2012-10-24T12:15:30-05:00 2011-12-31 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2011-01-01 020260334 Wentworth-Douglass Hospital WENT 6037425252 789 Central Avenue Dover NH 038202526 Peter E Walcek 6037422804 2012-10-15 1 Timothy R Hepburn CPA P00182393 2078792100 2012-10-15 2011 2016-02-24 21:20:13Z Gregory J Walker 789 Central Avenue Dover NH 038202526 362484137 0 X www.wdhospital.com X 1905 NH Help individuals and their families attain their highest level of health. 15 12 1967 114 47529 -79653 457903 457217 231897057 255309413 4296908 1973618 3127926 1831177 239779794 259571425 0 0 0 0 109299227 116699596 0 0 0 99588377 117837593 208887604 234537189 30892190 25034236 311808165 364821497 122256744 173617834 189551421 191203663 X Wentworth-Douglass is the largest acute care hospital in the Seacoast region of New Hampshire and Southern Maine, specializing in Trauma and Emergency Services, Surgery, Cancer Care, Birthing, Orthopedic Services, Cardiovascular Services, Sleep Disorders, Rehabilitation, Pain Management, Wound Healing, Wellness and Prevention Programs, plus extensive diagnostic services.A healthcare leader in the Seacoast region since 1906, Wentworth-Douglass Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations. 0 0 205092288 258065063 Wentworth-Douglass Hospital (WDH or the Hospital) is an acute care hospital located in Dover, New Hampshire. WDH is a not-for-profit organization, as described in Section 501(c)(3) of the Internal Revenue Code. Wentworth-Douglass Hospital is the largest acute care hospital in the Seacoast region of New Hampshire and Southern Maine, specializing in Trauma and Emergency Services, Surgery, Cancer Care, Birthing, Orthopedic Services, Cardiovascular Services, Sleep Disorders, Rehabilitation, Pain Management, Wound Healing, Wellness, and Prevention Programs plus extensive diagnostic services. A healthcare leader in the Seacoast since 1906, Wentworth-Douglass Hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations. At Wentworth-Douglass Hospital, we are committed to serving our community and addressing the needs of all our patients. Our community benefits programs are available to local residents with income at or below 300% of Federal Poverty Level guidelines, one of the most generous programs in the State of NH. WDH files an annual Community Benefits Report with the State of NH which outlines the community and charitable benefits provided. Numerous programs were developed to assist people in the area we serve, including Financial Aid, Family Resource Counselor Program, Medication Assistance Program, Physician Referral Services, Care-Van transportation services, and Wentworth-Douglass Community Dental Center. The Hospital provided $19,895,836 (as measured by gross charges) of community assistance programs in 2011, impacting 13,272 patients. In total, the Hospital and WDPC together provided $20,485,010 (as measured by gross charges) of community assistance programs in 2011, impacting 21,624 patients.The Hospital's core programs include our Cancer Center, Emergency Department, and Surgical Services. In addition, WDH offers other key services in the areas of Women's and Children's Services and Cardiology Services.1. The Seacoast Cancer Center at Wentworth-Douglass Hospital offers the most comprehensive cancer treatment services covering the Seacoast region of New Hampshire and Southern Maine. Founded 30 years ago as a single room adjacent to the Emergency Department, the Cancer Center's services now include extensive, state of the art medical and radiation oncology diagnostic services with multiple treatment options. In 2008, a $9.3 million expansion project brought the Novalis TX stereotactic radiosurgery to the Seacoast, saving patients travel time to distant treatment centers. The new service gives hope to patients with complex tumors of the brain, liver and other vital organs. Wentworth-Douglass Hospital was the first hospital, nationwide, to install the Novalis TX system created by BrainLab and Varian Medical.A multidisciplinary Chest Clinic, located in the Seacoast Cancer Center, saw its first patients in October 2008. The medical team focuses on timely access to services for patients with lung nodules and lung cancer. 2. The Emergency Department at Wentworth-Douglass Hospital is the busiest in the Seacoast and third busiest in the State of New Hampshire. Close linkages to local emergency services personnel and Fire & Rescue Departments continue to extend the skill and capabilities of the Department. Through internal and external education efforts, the Emergency Department focused on improving patient care for specific types of heart attack (STEMI) and stroke. The Department's efforts in the Fall of 2008, through a clinical collaboration with Massachusetts General Hospital, created the Stroke Initiative to form a center of excellence for stroke care. In October 2009 the American Heart/Stroke Association awarded WDH the Bronze Award for achieving its high standard, quality guidelines for six consecutive months. In 2011 the Hospital received a Gold Plus Award from The Joint Commission for 24 consecutive months of achievement at the Stroke Center.To accommodate increasing patients the Department also added additional space for six treatment rooms and opened a Walk-In Urgent Care Center in Lee, NH to support the growing population areas in the towns surrounding Lee.The Hospital's generous Charity Care Program offers emergency, walk-in and other hospital services at no charge for qualifying patients at 300% of the Federal Poverty Level. 3. Surgical Services at WDH include a wide array of services and technological advances frequently associated with larger medical centers. A recent renovation to enlarge operating rooms created digital ORs and space for new equipment such as the daVinci Robotic Surgical System. Now in its sixth year, the robotic program began with OB/GYN surgeons, and now includes Thoracic, General Surgery and Urology. Another clinical collaboration with MGH at WDH brings a GYN/Oncology surgeon to WDH to perform "medical center" surgery in the community setting, eliminating the time and the frustration of travel to and parking at metropolitan cities.A range of minimally invasive procedures including Robotic Surgery, Single Incision Laparoscopic Surgery (SILS) used by general surgeons and Video Assisted Thoracic Surgery (VATS) procedures used by the thoracic surgeon offer patients the benefits of complex surgery with less blood loss, less infection and faster recovery.The Joint Replacement Program introduced in 2006 offers a unique approach to joint replacement surgery with pre-op group education and post-op group rehab. Surgeons, anesthesiologists, nursing, rehab and nutrition staff worked collaboratively to create this new approach to joint replacement care. In 2009 the Hospital created the Northern New England Spine Center, a partnership of specialists to coordinate and expedite the care of patients with neck and back pain. The Spine Center members include a spine surgeon, physiatry specialists, pain specialists, WDH rehab, behavioral health specialists and a WDH Spine Coordinator. The virtual center holds bimonthly multidisciplinary conferences to coordinate the care and treatment of Spine Center patients.Other Services:In addition to the services listed above, Wentworth-Douglass Hospital offers traditional services with non-traditional components. One example is The Birth Center. Currently The Birth Center is the fastest growing birthing service in the Seacoast area with nearly 1,000 births per year. In an effort to support a small but growing and young Indonesian population, The Birth Center translated all forms and information for new mothers into Indonesian. Local church groups welcomed Indonesian families into their communities.Cardiology Services recently replaced the cath lab with new equipment and the Department added Non-Invasive Cardiovascular Services at a new, offsite medical office building in Dover, extending the options now available for patients. A second cardiovascular interventional lab was opened late in 2010 to accommodate growing patient volume and urgent cases.All the Community Assistance (Benefit) Services support low income, uninsured individuals and families in the Hospital's service area with Charity Care (Financial Assistance), Medication Assistance, the Wentworth-Douglass Community Dental Center and the Care-Van free patient transport service. 205092288 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 1 0 0 1 255 0 1 1967 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NH X X Peter E Walcek CFOVP of Finance 6037402804 789 Central Avenue Dover NH 038202526 X Neil Garvey 5.00 X X 0 0 0 Roger Hamel 3.00 X X 0 0 0 Michael Steinberg 3.00 X X 0 0 0 Carol Bailey 3.00 X X 0 0 0 William Boc 2.00 X 0 0 0 Gerald Daley EdD 2.00 X 0 0 0 Lisa Destefano 2.00 X 0 0 0 Peter Dirksmeier MD 2.00 X 0 0 0 David Flavin MD 2.00 X 0 0 0 Wes Kennedy 2.00 X 0 0 0 Donna Rinaldi 2.00 X 0 0 0 Theodore Ristaino 2.00 X 0 0 0 Steven C Webb 2.00 X 0 0 0 Joseph White MD 8.00 X 110000 0 0 Ann Torr 2.00 X 0 0 0 Robert Decolfmaker 0.10 X 0 0 0 Linda Hagan 1.00 X 0 0 0 Gregory J Walker 55.00 X X 645708 0 148296 Peter E Walcek 55.00 X 326016 0 75307 Paul R Cass DO 50.00 X 324310 0 76592 Ellen L Caille 50.00 X 290088 0 77688 Daniel N Dunn 50.00 X 258660 0 34904 Sheila M Woolley 50.00 X 247250 0 44188 Malcolm D Rosenson MD 50.00 X 223743 0 28718 2425775 0 485693 129 0 1 0 Siemens Medical Solutions 51 Valley Stream Parkway Malvern PA 19355 IT hardware/implementation services 3031741 Siemens Healthcare Diagnostics Inc 511 Benedict Avenue Tarrytown NY 10591 Lab system, service contracts 1715865 Sodexo Inc & Affiliates 9801 Washington Boulevard Gaithersburg MD 20878 Food services/management 1699440 Mayo Collaborative Services Inc PO Box 9146 Minneapolis MN 55480 Reference lab services 1064879 Health Plans Inc 1500 West Park Drive Suite 330 Westbrough MA 01581 TPA fees - health plan 988634 29 251570 205647 457217 Patient service revenu 900099 246390017 246390017 Disproportionate share 900099 5260300 5260300 Cafeteria 722320 1163133 1133439 29694 Child care service 624410 889521 889521 1606442 1606442 255309413 1631861 14235 1617626 2461744 504271 1957473 1957473 2296957 -339484 102750198 102374874 33567 375324 -33567 341757 341757 Transcription 900099 305923 305923 Loss on early extingui 900099 -618283 -618283 186064 182464 3600 -126296 259571425 258065063 47529 1001616 X 1195327 1195327 87528642 74399346 13129296 3228452 2744184 484268 16786386 14268428 2517958 7960789 6766671 1194118 942933 942933 82750 82750 31275 31275 125175 125175 1439300 1382007 57293 677707 677707 3691631 3137886 553745 3598659 2824947 773712 146829 110122 36707 5451973 5179374 272599 16352942 13900001 2452941 1603367 1523199 80168 Supplies & other expens 24834213 21109081 3725132 Provision for bad debt 16001909 16001909 Pharmacy 12942299 12942299 NH MET 11712300 11712300 18202331 16412827 1789504 234537189 205092288 29444901 0 52444 68164 32204188 33208218 27170789 29282969 3116219 3059986 2420487 3588952 309249560 160683499 131587530 148566061 81902090 109758354 17549525 19616533 13279816 14662537 2525077 3009723 311808165 364821497 30194996 39170281 128258 81832 84841863 125860687 7091627 8505034 122256744 173617834 X 186712004 188224079 1672323 1800315 1167094 1179269 189551421 191203663 311808165 364821497 X 25034236 -23381994 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 11660 0 0 1 2915 0 1 31275 45850 0 Explanation of Lobbying Activities: Part II-B, Line 1: During 2011, WDH representatives attended New Hampshire Hospital Association meetings and contacted state legislators to provide educational information and WDH's position on key bills. In addition, Gregory Walker, CEO, provided correspondence to and had limited direct contact with senators regarding pertinent federal and state issues. NHHA, portion of dues allocated to lobbying, $24,277 AHA, portion of dues allocated to lobbying, $6,998 99989314 27460290 3851272 22455 131278421 89122889 25362 21394694 10553631 99989314 87480527 9452164 9150040 16959842 89122889 98989793 17943608 -29452874 87480527 0.73700 0.00670 0.25630 0 0 3292772 3292772 94049595 38660820 55388775 18169086 2083993 16085093 119423026 91086017 28337009 74315081 28852669 45462412 148566061 Alternative investments 19616533 F 19616533 Est. third-party payor settlement 8505034 8505034 259571425 234537189 25034236 -3151041 -20230953 -23381994 1652242 236064256 -3151041 -20230953 -23381994 259446250 125175 125175 259571425 234412014 0 234412014 125175 125175 234537189 Description of Intended Use of Endowment Funds: Part V, Line 4: To further the Hospital's charitable mission. 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: Change in FV of interest rate swap agreement -1,805,549. Net change in restricted assets held by WDHHF -148,612. Net loss on investments in joint ventures & related organizations -18,276,792. Total to Schedule D, Part XI, Line 8: -20,230,953. Part XII, Line 2d - Other Adjustments: Change in FV of interest rate swap agreement -1,805,549. Net change in restricted contributions held by WDHHF -148,612. Investment in joint ventures & related organizations -18,276,792. Central America and the Caribbean 0 0 Investments - FMV as of 12/31/11 NONE 20321231 0 0 0 0 0 0 20321231 0 20321231 1 0 1 1 0 0 IRS Form 5471 is not required: Part IV, Line 3: This organization did not have an ownership of any foreign corporation that would be greater than the 10% ownership filing threshold. Accordingly, IRS Form(s) 5471 is not required to be filed. 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 13272 8818294 8818294 0.04040 7829251 7829251 0.03580 13272 16647545 16647545 0.07620 11323 922851 922851 0.00420 367073 367073 0.00170 937107 937107 0.00430 11323 2227031 2227031 0.01020 24595 18874576 18874576 0.08640 1 7092366 709236 59861701 103991672 -44129971 X 1 1 1 None 1 1 Wentworth-Douglass Hospital

789 Central Avenue Dover NH 038202526

X X X Wentworth-Douglass Hospital 1 1 1 300.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X 1 X X X 1 X X X X X X X 1 X 0 0 35 Wentworth Homecare & Hospice

113 New Rochester Road Dover NH 03820

Hospice And Home Care Services WDH Professional Center at Dover

10 Members Way Dover NH 03820

Diagnostic Services WDPC - Hospitalists

789 Central Avenue Level 2 Dover NH 03820

Inpatient Physician Services Lee OTPTImaging

65 Calef Highway Lee NH 03861

Occupational/Physical Therapy & Imaging WDPC - Strafford Medical Associates

10 Members Way Suite 302 Dover NH 03820

Primary Care Practice Seacoast General Surgery

750 Central Avenue Suite N Dover NH 03820

Specialty Care Practice WDPC - Adult & Children's Medicine

10 Members Way Suite 201 Dover NH 03820

Primary Care Practice WDPC - Dover Family Practice

10 Members Way Suite 203 Dover NH 03820

Primary Care Practice WDPC - Seacoast Pulmonary (Intensivists)

789 Central Avenue Level 3 Dover NH 03820

Specialty Care Practice WDPC - Endocrinology & Diabetes

19 Webb Place Dover NH 03820

Specialty Care Practice Lee Urgent Care

65 Calef Highway Lee NH 03861

Urgent Care Facility & Diagnostic Services WDPC - Primary Care of Dover

10 Members Way Suite 300 Dover NH 03820

Primary Care Practice WDPC - Dover Internal and Geriatric Medi

10 Members Way Suite 301 Dover NH 03820

Primary Care Practice WDPC - Durham Health Center

36 Madbury Road Durham NH 03824

Primary Care Practice WDPC - Lee Family Practice

65 Calef Highway Suite 200 Lee NH 03861

Primary Care Practice WDPC - South Berwick Family Practice

31 Colcord Street South Berwick ME 03908

Primary Care Practice Medical Oncology

789 Central Avenue Dover NH 03820

Specialty Care Practice WDPC - Barrington Health Center

2 Century Pines Drive Barrington NH 03825

Primary Care Practice WDPC - Hilltop Family Practice

85 Main Street Somersworth NH 03878

Primary Care Practice Manchester Urology Associates Dover

10 Members Way Suite 402 Dover NH 03820

Specialty Care Practice WDPC - Bellamy Health Center

15 Old Rollinsford Road Dover NH 03820

Primary Care Practice Durham Rehab and Sports Therapy Center

16 Jenkins Court Durham NH 03824

Specialty Care Practice WDPC - Seacoast Arthritis & Osteoporosis

15 Old Rollinsford Road Suite 204 Dover NH 03820

Specialty Care Practice WDPC - Wentworth Community Dental Care

668 Central Avenue Dover NH 03820

Dental Services WDPC - Marshwood Family Care

19 Levesque Drive Suite 2 Eliot ME 03903

Primary Care Practice Plastic Surgery Specialists

10 Members Way Suite 303 Dover NH 03820

Specialty Care Practice Wentworth-Douglass Hospital Early Learni

789 Central Avenue Dover NH 03820

Childcare Services WDPC - Great Bay Family Practice

60 Exeter Road Unit 3 Newmarket NH 03857

Primary Care Practice WHP Cardiovascular Group

19 Old Rollinsford Road Dover NH 03820

Specialty Care Practice Health Partners of New Hampshire Inc

789 Central Avenue Dover NH 038202526

Physician/Hospital Organization WDPC - Summit Infectious Disease

15 Old Rollinsford Road Dover NH 03820

Inpatient Physician Services Allergy Associates of NH

10 Members Way Suite 200 Dover NH 03820

Specialty Care Practice Center for Medical Genetics

17 Old Rollinsford Road Suite 6 Dover NH 03842

Specialty Care Practice WDPC - Palliative Care

789 Central Avenue Level 3 Dover NH 03820

Inpatient Physician Services Strafford Health Alliance

200 Route 108 3 Somersworth NH 038781106

Physical Therapy Clinics & Women's Imaging Services Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: The Hospital uses the ratio of cost to charge methodology to calculate the cost of the community benefits it provides. The ratio of cost to charge methodology was used to reduce charity care charges down to costs and was also used to calculate the Medicaid shortfall. 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 $ 16001909. Part I, Lines 3a and 3b and Part V, lines 9 and 10: In accordance with the instructions for Schedule H, which specify that the financial assistance eligibility criteria that applied to the largest number of the Hospital's patients based on patient contacts or encounters during 2011 should be used to answer questions regarding the cost of care and financial assistance policies, a family income limit of 300% has been reported. It should be noted, however, that, as of October 1, 2011, the family income limit was reduced to 200% of the Federal Poverty Guidelines threshold. Part II: See Form 990, Part III, Line 4a. Part III, Line 4: From Footnote 1 of the 2011 audited consolidated financial statements:"The allowances for doubtful accounts and charity care are provided based on an analysis by management of the collectibility of outstanding balances. Management considers the age of outstanding balances, past collection efforts and the current economic environment in determining the allowance for doubtful accounts. Accounts deemed uncollectible are charged off against the established allowance." The Hospital uses the ratio of cost to charge methodology to reduce total bad debt expenses of $16,001,909 (reported on Form 990, Part IX, Line 24b) down to cost. In 2011, it cost the Hospital $7,092,366 to provide care to patients, for which the Hospital received no payments for services rendered. While the Hospital considers the $7,092,366 to be the cost of care provided to patients for services rendered for which no payment was received, we do not consider this to be a community benefit and therefore have not reported it in Part I, Line 7. Part III, Line 8: In 2011, the Hospital provided care costing $103,991672 to Medicare patients, for which it was reimbursed $59,861,701, representing a loss on Medicare services of $44,129,971. This amount represents the amount by which the Hospital was underpaid (relative to cost) by the federal government for care provided to Medicare patients, who are 65 and older, regardless of income or disability. While the Hospital considers the $44,129,971 cost to be a significant shortfall compared to the cost of providing the services rendered, we do not consider this amount to be a community benefit and therefore have not reported it in Part I, Line 7. Additionally, the amount of New Hampshire's Medicaid Enhancement Tax (MET) of $11,712,300 (see Part IX, Line 24d) has not been reported in Part I, Line 7. Part III, Line 9b: Hospitals in New Hampshire work hard to make high-quality health care available, affordable, and accessible to all, regardless of ability to pay. Wentworth-Douglass Hospital offers many financial assistance and referral programs to ensure that cost will not be a barrier to anyone in our community obtaining the health care services that he or she may need. If payment of health care expenses creates a financial hardship for patients, our staff provides assistance to complete the financial application process. As part of this financial application process, the Hospital will assess patients' eligibility for health insurance coverage through federal or state programs such as New Hampshire Medicaid and Maine Medicaid. If it is determined that patients may be eligible for one of these programs, the Hospital assists patients through the application process. Patients are required to supply the financial or medical documentation that is necessary to secure such insurance coverage.The Hospital understands that health care costs can come up unexpectedly. Whether patients are insured or uninsured, and whether or not patients qualify for financial assistance, we understand that patients may have difficulty paying healthcare costs in full at the time of service or in a lump sum. Our billing team works with patients to set up interest-free payment plans to help ease the financial burden of health care costs. Part VI, Line 2: Wentworth-Douglass Hospital's Community Benefit Task Force, a committee of the Board of Trustees that was established in 2000, conducts Community Needs Assessments every 3-5 years. The most recent Needs Assessment, completed in 2008, included five focus groups with key leaders from providers, government, healthcare, schools and social service agencies in the Hospital's primary service area. Four main projects are contained in the annual Community Assistance (Benefit) Plan as a result of the needs identified in the original and subsequent assessments: Financial Assistance (Charity Care), Medication Assistance, Care-Van Free Patient Transport and the Wentworth-Douglass Community Dental Center which provides dental health services and access to dental care to needy families in the community. Part VI, Line 3: WDH & WDPC take an active role in assisting patients who may be interested and qualify for financial assistance, whether it is state, federal or our own charity care benefits. Our Family Resource/Community Benefits Department has several processes in place to ensure patients are aware of the financial assistance available to them.Patients can learn more about these programs by visiting our website, reading our Foundation newsletters, or contacting our Financial Assistance Office. From the time of registration through our billing process, patients have available the opportunity to obtain an application for financial assistance. All self pay patients at the time of registration are provided with our charity care cover letter and application, with information about the charity care program and details on how to contact our Financial Assistance Representative(s). Our representatives also see many patients while they are here for services. Social Work Services and Community Benefits team up to assist and make sure our patients are receiving the opportunities to get any and all assistance available to them. We send five billing statements to our patients with the financial assistance guidelines and contact information if patients feel they may meet these guidelines and need assistance with their bill(s). Part VI, Line 4: Wentworth-Douglass Hospital serves the Seacoast area of New Hampshire and Southern Maine - Strafford County, Rockingham County and York County, Maine. Our community includes a small but growing Indonesian population, welcomed by local church groups. The community also includes low-income, uninsured adults and children supported by the Hospital's Community Assistance Plan programs. Part VI, Line 5: WDH owns 100% of Wentworth-Douglass Physician Corporation (WDPC), d/b/a Wentworth Health Partners, which files its own Form 990 (see Schedule R for more details). WDH oversees all of WDPC's primary care practices, specialty practices, and its dental clinic. Accordingly, all of WDPC's facility locations have been listed on WDH'S Schedule H. WDPC provided community benefits exceeding $870,000 in 2011. WDPC supports numerous community based programs, including the Community Dental Center. The Wentworth-Douglass Community Dental Center is open to low-income, uninsured adults and children living in the 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 level, based on the number of members in the household. Minimum payments are charged on a discounted fee schedule based on household income. In 2011, the Dental Center provided $390,000 of community-based clinic services through 4,416 visits.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. In 2011 WDPC provided $482,000 of financial aid (stated at cost).Medicaid Costs Exceeding Reimbursement totaled $459,184 for WDPC in 2011. Part VI, Line 6: The affiliates of Wentworth-Douglass Hospital include Wentworth-Douglass Physician Corporation, Wentworth-Douglass Community Health Corporation and the Wentworth-Douglass Hospital and Health Foundation. Our affiliates serve to further our mission of helping our patients and their families attain their highest level of health. The Wentworth-Douglass Physician Corporation was formed in response to a community needs assessment that identified a lack of primary care services in the community. The formation of the Physician Corporation and recruitment of primary care physicians closed the gap by improving access to primary care medical services in our community. Today, WDPC also provides a vast array of specialty physician services to the community.Wentworth-Douglass Community Health Corporation (The Works), a for-profit taxable subsidiary of the Hospital, serves to promote community health and wellness, while remaining family focused. The Works offers specially designed and supervised fitness programs, aimed to help manage diabetes, lower risk of heart disease, and improve quality of life. In addition, the Hospital collaborates with The Works to offer group exercise programs to our patients, including Cancer Center patients, who are provided a free three month membership and invited to participate in a program that combines rehabilitation and group exercise. The Works also donates memberships as well as the use of its facilities and staff time to benefit various community organizations in support of health care initiaitives.The Wentworth-Douglass Hospital and Health Foundation serves to cultivate, secure and steward philanthropic gifts that will support the capital, programmatic and endowment needs of Wentworth-Douglass Hospital. Reports Filed With States Part VI, Line 7 NH X 1 1 X X X X 0 1 0 0 0 0 0 1 0 Gregory J Walker 416504 0 88826 0 140378 0 127804 0 20492 0 794004 0 0 0 Peter E Walcek 279133 0 37192 0 9691 0 56035 0 19272 0 401323 0 0 0 Paul R Cass DO 283574 0 37236 0 3500 0 57218 0 19374 0 400902 0 0 0 Ellen L Caille 244925 0 35143 0 10020 0 51616 0 26072 0 367776 0 0 0 Daniel N Dunn 227334 0 20193 0 11133 0 17150 0 17754 0 293564 0 0 0 Sheila M Woolley 217253 0 19233 0 10764 0 34752 0 9436 0 291438 0 0 0 Malcolm D Rosenson MD 219743 0 0 0 4000 0 11296 0 17422 0 252461 0 0 0 Part I, Line 1a Certain retirement and fringe benefits for Gregory J. Walker (President/CEO) have been grossed-up utilizing the applicable marginal federal tax rate as the most efficient and cost effective means to fulfill the target benefit goal at retirement. 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, Paul R. Cass, DO = $42,518, Ellen L. Caille = $40,126 and Sheila M. Woolley = $21,960. Part I, Line 7 At-risk compensation, which is subject to review and paid annually. It is based on several predefined metrics, including patient satisfaction, quality, and financial targets. NHHEFA Authority Revenue BondsWDH Issue Series 2011A 020279866 644614var 2011-04-06 87920000 Refinancing bonds & construction of new inpatient wing 0 0 0 NHHEFA Authority Revenue BondsWDH Issue Series 2011B 020279866 644614M63 2011-04-06 18820000 Refinancing bonds 0 0 0 30000000 87825276 12741700 1126031 43957545 2012 0 0 0 1 18390000 16675055 194599 1520345 2011 1 0 1 1 0 0 0 0 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 1 0 0 0 0 0 0 0 1 1 Piper Jaffray - See Part VI for more 0 0 0 0 0 Part IV, Line 2c Term of Hedge The $18,820,000 bond listed on line B of Part I is split into approximately two equal hedges, one with a term of 11.8 years (ending on 1/1/2023) and the other 19.8 years (ending on 1/1/2031). Peter Dirksmeier MD Employee of SOSMED 205313 In 2011, OATS Realty, LLC paid the Hospital $41,516 as rental fees for professional medical space located at the WD Professional Center in Lee, NH and $10,715 for practice support services. The Hospital collected on behalf of SOSMED accounts receivables for a supported physician in the amount of $153,082. 0 Wentworth Homecare and Hospice LLC Current officer serves both organizations 825000 The Hospital has a 50% ownership interest in Wentworth Homecare and Hospice, LLC. The Hospital accounts for its investment in joint ventures under the equity method. The 2011 income recorded for the Hospital's share of revenues equaled $857,712 from which it received a cash distribution of $825,000. 1 Granite Shield Insurance Exchange Current officer serves both organizations 1422063 The 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. 1 Granite Healthcare Network Current officer serves both organizations 48315 The Hospital made a capital contribution of $92,854 to Granite Healthcare Network for an ownership interest of 16.9%. The 2011 income recorded for the Hospital's share of revenues equaled $7,839. There was no cash distribution. The Hospital paid a total of $48,315 in 2011 for monthly shared services. 1 Northeast Purchasing Coalition LLC Current officer serves both organizations 55000 The Hospital made a capital contribution of $55,000 to Northeast Purchasing Coalition for an ownership interest of 2.439%. The Hospital's share of the 2011 ordinary business loss was $36,229. 1 GSI Services Current officer serves both organizations 1250 Pending confirmation that current officer serves both organizations. 1 Form 990, Part IV, Line 26 AND Part X, Line 15: WDH sponsors a split-dollar life insurance employee benefit program for certain officers and key employees. Split dollar life insurance is an arrangement in which the employee is the owner of the life insurance policy and the premiums are paid by the employer. Pursuant to WDH's split-dollar agreement, and the collateral assignment therein, the employer's share of the policy premiums paid is recovered either upon termination of the policy or at the death of the participant. Note that the split-dollar arrangement is part of an employee benefit program and economically not a direct extension of credit. Furthermore, the reportable compensation of the respective employees includes the annual value of the life insurance. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is initially reviewed in detail by the Finance Committee and key 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 the Hospital'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 CEO's compensation and benefits are reviewed, adjusted, and voted on by all independent members of the board annually. Every other year, a national independent consulting firm is engaged by the board to provide comparative market compensation data for executive and management positions at the hospital. The Board of Trustees uses the data to compare Wentworth-Douglass's CEO compensation with that of other hospital executives nationally and in the Northeast region to determine the CEO's total compensation. On alternate years, when the consulting firm is not engaged, the Board uses salary ranges established the prior year and market economic data to validate that the CEO's salary is competitive and make market adjustments. Additional factors taken into account to determine the CEO's salary are based on several predefined metrics, including patient satisfaction, quality, and financial targets. The CEO is excused from Board discussion and voting on issues surrounding CEO compensation and benefits. Compensation of Key Employees: The CEO reviews the salaries of Key Employees annually and recommends compensation based on performance, salary ranges and market competitive data. Compensation data is provided by an independent national consulting firm every other year. The CEO presents salary range data for Key Employees to the board annually for approval. Using the Board approved salary range data, the CEO recommends salary increases for Vice Presidents to the Board for approval and the Vice Presidents recommend salary increases for Directors and other Management positions to the CEO, for approval. Physician salary ranges are established using the Medical Group Management Association (MGMA) salary survey data. Form 990, Part VI, Section C, line 19 Wentworth-Douglass Hospital 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 WDH 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. Governing Body and Management: Form 990, Part VI, Line 1a and Line 1b: Steven C. Webb is a trustee of the Hospital and an executive at TD Banknorth. The Hospital maintains operating and payroll accounts with TD BankNorth. Transactions in 2011 were in excess of $10,000. An exact figure cannot be stated due to daily account activity and balance changes. Both accounts were active prior to Mr. Webb joining the Board and all transactions with TD Banknorth are at a fair market rate. For 2011, Mr. Webb has been classified as an independent board member. Reportable Compensation from the Organization: Form 990, Part VII, Section A, Column D: The 2011 compensation reported for Dr. Joseph White was paid by Wentworth-Douglass Hospital for his services as the president of the medical staff. Dr. White is not compensated for his services as a trustee of WDH. Fundraising expenses: Form 990, Part IX, Column D: Wentworth-Douglass Hospital and Health Foundation (a related organization) performs all fundraising activities on behalf of Wentworth-Douglass Hospital. All fundraising expenses are reported on the Foundation's separate Form 990. Increase in Medicaid Enhancement Tax: Part IX, Line 24d: The New Hampshire Medicaid Enhancement Tax (MET) is a 5.5% tax on net patient service revenue paid by hospitals to the State of New Hampshire. Hospitals have been paying the MET since 1991, but in previous years, after the State had received matching federal funds, it provided the hospitals uncompensated care payments towards the cost of care of patients without insurance and those covered by Medicaid. The net effect was that most of the MET was returned to the hospitals. Accordingly, in 2010 Wentworth-Douglass Hospital paid $11,257,754 in MET and received $10,520,601 in uncompensated care payments from the State. However, in 2011, the State reduced and/or eliminated payments to the hospitals for uncompensated care. Although Wentworth-Douglass Hospital paid $11,712,300 in MET in 2011 (see Part IX, line 24d), uncompensated payments received from the State were only $5,260,300. Thus, the 2011 net impact of increased MET expense and the reduced uncompensated care revenue was $6,452,000. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -3,151,041. Change in FV of interest rate swap agreement -1,805,549. Net change in restricted assets held by WDHHF -148,612. Net loss on investments in joint ventures & related organizations -18,276,792. Total to Form 990, Part XI, Line 5: -23,381,994. Audit Review Process: Form 990, Part XII, Line 2c: The Finance Committee oversees the audit process for Wentworth-Douglass Hospital and all related organizations. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2010 and 2011. Wentworth-Douglass Physician Corporation 789 Central Avenue Dover NH 03820 020497927 Health care NH 501(c)(3) 170(b)(1) (A)(iii) N/A 1 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 1 Wentworth-Douglass Community Health Corporation 789 Central Avenue Dover NH 03820 020399963 Health fitness center NH N/A C -202008 11600932 1.00000 1 1 1 0 0 0 0 0 1 1 1 0 1 1 0 1 1 1 Wentworth-Douglass Hospital & Health Foundation C 251570 Actual per books Wentworth-Douglass Hospital & Health Foundation B 613697 Actual per books Wentworth-Douglass Community Health Corporation A 14235 Actual per books Wentworth-Douglass Community Health Corporation J 144000 Actual per books Wentworth-Douglass Community Health Corporation N 147664 Actual per books Wentworth-Douglass Community Health Corporation P 105408 Actual per books Wentworth-Douglass Community Health Corporation Q 471695 Actual per books Wentworth-Douglass Physician Corporation P 284127 Actual per books Wentworth-Douglass Physician Corporation B 17819989 Actual per books Wentworth-Douglass Physician Corporation I 2296957 Actual per books Wentworth-Douglass Physician Corporation K 718523 Actual per books