2012-11-15T12:24:30-06:00 2011-12-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2011-01-01 310650283 MCCULLOUGH-HYDE MEMORIAL HOSPITAL MCCU 5135245310 110 NORTH POPLAR STREET OXFORD OH 45056 JOHN CLEMENTS 5135245310 2012-10-31 1 NANCY KIRCHNER P00386751 6148852583 2011 2016-02-24 21:20:13Z JOHN CLEMENTS 110 NORTH POPLAR STREET OXFORD OH 45056 63344749 0 X WWW.MHMH.ORG X 1953 OH ACUTE CARE HOSPITAL FACILITY DELIVERING QUALITY SERVICES TO OUR PATIENTS AND THE COMMUNITIES WE SERVE. 10 10 642 0 168995 -39715 472450 320518 64810749 61910538 14279 83268 897708 1030425 66195186 63344749 10000 34322 0 0 28783775 28385199 0 0 0 36832589 33959927 65626364 62379448 568822 965301 50013680 45819702 27186878 22027599 22826802 23792103 X ACUTE CARE HOSPITAL FACILITY DELIVERING QUALITY SERVICES TO OUR PATIENTS AND THE COMMUNITIES WE SERVE. 0 0 4237617 20507580 OPERATING ROOM-CONSISTING OF INPATIENT (34%) AND OUTPATIENT (66%) SURGICAL SERVICES INCLUDING GENERAL SURGERY (1,621 PROCEDURES), ENDOSCOPY AND MINOR PROCEDURES (3,526 PROCEDURES) AND POST ANESTHESIA CARE UNIT. 4617910 15727056 PHARMACY-CONSISTING OF CARE PROVIDED TO INPATIENTS (26%) AND OUTPATIENTS (74%). OUTPATIENT CARE INCLUDES A MAJOR PROGRAM FOR ONCOLOGY TREATMENT. 4170728 26176606 IMAGING-COMPRISED OF A FULL RANGE OF RADIOLOGY SERVICES INCLUDING XRAY, ULTRASOUND, CT, MRI AND NUCLEAR MEDICINE. TOTAL PROCEDURE VOLUME IS 43,379 CONSISTING OF IP CARE (26%) AND OUTPATIENT CARE (74%). 40030689 17500 INPATIENT VOLUME CONSISTED OF 2,608 DISCHARGES AND 9,943 PATIENT DAYS WITH AN AVERAGE LENGTH OF STAY OF 3.5 DAYS. IN ADDITION, 744 OBSERVATION DAYS OF SERVICE WERE PROVIDED. OVERALL, INPATIENT AND OUTPATIENT CARE REPRESENT 29% AND 81% OF GROSS PATIENT REVENUE, RESPECTIVELY. BAD DEBT EXPENSE IS INCLUDED IN THIS NUMBER. 40030689 17500 53056944 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 64 0 1 642 1 1 1 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IN OH X JAMES MILLER 5135245310 110 NORTH POPLAR STREET OXFORD OH 450561292 JOHN HARLAND MD 1.00 X 0 0 0 SUSAN CROSS LIPNICKEY 1.00 X 0 0 0 JACK MANN 1.00 X 0 0 0 RICHARD M NORMAN 1.00 X 0 0 0 ALAN OAK 1.00 X 0 0 0 WILLIAM R RICHARDSON 1.00 X 0 0 0 WILLIAM DOUGLAS ROSS DO 1.00 X 0 0 0 MICHAEL RUDOLPH 1.00 X 0 0 0 THOMAS W SPEH 1.00 X 0 0 0 PAIGE WOOD 1.00 X 0 0 0 BRYAN HEHEMANN 40.00 X 202613 0 14797 JOHN CLEMENTS 40.00 X 96330 0 4938 PAMELA COLLINS 40.00 X 127687 0 7511 TAMMY WOOD 40.00 X 118501 0 14378 KENNETH KELLER 40.00 X 244989 0 3654 MATTHEW BIRKLE 40.00 X 247235 0 3686 RODNEY HOLDERMAN 40.00 X 121681 0 15560 MARK CRISTELL 40.00 X 126735 0 15632 MATTHEW DAGGY 40.00 X 111347 0 1708 1397118 0 81864 14 0 1 0 HUMANA 101 EAST MAIN STREET LOUISVILLE KY 40202 HEALTH INSURANCE 1857637 CPSI 600 WALL STREET MOBILE AL 36695 COMPUTER SYSTEMS 742147 MAYO MEDICAL LABORATORIES 200 FIRST STREET SW ROCHESTER MN 55905 MEDICAL 427977 SOAP 118 EAST SUPERIOR STREET WAYLAND MI 49348 TRANSCRIPTION 388191 MASTERPLAN 9582 TOPANGA CANYON BLVD CHASTSWORTH CA 91311 BIOMEDICAL 353731 34 206331 114187 320518 PATIENT SERVICES 900099 61910538 61910538 61910538 82344 82344 292371 0 292371 292371 168995 123376 924 0 924 924 924 DIETARY 722210 237350 237350 MISCELLANEOUS 900099 170610 170610 OCCUPATIONAL HEALTH 624310 154749 154749 175345 175345 738054 63344749 62411242 168995 443994 34322 34322 22394180 20668042 1726138 342714 246754 95960 4053719 2918678 1135041 1594586 1148102 446484 228287 228287 162726 162726 7503758 6414465 1089293 296384 210735 85649 810632 624749 185883 802638 800284 2354 2463001 1084111 1378890 48457 20541 27916 49705 37191 12514 806496 806496 4130611 2932734 1197877 502035 373033 129002 MEDICAL SUPPLIES 9414011 9336988 77023 BAD DEBT 6013424 6013424 OTHER EXPENSES 727762 192791 534971 62379448 53056944 9322504 0 700 6276513 3495515 8061967 8206772 0 1143460 1176581 906249 1302270 72678641 43821722 30233845 28856919 3391646 2780945 50013680 45819702 5334341 4241958 19461501 17328895 2391036 456746 27186878 22027599 X 22826802 23792103 22826802 23792103 50013680 45819702 965301 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6500 6500 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: SUPPORT PROVIDED THROUGH DUES PAID TO OHA AND AHA OHA = $1,469 AHA = $5,031 548616 548616 26251708 12778270 13473438 5718699 2096242 3622457 39829167 28947210 10881957 330451 330451 28856919 UNAMORTIZED FINANCE COSTS 122537 DOCTORS' LOANS RECEIVABLE 942035 CASH SURRENDER VALUE 36629 DUE FROM RELATED PARTY 1679744 2780945 ESTIMATED THIRD PARTY SETTLEMENTS 456746 456746 63344749 62379448 965301 965301 63344749 0 63344749 0 63344749 62379448 0 62379448 0 62379448 1 1 1 X 1 X 1 1 0 1 1 1397381 1397381 0.02480 5477152 3680357 1796795 0.03190 6874533 3680357 3194176 0.05670 89496 89496 0.00160 89496 89496 0.00160 6964029 3680357 3283672 0.05830 43693 43693 0.00080 43693 43693 0.00080 1 2525638 0 9376842 11734125 -2357283 X 1 1 5 1 MCCULLOUGH HYDE MEMORIAL HOSPITAL

110 N POPLAR STREET OXFORD OH 45056

X X X X DSH 2 MCCULLOUGH HYDE MEMORIAL HOSPITAL

5151 MORNING SUN RD OXFORD OH 45056

X PHYSICAL THERAPY 3 MCCULLOUGH HYDE MEMORIAL HOSPITAL

10058 COOLEY RD BROOKVILLE IN 47012

X OUTPATIENT 4 MCCULLOUGH HYDE MEMORIAL HOSPITAL

1390 EATON RD HAMILTON OH 45013

X PHYSICAL THERAPY 5 MCCULLOUGH HYDE MEMORIAL HOSPITAL

2449 ROSS-MILLVILLE RD HAMILTON OH 45013

X OUTPATIENT-URGENT CARE-PT MCCULLOUGH-HYDE MEMORIAL HOSPITAL 1 1 1 100.000000000000 1 300.000000000000 1 X 1 1 X X X X 1 X 1 X X X X 1 X 0 0 PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 6013424. PART II: MCCULLOUGH-HYDE MEMORIAL HOSPITAL PROMOTES HEALTH AND WELLBEING IN OUR COMMUNITY IN NUMEROUS WAYS NOT LISTED IN THE COMMUNITY EVENTS AND PROGRAMS SECTION OF THE 990. EXAMPLES INCLUDE: 1. MHMH HELPED PROMOTE WELLNESS BY PROVIDING MEETING SPACE TO THE INFANT/CHILD LOSS BEREAVEMENT SUPPORT GROUP AND FIBROMYALGIA SUPPORT GROUP. 2. MHMH ASSISTED OUR LOCAL SCHOOL DISTRICT WITH IDENTIFIEDHEALTH/WELLNESS NEEDS. EXAMPLES INCLUDE: A. DEVELOPED AND PROVIDED CRISIS CARDS FOR ALL 8TH GRADERS AND ALL COUNSELORS IN THE SCHOOL DISTRICT B. DEVELOPED CURRICULUM THAT COMBINED TRADITIONAL LEARNING WITH EXERCISE TO HELP FIGHT OBESITY IN OUR ELEMENTARY STUDENTS C. DEVELOPED AND HELD MINI HEALTH SEMINARS FOR 6TH GRADE STUDENTS ON SLEEP, NUTRITION, EXERCISE AND MENTAL HEALTH 3. MHMH PROVIDED OFFICE SPACE AND MEETING SPACE FOR THE OXFORD COLLEGE CORNER CLINIC, WHICH IS A CLINIC THAT PROVIDES FREE HEALTH CARE TO THE UNINSURED AND UNDERINSURED ADULTS IN OUR COMMUNITY 4. MHMH IMPROVED THEIR EMPLOYEE WELLNESS PROGRAM BY: A. IMPLEMENTING A HEALTH RISK ASSESSMENT FOR THEIR EMPLOYEES TO IDENTIFY HEALTH NEEDS/CONCERNS IN OUR EMPLOYEE POPULATION B. OFFERING MAMMOGRAMS AND PROSTATE SCREENING TO APPROPRIATE EMPLOYEES FREE OF CHARGE C. INCENTIVIZING EMPLOYEES TO ADOPT HEALTHIER BEHAVIOR PART III, LINE 4: THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED DECEMBER 31, 2011 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: ONCE IT HAS BEEN DETERMINED THAT A PATIENT QUALIFIES FOR CHARITY CARE/FINANCIAL ASSISTANCE, COLLECTION PRACTICES ARE STOPPED. MCCULLOUGH-HYDE MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: DISCOUNT BASED ON AVG COMMERCIAL INSURANCE WRITEDOWN PART VI, LINE 2: MCCULLOUGH-HYDE USES A PROCESS OF ASSESSMENT TO GAUGE THE HEALTHCARE NEEDS OF THE COMMUNITY WE SERVE. THE COMPONENTS OF THAT PROCESS FOR 2011 WERE:1. A NINE-MONTH STRATEGIC PLANNING PROCESS WITH INPUT FROM VARIOUS STAKEHOLDER GROUPS INCLUDING THE MEDICAL STAFF, THE LOCAL COMMUNITY FOUNDATION, THE LOCAL FREE MEDICAL CLINIC (OXFORD COLLEGE CORNER CLINIC), THE LOCAL SOCIAL NEEDS UMBRELLA ORGANIZATION (FAMILY RESOURCE CENTER), AND SEVERAL SMALLER FOCUS GROUPS OF PATIENTS, COMMUNITY LEADERS, AND NON-PATIENTS.2. ALL UNINSURED EMERGENCY DEPARTMENT PATIENTS ARE ASSESSED BY STAFF AND REFERRED TO THE LOCAL FREE MEDICAL CLINIC FOR FOLLOW-UP CARE AND ASSISTANCE, WHEN APPROPRIATE. THAT DATA INFORMS POTENTIAL EDUCATION AND SERVICE PROGRAMS THAT THE HOSPITAL OFFERS TO THE COMMUNITY.3. ON-GOING PARTNERSHIPS WITH MIAMI UNIVERSITY, THE CITY OF OXFORD, AND THE LOCAL SCHOOL DISTRICT TO JOINTLY ADDRESS SPECIFIC HEALTH CARE NEEDS OF THEIR RESPECTIVE POPULATIONS.4. AN ON-GOING, LESS FORMAL PROGRAM, GATHERS INPUT FROM MINISTERS IN OUR CHAPLAIN PROGRAM AND FROM OUR MANY VOLUNTEERS. PART VI, LINE 3: FINANCIAL COUNSELORS ARE LOCATED IN THE PATIENT ACCESS AREAS AND PATIENTS ARE OFTEN REFERRED TO THEM AFTER THE COMPLETION OF THE REGISTRATION PROCESS. IN THE EVENT THAT FINANCIAL COUNSELORS ARE NOT AVAILABLE PATIENT ACCESS STAFF IS EDUCATED ON THE CHARITY CARE/FINANCIAL ASSISTANCE POLICIES AND HAVE APPLICATIONS AVAILABLE. CHARITY CARE INFORMATION IS ALSO INCLUDED ON OUR PATIENT STATEMENTS. ALL CUSTOMER SERVICE REPRESENTATIVES ARE FAMILIAR WITH OUR POLICIES AND CAN SPEAK TO OUR CUSTOMERS ABOUT CHARITY CARE/FINANCIAL ASSISTANCE ELIGIBILITY. BROCHURES EXPLAINING CHARITY CARE/FINANCIAL ASSISTANCE ARE ALSO AVAILABLE IN VARIOUS LOCATIONS THROUGHOUT THE HOSPITAL. PART VI, LINE 4: MCCULLOUGH HYDE MEMORIAL HOSPITAL SERVES A DIVERSE DEMOGRAPHIC INCLUDING THE NORTHWESTERN CORNER OF BUTLER COUNTY, OHIO, THE SOUTHWESTERN CORNER OF PREBLE COUNTY, OHIO AND THE COUNTIES OF FRANKLIN, UNION AND FAYETTE IN INDIANA. THE MAIN CAMPUS IS LOCATED IN OXFORD, OHIO, THE HOME OF MIAMI UNIVERSITY WITH A POPULATION RANGING TO NEARLY 30,000 DURING THE SCHOOL YEAR TO HALF THAT NUMBER DURING THE SUMMER.MHMH COUNTS ITS PRIMARY SERVICE AREA AS THE FOLLOWING: OXFORD,OH - 45056 - POPULATION 29,739 BROOKVILLE, IN - 47012 - POPULATION 10,455 COLLEGE CORNER, OH - 45003 - POPULATION 971 EATON, OH - 45320 - POPULATION 15,354 SOMERSVILLE, OH - 45064 - 2,963 CAMDEN, OH - 45311 - 7,215 LIBERTY, IN - 47353 - 5,698 WEST COLLEGE CORNER, IN - 47003 - 834 TOTAL PRIMARY SERVICE AREA POPULATION = 73,229AND ITS PRIMARY AND ITS SECONDARY SERVICE AREAS ARE THE FOLLOWING: HAMILTON, OH - 45013 - 54,814 CONNERSVILLE, IN - 47331 - 23,438 METAMORA, IN - 47030 - 1,631 OKEANA, OH - 45053 - 3,712 TOTAL SECONDARY SERVICE AREA POPULATION = 83,595IN TERMS OF SOCIO-ECONOMIC DEMOGRAPHICS, THE EDUCATIONAL ATTAINMENT IS LOWER THAN COUNTY, STATE AND NATIONAL AVERAGES AND THE UNEMPLOYMENT HIGHER THAN COUNTY, STATE AND NATIONAL AVERAGES IN ALL OF THE UNINCORPORATED AND RURAL AREAS SERVED BY MHMH. ALL OF THE AREAS IN INDIANA AND THE RURAL AREAS IN PREBLE AND BUTLER COUNTIES (CAMDEN, SOMERVILLE) ARE DESIGNATED AS HEALTH PROFESSIONAL SHORTAGE AREAS BY THE NATIONAL HEALTH SERVICE CORPS.MCCULLOUGH HYDE HAS RECRUITED, SUPPORTED AND WILL CONTINUE TO RECRUIT AND SUPPORT BOTH PRIMARY CARE PHYSICIANS AND SPECIALISTS TO MEET THE NEEDS OF RESIDENTS OF THESE COMMUNITIES. 0 TALAWANDA SCHOOL DISTRICT 131 WEST CHESTER ST OXFORD OH 45056 316005340 10000 SCHOOL PROGRAMS SANE OF BUTLER COUNTY PO BOX 18818 FAIRFIELD OH 45018 311604036 7500 FORENSIC CARE X X X X 0 1 0 0 0 0 0 0 0 BRYAN HEHEMANN 198026 0 0 0 4587 0 938 0 13859 0 217410 0 0 0 KENNETH KELLER 240419 0 0 0 4570 0 0 0 3654 0 248643 0 0 0 MATTHEW BIRKLE 247235 0 0 0 0 0 0 0 3686 0 250921 0 0 0 PART I, LINE 4B BRYAN HEHEMANN - LIFE INSURANCE POLICY - PAID UP POLICY AT 65. FACE AMOUNT IS 100K WITH CASH SURRENDER VALUE. THERE IS AN ANNUAL PREMIUM OF $8,874 WITH THE VALUE AT 12/31/11 AT $36,629. BUTLER COUNTY-SERIES 2009A 316000061 2003-05-07 17223844 CONTRUCTION/EXPANSION 0 0 0 BUTLER COUNTY-SERIES 2009B 316000061 2003-05-07 4776156 CONTRUCTION/EXPANSION 0 0 0 17223844 176587 1735397 2011 1 0 1 1 477156 49807 489470 2011 1 0 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED BY THE CPA FIRM, BLUE & CO LLC AND PRESENTED TO CFO AND FINANCE COMMITTEE FOR REVIEW. THE 990 IS THEN PRESENTED AT THE BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY THE CORPORATE COMPLIANCE OFFICER REQUIRES THE OFFICERS, TRUSTEES, DIRECTORS AND KEY EMPLOYEES TO DISCLOSE IN WRITING ANY INTEREST THAT COULD GIVE RISE TO CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING COMPENSATION INCLUDES INDEPENDENT CONSULTANT INPUT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY STUDY AND APPROVAL BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 UPON INDIVIDUAL REQUEST MCCULLOUGH-HYDE MEMORIAL HOSPITAL ENDOWMENT 110 NORTH POPLAR OXFORD OH 45056 237374256 OBTAIN CHARITABLE CONTRIBUTIONS, MANAGE THEM AND DISBURSE BY BOARD DIRECTION OH 501(C)(3) LINE 11A, I 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MCCULLOUGH-HYDE MEMORIAL HOSPITAL ENDOWMENT C 206331