2011-05-16T13:44:40-05:00 2010-06-30 DELOITTE TAX LLP 555 E Wells St Suite 1400 Milwaukee WI 53202 990 2009-07-01 391834639 Columbia St Mary's Inc COLU 4143262230 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 RHONDA ANDERSON 4143262230 2011-05-16 1 4142713000 2009 2016-02-24 21:20:13Z LEO BRIDEAU 4425 NORTH PORT WASHINGTON ROAD GLENDALE WI 53212 27010189 0 0928 X COLUMBIA-STMARYS.ORG X 2001 WI HEALTH CARE SYSTEM DEDICATED TO MAKING A POSITIVE DIFFERENCE IN INDIVIDUALS AND OUR COMMUNITY. 15 12 21 12 106322 16720 0 4293182 13846832 1236795 1332905 13221334 11830452 18751311 27010189 360000 0 943877 8133293 0 0 13997201 16101502 14941078 24594795 3810233 2415394 233657811 292829491 158280048 224000083 75377763 68829408 COLUMBIA ST. MARY'S INC. ("CSM") IS A HEALTHCARE PROVIDER FOUNDED IN RESPONSE TO IDENTIFIED COMMUNITY NEEDS, WHICH IS SPONSORED BY ASCENSION HEALTH, A CATHOLIC NATIONAL HEALTH SYSTEM, AND COLUMBIA HEALTH SYSTEM, A NON-SECTARIAN COMMUNITY HEALTH SYSTEM. CSM EXISTS TO MAKE A POSITIVE DIFFERENCE IN THE HEALTH STATUS AND LIVES OF INDIVIDUALS AND OUR COMMUNITY, WITH SPECIAL CONCERN FOR THOSE WHO ARE VULNERABLE. CSM AND ITS AFFILIATES ARE COMMITTED TO PROVIDING HIGH-QUALITY, ACCESSIBLE, VALUES-DRIVEN PROGRAMS AND SERVICES WITH EQUAL ATTENTION TO THE PHYSICIAL, SPIRITUAL, AND EMOTIONAL DIMENSIONS OF HEALTH. 0 0 20341231 23734439 CSM INC EXISTS AS THE PARENT CORPORATION IN THE CSM SYSTEM, WHICH IS COMPRISED OF FOUR HOSPITALS, (ST. MARY'S HOSPITAL MILWAUKEE INC, COLUMBIA HOSPITAL, COLUMBIA ST. MARY'S HOSPITAL OZAUKEE INC, AND SACRED HEART REHABILITIATION INSTITUTE INC.), 66 COMMUNITY CLINICS, THE COLUMBIA COLLEGE OF NURSING, SETON CHILDREN'S SCHOOL, A PARTNERSHIP WITH THE ORTHOPAEDIC HOSPITAL OF WISCONSIN, AND FOUR URGENT CARE CENTERS. DURING FISCAL 2010, CSM'S HEALTH SYSTEM PROVIDED CARE TO 246,625 PATIENTS. THE ESTIMATED UNREIMBURSED COST OF SERVICES PROVIDED TO THE ELDERLY, UNINSURED AND UNDERINSURED TOTALED $149,823,841. REFER TO THE COMMUNITY BENEFIT INFORMATION IN SCHEDULE H FOR DISCUSSION OF HOW CSM MAKES A POSITIVE DIFFERENCE IN THE HEALTH STATUS OF ITS COMMUNITY, FOCUSING ON THOSE WHO ARE VULNERABLE. 20341231 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 57 0 1 21 1 1 1 0 0 0 0 0 0 0 0 15 12 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Rhonda Anderson 4143262230 4425 N PORT WASHINGTON ROAD GLENDALE WI 53212 Christopher Doerr 1.00 X 0 0 0 David Hoogerland MD 5.00 X 0 432564 121867 George H Hoff 1.00 X 0 0 0 James B Wigdale 1.00 X 0 0 0 Kevin Goniu MD 5.00 X 0 639309 121858 Leo P Brideau 10.00 X X 1473308 0 101102 MASON G ROSS 1.00 X 0 0 0 Michael Grebe 1.00 X 0 0 0 R Bruce McDonald 1.00 X 0 0 0 Randall Perry 1.00 X 0 0 0 Robert Lyon MD 1.00 X 0 0 0 Robert Venable 1.00 X 0 0 0 Sister Theresa Sullivan DC 1.00 X 0 0 0 Tina Chang 1.00 X 0 0 0 CHRISTINE NUERNBERG 1.00 X 0 0 0 RHONDA ANDERSON 5.00 X 407494 0 69001 Amy Marquardt 5.00 X 298810 0 71352 Cheryl Hill 5.00 X 297147 0 83703 David H Shapiro MD 5.00 X 384210 0 71879 Gerri Lietz-Staffileno 5.00 X 0 270954 109265 Karol Marciano 5.00 X 353065 0 63358 Mary Paul 5.00 X 0 501197 46050 Sue Sanicola 5.00 X 241558 0 64704 William Hart 5.00 X 0 320296 43653 DEBORAH FRIBERG 5.00 X 0 5308 0 BRUCE MCCARTHY 5.00 X 0 0 0 Constance J Bradley 5.00 X 0 235716 33230 Paul Westrick 5.00 X 229529 0 96821 David Olson 5.00 X 0 25017 0 Brian Regan 5.00 X 307340 0 36788 Therese Pandl 0.00 X 0 774991 71841 3992461 3175027 1206472 9 1 1 0 CG SCHMIDT BARTON MALOW 26500 AMERICAN DRIVE Southfield MI 48034 PROJECT MANAGEMENT 7021241 HOK GROUP PO BOX 200119 DALLAS TX 753200119 ARCHITECTURAL DESIGN 1151604 MARSH USA INC PO BOX 1450 NUBBEAOIKUS MN 554858625 FINANCIAL SERVICES 716595 ZURICH NORTH AMERICA 8745 PAYSPHERE CIRCLE CHICAGO IL 60674 FINANCIAL SERVICES 669034 CHRISTOPHER SMOCKE & ASSOC INC 2221 NORTH TERRACE AVENUE MILWAUKEE WI 53202 DESIGN AND CONSTRUCTION 499349 16 Home office allocation 900099 13805732 13805732 Rental Income-Physicia 532000 41100 41100 13846832 1332905 1332905 JOINT VENTURE INCOME 622110 9674963 9674963 Capitalized Interest 900099 1604553 1604553 GAIN/LOSS ON INVEST 900099 292212 292212 258724 106322 106322 46080 11830452 27010189 23628117 106322 3275750 360000 360000 4091909 4091909 2192881 2105166 87715 1073587 1030644 42943 332065 318782 13283 442851 425137 17714 111564 111564 650780 650780 742159 742159 5657346 5657346 1814 1814 32231 32231 3397095 3397095 859996 859996 66104 66104 Ascension Fees/Dues 4322416 4322416 AFFILIATION EXPENSE 101579 101579 SPECIAL PROGRAMS 89547 89547 68871 68871 24594795 20341231 4253564 0 703246 657752 6878320 46409397 68176 4388169 2004600 617320 708915 662258 1535119 2152411 273579842 108890534 155952785 164689308 38825241 39806060 9611934 9029392 17369475 24417424 233657811 292829491 23716010 19869030 134564038 204131053 158280048 224000083 X 51211275 46835982 18067766 15571920 6098722 6421506 75377763 68829408 233657811 292829491 X 0 1 1 X 0 X X X X 0 0 0 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE 390806315 3 1 1 1 9583711 COLUMBIA ST MARY'S HOSPITAL OZAUKEE 390807063 3 1 1 1 4100225 SACRED HEART REHABILITATION INSTITUTION 390902199 3 1 1 1 121795 SETON CHILDREN'S SCHOOL 391391245 9 1 1 1 0 COLUMBIA COLLEGE OF NURSING INC 391596986 2 1 1 1 0 5 13805731 0 1 0 0 0 0 1 22637 0 1 8181 30818 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: A key employee spends 10% of time (amount reported on line g) researching issues and preparing for meetings and presentations for: County officials - funding and operational issues related to the General Assistance Medical Program State Legislators, other elected officials and staff - lobbying on Medical Assistance funding, public health initiatives, and provider regulations; federal elected officials and staff - lobbying and Medicare and Medicaid funding and provider regulations. OTHER ACTIVITIES: AMOUNT PAID TO GOVERNMENT AFFAIRS CONSULTING FIRM PROVIDING LEGISLATIVE, REGULATORY, AND COMMUNICATIONS SERVICES. 9243279 9243279 105589911 68141598 37448313 1636737 306278 1330459 46088507 38831276 7257231 111021408 1611382 109410026 164689308 ORTHOPAEDIC HOSPITAL OF WISC LLC 13211340 C HOME CARE MEDICAL 967055 C CSM STRATEGIC ALLIANCE 43395 C HORIZON HOMECARE 3550844 C WI MEDICAL CYCLOTRON LLC 40000 C CSM FOUNDATION (RESTRICTED FUNDS) 21993426 C 39806060 Deferred Compensation 440690 Assets Held for sale 4770111 Pension Prefunding 19206623 24417424 Due to affiliates 50644407 INTERCOMPANY DEBT TO ASCENSION HEALTH 145678466 Deferred Pension 1767648 Deferred Compensation 440690 Misc Noncurrent Liab 2436692 Misc Current Liabilities 3163150 204131053 PART X: ASC 740 footnote regarding uncertain tax positions in audited financials: Not applicable. 1 1 1 X 1 X 1 1 0 1 1 242716 0 242716 0.01000 4380330 2449473 1930857 0.07950 4623046 2449473 2173573 0.08950 4623046 2449473 2173573 0.08950 0 90608 0 1391681 4891229 -3499548 X 1 1 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC ORTHOPAEDIC SURGERIES 0.50000 0.50000 ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC

475 WEST RIVER WOODS PARKWAY GLENDALE WI 53212

X Part I, Line 3c: The hospitals of CSM provide medically necessary care to all patients, regardless of race, color, creed, ethnic origin, gender, disability or economic status. OHOW's specific policy uses a percentage of Federal Poverty Level (FPL) to determine free and discounted care. At a minimum, patients with income less than or equal to 200% of the FPL, which may be adjusted for cost of living utilizing the local wage index compared to national wage index, will be eligible for 100% charity care write off of charges for services that have been provided to them. Part I, Line 6a: OHOW files an annual community benefit report with the Wisconsin Hospital Association ("WHA"). CSM does not file a community benefit report with the WHA since CSM does not have any patient care revenue. However, CSM is the parent entity of 4 hospitals, Columbia Hospital, St. Mary's Hospital Milwaukee, Inc., Columbia St. Mary's Hospital Ozaukee, Sacred Heart Rehabilitation, Inc. each of which file community benefit reports with WHA. CSM does, however, prepares a report to the community, available on its website at www.columbia-stmarys.org, which describes the benefits that the CSM organization provides to the community. Part I, Line 7: The cost of providing charity care, means tested government programs, and community benefit programs is estimated using internal cost data, and is calculated in compliance with Catholic Health Association ("CHA") guidelines. The organization uses a costing accounting system that addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self pay). The best available data was used to calculate the amounts reported in the table. For certain categories in the table, this was a cost accounting system; in other categories, a specific cost- to-charge ration was applied.Part I, Line 7g: The organization has not included costs attributable to a physician clinic as part of subsidized health services. Part I, Line 7f: CSM's share of the amount of bad debt expense reported by OHOW in 2009 but subtracted for purposes of calculating the percentages in Part I, Line 7, column (f) is $309,242. Part III, Line 4: OHOW, which files financial statements separate from CSM, includes the following footnote related to accounts receivables: "The majority of the Hospital's accounts receivables are due from third-party payors under reimbursement agreements and from patients for services provided. Accounts receivable are due upon receipt of invoice. Receivables are stated net of any allowance for contractual discounts and uncollectible accounts by considering the number of days past due, collection history, and the general economy and industry as a whole. Contractual adjustments are based on expected payment rates in accordance with third-party payor agreements. The Hospital writes off accounts receivable when they are determined to be uncollectible. Payments subsequently received are credited to the allowance for doubtful accounts." CSM's share of OHOW bad debt expense in 2009 was $309,242 at charges ($90,608 at cost). Part III, Line 8: OHOW follows the Catholic Health Association ("CHA") guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit. Part III, Line 9b: OHOW has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance certain collection practices do not apply. Part V: COLUMBIA ST. MARY'S, INC. ("CSM") OWNS 50% OF A JOINT VENTURE THAT IS AN ENTITY TAXED AS A PARTNERSHIP, ORTHOPAEDIC HOSPITAL OF WISCONSIN, LLC ("OHOW"). THE INFORMATION REPORTED ON PARTS I, II AND III ONLY PERTAIN TO CSM'S SHARE OF OHOW'S ACTIVITY. FURTHER, OHOW MAINTAINS ITS BOOKS AND RECORDS ON A CALENDAR YEAR BASIS. AS A RESULT, ALL INFORMATION REPORTED ON THE 2009 SCHEDULE H REFLECTS OHOW'S 2009 CALENDAR YEAR RESULTS. CSM DOES NOT FILE A COMMUNITY BENEFIT REPORT SINCE IT DOES NOT HAVE ANY PATIENT CARE REVENUE. HOWEVER, CSM'S FOUR HOSPITAL ORGANIZATIONS, COLUMBIA HOSPITAL, ST. MARY'S HOSPITAL MILWAUKEE, INC., COLUMBIA ST. MARY'S HOSPITAL OZAUKEE, AND SACRED HEART REHABILITATION, INC. EACH FILE COMMUNITY BENEFIT REPORTS WITH THE WISCONSIN HOSPITAL ASSOCIATION. Part VI, Line 2: The health needs of the communities which CSM serve are assessed as part of CSM overall through the work of the CSM Community Benefit Committee ("CBC"), which addresses the needs of CSM's three hospital campuses collectively. The CBC is guided by the mission statement of CSM, and is comprised of administrative level leadership, managers, and staff involved in direct service to vulnerable people. Additionally, CBC includes a representative of the Patient Family Advisory Committee of CSM as a structured method for receiving community input. The CBC roles include the following:- Develop Community Assessment to determine needs over a two year period to address through CSM resources.- Create a Community Benefit Plan to drive CSM activities over several years.- Review and provide input to Community Benefit Reports to Ascension Health, Wisconsin Health Association and CHA.- Develop annual community benefit goals to include within CSM Integrated, Strategic, Operational and Financial Plan.- Provide input to and advocate for CSM organizational policies focused on vulnerable populations (e.g. outreach screening guidelines, transportation, collection policies).- Develop and implement communication strategies to inform multiple communities about Community Benefit achievements.- Develop a strategy to measure and increase the impact of Community Benefit programs.In fiscal 2010, the CBC prepared a Milwaukee Needs Assessment and Ozaukee Needs Assessment to guide its planning. The assessments were developed by gathering key public health and disease specific assessments for each community and synthesizing the assessments into one document for Milwaukee and Ozaukee from public sources such as HRSA Community Health Status Report for Ozaukee County, the Ozaukee Health Initiative 2002-2007, Children's Health in Wisconsin (Center for Health Statistics), Start Smart Milwaukee State of Milwaukee's Children Health Report, Healthiest Wisconsin 2010, City of Milwaukee Health Dept. Report, City of Milwaukee Community Health Survey, HRSA Community Health Status Report for Milwaukee County, Wisconsin DHFS Family Health Survey, Wisconsin DHFS Health Insurance Coverage Report, Riverwest Health Initiatives Survey Report, Milwaukee's Commitment to Action: Report from the 2003 Urban Health Forum, Milwaukee Public Health Report by Aldermanic District, Wisconsin County Health Rankings 2006 and Wisconsin Nutrition and Physical Activity State Plan. Several of these surveys include direct citizen input regarding the state of their health.The Needs Assessment was discussed in detail by the CBC to gain the insight of those at CSM involved in all areas of health and community health. The plan that was subsequently developed focused on care for vulnerable people consistent with the CSM Mission Statement. Part VI, Line 3: CSM attempts to identify patients who may be eligible for charity or discounted care as outlined in the charity care policy during the pre-registration, registration, admissions and discharge processes. A copy of the charity care policy is posted in the emergency room, and a summary of the policy is provided to patients with admission and discharge paperwork. CSM has trained financial counselors available to discuss payment options to the patients. Upon making an appointment, the financial counselors will meet with the patient to determine what other financial assistance programs the patient may qualify for. Part VI, Line 4: CSM primarily serves the Milwaukee and Ozaukee counties in southeastern Wisconsin. OHOW is located in an urban community within Milwaukee County. The population of Milwaukee County is approximately 960,000, with over 17% of the households living at or below federal poverty guidelines. The median income is approximately $46,000, over 42% of the population is a minority, and approximately 13% of the population speak a language other than English. Discounts for the uninsured and underinsured are not included in Parts I or II of Schedule H. Part VI, Line 5: OHOW has not reported any community buidling activities; however, CSM provides significant community building activities throughout its system. In order to accomplish the collaborative work in the community and to oversee access clinics and outreach programs, CSM has a Community Services Department which oversees the CSM Community Benefit Process. Programs to promote the health of the communities which the CSM organizations are affiliated with include:- The INROADS Program -- this program is a collaboration between CSM and the Milwaukee INROADS cooperative to provide culturally diverse college students an opportunity to experience the healthcare workplace. CSM has a strong record of hiring INROADS graduates after their internship experience. - Milwaukee Health Care Partnership (MHCP) -- CSM is a founding member of the Milwaukee Health Care Partnership (MHCP), which is a collaboration between the five Milwaukee health systems and Federally Qualified Health Centers to improve access to health care in the community. The partnership has worked with County health officials to improve behavioral access and Partnership funding supports mental health respite beds in the community. CSM's CEO and Mission Access Vice President each spend significant time in MHCP collaborative work. - Collaboration with community churches -- Access to health education and screening in many areas of the city is best accomplished through church collaboration. CSM employs three nurses to work in collaboration with churches and community organizations to offer health education, health screening, and care management support to parishioners and community members in a variety of outreach programs affiliated with churches. CSM developed the beginning stages of a collaboration with 44 Church of God in Christ churches in Milwaukee to accomplish better health awareness and improve screening rates. Part VI, Line 6: Community benefit activities often focus on access to primary care through free or reduced cost clinics sponsored by CSM. Following are several examples in which the hospitals of CSM focus on the connection between community needs and Community Benefit Plan activities. Infant mortality, particularly among the African American community in Milwaukee, is a particular health issue needing improvement. CSM has been an important collaborator in city and state efforts to improve birth outcomes and reduce infant mortality rates in Milwaukee. CSM has supported the Lifecourse Initiative for Healthy Families as a community/academic partnership for initiation of a five year funded plan for mortality improvement. CSM has an internal committee, CSM Healthy Families, that meets to plan improvements in support to families. A particular focus has been that of Safe Sleep initiatives to assure that infants have a safe place to sleep by providing Pack and Play cribs for mothers without a dedicated infant sleep space. Additionally, parents are educated about the importance of an infant sleeping on his back through a "Back to Sleep" campaign of infant apparel with that message imprinted. CSM's Community Needs Assessment has identified access to primary care has been a community problem in Milwaukee. CSM has responded to that need by sponsoring St. Ben's Clinic, the Community-based Chronic Disease Management Clinic which is a hypertension treatment center housed in a food pantry, the Seton Dental Clinic and the Saturday Clinic for the Uninsured. CSM sponsors medical residency education programs through the CSM Family Health Center and the OB/GYN Clinic. Each center offers sliding fee scales to uninsured and underinsured patients. Lack of access to oral health care has also been identified in the Needs Assessment. CSM sponsored the Smart Smiles program of school-based oral health care to serve 4,000 children in fiscal 2010. Dentist assessment, oral hygiene care, dental sealants and fluoride treatments are provided in more than 30 schools to meet these needs. The St. Elizabeth Ann Seton Dental Clinic serves as the urgent dental care provider for uninsured people in Milwaukee. Disparities exist in cancer diagnosis and treatment in the communities CSM serves. CSM responded by providing a Breast Health Advocate to link African American and Hispanic women into mammography and further diagnostic testing to find disease earlier and to provide more effective treatment. Columbia College of Nursing students and faculty staff El Centro de Salud nursing center at the United Community Center, which provides immunizations, physicals, health education, health promotion, screening and support to students of United Community Center preschool, elementary and middle schools, as well as to adults in family programs and older adult services.CSM collaborates with the Medical College of Wisconsin in sponsoring the following:-The Family Health Center, a residency-based Family Medicine clinic that provides primary care to more than 9,000 individuals in the community.- The OB/GYN Clinic, a residency-based program that serves over 150 patients, 250 OB appointments per month, and 325 deliveries per year.- The Chronic Disease Management Clinic, which screens and manages hypertension, diabetes, obesity, and smoking for low income adults through a clinic based in a food pantry. - The Saturday Clinic for the Uninsured, which uses medical students and volunteer physicians to serve hundreds of uninsured patients each year.Housecalls for the Homebound provides high-quality primary care to approximately 90 elderly patients in their homes who are too frail to travel to physicians' offices. Additional areas of Community Support include CSM's partnership with Sixteenth Street Community Health Center (SSCHC), a Federally Qualified Health Center (FQHC) that serves primarily Hispanic and Asian people in Milwaukee. CSM is the primary hospital to accept admissions and work closely with SSCHC to improve the health of its patients. Many of its patients are uninsured and ineligible for coverage. This has impact on CSM's charity care funding. CSM also employs a cadre of skilled interpreters to assure that communication is excellent for Spanish-speaking patients. Part VI, Line 7: The CSM health system focuses on contributing to the positive health status of the communities it serves. CSM is an organization comprised of FOUR hospitals, 66 community clinics, The Columbia College of Nursing, Seton Children's School, a partnership with the Orthopaedic Hospital of Wisconsin, and four Urgent Care Centers. CSM provides care for individuals and families throughout Milwaukee, Ozaukee, Washington, and Sheboygan counties - with more than 160 years of service to individuals and families in these communities.OHOW itself is a specialty hospital which performs more than 5,000 surgical procedures each year and offers the complete range of orthopaedic services, including joint replacements and spine procedures, rehabilitation, diagnostic testing and pain management services. As a member of Ascension Health, the nation's largest Catholic healthcare system, CSM continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. The goal of CSM is to perpetuate the health mission of the church. CSM furthers this goal through delivery of patient services, care to the elderly and indigent, patient education and health awareness programs for the community, and medical research. Our concern for all human life and dignity of each person leads the organization to provide medical services to all people in the community without regard to the patient's race, creed, national origin, economic status, or ability to pay.CSM employs a Community Benefit Philosophy in program planning and implementation. CSM provides for the health of the community through financial support provided to patients by financial discounts and contracts, by developing clinics and services for specific vulnerable groups, by sponsoring community education and training and by collaborating with government programs.During fiscal 2010, the CSM system provided more than $76,293,000 in unreimbursed services, including $8,296,000 in traditional charity care, $4,682,000 in discounts to the uninsured, $15,497,000 in community benefit programs, and $47,818,000 in other unpaid public programs, including subsidized health care, professional education, financial contributions and community building activities.In addition, CSM's governing body is comprised of local community leaders and physicians, the majority of whom reside within the communities CSM serves and are neither employees nor contractors of the organization, nor family members thereof. The CSM hospitals extend medical staff privileges to all qualified physicians in its community; however, the clinics within the organization are served by physicians affiliated with CSM. WI 1 WISCONSIN PRIMARY HEALTH CARE ASSOCIATION 4600 AMERICAN PARKWAY SUITE 204 MADISON WI 53718 360000 0 Contribution to Milwaukee Health Centers Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: CONTRIBUTIONS TO GOVERNMENTS AND ORGANIZATIONS IN THE UNITED STATES ARE APPROVED BY THE BOARD OF DIRECTORS AND/OR THE PRESIDENT & CEO. ALL RECORDS OF OUTGOING CONTRIBUTIONS ARE RETAINED FOR A PERIOD OF 10 YEARS, PLUS THE CURRENT FISCAL YEAR, AND CAN BE LOCATED AT THE OFFICE CENTER AT 4425 NORTH PORT WASHINGTON RD, GLENDALE, WI 53212. X X X X X 0 1 0 0 0 0 0 1 0 David Hoogerland MD 0 277661 0 130953 0 23950 0 77222 0 44645 0 554431 0 0 Kevin Goniu MD 0 486446 0 128304 0 24559 0 60246 0 61612 0 761167 0 0 Leo P Brideau 798447 0 476201 0 198660 0 28394 0 72708 0 1574410 0 0 0 RHONDA ANDERSON 195895 0 34948 0 176651 0 42866 0 26135 0 476495 0 0 0 Amy Marquardt 233573 0 57036 0 8201 0 54863 0 16489 0 370162 0 0 0 Cheryl Hill 219299 0 53299 0 24549 0 52790 0 30913 0 380850 0 0 0 David H Shapiro MD 285875 0 76138 0 22197 0 58604 0 13275 0 456089 0 0 0 Gerri Lietz-Staffileno 0 201070 0 46991 0 22893 0 80675 0 28590 0 380219 0 0 Karol Marciano 254858 0 74629 0 23578 0 39499 0 23859 0 416423 0 0 0 Mary Paul 0 351746 0 90618 0 58833 0 33570 0 12480 0 547247 0 0 Sue Sanicola 169501 0 42068 0 29989 0 33659 0 31045 0 306262 0 0 0 William Hart 0 256800 0 58441 0 5055 0 21157 0 22496 0 363949 0 0 Constance J Bradley 0 186947 0 41176 0 7593 0 15567 0 17663 0 268946 0 0 Paul Westrick 180760 0 40828 0 7941 0 57618 0 39203 0 326350 0 0 0 Brian Regan 166422 0 92185 0 48733 0 18436 0 18352 0 344128 0 0 0 Therese Pandl 0 192746 0 37500 0 544745 0 51668 0 20173 0 846832 0 0 Part I, Line 4a PART I, LINE 4B: ELIGIBLE EXECUTIVES PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. THE FILING ORGANIZATION (CSM) DID NOT CONTRIBUTE ANY AMOUNT TO THIS PLAN THIS YEAR. Part I, Line 7 BOARD MEMBERS, OFFICERS, KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES WHO ARE EMPLOYED BY THE CSM ORGANIZATIONS AND ARE MEDICAL DOCTORS ARE ELIGIBLE TO RECEIVE A PERCENTAGE OF THE REVENUE GENERATED FROM PATIENTS THEY SERVE, BASED ON ESTABLISHED GUIDELINES. OFFICERS AND KEY EMPLOYEES PARTICIPATE IN A MANAGEMENT INCENTIVE PLAN, WHEREBY CERTAIN FINANCIAL TRIGGERS OF THE CSM SYSTEM AS APPROVED BY THE BOARD MUST BE MET BEFORE ANY ELIGIBLE EMPLOYEE MAY RECEIVE PAYMENT OF THE INCENTIVE. ONCE THE TRIGGER IS MET, THE INCENTIVE IS MEASURED BASED ON VARIOUS ESTABLISHED GOALS, INCLUDING OPERATING MARGIN, PATIENT SATISFACTION, QUALITY, AND PRODUCTIVITY. Form 990, Part VI, Section A, line 4 CSM AMENDED ITS ARTICLES OF INCORPORATION EFFECTIVE MARCH 2010. A FEW SMALL CHANGES WERE MADE TO THE ARTICLES AND BYLAWS OF COLUMBIA ST. MARY'S, INC. AND COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, INC. TO BETTER ALIGN WITH CSM'S MAIN SPONSOR, ASCENSION HEALTH. OF SIGNIFICANCE, HOWEVER, IS THE LEGAL NAME CHANGE OF ST. MARY'S HOSPITAL OZAUKEE, INC. TO COLUMBIA ST. MARY'S HOSPITAL OZAUKEE, INC. Form 990, Part VI, Section A, line 6 CSM HAS TWO CORPORATE MEMBERS: ASCENSION HEALTH AND COLUMBIA HEALTH SYSTEM. Form 990, Part VI, Section A, line 7a ONE OF CSM'S CORPORATE MEMBERS, ASCENSION HEALTH, HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF CSM. Form 990, Part VI, Section A, line 7b Ascension Health has designed a system authority matrix which assigns authority for key decisions that are necessary in the operation of the system. Specific areas that are identified in the authority matrix are: new organizations & major transactions; governing documents; appointments/removals; evaluation; debt limits; strategic & financial plans; assets; system policies & procedures. These areas are subject to certain levels of approval by Ascension per the system authority matrix. Columbia Health System has the authority to approve any changes to the governing documents which would affect its interest or rights in CSM, the mission and vision statements of CSM, and any major corporate structural transactions of CSM. Form 990, Part VI, Section B, line 11 Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form to the Board, or a designated committee, to review and answer any questions. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members questions. Form 990, Part VI, Section B, line 12c CSM HAS A WRITTEN CONFLICT OF INTEREST POLICY. THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE POLICY IN THAT ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF THE COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING INDIVIDUALS ON THE GOVERNING BOARD OR COMMITTEE MEETING WILL DECIDE IF CONFLICTS OF INTEREST EXIST. EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ITS TAX EXEMPT PURPOSE. Form 990, Part VI, Section B, line 15 IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE AUDIT COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO WAS COMPARED TO OTHER HOSPITALS IN THE AREA THAT HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. THE CEO WAS NOT PRESENT WHEN HIS COMPENSATION WAS DECIDED. IN DETERMINING COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE AUDIT COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATIONS, THE OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO OTHER HOSPITALS' EMPLOYEES IN THE AREA THAT HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. Form 990, Part VI, Section C, line 19 THE ORGANIZATION WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. CSM DOES PUBLISH AN ANNUAL REPORT AND FACT SHEETS ON THE EXTERNAL WEBSITE, WHICH IS AVAILABLE FOR PUBLIC VIEWING. FORM 990, PART VII AVERAGE HOURS OF OFFICERS/KEY EMPLOYEES THE KEY EMPLOYEES AND OFFICERS LISTED ON FORM 990, PART VII PROVIDE SERVICES TO THIS ORGANIZATION AS WELL AS OTHER RELATED CSM ORGANIZATIONS. THE HOURS REPORTED IN COLUMN (B) REPRESENT THE ESTIMATED PERCENTAGE OF TIME THESE INDIVIDUALS DEVOTE TO THE REPORTING ORGANIZATION BASED ON A 40-HOUR WEEK. THE TOTAL AVERAGE HOURS PER WEEK THESE INDIVIDUALS SPEND ON ALL CSM ORGANIZATIONS, INCLUDING THIS ORGANIZATION, EXCEED 40 HOURS. COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390806315 HOSPITAL WI 501(c)(3) 3 COLUMBIA ST MARY'S INC COLUMBIA ST MARY'S HOSPITAL OZAUKEE INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390807063 HOSPITAL WI 501(c)(3) 3 COLUMBIA ST MARY'S INC SACRED HEART REHABILITATION INSTITUTE INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390902199 REHAB FACILITY WI 501(c)(3) 3 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC COLUMBIA COLLEGE OF NURSING INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 391596986 COLLEGE WI 501(c)(3) 2 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC SETON CHILDREN'S SCHOOL INC 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 391391245 SCHOOL WI 501(c)(3) 9 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC ASCENSION HEALTH 4600 EDMUNDSON ROAD ST LOUIS MO 63136 311662309 Health System MO 501(c)(3) 11 N/A HORIZON HOME CARE & HOSPICE INC 8949 N DEERBROOK TRL MILWAUKEE WI 53223 391171298 HOME CARE/HOSPICE WI 501(c)(3) 3 COLUMBIA ST MARY'S INC COLUMBIA HEALTH SYSTEM 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 391494977 Health System WI 501(c)(3) 11 N/A ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC 575 RIVERWOODS PKWY GLENDALE WI 53212 392015655 HEALTH CARE WI COLUMBIA ST MARY'S INC RELATED 9406958 13211340 0 1 CSM STRATEGIC ALLIANCE 4425 NORTH PORT Washington Rd GLENDALE WI 53212 391871856 HEALTHCARE WI COLUMBIA ST MARY'S INC C -1383 43395 0.50000 MADISON MEDICAL AFFILIATES INC 4425 NORTH PORT Washington Rd GLENDALE WI 53212 391855720 HEALTHCARE WI COLUMBIA ST MARY'S HOSPITAL MILWAUKEE INC C -7062669 13360266 1.00000 PROSPECT MEDICAL COMMONS CONDO ASSOCIATION 4425 NORTH PORT Washington Rd GLENDALE WI 53212 208042108 CONDO ASSOC WI COLUMBIA ST MARY'S INC C 0.70000 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN O 446797 ASCENSION HEALTH E 145678466 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE Q 9583711 COLUMBIA ST MARY'S HOSPITAL OZAUKEE Q 4100225 SACRED HEART REHABILITATION INSTITUTE Q 121795 orthOPAEDIC HOSPITAL OF WISCONSIN Q 24507000 COLUMBIA COLLEGE OF NURSING Q 2845000 SETON CHILDREN'S SCHOOL Q 1800000 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE Q 524529000 COLUMBIA ST MARY'S HOSPITAL OZAUKEE Q 96291000 ascENSION HEALTH Q 6703068 asCENSION HEALTH Q 4322416