 COMMUNITY MEMBERS IN ATTENDANCE. OTHER HEALTH EDUCATIONAL EVENTS AND CLASSES HIGHLIGHT TOPICS SUCH AS PREPARED CHILDBIRTH, SIBLING ADJUSTMENT, BREASTFEEDING, INFANT MASSAGE AND NURTURING. SOME OF THE CLASSES CHARGE A NOMINAL FEE FOR PARTICIPATION.SUPPORT GROUPS: MEDCENTER ONE SPONSORS SUPPORT GROUPS WITH A DONATION OF SPACE AND/OR LEADERSHIP. MEDCENTER ONE OFFERS SEVERAL SUPPORT GROUPS FOR PATIENTS AND FAMILIES DEALING WITH ALZHEIMER'S DISEASE, CANCER, DIABETES, WEIGHT-LOSS SURGERY, HEPATITIS, INFANT DEATH, MULTIPLE SCLEROSIS, SLEEP DISTURBANCES, PROSTATE CANCER AND STROKE AND BRAIN INJURY. MEDCENTER ONE DAKOTA CHILDREN'S ADVOCACY CENTER IS A PROGRAM DESIGNED TO IMPROVE THE RESPONSE TO CHILD ABUSE BY PROVIDING A COMMUNITY-WIDE MULTIDISCIPLINARY TEAM APPROACH. IN 2011, THE CENTER PROVIDED MEDICAL AND MENTAL HEALTH SERVICES TO 346 CHILDREN AND PROVIDED TRAINING AND TEACHING TO 2,108 CHILDREN. SAFETY AND PREVENTION SERVICES: STAFF WITHIN THE TRAUMA SERVICES DEPARTMENT AT MEDCENTER ONE WORK CLOSELY WITH THE NORTH DAKOTA SAFETY COUNCIL TO PROVIDE TWO WEEK-LONG EDUCATIONAL CAMPS FOR 5 AND 6-YEAR-OLD CHILDREN IN THE BISMARCK-MANDAN AREA. ACTIVITIES INCLUDE GAMES AND SONGS THAT EMPHASIZE SAFETY RISKS AND APPROPRIATE RESPONSES, SO THAT CHILDREN UNDERSTAND HOW TO MAINTAIN THEIR SAFETY IN VARIOUS ENVIRONMENTS. CHILDREN TAKE TURNS DRIVING PEDAL CARS TO LEARN TRAFFIC RULES FOR DRIVERS AND WALKING ACROSS INTERSECTIONS TO ADOPT SAFE PRACTICES FOR PEDESTRIANS. PLAYGROUND AND BIKE SAFETY ARE ALSO HIGHLIGHTED. MEDCENTER ONE PROVIDES INSTRUCTION AND MATERIALS ON SAFETY TO EACH STUDENT. OTHER TRAUMA SERVICES COMMUNITY OUTREACH PROGRAMS INCLUDE:* TRAUMA SERVICES STAFF PROMOTE BIKE HELMET USE AND CONDUCT CAR SEAT SAFETY CHECKS IN COORDINATION WITH OTHER LOCAL AGENCIES. * PARTICIPATE IN A SPECIAL PROGRAM ENTITLED TEEN MAZE THAT PROMOTES SAFETY WITH MIDDLE SCHOOL CHILDREN.* IN 2010, TRAUMA SERVICES BEGAN WORK ON ADULT FALL PREVENTION PROGRAMS. WESTERN NORTH DAKOTA HAS AN ABOVE-AVERAGE ELDERLY POPULATION AND SO ADDRESSING CRITICAL HEALTH RISKS LIKE FALLING DOWN HAVE BECOME INCREASINGLY IMPORTANT. * EVERY TIME PROGRAM-EDUCATION PROGRAM FOR HIGH SCHOOL STUDENTS TO PREVENT TEXTING AND DRINKING WHILE DRIVING AND TO INCREASE SEATBELT USE. * PROVIDED A HYPOTHERMIA PREVENTION EDUCATION BOOTH AT THE MEDCENTER ONE RUN/WALK FOR BREAST CANCER HEALTH FAIR. * CAR SEAT ROUNDUP-STAFF DISASSEMBLES UNSAFE CAR SEATS.WOMEN'S HEALTH CENTER: A MEDICALLY SOUND FITNESS AND EXERCISE PROGRAM WHERE PHYSICAL THERAPISTS PROVIDE FREE INJURY SCREENINGS AND MAKE RECOMMENDATIONS FOR PERSONAL WORKOUT ROUTINES. PHYSICAL FITNESS AND HEALTHY LIFESTYLES ARE PROMOTED TO WOMEN AT EVERY STAGE OF THEIR LIVES. EDUCATIONAL AND PROMOTIONAL EVENTS ARE SCHEDULED ON A REGULAR BASIS AND THE CENTER HOSTS THE REGIONAL WALK/RUN FOR BREAST CANCER AWARENESS EVENT ANNUALLY, WHICH INCLUDES A MULTIPURPOSE HEALTH EDUCATION FAIR. PARISH NURSE PROGRAM: PARISH NURSES MINISTER TO THE PHYSICAL, SPIRITUAL AND EMOTIONAL NEEDS OF THE CONGREGATION THROUGH HEALTH EDUCATION, HEALTH SCREENINGS, MAKING REFERRALS, SERVING AS A PERSONAL HEALTH COUNSELOR, OFFERING FLU SHOT CLINICS AND VISITING PEOPLE WHO ARE HOMEBOUND, HOSPITALIZED OR IN A NURSING HOME. THE PARISH NURSES PROGRAM PARTNERS WITH EIGHT CONGREGATIONS THAT REPRESENT THREE DENOMINATIONS. MEDCENTER ONE PROVIDED $13,881 OF SUPPORT IN 2011.SCREENINGS INCLUDE WELL BABY CLINIC, PROSTATE CANCER, HEARING AND ATHLETIC SCREENINGS THROUGHOUT THE YEAR. THE WELL BABY CLINICS ARE HELD WEEKLY, AND PARENTS CAN BRING THEIR BABY TO BE WEIGHED AND MEASURED BY A REGISTERED NURSE WHO ALSO ANSWERS ANY QUESTIONS PARENTS MAY HAVE. SPEECH THERAPY PARTNERS WITH THE SCOTTISH RITE TO PROVIDE FREE SPEECH SCREENING AND THERAPY SERVICES TO CHILDREN WITH SPEECH ISSUES. SPONSORSHIPS AND DONATIONS: IN 2011, MEDCENTER ONE PROVIDED $5,500 OF DONATIONS AND SPONSORSHIPS FOR COMMUNITY NON-PROFIT AGENCIES.ADDITIONAL IN-KIND SUPPORT AND SERVICES: IN 2011, MEDCENTER ONE COLLEGE OF NURSING FACULTY AND STUDENTS SPENT 8,439 HOURS PROVIDING SCHOOL AND COMMUNITY NURSING, PRESENTATIONS AND HEALTH CAREER INFORMATION TO ELEMENTARY AND JUNIOR HIGH STUDENTS PROVIDING IN-KIND SERVICES VALUED AT $179,835.STATEMENT CONTINUED ON SCH H, OTHER INFORMATION... PART VI, LINE 6: MEDCENTER ONE IS A DIVISION OF MEDCENTER ONE HEALTH SYSTEMS. A COMPLETE CONTINUUM OF CARE IS PROVIDED UNDER THE MEDCENTER ONE HEALTH SYSTEMS UMBRELLA AGENCY. LONG-TERM CARE SERVICES, LABORATORY (INCLUDING HISTOCOMPATIBILITY SERVICES FOR ORGAN TRANSPLANT SURGERY) AND RADIOLOGY SERVICES, A JOINT OWNED AIR AMBULANCE SERVICE AND LAUNDRY SERVICE, AND A DURABLE MEDICAL EQUIPMENT SERVICE ARE A FEW OF THE SUPPORTING SERVICES PROVIDED BY MEDCENTER ONE HEALTH SYSTEMS. THE LIVING CENTERS DIVISION PROVIDES CARE TO LONG-TERM CARE RESIDENTS WHO OCCUPY 343 NURSING HOME BEDS. THE NURSING HOMES OPERATE AT A 97% OCCUPANCY RATE. THE DIVISION ALSO OPERATES 77 ASSISTED LIVING APARTMENTS.JOINT OWNERSHIP OF AIR AMBULANCE AND LAUNDRY SERVICES ARE COST-EFFECTIVE WAYS TO SUPPORT OTHER MEDCENTER ONE OPERATIONS. THE LABORATORY AND RADIOLOGY SERVICES PROVIDE TECHNICAL SUPPORT TO THE PHYSICIANS AND PATIENTS SERVED BY MEDCENTER ONE AND ALLOW MEDCENTER ONE TO BE THE ONLY FACILITY IN WESTERN NORTH DAKOTA THAT PROVIDES TRANSPLANT SERVICES. PROFITS FROM THE LABORATORY AND RADIOLOGY DIVISION SUPPORT SUBSIDIZED PROGRAMS OF MEDCENTER ONE. SCH H, PART VI, LINE 5: OTHER INFORMATIONCONTINUED FROM SCH H, PART VI, LINE 5:BESIDES PROVIDING SPACE FOR MANY SUPPORT GROUPS AND COMMUNITY EVENTS, MEDCENTER ONE ALLOWS THE LOCAL POLICE AND SHERIFF DEPARTMENTS TO USE THE MEDCENTER ONE SECURITY TRAINING FACILITY AND EQUIPMENT FOR THEIR TRAINING NEEDS. IN 2011, 580 HOURS OF FACILITY MEETING AND TRAINING SPACE WAS PROVIDED TO THESE GROUPS. MEDCENTER ONE PROVIDES FREE FOOD AND BEVERAGES FOR MANY OF THE SUPPORT GROUPS AND COMMUNITY MEETINGS HOSTED AT OUR FACILITY AS WELL AS DOOR PRIZES AND OTHER GIVEAWAYS TO PROMOTE NON-PROFIT AND OTHER FUNDRAISING ACTIVITIES.IN-KIND SUPPORT INCLUDES THE VALUE OF MEDICAL SUPPLIES THAT ARE DONATED TO OTHER NON-PROFITS, AREA AMBULANCE AND FIREFIGHTING ORGANIZATIONS AND HEALTHCARE PROVIDERS. 1 GOD'S CHILD 721 MEMORIAL HIGHWAY BISMARCK ND 58504 450459314 501(C)(3) 30700 FMV MEDICAL SUPPLIES OVERSTOCK AND NEARING OUTDATE, THE SUPPLIES WERE DONATED TO A CHARITABLE MISSION. UNIVERISTY OF NORTH DAKOTA SCHOOL OF MEDICINE 515 EAST BROADWAY BISMARCK ND 58501 456002491 GOVERNMENT 25829 FMV MEDICAL SUPPLIES OVERSTOCK AND NEARING OUTDATE, THE SUPPLIES WERE DONATED TO THE RESIDENCY PROGRAM. ND-SD MEDICAL TRANSPORT 2317 79TH ST SE LINTON ND 58552 272849014 501(C)(3) 25000 DONATION 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION ONLY MAKES CHARITABLE DISTRIBUTIONS OVER $5,000 TO OTHER 501(C)(3) ORGANIZATIONS. OTHER ORGANIZATIONS THAT RECEIVE SMALL DISTRIBUTIONS INCLUDE DAY CARE CENTERS WHICH PROMOTES THE HEALTH AND WELL-BEING OF CHILDREN. ONCE FUNDS ARE DISTRIBUTED NO FURTHER MONITORING IS DONE. X X 1 1 X X X X 0 0 0 0 0 0 0 1 0 DR ALAN VANNORMAN 664668 0 0 0 23362 0 9800 0 17388 0 715218 0 0 0 DR CRAIG LAMBRECHT 537839 0 146940 0 69218 0 26300 0 28152 0 808449 0 0 0 DR GRETCHEN BELZER-CURL 142256 0 73905 0 500 0 9800 0 17945 0 244406 0 0 0 DR KIMBER BOYKO 548396 0 141765 0 1242 0 39200 0 18263 0 748866 0 0 0 DR WILLIAM CANHAM 504505 0 0 0 20064 0 9800 0 20817 0 555186 0 0 0 DR C KENT MARTIN 297211 0 0 0 6858 0 9800 0 16722 0 330591 0 0 0 DR MICHAEL MCINTEE 713527 0 173174 0 810 0 9800 0 17388 0 914699 0 0 0 DR CHRISTOPHER MEEKER 371289 0 66246 0 525 0 9800 0 18474 0 466334 0 0 0 DR DAVID PENGILLY 267831 0 97088 0 810 0 9800 0 13154 0 388683 0 0 0 DR SEAN RUSSELL 618605 0 100000 0 1242 0 39200 0 20581 0 779628 0 0 0 DR MICHELLE TINCHER 262852 0 74658 0 810 0 9800 0 16796 0 364916 0 0 0 PAUL MORTH 227117 0 3306 0 24629 0 25912 0 22714 0 303678 0 0 0 KAREN PAUL 156947 0 3306 0 14119 0 6481 0 23256 0 204109 0 0 0 JAN KAMPHUIS 199224 0 3615 0 24444 0 9173 0 25177 0 261633 0 0 0 SCOTT BOEHM 201461 0 3356 0 18392 0 24686 0 17146 0 265041 0 0 0 DR ANTHONY TELLO 365267 0 84864 0 18822 0 9800 0 17388 0 496141 0 0 0 JOHN MILLER 277796 0 0 0 0 0 0 0 0 0 277796 0 0 0 DR DOUGLAS BERGLUND 903011 0 281642 0 1242 0 39200 0 15595 0 1240690 0 0 0 DR JOHN WATKINS 687847 0 540578 0 15432 0 9800 0 13920 0 1267577 0 0 0 DR MICHAEL QUAST 456209 0 543652 0 540 0 39200 0 21963 0 1061564 0 0 0 DR TED FOGARTY 708199 0 169820 0 17040 0 39200 0 24570 0 958829 0 0 0 DR TAREK DUFAN 485882 0 809683 0 10486 0 29400 0 16463 0 1351914 0 0 0 EVY OLSON 115523 0 3615 0 14423 0 5412 0 17260 0 156233 0 0 0 PAM HOPKINS 108045 0 3356 0 18347 0 4667 0 4944 0 139359 0 0 0 PART I, LINE 1A COMPANION TRAVEL WAS PROVIDED FOR CRAIG LAMBRECHT'S (CEO) WIFE. THESE AMOUNTS WERE REPORTED AS TAXABLE INCOME ON HIS W-2. PART I, LINE 7 MEDCENTER ONE, INC. HAS A SENIOR MANAGEMENT INCENTIVE COMPENSATION PLAN. THERE ARE VARIOUS PAYOUT LEVELS, DEPENDING ON WHERE THE BOTTOM LINE IS AT, USING THE CONSOLIDATED TOTAL MARGIN PERCENTAGE AS THE MEASUREMENT. ACTUAL PAYMENT IS SUBJECT TO RECOMMENDATION BY THE CEO TO THE CHAIRMAN OF THE BOARD AND MAY NOT BE MADE EVEN IF MINIMUM THRESHOLDS ARE MET. SUPPLEMENTAL INFORMATION PART III PART II: JOHN MILLER PROVIDES PROJECT MANAGEMENT SERVICES TO MEDCENTER ONE, INC., BUT IS COMPENSATED BY AN INDEPENDENT MANAGEMENT COMPANY FOR THOSE SERVICES. JOHN MILLER II SON OF JOHN MILLER, KEY EMPLOYEE 34000 EDUCATIONAL STIPEND AND SIGNING BONUS JESSICA MILLER DAUGHTER-IN-LAW OF JOHN MILLER, KEY EMPLOYEE 34000 EDUCATIONAL STIPEND AND SIGNING BONUS STEPHANIE MILLER CARLSON DAUGHTER OF JOHN MILLER, KEY EMPLOYEE 24000 EDUCATIONAL STIPEND AND SIGNING BONUS ASSOCIATED LAND DEVELOPMENT PARTNERSHIP OF WHICH A BOARD MEMBER HAS MORE THAN A 5% OWNERSHIP 290740 MCO, INC. LEASES PROPERTY FOR BISMARCK SOUTH CLINIC FROM ASSOCIATED LAND DEVELOPMENT OF WHICH MR. TERNES HAS OWNERSHIP. 0 INFORMATION TECHNOLOGIES INC ENTITY OWNED MORE THAN 35% BY A KEY EMPLOYEE 664665 MR. MILLER IS OWNER OF INFORMATION TECHNOLOGIES INC. WHICH IS CONTRACTED BY MEDCENTER ONE TO PROVIDE THE CIO AND OTHER INFORMATION SERVICES EMPLOYEES AND EXPERTISE. 0 KIMBERLY A VANNORMAN DAUGHTER OF BOARD MEMBER - ALAN VANNORMAN 21751 EMPLOYMENT COMPENSATION 0 MEGAN J SUCHY DAUGHTER OF OFFICER - PAUL MORTH 53897 EMPLOYMENT COMPENSATION 0 BRENDA MILLER WIFE OF OFFICER - JOHN MILLER 376669 EMPLOYMENT COMPENSATION 0 SUSAN K BOEHM WIFE OF KEY EMPLOYEE - SCOTT BOEHM 32856 EMPLOYMENT COMPENSATION 0 JOHN DURICK BROTHER OF KEY EMPLOYEE - PATRICK DURICK 99718 EMPLOYMENT COMPENSATION 0 CHERYL PAGE DAUGHTER OF BOARD MEMBER - ROBERT SCHULTY 69402 EMPLOYMENT COMPENSATION 0 LISA CLAIRMONT DAUGHTER OF BOARD MEMBER - IRENE WENTZ 76503 EMPLOYMENT COMPENSATION 0 ALLISON SADOWSKI DAUGHTER OF KEY EMPLOYEE - ANTHONY TELO 42144 EMPLOYMENT COMPENSATION 0 JOHN MILLER II SON OF KEY EMPLOYEE - JOHN MILLER 237819 EMPLOYMENT COMPENSATION 0 LAURA BOEHM DAUGHTER OF KEY EMPLOYEE - SCOTT BOEHM 17114 EMPLOYMENT COMPENSATION 0 MONTANA-DAKOTA UTILITIES OFFICER IS A BOARD MEMBER 1525915 DAVE GOODIN IS A BOARD MEMBER BUT IS ALSO AN OFFICER OF MDU 0 JESSICA CARLSON DAUGHTER OF KEY EMPLOYEE - JOHN MILLER 53466 EMPLOYMENT COMPENSATION 0 STEPHANIE MILLER DAUGHTER-IN-LAW OF KEY EMPLOYEE - JOHN MILLER 53836 EMPLOYMENT COMPENSATION 0 GERI MCINTEE SISTER OF BOARD MEMBER - MICHAEL MCINTEE 74976 EMPLOYMENT COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1 THE HOSPITAL HAS AN EXECUTIVE COMMITTEE THAT CAN MAKE A DECISION ON THE BOARD OF DIRECTORS BEHALF IN AN EMERGENCY. THE EXECUTIVE COMMITTEE CONSISTS OF THE CHAIR, VICE CHAIR, SECRETARY/TREASURER, CEO AND EIGHT BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 3 PROJECT MANAGEMENT SERVICES ARE PROVIDED BY JOHN MILLER, WHO IS COMPENSATED BY AN INDEPENDENT MANAGEMENT COMPANY FOR THOSE SERVICES. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS MEDCENTER ONE HEALTH SYSTEMS. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, MEDCENTER ONE HEALTH SYSTEMS, HAS THE POWERS AND RIGHTS TO FIX THE NUMBER OF, ELECT, APPOINT, FILL VACANCIES IN AND REMOVE, WITH OR WITHOUT CAUSE, THE DIRECTORS OF THE CORPORATION; AND ELECT, APPOINT, AND REMOVE THE CHAIR OF THE BOARD OF DIRECTORS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER, MEDCENTER ONE HEALTH SYSTEMS, APPROVES ALL GOVERNING DECISIONS OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE DRAFT FORM 990 IS REVIEWED BY THE CFO AND CONTROLLER. THE TIMING OF THE FILING DEADLINE AND FINALIZING THE DRAFT DOES NOT ALLOW APPROPRIATE TIME FOR PRESENTATION TO THE GOVERNING BODY BEFORE THE FILING. AN E-MAIL WITH A PDF OF THE ENTIRE DRAFT WILL BE SENT TO THE MEMBERS OF THE GOVERNING BODY. IF REQUESTS ARE MADE FOR CHANGES AN AMENDED RETURN WILL BE SENT. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY A LETTER IS DISTRIBUTED EXPLAINING OUR CONFLICT OF INTEREST POLICY WITH EXAMPLES OF WHAT MAY BE CONSIDERED A CONFLICT OF INTEREST. OFFICERS, DIRECTORS OR TRUSTEES, AND KEY EMPLOYEES ARE ASKED TO COMPLETE A SURVEY WHICH WOULD DISCLOSE ANY CONFLICTS. THESE SURVEYS ARE TO BE SIGNED AND RETURNED TO THE FINANCE DEPARTMENT. ANY INDIVIDUALS WHO DO NOT RETURN THE SURVEY IN A REASONABLE TIME ARE CONTACTED AGAIN TO RETURN THE SURVEY. OFFICERS AND DIRECTORS WITH A CONFLICT OF INTEREST ARE ASKED TO REMOVE THEMSELVES FROM APPLICABLE DISCUSSIONS AND VOTING. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED BY THE BOARD'S EXECUTIVE COMMITTEE. THEY RECEIVE INPUT ON SALARY SURVEY INFORMATION WHICH IS DOCUMENTED IN THE MINUTES OF THE EXECUTIVE COMMITTEE. ANY ADJUSTMENT THAT THE BOARD DETERMINES IS THEN DOCUMENTED ON AN INTERNAL COMPENSATION CHANGE FORM IN WHICH THE CHAIRMAN OF THE BOARD SIGNS OFF. COMPENSATION CONSULTANTS ARE USED ONCE A YEAR FOR THE CEO, VP'S AND MEDICAL DIRECTOR. THIS PROCESS IS DONE ON AN ANNUAL BASIS. COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES (NON-PHYSICIANS) IS BASED ON SALARY SURVEY INFORMATION. THE CEO MAKES A RECOMMENDATION TO THE CHAIRMAN OF THE BOARD AND THE CHAIRMAN APPROVES AND SIGNS OFF. A BONUS SYSTEM IS IN PLACE AND IS APPROVED BY THE EXECUTIVE COMMITTEE. THIS PROCESS IS DONE ON AN ANNUAL BASIS. COMPENSATION OF TOP HIGHLY COMPENSATED EMPLOYEES, WHO ARE PHYSICIANS, IS DETERMINED BY A COMPENSATION COMMITTEE THAT CONSIDERS COMPENSATION PLANS AND USES GUIDELINES FROM THE EXECUTIVE COMMITTEE. THE BOARD VOTES ON THE COMPENSATION PLANS (MINUS THE PHYSICIANS ON THE BOARD). LEGAL COUNSEL ALSO REVIEWS COMPLIANCE WITH BOARD GUIDELINES AND REASONABLE MARKET RATES. THE LAST FULL REVIEW WAS COMPLETED FOUR YEARS AGO. IN 2010 A CONSULTANT WAS HIRED TO DO A FAIR MARKET VALUE COMPARISON AND MEDCENTER ONE RECEIVED THE FINAL REPORT ON THAT ASSESSMENT DURING 2011. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE NOT AVAILABLE FOR PUBLIC DISCLOSURE; HOWEVER THE FINANCIAL STATEMENTS WILL BECOME PART OF THE DOCUMENTS AVAILABLE AT GUIDESTAR.ORG. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 6,178. PRIOR PERIOD ADJUSTMENTS: -145,198. PENSION-RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -11,568,925. CHANGE IN INTEREST IN NET ASSETS OF MEDCENTER ONE FOUNDATION -88,043. TOTAL TO FORM 990, PART XI, LINE 5: -11,795,988. FORM 990, PAGE 7, PART VIII, COLUMN B: THE BOARD MEMBER HOURS ARE NOT CAPTURED BY THE FILING ENTITY AND THEREFORE HOURS REPORTED RELATE TO WORK DONE FOR THE REPORTING ORGANIZATION AND ALSO THE RELATED ORGANIZATIONS MEDCENTER ONE LIVING CENTERS, MEDCENTER ONE FOUNDATION, AND MEDCENTER ONE HEALTH SYSTEM MEDCENTER ONE HEALTH SYSTEMS 300 NORTH 7TH STREET BISMARCK ND 58501 450397195 PROMOTION OF HEALTH ND 501(C)(3) LINE 3 N/A 0 MEDCENTER ONE FOUNDATION 300 NORTH 7TH STREET BISMARCK ND 58501 450397196 PROMOTION OF HEALTH THROUGH FUNDRAISING ND 501(C)(3) LINE 7 MEDCENTER ONE HEALTH SYSTEMS 0 MEDCENTER ONE LIVING CENTERS 1000 18TH ST NW SUITE 1 MANDAN ND 58554 450416454 LONG-TERM CARE FACILITY ND 501(C)(3) LINE 9 MEDCENTER ONE HEALTH SYSTEMS 0 BISMARCK AIR MEDICAL 2940 N 19TH STREET BISMARCK ND 58503 721538378 AIR AMBULANCE SERVICE ND N/A MEDCENTER ONE AFFILIATED SERVICES INC 300 NORTH 7TH STREET BISMARCK ND 58501 450403146 INVESTMENT ACTIVITY ND N/A C 0 0 1 0 0 1 0 0 0 1 1 1 1 1 1 1 1 1