2011-05-16T13:41:16-05:00 2010-06-30 Deloitte Tax LLP 555 E Wells SUITE 1400 MILWAUKEE WI 53202 990 2009-07-01 390806315 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE COLU 4143262230 4425 N Port Washington Road Glendale WI 53212 RHONDA ANDERSON 4143262230 2011-05-16 1 4142713000 2009 2016-02-24 21:20:13Z LEO BRIDEAU 4425 N Port Washington Road Glendale WI 53212 548625914 0 0928 X columbia-stmarys.org X 1859 WI 2 FULL-SERVICE HOSPITALS WITH MEDICAL, SURGICAL, ADVANCED CLINICAL AND OTHER COMMUNITY SERVICES. 15 12 4288 449 13063929 -968735 1055606 1658641 574279547 532590776 1200510 164407 12153660 13954930 588689323 548368754 0 0 263084898 263906425 0 0 311557122 284873511 574642020 548779936 14047303 -411182 516387912 540593519 341994459 365970737 174393453 174622782 COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE ("CSM-M") IS PART OF COLUMBIA ST. MARY'S INC. ("CSM"), 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-M'S GOVERNING BODY HAS ADOPTED THE MISSION OF CSM. 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 529145057 523145486 CSM-M OPERATES 2 FULL-SERVICE HOSPITALS, COLUMBIA HOSPITAL, A 370-BED HOSPITAL, AND COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE, A 294-BED HOSPITAL, WHICH OFFER A COMPLETE RANGE OF MEDICAL, SURGICAL AND ADVANCED CLINICAL SPECIALITIES. BOTH HOSPITALS OPERATE EMERGENCY DEPARTMENTS THAT ARE OPEN TO ALL PERSONS, REGARDLESS OF ABILITY TO PAY. DURING FISCAL 2010, CSM-M'S HOSPITALS AND CLINICS PROVIDED CARE TO 7,537 INPATIENTS AND 186,039 OUTPATIENTS. CSM-M'S ESTIMATED UNREIMBURSED COSTS OF SERVICES TO THE ELDERLY, UNINSURED, AND UNDERINSURED TOTALED $111,020,474. CSM-M ALSO SPONSORS A NUMBER OF PROGRAMS DESIGNED TO IMPROVE THE HEALTH CARE IN ITS COMMUNITY. REFER TO THE COMMUNITY BENEFIT INFORMATION IN SCHEDULE H FOR DISCUSSION OF HOW CSM-M MAKES A POSITIVE DIFFERENCE IN THE HEALTH STATUS OF ITS COMMUNITY, FOCUSING ON THOSE WHO ARE VULNERABLE. 529145057 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 1 417 0 1 4288 1 1 1 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 0 X Rhonda Anderson 4143262230 4425 N Port Washington Road Glendale WI 53212 Christopher Doerr 1.00 X 0 0 0 David Hoogerland MD 40.00 X 432564 0 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 30.00 X X 0 1473308 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 20.00 X 0 407494 69001 Amy Marquardt 20.00 X 0 298810 71352 Cheryl Hill 20.00 X 0 297147 83703 David H Shapiro MD 40.00 X 0 384210 71879 Gerri Lietz-Staffileno 5.00 X 0 270954 109265 Karol Marciano 30.00 X 0 353065 63358 Mary Paul 20.00 X 0 501197 46050 Sue Sanicola 20.00 X 0 241558 64704 William Hart 30.00 X 320296 0 43653 DEBORAH FRIBERG 30.00 X 5308 0 0 BRUCE MCCARTHY 20.00 X 0 0 0 Constance J Bradley 30.00 X 235716 0 33230 Paul Westrick 30.00 X 0 229529 96821 DAVID OLSON 5.00 X 0 25017 0 ROBERT B ROTH MD 40.00 X 1755713 0 103344 ROBERT L HUXLEY MD 40.00 X 1549034 0 112704 DAVID W GRAMBOW MD 40.00 X 1360555 0 110632 SANJAY S DESHPANDE MD 40.00 X 1182049 0 49079 RICHARD A PIRCON MD 40.00 X 1108818 0 86597 Brian Regan 20.00 X 0 307340 36788 Therese Pandl 0.00 X 774991 0 71841 8719736 5403921 1668828 9 1 1 0 CG Schmidt-Barton Malow 26500 AMERICAN DRIVE SOUTHFIELD MI 48034 Project Mgmt 42575527 FW Madison Medical Asso SC 788 N Jefferson St Suite 300 Milwaukee WI 53202 Third Party Med Service 10115011 Trimedx LLC 6325 Digital Way 400 Indianapolis IN 46278 Equip Repair/Maint 7896158 MEDICAL COLLEGE OF WISCONSIN 8701 WATERTOWN PLANK ROAD MILWAUKEE WI 53226 RESIDENT AND INTERN PROGRAM 2066081 ST JUDE MEDICAL SC INC 14901 MINNETONKA INDUSTRIAL MINNETONKA MN 55345 MEDICAL SERVICES 1806937 254 1658641 1658641 Net Patient Services 621990 493138967 493138967 From Affiliates 900099 24382605 24382605 Diagnostic Lab Revenue 621500 6516647 6516647 Retail Pharmacy Revenu 446110 5387336 5387336 Rental income 531120 1690932 1690932 1474289 1474289 532590776 421567 421567 257160 -257160 -257160 -257160 Capitalized Interest 900099 4586437 4586437 Sales to outside orgs 900099 2421149 2421149 Master Services 561000 1761770 601824 1159946 5185574 1167169 4018405 13954930 548368754 523145486 13063929 10500698 9456897 9456897 200730224 192701015 8029209 15269495 14658715 610780 24273788 23302836 970952 14176021 13608980 567041 15602458 15602458 497825 497825 1060348 1060348 55963544 55963544 511838 511838 10826770 10826770 34126958 34126958 18893946 18893946 111301 111301 849035 849035 3496107 3496107 27274062 27274062 4380540 4380540 Patient Care Supplies 63800625 63800625 Bad Debt Expense 32659227 32659227 Hospital Tax Assessment 14567998 14567998 Licenses and Permits 331969 331969 -81040 -81040 548779936 529145057 19634879 0 8958186 9116988 19855446 16184357 76077640 68058676 1046393 862356 6657271 5833813 13081583 13189549 659377973 239354751 385699872 420023222 37800 82500 4973721 7242058 516387912 540593519 47194177 43187012 5000 294795282 322783725 341994459 365970737 X 174393453 174622782 174393453 174622782 516387912 540593519 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 42511 42511 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: LOBBYING EXPENSES REPRESENT THE PORTION OF DUES PAID TO NATIONAL AND STATE HOSPITAL ASSOCIATIONS THAT IS SPECIFICALLY ALLOCABLE TO LOBBYING. 4689826 4689826 196874668 73832570 123042098 5074474 2239712 2834762 229642129 160741579 68900550 223096876 2540890 220555986 420023222 Custodial 718776 Pension/Deferred Compensation 59660545 Payable to third parties 1469665 payable to affiliates 142567186 Other long term liability 5195959 INTERCOMPANY DEBT TO ASCENSION HEALTH 113171594 322783725 PART X: ASC 740 footnote regarding uncertain tax positions in audited financials: Not applicable. 1 1 X 1 X 1 X 1 1 0 1 1 5804067 0 5804067 0.01120 189525805 148569178 40956627 0.07940 195329872 148569178 46760694 0.09060 1217047 64204 1152843 0.00220 10032138 0 10032138 0.01940 3241756 826781 2414975 0.00470 0 0 181276 0 181276 0.00040 14672217 890985 13781232 0.02670 210002089 149460163 60541926 0.11730 2388 0 2388 0.00000 0 0 0 0 88980 0 88980 0.00020 787379 0 787379 0.00150 126420 0 126420 0.00020 1005167 1005167 0.00190 0 16462000 2469300 251832299 265546287 -13713988 X 1 1 Columbia St Marys Hospital Columbia

2025 E Newport Avenue Milwaukee WI 53211

X X X Columbia St Marys Hospital Milwaukee

2323 N Lake Drive Milwaukee WI 53211

X X X Part I, Line 3c: Part I, Line 5b: The organization used prior history in setting its budgeted amounts of charity care for fiscal 2010. Due to the impact of expanded Medicaid rules during fiscal 2010, however, more patients were eligible for Medicaid than in prior years. As a result, the organization's actual charity care was less than its budgeted amounts, while its actual discounted care exceeded the budgeted amounts. In total, the organization was only slightly under the budgeted amounts for free and discounted care. Part I, Line 6a: CSM Hospital Milwaukee prepares and files an annual Community Benefit Plan report with the Wisconsin Hospital Association ("WHA"). The information on this report includes information only for CSM Milwaukee and not any of its affiliated hospitals. 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 cost 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 ratio was applied. Part I, Line 7: The total amount of Charity Care and Other Community Benefits in Part I, Line 7 is different from the Community Benefit as reported in the annual Community Benefit Report by the amount of Community Building Activities reported on Part II of Schedule H. The IRS does not consider Community Building Activities to be Community Benefit; however, these costs are included in the total Community Benefit amount as reported in the annual Community Benefit Report.Part I, Line 7g: The organization employs its physicians at its hospitals and physician clinics, so the associated costs and charges relating to those physician services are included in all relevant categories in Part I. Part I, Line 7f: The amount of bad debt expense reported on Form 990, Part IX, Line 25, column (A), but subtracted for purposes of calculating the percentages in Part I, Line 7, column (f) is $32,072,211. Part III, Line 4: The organization is a part of the Columbia St. Mary's, Inc. consolidated audit and further included as part of the Ascension Health consolidated audited financials. The footnote that references bad debt expense in the fiscal 2010 consolidated audit is as follows: "The provision for bad debts is based upon management's assessment of expected net collections considering economic conditions, historical experience, trends in health care coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of allowance for uncollectible accounts based upon historical write off experience by payor category, including those amounts no covered by insurance. The results of this review are then used to make any modifications to the provision for bad debts to establish an appropriate allowance for uncollectible accounts. After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted, the organization follows established guidelines for placing certain past due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by the organization. Accounts receivable are written off after collection efforts have been followed in accordance with the Organization's policies." CSM Hospital Milwaukee's share of bad debt expense in fiscal 2010 was $32,702,211 at charges ($16,462,000 at cost). No bad debt amounts are included in community benefit. Part III, Line 8: Ascension Health and related health ministries follow 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: The organization 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: In addition to the hospitals listed on Part V, CSM Hospital Milwaukee includes the following health care facilities: 2 urgent care centers, 22 general practice offices, 8 cardiac centers, 2 cancer clinic, 2 neurology clinic, 2 surgical center, 1 urology clinic, 1 pain management clinic, and 1 perinatal center. Part VI, Line 8: CSM Hospital Milwaukee files a community benefit report with the WHA in Wisconsin which includes the data only for CSM Hospital Milwaukee. The affiliate hospitals of CSM, including CSM Hospital Ozaukee, Inc. and Sacred Heart Rehabilitation Institute, Inc. also file separate community benefit reports with WHA. Part VI, Line 2: The health needs of the communities which CSM Hospital Milwaukee serves are assessed as part 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, WHA 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 consolidated needs assessment which addresses the communities in which all of the hospitals serve to guide the CSM planning. The assessment was developed by gathering key public health and disease specific assessments for each community and synthesizing the assessments into one document 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 Hospital Milwaukee 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 Hospital Milwaukee 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 for which the patient may qualify. Part VI, Line 4: CSM Hospital Milwaukee serves a primary service area of eastern Milwaukee County, from the near South Side of Milwaukee north through Ozaukee County. CSM Hospital Milwaukee 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. The service area is varied, with some sectors having high incomes and many health resources while other high admission zip codes are located in the impoverished central city and in medically underserved areas. Several high admitting zip codes for CSM have a high proportion of African American people and two high admitting zip codes have high proportions of people of Hispanic background. Addressing the health disparity issues of these populations is an important part of the Community Benefit service of CSM Hospital Milwaukee. In fiscal 2010, CSM Hospital Milwaukee served 193,576 patients and provided $5,804,067 in traditional charity care, $40,956,627 in unpaid costs of public programs, $3,601,659 in uninsured discounts and $14,786,399 in other community programs and services, which are reported on Part I, Line 7j and Part II. Discounts for the uninsured and underinsured are not included in Parts I or II of Schedule H. Part VI, Line 5: CSM Hospital Milwaukee provided the following community building activities in fiscal 2010:- 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. In order to accomplish the collaborative work in the community and to oversee access clinics and outreach programs, a Community Services Department exists. The Department also oversees the Community Benefit Process. The expense of departmental support is included in the reporting of community benefit. Part VI, Line 6: Community benefit activities often focus on access to primary care through free or reduced cost clinics sponsored by Hospital CSM Milwaukee. Following are several examples in which CSM Hospital Milwaukee focuses 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 Milwaukee 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 Milwaukee serves. CSM Milwaukee 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: CSM Hospital Milwaukee is part of the CSM health system, which contributes 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.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 community health benefit services, including subsidized health care, professional education, financial contributions and community building activities.In addition, the organization'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 hospital extends medical staff privileges to all qualified physicians in its community; however, the clinics within the organization are served by physicians affiliated with CSM. X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 David Hoogerland MD 277661 0 130953 0 23950 0 77222 0 44645 0 554431 0 0 0 Kevin Goniu MD 0 486446 0 128304 0 24559 0 60246 0 61612 0 761167 0 0 Leo P Brideau 0 798447 0 476201 0 198660 0 28394 0 72708 0 1574410 0 0 RHONDA ANDERSON 0 195895 0 34948 0 176651 0 42866 0 26135 0 476495 0 0 Amy Marquardt 0 233573 0 57036 0 8201 0 54863 0 16489 0 370162 0 0 Cheryl Hill 0 219299 0 53299 0 24549 0 52790 0 30913 0 380850 0 0 David H Shapiro MD 0 285875 0 76138 0 22197 0 58604 0 13275 0 456089 0 0 Gerri Lietz-Staffileno 0 201070 0 46991 0 22893 0 80675 0 28590 0 380219 0 0 Karol Marciano 0 254858 0 74629 0 23578 0 39499 0 23859 0 416423 0 0 Mary Paul 0 351746 0 90618 0 58833 0 33570 0 12480 0 547247 0 0 Sue Sanicola 0 169501 0 42068 0 29989 0 33659 0 31045 0 306262 0 0 William Hart 256800 0 58441 0 5055 0 21157 0 22496 0 363949 0 0 0 Constance J Bradley 186947 0 41176 0 7593 0 15567 0 17663 0 268946 0 0 0 Paul Westrick 0 180760 0 40828 0 7941 0 57618 0 39203 0 326350 0 0 ROBERT B ROTH MD 1684923 0 53000 0 17790 0 25771 0 77573 0 1859057 0 0 0 ROBERT L HUXLEY MD 1546623 0 0 0 2411 0 31987 0 80717 0 1661738 0 0 0 DAVID W GRAMBOW MD 1313410 0 38552 0 8593 0 36383 0 74249 0 1471187 0 0 0 SANJAY S DESHPANDE MD 804048 0 349360 0 28641 0 7350 0 41729 0 1231128 0 0 0 RICHARD A PIRCON MD 668529 0 438999 0 1290 0 24905 0 61692 0 1195415 0 0 0 Brian Regan 0 166422 0 92185 0 48733 0 18436 0 18352 0 344128 0 0 Therese Pandl 192746 0 37500 0 544745 0 51668 0 20173 0 846832 0 0 0 Part I, Line 1a TAX INDEMNIFICATION PAYMENTS ARE MADE ON THE PERSONAL USE OF EMPLOYER-PROVIDED CELL PHONES. THIS POLICY EXISTS FOR ALL EMPLOYEES ISSUED EMPLOYER-PROVIDED CELL PHONES. Part I, Line 4a 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 CONTRIBUTED TO THE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN IN THE AMOUNT AS NOTED: L. BRIDEAU $31,798 A. MARQUARDT 8,320 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. R BRUCE MCDONALD CHAIR-ELECT 1124154 CFO OF JOHNSON CONTROLS, INC., A PUBLIC COMPANY WHICH PROVIDES SERVICES TO CSM AND ITS AFFILIATES. ALL TRANSACTIONS ARE CONDUCTED AT ARMS' LENGTH. 0 DAVID SHAPIRO MD KEY EMPLOYEE 152719 SPOUSE IS ALSO EMPLOYED BY CSM SYSTEM. ALL COMPENSATION IS DETERMINED IN ACCORDANCE WITH PAYROLL POLICY GUIDELINES. 0 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 TO BETTER ALIGN WITH CSM'S MAIN SPONSOR, ASCENSION HEALTH. Form 990, Part VI, Section A, line 6 CSM-M HAS A SINGLE CORPORATE MEMBER, CSM. Form 990, Part VI, Section A, line 7a CSM-M HAS A SOLE MEMBER, HAS A SINGLE CORPORATE MEMBER, CSM, WHO HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF CSM-M. Form 990, Part VI, Section A, line 7b ALL DECISIONS THAT HAVE A MATERIAL IMPACT TO CSM-M'S FINANCIAL INFORMATION OR CORPORATION AS A WHOLE ARE SUBJECT TO APPROVAL BY ITS SOLE CORPORATE MEMBER, CSM. Form 990, Part VI, Section B, line 11 MANAGEMENT, INCLUDING CERTAIN KEY EMPLOYEES, 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 15A. 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. 15B. 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. ST MARY'S HOSPITAL OZAUKEE 4425 NORTH PORT WASHINGTON ROAD MILWAUKEE WI 53212 390807063 HOSPITAL WI 501(c)(3) 3 N/A SACRED HEART REHABILITATION INSTITUTE 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 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 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 N/A COLUMBIA ST MARY'S INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391834639 HEALTH SYSTEM WI 501(c)(3) 11 N/A COLUMBIA HEALTH SYSTEM 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391494977 HEALTH SYSTEM WI 501(c)(3) 11 N/A COLUMBIA ST MARY'S FOUNDATION INC 4425 NORTH PORT WASHINGTON RD GLENDALE WI 53212 391494981 FOUNDATION WI 501(c)(3) 7 N/A ORTHOPAEDIC HOSPITAL OF WISCONSIN LLC 575 RIVERWOODS PKWY GLENDALE WI 53212 392015655 HEALTHCARE WI N/A CSM STRATEGIC ALLIANCE 4425 NORTH PORT Washington Rd GLENDALE WI 53212 391871856 HEALTH CARE WI N/A C MADISON MEDICAL AFFILIATES INC 4425 NORTH PORT Washington Rd GLENDALE WI 53212 391855720 HEALTH CARE WI COLUMBIA ST MARY'S HOSPITAL INC C 0.72000 PROSPECT MEDICAL COMMONS CONDO ASSOCIATION 4425 NORTH PORT Washington Rd GLENDALE WI 53212 208042108 CONDO ASSOCIATION WI N/A C 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 1 0 ORTHOPAEDIC HOSPITAL OF WISCONSIN K 1159946 SACRED HEART REHABILITATION INSTITUTE K 1167169 ASCENSION HEALTH E 113171594 ORTHOPAEDIC HOSPITAL OF WISCONSIN I 422948 COLUMBIA ST MARY'S INC Q 9583711 ST MARY'S HOSPITAL OZAUKEE Q 32455265 SACRED HEART REHABILITATION INSTITUTE Q 1511051 COLUMBIA HEALTH SYSTEM Q 320010 ASCENSION HEALTH Q 639119