2011-11-15T12:11:14-06:00 2010-12-31 990 2010-01-01 382146751 Northern Michigan Hospitals NORT 2314874094 416 Connable Avenue Petoskey MI 49770 Stephen J Scannell 2314874094 2011-11-15 2010 2016-03-07 17:11:31Z Northern Michigan Regional Hospital Stephen J Scannell 416 Connable Avenue Petoskey MI 49770 191279453 0 X www.northernhealth.org X 1977 MI To provide healthcare as we expect for our own family. 12 11 1508 281 399769 24615 1177098 4058815 184828665 179137908 567108 759413 2048205 2383786 188621076 186339922 597563 692174 0 0 85130467 81376953 0 0 0 90636192 97284195 176364222 179353322 12256854 6986600 126226022 110661858 50720436 49605850 75505586 61056008 X Establish, maintain and operate hospital to care for the sick, injured and disabled. Prevention of illness, injury and disability and maintenance of health. More specifically, Northern Michigan Regional Hospital and its 1,508 employees are dedicated to providing quality healthcare services to the people of northern Michigan. 0 0 21562800 37627866 The treatment and diagnosis of cardiac disease. Discharges 1,862 9426351 16542976 The treatment and diagnosis of orthopaedic care. Discharges 932 6253061 12854756 The treatment and diagnosis of oncology care. Discharges 541 99641450 692174 112112310 99641450 692174 112112310 136883662 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 216 0 1 1508 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MI X Stephen J Scannell 2314874094 416 Connable Avenue Petoskey MI 49770 X Catherine DeVet 22.00 X X 431554 0 54591 David Buzzelli 2.50 X 0 0 0 Thomas Irwin 2.50 X 0 0 0 Robert Foster 2.00 X 0 0 0 Thomas Moran 2.00 X 0 0 0 Ann Stallkamp 2.00 X 0 0 0 Joseph Hance MD 1.30 X 0 0 0 Elise Hayes 1.30 X 0 0 0 John Kohler 2.00 X 0 0 0 Stephen Eibling 2.00 X 0 0 0 David Rynbrandt MD 1.30 X 0 0 0 Irene Kazmers MD Chief of Staff 1.30 X 0 0 0 Stephen Scannell 22.00 X 44335 0 27953 Eugene Kaminski 22.00 X 213264 0 34721 Robert Dean Jr 22.00 X 147135 0 27291 Mary-Anne Ponti 22.00 X 251161 0 29375 Caroline Seagren 22.00 X 144575 48192 33917 Timothy Jodway 22.00 X 204424 0 12402 Andrew Smith 22.00 X 101882 0 3428 Mark Gray 40.00 X 188192 0 18652 Guy Golembiewski 40.00 X 206226 0 9052 Daniel Dryden 40.00 X 146884 0 25489 Kevin Pendleton 40.00 X 156146 0 12029 Barbara Berry 40.00 X 153827 0 7129 Linda Schofield 40.00 X 138658 0 10764 2528263 48192 306793 39 0 1 0 Northern Anesthesia Providers 602 Jackson Petoskey MI 49770 Physician Services 1457582 Mayo Collaborative Services PO Box 9146 Minnepolis MN 554809146 Laboratory Services 782205 Nuyen Tomtishen and Aoun PC 2001 Commonwealth Blvd Suite 300 Ann Arbor MI 48105 Legal Services 567661 Caretech Solutions Inc PO Box 674271 Detroit MI 482674271 Information Technology Services 384524 Northern Pathology Associates 416 Connable Avenue Petoskey MI 49770 Physician Services 340160 18 4058815 4058815 Net IP, OP and Prof Sv 622110 176998605 176998605 Revenue From Affil 622110 1367012 1367012 Other Ancillary Svcs 622110 520951 520951 Miscellaneous 622110 130295 130295 Other Community Svc 622110 121045 121045 179137908 819728 819728 401888 401888 401888 401888 4879216 4904184 35347 -24968 -35347 -60315 -60315 Cafeteria Sales 900099 873002 873002 Pharm Research 900099 541538 541538 Gift Shop 453220 269633 269633 297725 130136 167589 1981898 186339922 179137908 399769 2743430 692174 692174 1962284 1962284 64244460 50990871 13253589 10755227 8283422 2471805 4414982 3400315 1014667 681178 681178 102473 102473 11880342 5743094 6137248 722868 41811 681057 46841433 42179150 4662283 5327253 2938982 2388271 4222599 1918652 2303947 250815 111901 138914 495287 348152 147135 1519782 838446 681336 7291717 3154414 4137303 2297363 2219891 77472 Income Tax 9901 9901 Bad Debt Expense 11187423 10405179 782244 Medicaid QAAP Tax 3523666 3523666 Dues 529811 33683 496128 Miscellaneous 276317 24310 252007 123967 35549 88418 179353322 136883662 42469660 0 1640 1923 39465191 26163975 14401437 9218394 7017232 7464818 2816704 2829776 167479235 115468842 47593499 52010393 661428 665343 14159579 12197924 109312 109312 126226022 110661858 14792257 15792301 48000 27204 35799660 33786345 80519 50720436 49605850 X 75505586 61056008 75505586 61056008 126226022 110661858 X 6986600 -21436178 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 496200 496200 91386752 58053047 33333705 75596283 57415795 18180488 52010393 Osborn Property 32319 C Investment - Caymich Insurance Co., Ltd. 7260 C Investment - Petoskey Assurance Ltd. 120000 C Investment - Board Designated Funds 12038345 C 12197924 Central America and the Caribbean Program Services Transfer funds to wholly owned subsidiary for insurance services 1226131 0 0 0 1226131 0 1226131 1 0 1 0 0 0 1 1 X 1 X 1 X 1 1 1 0 1 1 2862322 2862322 0.01600 12550522 10611444 1939078 0.01080 1343875 1343875 0.00750 16756719 10611444 6145275 0.03430 367 20117 880235 880235 0.00490 2 4 400654 400654 0.00220 20813960 16645677 4168283 0.02320 1 318001 318001 0.00180 304 1743 76884 76884 0.00040 674 21864 22489734 16645677 5844057 0.03250 674 21864 39246453 27257121 11989332 0.06680 6 1355 17797 17797 0.00010 1 154 373 373 0.00000 1 946 946 0.00000 6 696 13916 13916 0.00010 4 58 5841 5841 0.00000 12 100 3432 3432 0.00000 30 2363 42305 42305 0.00020 1 7991225 36613629 44335989 -7722360 X 1 0 1 1 Northern Michigan Hospitals

416 Connable Avenue Petoskey MI 49770

X X X X Northern Michigan Hospitals 1 1 1 200.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X X 1 X X 1 X X X X X X 1 X X 1 1 Part I, Line 7: We utilize a step down costing methodology. First direct expenses are reduced by any non patient revenues received. Then indirect departments (those without patient charges) are allocated to direct departments using department specific statistics. The step down process includes nine iterations. When the costing process is complete, costs are assigned to each unique patient. This allows us to determine the actual cost of providing services to each unique patient. Part II: Community building activities support identified community needs and community collaboratives such as poverty reduction, transportation, workforce development and community health, by providing in-kind services, financial resources and staff expertise from the hospital. Part III, Line 4: An allowance for uncollectible accounts is established on an aggregate basis by using historical write-off rate factors applied to unpaid accounts based on aging. Loss rate factors are based on historical loss experience and adjusted for economic conditions and other trends affecting the Hospital's ability to collect outstanding amounts. Uncollectible amounts are written off against the allowance for doubtful accounts in the period they are determined to be uncollectible. To determine the cost of bad debt, we isolated all patient accounts written off during the reporting year. We then offset the cost of providing those services by any payment received for those services, thus reporting the true net cost to the system. The same methodology was used for determining the cost of charity care. Part III, Line 8: To determine the cost of Medicare shortfalls, we isolated all patient accounts where Medicare was the primary payers, and offset the cost of services provided by any payment received, from either the patient, primary, secondary or tertiary payors. We then rolled those accounts up by sub service line for both in- and out-patient accounts, and reported the net shortfall of services provided at a loss. One hundred percent of that shortfall should be treated as community benefit. Part III, Line 9b: The organization's written debt collection policy does not contain provisions on the collection practices to be followed for patients who are known to qualify for charity care because if possible we try to identify and determine eligibility for charity care before services are provided. Also, it is stated in our Charity Care policy that once eligible, no collection agencies or other collection processes will be followed unless the patient's financial circumstances materially change. Part V, Section B, Question 19 C. The hospital facility uses the Medicare rates for services when requested by the patient.D. The hospital facility uses 20% on uninsured claims for 2010. Part V, Section B, Question 20 If the patient did not respond to charity care applications or to statements received they did not know of discounts and would have been charged more than the amounts generally billed to individuals who had insurance. The hospital facility has now implemented that discounts for self pay be printed on statements and are implementing presumptive charity care. Part V, Section B, Question 21 Yes, for patients that did not respond to charity care applications or statements received. Part VI, Line 2: Northern Michigan Regional Hospital assesses the needs and assets of the community by collaborating with community and strategic partners, reviewing demographics, health indicators, morbidity and mortality data, analyzing cost drivers, and conducting focus groups, surveys, and community forums. Part VI, Line 3: As patients are registered either in person or over the phone they are given contact information for Patient Financial Services representatives if they have no insurance, are under insured or have high co-pay's. There are Patient Financial Services brochures displayed at all registration areas that describe the various financial assistance programs available. Through our Care Coordination program all patients with no insurance are seen to assist with financial assistance programs. Part VI, Line 4: Northern Michigan Regional Hospital is a 214-bed regional referral center serving a 22-county region spanning northern Michigan and the eastern part of the Upper Peninsula. With a total market population of over 440,000, US Census Bureau data (2006) estimates that nearly 30% are age 45-64, and nearly 20% are over age 65. According to the Michigan Department of Community Health, top adult health concerns include: overweight and obese, high cholesterol, high blood pressure, smoking, diabetes and uninsured. Predicated on a vision to provide patient-centered care, extensive efforts in targeting regional health concerns has led to collaborative programs and services in primary care, heart, cancer and diagnostics. This approach to high quality, cost effective healthcare delivery in this rural and remote area has been strengthened by a long standing practice of specialty physicians hosting on-site clinic visits to outlying communities. Northern Michigan Regional Hospital is working to infuence behavior through education, prevention through screening,and provide accessible treatment through physician clinics and health centers throughout the region. Part VI, Line 6: The hospital has an established regional Community Advisory Board which meets to actively address healthcare issues in the region. The hospital provides community benefit activities including community health improvement and health education programs and services to improve access to healthcare, promote health and wellness, and manage chronic disease. Part VI, Line 7: Affiliates of the Northern Michigan Regional Health System include the following organizations, each of which contribute to health promotion in the manner indicated:Northern Michigan Regional Health System Foundation - raises, manages, and dispenses funds to support the mission of Northern Michigan Regional Health System and provide programs that enhance the well-being of the community.Community Free Clinic - provides medical treatment to the area's uninsured.Boulder Park Terrace - provides skilled nursing and sub-acute rehabilitation services.VitalCare - provides home health services, home medical equipment and supplies, hospice services, private duty services, and adult day services.Physician Practices - offer the opportunity for seamless patient care within the region through a system of wholly-owned specialty medicine practices: Michigan Heart & Vascular Specialists, Northern Michigan Infectious Diseases, Northern Michigan Hematology/Oncology, Rogers City Medical Group (primary care), and Northern Michigan Regional Hospital Neurosurgery Services.Prescriptions Services Pharmacy - offers retail pharmacy services. 1 Petoskey Regional Chamber of Commerce 401 East Mitchell Petoskey MI 49770 380924480 501 (c) 6 8001 Various Sponsorships Northern Michigan Regional Hospital Foundation 360 Connable Avenue Petoskey MI 49770 382445611 501 (c) 3 152166 Home Office Expense/Rent Petoskey Community Free Clinic 416 Connable Avenue petoskey MI 49770 203675817 501 (c) 3 408364 Home Office Expense/General Operations ALcona Health Center PO Box 655 Alpena MI 49707 382170985 501 (c) 3 112944 General Operations Health Clinic 3 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Grants made to related organizations are monitored through the monthly accounting processes. Grants made to the Regional Chamber of Commerce are event specific sponsorships. Grants made to Alcona Health Center, a FQHC, are based on a percent of their operating losses as presented on their financial statements. X X 0 1 0 0 0 0 0 0 0 Catherine DeVet 327587 0 43669 0 60298 0 48976 0 5615 0 486145 0 0 0 Eugene Kaminski 162274 0 31652 0 19338 0 22886 0 11835 0 247985 0 0 0 Robert Dean Jr 123614 0 20000 0 3521 0 9800 0 17491 0 174426 0 0 0 Mary-Anne Ponti 200558 0 33272 0 17331 0 22898 0 6477 0 280536 0 0 0 Caroline Seagren 98620 48192 29455 0 16500 0 13833 0 13518 6566 171926 54758 0 0 Timothy Jodway 111845 0 40042 0 52537 0 3891 0 8511 0 216826 0 16500 0 Mark Gray 164902 0 20452 0 2838 0 6817 0 11835 0 206844 0 0 0 Guy Golembiewski 204456 0 0 0 1770 0 7841 0 1211 0 215278 0 0 0 Daniel Dryden 146541 0 161 0 182 0 6028 0 19461 0 172373 0 0 0 Kevin Pendleton 138705 0 16803 0 638 0 5601 0 6428 0 168175 0 0 0 Barbara Berry 134741 0 16501 0 2585 0 5500 0 1629 0 160956 0 0 0 Part I, Line 4b All officers listed participated in a supplemental qualified 457(b) and a nonqualified 457(f) retirement plan. Catherine DeVet received a payment of $42,372 from the nonqualified 457(f) retirement plan in 2010. Petoskey Hospital Finance Authority 382834360 2003-10-15 10000000 ER/Heart Ctr addtn 0 0 0 10000000 110249 9889751 2004 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 Form 990, Part VI, Section B, line 11 Once the Form 990 has been prepared, it is reviewed by the Finance Manager, the CFO, and the CEO. The completed Form 990 is then provided to the Board of Directors before it is filed. Form 990, Part VI, Section B, line 12c The Board of Trustees review and sign a conflict of interest statement annually. If any conflicts of interest arise during a board meeting, the trustee will leave the room or refrain from voting. Colleagues are reminded at their annual evaluation to abide by the Code of Conduct, which includes a statement on Conflict of Interest. All researchers sign a Conflict of Interest Statement prior to any research being initiated. These statements are reviewed by the Medical Research Committee and the Internal Review Board. Form 990, Part VI, Section B, line 15 To determine executive compensation for the CEO, Vice Presidents, and Officers of the corporation, NMRHS uses an independent consultant to conduct salary surveys of the health care market. Recommendations are reviewed at the Board level and approved before implementation. This was last reviewed January-April of 2010. Form 990, Part VI, Section C, line 19 No documents are made available to the public. Reportable compensation from related organizations: Form 990, Part VII Reportable compensation in Column E is from a related organization to which an average of 40 hours or more per week was devoted. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 1,581,355. Rounding -1. Equity Transfer-Northern Michigan Regional Health System -23,173,397. Equity Transfer-Northern Michigan Auxiliary 155,865. Total to Form 990, Part XI, Line 5: -21,436,178. Review of financial statements and oversight of audit: Form 990, Part XII, line 2c. The Finance Committee of the health system assumes responsibility for review of financial statements and oversight of the consolidated audit. Living Room Adult Day Services 416 Connable Avenue Petoskey MI 49770 204047415 Adult Day Care MI 501(c)3 9 N/A 0 Northern Michigan Medical Management 416 Connable Avenue Petoskey MI 49770 208458840 Physician Practice MI 501(c)3 3 N/A 0 Northern Michigan Hematology and Oncology 416 Connable Avenue Petoskey MI 49770 320020293 Physician Practice MI 501(c)3 3 N/A 0 The Cardiac Institute DBA Michigan Heart & Vascular Specialists 416 Connable Avenue Petoskey MI 49770 262774689 Physician Practice MI 501(c)3 3 N/A 0 Hospice of Little Traverse Bay 1 Hiland Drive Petoskey MI 49770 382425019 Hospice Care MI 501(c)3 7 N/A 0 Petoskey Community Free Clinic 416 Connable Avenue Petoskey MI 49770 203675817 Health Services MI 501(c)3 3 N/A 0 Northern Michigan Regional Hospital Auxiliary 416 Connable Avenue Petoskey MI 49770 382835548 Fundraising MI 501(c)3 11 N/A 0 Northern Michigan Regional Health System 416 Connable Avenue Petoskey MI 49770 382445613 Health Services MI 501(c)3 11 N/A 0 Charlevoix Nursing Home Corporation DBA Boulder Park Terrace 14676 West Upright Charlevoix MI 49720 383038683 Skilled Nursing Facility MI 501(c)3 9 N/A 0 Healthshare Real Estate 416 Connable Avenue Petoskey MI 49770 382492223 Real Estate Holdings MI 501(c)2 N/A 0 Northern Michigan Regional Health System Foundation 360 Connable Avenue Petoskey MI 49770 382445611 Fundraising MI 501(c)3 11 N/A 0 VitalCare Inc 761 Lafayette Avenue Cheboygan MI 49721 382527255 Hospice Care/Home Health Services MI 501(c)3 9 N/A 0 VitalCare Home Medical Equipment Inc 761 Lafayette Avenue Cheboygan MI 49721 382662954 Retail for Home Medical Equipment MI N/A C Petoskey Assurance LTD 68 West Bay Road PO Box 1109 Grand Cayman Cayman Islands CJ KY1-1102 980628316 Professional and General Liability Coverage CJ N/A C 1.00000 Rapin & Rapin Inc DBA Prescription Services Pharmacy 416 Connable Avenue Petoskey MI 49770 383465261 Retail Pharmacy MI N/A C 0 1 1 1 0 0 0 0 1 1 0 0 0 0 1 1 1 1 Northern Michigan Regional Health System Foundation B 152166 Cost Petoskey Community Free Clinic B 408364 Cost Northern Michigan Regional Health System Foundation C 4058815 Cost Northern Michigan Regional Health System O 82717209 Cost Northern Michigan Hematology and Oncology O 350004 Cost Northern Michigan Medical Management O 2531206 Cost Northern Michigan Hematology and Oncology P 1496109 Cost Northern Michigan Medical Management P 425774 Cost The Cardiac Institute P 794671 Cost Hospice of Little Traverse Bay P 245561 Cost Charlevoix Nursing Home Corporation P 168518 Cost Rapin & Rapin Inc P 79308 Cost Petoskey Community Free Clinic P 57868 Cost Northern Michigan Regional Health System Q 23173397 Cost Northern Michigan Regional Health System Foundation P 152166 Cost Northern Michigan Hospital Auxiliary R 155865 Cost