2011-10-03T06:45:36-05:00 2010-12-31 BAKER NEWMAN & NOYES LLC PO BOX 507 PORTLAND ME 04112 990 2010-01-01 020497927 WENTWORTH-DOUGLASS PHYSICIAN CORPORATION WENT 6037425252 789 CENTRAL AVENUE DOVER NH 038202526 PETER E WALCEK 6037422804 2011-09-27 1 TIMOTHY R HEPBURN 2078792100 2010 2016-03-07 17:11:31Z GREGORY J WALKER 789 CENTRAL AVENUE DOVER NH 038202526 23740024 0 X N/A X 1998 NH IMPROVE THE HEALTH OF THE COMMUNITY BY PROVIDING HIGH QUALITY HEALTHCARE. 11 4 328 0 47871 -6468 0 0 23317630 23560980 0 27938 1800 67768 23319430 23656686 0 0 0 0 28291751 29934723 0 0 0 12072437 11388085 40364188 41322808 -17044758 -17666122 4529504 3962487 3232209 4079036 1297295 -116549 X IMPROVE THE HEALTH OF THE COMMUNITY BY PROVIDING HIGH QUALITY HEALTHCARE THAT EXCEEDS EXPECTATIONS THROUGH AN INTEGRATED NETWORK OF HIGHLY QUALIFIED PROFESSIONALS. 0 0 37189365 22609097 WENTWORTH-DOUGLASS PHYSICIAN CORPORATION (WDPC) WAS FORMED IN RESPONSE TO A COMMUNITY NEEDS ASSESSMENT THAT IDENTIFIED A LACK OF PRIMARY CARE AND SPECIALTY SERVICES IN THE COMMUNITY. THE FORMATION OF THE PHYSICIAN CORPORATION AND RECRUITMENT OF PRIMARY CARE AND SPECIALTY PHYSICIANS CLOSED THE GAP BY IMPROVING ACCESS TO PRIMARY CARE MEDICAL SERVICES IN DOVER, NH AND SURROUNDING AREAS. (SEE SCHEDULE O FOR A LIST OF FACILITIES OPERATED BY WDPC.)IN 2010, THE CORPORATION PROVIDED FOR A TOTAL OF 165,927 PATIENT VISITS. 1493142 999718 THE WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER IS OPEN TO LOW-INCOME, UNINSURED ADULTS AND CHILDREN LIVING IN WENTWORTH-DOUGLASS HOSPITAL'S PRIMARY SERVICE AREA (DOVER, DURHAM, MADBURY, LEE, BARRINGTON, SOMERSWORTH, ROLLINSFORD, NH AND BERWICK AND SO. BERWICK, ME) OR PATIENTS OF THE PHYSICIAN PRACTICES WHO HAVE A FAMILY INCOME AT OR BELOW 300% OF THE FEDERAL POVERTY GUIDELINES. IN 2010, A TOTAL OF 4,760 PATIENT VISITS WERE RECORDED, WITH TOTAL REVENUE OF $999,718 AND EXPENSES OF $1,493,142, RESULTING IN A NET COMMUNITY BENEFIT COST OF $493,424.IN ADDITION, WDPC PROVIDED COMMUNITY BENEFITS EXCEEDING $450,000 IN 2010. THE CORPORATION SUPPORTS NUMEROUS COMMUNITY BASED PROGRAMS, INCLUDING THE COMMUNITY DENTAL CENTER AND PETE'S PLACE, WHICH IS A GRIEF SUPPORT ORGANIZATION FOR CHILDREN WHO HAVE SUFFERED THE LOSS OF A LOVED ONE OR FRIEND. THE PROGRAM ALSO PROVIDES GROUP COUNSELING AT AREA SCHOOLS FOR STUDENTS WHO HAVE LOST A CLASSMATE.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 2010 WDPC PROVIDED $374,840 OF FINANCIAL AID (STATED AT COST). MEDICAID COSTS EXCEEDING REIMBURSEMENT TOTALED $520,000 FOR THE CORPORATION IN 2010. 38682507 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 328 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 11 4 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X PETER E WALCEK CFOVP OF FINANCE 6037402804 789 CENTRAL AVENUE DOVER NH 038202526 X THEODORE RISTAINO 1.00 X X 0 0 0 NEIL GARVEY 1.00 X X 0 0 0 ROGER HAMEL 1.00 X X 0 0 0 WILLIAM BOC 0.50 X X 0 0 0 GREGORY P ANDRECYK MD 65.00 X 254866 0 24744 MARK R BLACKWOOD MD 65.00 X 178028 0 7061 WILLIAM BRANDON MD 65.00 X 158484 0 6603 ELLEN L CAILLE 2.00 X 0 257999 72398 BARBARA CIVIELLO MD 65.00 X 444854 0 30969 GIRISH C JOSHI MD 65.00 X 395306 0 25331 PETER E WALCEK 2.00 X X 0 302237 74502 GREGORY J WALKER 2.00 X X 0 605304 147782 ROGER EVANS MD 65.00 X 495683 0 24993 SHUBHRA RAY MD 65.00 X 376205 0 23771 NOEL WHEELER MD 65.00 X 337846 0 20716 PATRICIA AUTY MD 65.00 X 334904 0 22076 CECIL W BEAN MD 65.00 X 323005 0 16135 3299181 1165540 497081 62 0 1 0 0 PATIENT SERVICE REVENU 621110 22988103 22988103 OTHER RELATED FUNCTION 621990 392288 344417 47871 OTHER - UNH 621990 180589 180589 23560980 98708 30940 67768 67768 67768 80336 52398 27938 27938 27938 23656686 23608815 47871 0 1534603 1534603 23516814 22039958 1476856 259464 243170 16294 2623479 2458725 164754 2000363 1874740 125623 23961 23961 19251 19251 3338256 3103053 235203 150 150 823277 751358 71919 3387550 3172869 214681 217464 170363 47101 398288 398288 427457 427457 PROVISION FOR BAD DEBT 1165571 1165571 PHARMACY EXPENSE 512352 512352 DENTAL COMMUNITY BENEFI 493424 493424 TRANSCRIPTION 315586 315586 OTHER NONOPERATING BUIL 5107 5107 260391 15883 244508 41322808 38682507 2640301 0 164233 68715 2409576 2112888 6915145 5137958 1951998 1777187 3697 3697 4529504 3962487 3232209 4079036 3232209 4079036 X 1297295 -116549 1297295 -116549 4529504 3962487 X -17666122 16252278 X X 0 1 1 X 0 X 2611346 1779401 831945 4303799 3358557 945242 1777187 23656686 41322808 -17666122 16252278 16252278 -1413844 23659688 30940 30940 23628748 27938 27938 23656686 41325810 30940 30940 41294870 27938 27938 41322808 PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY TRANSFER FROM WENTWORTH-DOUGLASS HOSPITAL 16,252,278. PART XII, LINE 2D - OTHER ADJUSTMENTS: OCCUPANCY EXPENSES ALLOCATED TO BUILDING RENTAL 30,940. PART XII, LINE 4B - OTHER ADJUSTMENTS: NET GAIN FROM SALE OF ASSETS INCLUDED IN NET NONOPERATING LOSSES 27,938. PART XIII, LINE 2D - OTHER ADJUSTMENTS: OCCUPANCY EXPENSES ALLOCATED TO BUILDING RENTAL 30,940. PART XIII, LINE 4B - OTHER ADJUSTMENTS: NET GAIN FROM SALE OF ASSETS NETTED WITH NONOPERATING LOSSES 27,938. X 1 1 X X X X 0 1 0 0 0 0 0 1 0 GREGORY P ANDRECYK MD 208885 0 41635 0 4346 0 7670 0 17074 0 279610 0 0 0 MARK R BLACKWOOD MD 150958 0 22350 0 4720 0 895 0 6166 0 185089 0 0 0 WILLIAM BRANDON MD 130387 0 11984 0 16113 0 0 0 6603 0 165087 0 0 0 ELLEN L CAILLE 0 224833 0 23146 0 10020 0 46320 0 26078 0 330397 0 0 BARBARA CIVIELLO MD 352536 0 86353 0 5965 0 9686 0 21283 0 475823 0 0 0 GIRISH C JOSHI MD 165557 0 225029 0 4720 0 8629 0 16702 0 420637 0 0 0 PETER E WALCEK 0 271159 0 21465 0 9613 0 55200 0 19302 0 376739 0 0 GREGORY J WALKER 0 406373 0 65462 0 133469 0 127804 0 19978 0 753086 0 0 ROGER EVANS MD 490963 0 0 0 4720 0 7727 0 17266 0 520676 0 0 0 SHUBHRA RAY MD 317605 0 53280 0 5320 0 10055 0 13716 0 399976 0 0 0 NOEL WHEELER MD 286721 0 47125 0 4000 0 10608 0 10108 0 358562 0 0 0 PATRICIA AUTY MD 329184 0 1000 0 4720 0 10194 0 11882 0 356980 0 0 0 CECIL W BEAN MD 319005 0 0 0 4000 0 0 0 16135 0 339140 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) - 2010 TOTAL CONTRIBUTIONS TO 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. DURING CALENDAR YEAR 2010 THE HOSPITAL IMPLEMENTED A 457(F) PLAN TO COVER OTHER KEY EXECUTIVES. THE CONTRIBUTIONS ARE INTENDED TO PROVIDE A FOREITABLE SUPPLEMENTAL RETIREMENT BENEFIT AND ARE BEING PROVIDED IN CONSIDERATION FOR MANY YEARS OF SERVICE TO THE HOSPITAL. THE RESPECTIVE CONTRIBUTIONS FOR THE 2010 PLAN YEAR, FOR THOSE INDIVIDUALS IDENTIFIED IN SCHEDULE J - PART II, ARE AS FOLLOWS: PETER E. WALCEK = $40,500 AND ELLEN L. CAILLE =$37,500. PART I, LINE 7 AT-RISK COMPENSATION FOR WENTWORTH-DOUGLASS EXECUTIVES, WHICH IS SUBJECT TO REVIEW AND PAID ANNUALLY. WENTWORTH-DOUGLASS PHYSICIAN CORPORATION HAS AN INCENTIVE-BASED COMPENSATION MODEL THAT USES RELATIVE VALUE UNITS (RVUS) AS A MEASURE FOR DETERMINING PHYSICIAN COMPENSATION WITHIN THE MEDICAL GROUP MANAGEMENT ASSOCIATION PUBLISHED SALARY RANGES. THE MODEL INCLUDES A BASE SALARY PLUS INCENTIVE COMPENSATION THAT HAS BOTH PRODUCTIVITY AND PERFORMANCE COMPONENTS INCLUSIVE OF PATIENT SATISFACTION, QUALITY, AND COMMUNITY CITIZENSHIP METRICS. BOTH BUDGETED PERFORMANCE AND ACTUAL PERFORMANCE ARE MEASURED. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS INITIALLY REVIEWED IN DETAIL BY KEY WENTWORTH-DOUGLASS HOSPITAL FINANCE EMPLOYEES. THEREAFTER, THE FINAL DRAFT IS PRESENTED TO THE FULL BOARD PRIOR TO FILING WITH THE IRS. EACH MEMBER OF THE BOARD AND FINANCE COMMITTEE IS PROVIDED WITH A DRAFT OF THE FORM 990 IN ADVANCE OF EACH MEETING. FORM 990, PART VI, SECTION B, LINE 12C A COPY OF WDPC'S CONFLICT OF INTEREST POLICY IS DISTRIBUTED ANNUALLY TO ALL OFFICERS, TRUSTEES, MEDICAL STAFF OFFICERS AND COMMITTEE MEMBERS, AND THE MANAGEMENT TEAM. ALL ARE REQUIRED TO REPORT ANY CONFLICTS AND SIGN, DATE, AND RETURN THE POLICY, WHETHER OR NOT A CONFLICT EXISTS, TO CONFIRM COMPLIANCE. CONFLICTS ARE DISCLOSED IN ACCORDANCE WITH STATE OF NEW HAMPSHIRE RSA 7:19-A, IN THE LOCAL NEWSPAPER AND SUBMITTED TO THE NEW HAMPSHIRE ATTORNEY GENERAL. FORM 990, PART VI, SECTION B, LINE 15 CEO'S COMPENSATION: THE COMPENSATION AND BENEFITS OF WENTWORTH-DOUGLASS HOSPITAL'S CEO ARE REVIEWED, ADJUSTED AND VOTED ON BY THE FULL WENTWORTH-DOUGLASS HOSPITAL (WDH) BOARD ANNUALLY. SEE WDH'S SEPARATE FORM 990 FOR FURTHER DETAILS. COMPENSATION OF KEY EMPLOYEES: THE WDH CEO REVIEWS THE SALARIES OF WENTWORTH-DOUGLASS PHYSICIAN CORPORATION'S KEY EMPLOYEES ANNUALLY AND DETERMINES COMPENSATION BASED ON PERFORMANCE, SALARY RANGES AND MARKET COMPETITIVE DATA. COMPENSATION DATA IS PROVIDED BY AN INDEPENDENT NATIONAL CONSULTING FIRM EVERY OTHER YEAR. USING THE BOARD APPROVED SALARY RANGE DATA, THE CEO RECOMMENDS SALARY INCREASES. PHYSICIAN SALARY RANGES ARE ESTABLISHED EVERY OTHER YEAR USING THE MEDICAL GROUP MANAGEMENT ASSOCIATION (MGMA) PUBLISHED SALARY SURVEY DATA. FORM 990, PART VI, SECTION C, LINE 19 WENTWORTH-DOUGLASS PHYSICIAN CORPORATION (WDPC) FILES AUDITED FINANCIAL STATEMENTS ANNUALLY WITH THE NEW HAMPSHIRE ATTORNEY GENERAL'S CHARITABLE TRUST UNIT AND INFORMS THE DIRECTOR OF CHARITABLE TRUSTS OF PECUNIARY BENEFIT TRANSACTIONS THAT HAVE OCCURRED BETWEEN WDPC AND A BOARD MEMBER OR OFFICER. NOTICES OF SUCH TRANSACTIONS OF $5,000 OR MORE ARE ALSO PUBLISHED IN THE LOCAL NEWSPAPER IN ACCORDANCE WITH NH RSA 7:19-A, II(D). CURRENT COPIES OF THE BYLAWS, CONFLICT OF INTEREST POLICY AND FORM 990 ARE ON FILE WITH THE CHARITABLE TRUST UNIT. REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A, COLUMN E THE 2010 COMPENSATION REPORTED FOR GREGORY WALKER, PETER WALCEK, AND ELLEN CAILLE WAS PAID BY WENTWORTH-DOUGLASS HOSPITAL FOR THEIR SERVICES AS FULL-TIME EXECUTIVES. GREGORY WALKER, PETER WALCEK AND ELLEN CAILLE EACH WORKED AN AVERAGE OF 55 HOURS PER WEEK. OF THE RESPECTIVE HOURS WORKED BY EACH, AN AVERAGE OF 2 HOURS PER WEEK WAS DEDICATED TO WENTWORTH-DOUGLASS PHYSICIAN CORPORATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: EQUITY TRANSFER FROM WENTWORTH-DOUGLASS HOSPITAL 16,252,278. TOTAL TO FORM 990, PART XI, LINE 5: 16,252,278. AUDIT REVIEW PROCESS FORM 990, PART XII, LINE 2C THE AUDIT PROCESS FOR WDPC IS OVERSEEN BY THE FINANCE COMMITTEE IN CONJUNCTION WITH THAT FOR WENTWORTH-DOUGLASS HOSPITAL. THE AUDIT PROCESS FOR THE FINANCIAL STATEMENTS DID NOT CHANGE FROM THE PRIOR YEAR. INDEPENDENT ACCOUNTANTS PERFORMED THE AUDIT IN BOTH 2009 AND 2010. WDPC'S FACILITIES FORM 990, PART III, LINE 4A WENTWORTH-DOUGLASS PHYSICIAN CORPORATION DOES NOT FILE A SEPARATE ANNUAL COMMUNITY BENEFITS REPORT. RATHER, WENTWORTH-DOUGLASS HOSPITAL (WDH) INCLUDES WDPC DATA WITH ITS COMMUNITY BENEFITS REPORT THAT IS FILED ANNUALLY WITH THE STATE OF NEW HAMPSHIRE. WDH OWNS 100% OF WDPC, AND OVERSEES ALL OF WDPC'S PRIMARY CARE PRACTICES, OUTPATIENT PHYSICIAN CLINICS AND ITS DENTAL CLINIC, WHICH ARE LOCATED AS FOLLOWS: ADULT & CHILDREN'S MEDICINE, 10 MEMBERS WAY, SUITE 201, DOVER, NH BARRINGTON HEALTH CENTER, 2 CENTURY PINES DRIVE, BARRINGTON, NH BELLAMY HEALTH CENTER, 15 OLD ROLLINSFORD ROAD, DOVER, NH DOVER FAMILY PRACTICE, 789 CENTRAL AVENUE, DOVER, NH DOVER INTERNAL AND GERIATRIC MEDICINE, 10 MEMBERS WAY, SUITE 301, DOVER, NH DURHAM HEALTH CENTER, 36 MADBURY ROAD, DURHAM, NH GREAT BAY FAMILY PRACTICE, 60 EXETER ROAD, UNIT 3, NEWMARKET, NH HILLTOP FAMILY PRACTICE, 85 MAIN STREET, SOMERSWORTH, NH LEE FAMILY PRACTICE, 65 CALEF HIGHWAY, SUITE 200, LEE, NH MARSHWOOD FAMILY CARE, 19 LEVESQUE DRIVE, SUITE 2, ELIOT, ME PRIMARY CARE OF DOVER, 10 MEMBERS WAY, SUITE 300, DOVER, NH SOUTH BERWICK FAMILY PRACTICE, 31 COLCORD STREET, SOUTH BERWICK, ME STRAFFORD MEDICAL ASSOCIATES, 10 MEMBERS WAY, SUITE 302, DOVER, NH WENTWORTH INTERNAL MEDICINE, 10 MEMBERS WAY, SUITE 303, DOVER, NH ENDOCRINOLOGY & DIABETES, 19 WEBB PLACE, DOVER, NH HOSPITALISTS, 789 CENTRAL AVENUE, LEVEL 2, DOVER, NH PALLIATIVE CARE, 789 CENTRAL AVENUE, LEVEL 3, DOVER, NH SEACOAST ARTHRITIS & OSTEOPOROSIS, 15 OLD ROLLINSFORD ROAD, SUITE 204, DOVER, NH SEACOAST PULMONARY (INTENSIVISTS), 789 CENTRAL AVENUE, LEVEL 3, DOVER, NH SUMMIT INFECTIOUS DISEASE, 15 OLD ROLLINSFORD ROAD, DOVER, NH WENTWORTH COMMUNITY DENTAL CARE CENTER, 668 CENTRAL AVENUE, DOVER, NH WENTWORTH-DOUGLASS HOSPITAL 789 CENTRAL AVENUE DOVER NH 03820 020260334 HEALTH CARE NH 501(C)(3) 170(B)(1)(A)(III) N/A 0 WENTWORTH-DOUGLASS HOSPITAL & HEALTH FOUNDATION 789 CENTRAL AVENUE DOVER NH 03820 510491062 PHILANTHROPIC FUND RAISING & STEWARDSHIP NH 501(C)(3) 509(A)(3) N/A 0 WENTWORTH-DOUGLASS COMMUNITY & HEALTH CORPORATION 789 CENTRAL AVENUE DOVER NH 03820 020399963 HEALTH FITNESS CENTER NH N/A C 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 WENTWORTH-DOUGLASS HOSPITAL C 16252278 ACTUAL PER BOOKS WENTWORTH-DOUGLASS HOSPITAL O 315586 ACTUAL PER BOOKS WENTWORTH-DOUGLASS HOSPITAL J 2302562 ACTUAL PER BOOKS