2011-11-07T10:21:24-07:00 2010-12-31 990 2010-01-01 840175870 THE COMMUNITY HOSPITAL ASSOCIATION COMM 3034402358 PO Box 9019 1100 Balsam Ave Boulder CO 803019019 William A Munson Jr 3034402214 2011-11-07 2010 2016-02-24 21:20:13Z Boulder Community Hospital William A Munson Jr PO Box 9019 1100 Balsam Ave Boulder CO 803019019 516392406 0 X www.bch.org X 1922 CO To provide our community with the safest and highest quality healthcare in an innovative, patient-centered environment. 15 11 2535 585 3848228 -713096 2392215 3015535 250660703 259222326 1482242 8552011 9719578 11034954 264254738 281824826 597364 607040 0 0 131621519 126118985 0 0 311110 126314054 141832782 258532937 268558807 5721801 13266019 455617964 484095441 194474330 210902522 261143634 273192919 To provide our community with the safest and highest quality healthcare in an innovative, patient-centered environment. 0 0 199455521 604040 281824826 Health Care Delivery of IP & OP medical care. In 2010, the hospital discharged 8,785 adult & pediatric patients with an average length of stay of 4.3 days. 48,352 patients were seen in ou ERs/urgent care facilities. 7,271 surgeries were performed. The hospital had adjusted patient days of 86,571. 0 0 0 199455521 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 0 1 0 0 0 1 1 1 0 0 0 1 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 206 0 1 2535 1 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Lisa Rogowski Controller 3034402358 PO Box 9019 1100 Balsam Ave Boulder CO 803019019 David Gehant 40 X X 862943 0 26890 Rich Lopez 4 X X 0 0 0 Lou DellaCava 4 X X 0 0 0 Karen McMurry 4 X X 0 0 0 Tom Metz 4 X X 0 0 0 Jim Williams 2 X 0 0 0 Richard Porreca 2 X 0 0 0 Lee Carlin 2 X 0 0 0 John Meyer MD 2 X 0 0 0 R David Hoover 2 X 0 0 0 Jean Dubofsky 2 X 0 0 0 Janet Martin 2 X 0 0 0 Alexander Bracken 2 X 0 0 0 Steve Fries MD 2 X 0 0 0 Mako Shimoda MD 2 X 29400 0 0 William A Munson Jr 40 X 253526 0 102299 Michael D Moran 40 X 243164 0 25250 Gail Osterbur 40 X 241771 0 99385 Paul Kenneth Lewis Jr 26 X 224008 0 102009 Sarah E Meshak 40 X 197060 0 85380 James Peters 40 X 188723 0 87293 Linda S Minghella 40 X 174090 0 58876 Ronald Secrist 40 X 189561 0 40163 Valerie E Lipetz 40 X 225675 0 37156 James M Oberwetter 40 X 220495 0 36842 Benjamin J Keidan 40 X 205120 0 32035 Mark D King 40 X 195605 0 35200 Todd D Turner 40 X 191447 0 12085 Margaret Van Cleave 0 X 207544 0 9173 3850132 0 790036 109 1 1 0 CK Leasing LLC 905 Alpine Avenue Boulder CO 80304 Cyberknife services 2180066 Dr Laurie Coryell Community Medical Center 1000 W So Boulder Rd Lafayette CO 80026 Urgent Care Phys. Group 1093268 Boulder Valley Pulmonology PC 1000 Alpine Suite 100 Boulder CO 80304 Hospitalists 841764 Emergency Courier Services in care of Aaron Ramsey 7713 N 41st St Niwot CO 80503 medical courier service 722665 Boulder Valley Anesthesiology LLC PO Bpx 17389 Denver CO 80217 Anesthesiology coverage 720252 16 0 5165 0 2269475 679121 61774 0 3015535 Acute care hospital 622000 259222326 256060475 3100644 61207 0 0 0 0 259222326 4598291 0 0 4598291 372116 0 0 372116 0 0 0 0 0 0 0 0 0 0 0 0 0 0 236465813 1601142 233195526 1289825 3270287 311317 3581604 311317 0 3270287 0 9760 175 9585 0 0 9585 157693 82054 75639 0 0 75639 Misc Hospital Revenue 622000 5127915 3121528 747584 1258803 Health Care Joint Ventures 621400 5821815 5821815 0 0 0 0 0 0 10949730 281824826 265315135 3848228 9645928 184427 184427 121940 121940 300673 300673 4344922 1184755 2947578 212589 96078032 74556719 21488112 33201 6325891 4946079 1374622 5190 11968143 8984323 2965970 17850 7401997 5648097 1738268 15632 1673469 104282 1569187 0 70057 0 70057 0 88884 9192 79692 0 13665 0 13665 0 0 0 599446 0 599446 0 17575090 14696624 2866555 11911 1043447 0 1043447 0 47850320 43973250 3858460 18610 5081986 424138 4657848 0 0 0 0 0 4590761 1907124 2681893 1744 264215 135910 127862 443 156260 51999 104261 0 2595169 0 2595169 0 0 0 0 0 19710504 10199327 9489327 21850 1408497 1408497 0 0 Equip Repairs & Mtnc 6928413 586389 6342024 0 Provision for Bad Debts 20752755 20752755 0 0 Other Direct Costs 2600412 449589 2178733 -27910 Medicaid Provider Fee 8829432 8829432 0 0 268558807 199455521 68792176 311110 131910 778067 2522110 6138195 39393999 33865301 0 0 0 0 3374306 3048524 1234078 1368422 2419095 2464216 317275331 172384767 148225553 144890564 158530873 222110411 72062636 41351004 2325989 2391182 131250 370417 25266165 25319138 455617964 484095441 35165350 35101226 0 0 0 0 142624294 157613306 0 0 0 0 0 0 73558 70000 16611128 18117990 194474330 210902522 X 240505844 250961074 15849846 17224476 4787944 5007369 261143634 273192919 455617964 484095441 X 13266019 -1216734 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 16665 0 0 0 16665 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 7.74% of the hospitals dues paid to the Colorado Hospital Association are spent on lobbying activities. This amounts to $5,415. 24.2% of dues paid to the American Hospital Association are spent on lobbying activities. This amounts to $8,250. 20637790 3702912 2390484 0 4499341 0 22231845 17569973 3021313 3252269 0 3205765 0 20637790 22397933 3484109 -4795385 0 3516684 0 17569973 0 0.23 0.77 0 1 1 0 21801622 21801622 0 191872636 106551336 85321300 0 487314 326718 160596 0 98117038 65506713 32610325 0 4996721 0 4996721 144890564 -11822954 F 31294048 F Municipal Bonds, infrequently traded 1411810 F Corp Bonds and Notes, infrequently traded 16349223 F Fund of Hedge Funds 4118877 F 41351004 Interest in Net Assets Held by Foundation 21893738 Unamortized Bond Issue Costs 1298946 Deferred Comp Investments 1065541 Other Accounts Receivable 884486 Unamortized Swap Fees 176427 25319138 0 Accrued Pension Liability 17052449 Deferred Compensation Liability 1065541 18117990 281824826 268558807 13266019 -841642 0 0 0 -289454 -1131096 12134923 279887599 -841642 0 0 -392530 -1234172 281121771 599446 103609 703055 281824826 267752676 0 0 0 0 0 267752676 599446 206685 806131 268558807 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Boulder Community Hospital Foundation, a related organization, holds permanent endowment funds. The income earned on these endowment funds is used to support hospital programs for diabetes, cancer, neonatology, healthcare scholarships, or for the foundation to direct if the endowment fund does not restrict how the income is to be spent. Term restricted funds held by the Foundation include funds for cancer, as well as other hospital programs. Any Unrestricted funds held at the Foundation are for the hospital, but designation is decided by the Foundation board when granting to the hospital. SchD_P11_S00_L08 Schedule D, Part XI, Line 8 Other of -289,454 = +1,725,628 Change in Foudation Net Assets not on TR + 85,638 Tax vs Bk JV Income less 2,100,722 change in minimum pension liability + 2 rounding. SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Other revenues of -392,530 = +1,725,628 change in Foundation assets -2,100,723 change in minimum pension liablility+85,638 Tax vs book JV income recognition -181,635 Other Expense shown in net revenue on Audit but as Exp in Tax + 78,560 Auxiliary component of Contributions to Temp Rest Net Assets on audit but as Revenue on TR + 2 rounding. SchD_P12_S00_L04b Schedule D, Part XII, Line 4b Other 103,609 = Auxiliary revenue reflected in Rev on TR but as restricted donation on Audit SchD_P13_S00_L04b Schedule D, Part XIII, Line 4b Other 206,685 = 181,635 expenses reflected in revenue on audit but as exp on TR + 25,049 of Aux expenses reflected as a net Restricted Contribution on audit but as expense on TR + 1 rounding. 1 North America (including Canada and Mexico, but not the United States) 0 0 Program Services The hospital is a participant in a medical mission to Mante, Mexico. Mante is a sister city of Boulder, CO. 79951 Sub-Saharan Africa 0 0 Program Services The hospital is the recipient of a grant from the Department of Health and Human Services via the American International Health Alliance Training Center to help with development of zonal laboratories in Tanzania, Africa in response to the HIV/AIDS crisis. 220722 Central America and the Caribbean 0 0 Program Services Passive Investments 18350607 0 0 18651280 Sub-Saharan Africa The hospital is a recipient of a grant from the Department of Health and Human Services via the American International Health Alliance Training Center to help with the development of zonal laboratories in response to the HIV/AIDS crisis. The hospital donated in kind labor to provide education, training and managment services towards this effort. The grant covers travel and in-country expenses. 220722 Airfare, in-country expenses for mission, other mission costs reimbursed by AIHA grant to hospital, $177,051. In kind labor and other expenses donated by hospital for mission, $46,671. Cost 1 0 The hospital participates in a medical mission to Mante, Mexico. Mante is a sister city of Boulder, CO. The hospital donates supplies, shipping, and airfare for the mission. Physicians, NP, nurses, physical therapists and audiologists all donate their time to the medical mission. 2,271 patients were served over a 6 day period. 269 surgeries were performed. Patients did not pay for services. North America (including Canada and Mexico, but not the United States) 2271 79951 Donated supplies, shipping and airfare of $79,951. Cost 1 0 1 1 0 0 SchF_P01_S00_L02 Schedule F, Part I, Line 2 For the Mante, Mexico medical mission, the local Medical Director tours the region to identify appropriate care recipients based on financial need and medical need. Most supplies are hand carried by volunteer medical participants, although some are pre-shipped. The Mante, Mexico medical mission is led by a top administrative official from Boulder Community Hospital. The Tanzania, Africa project is subject to American International Health Alliance monthly grant reporting requirements. SchF_P01_S00_L03 Schedule F, Part I, Line 3 Passive Investments in Cayman Islands have a YE market value of $18,204,246 and incurred management fees of $146,361. 1 1 X 1 X 2.50 1 X 8.00 1 1 0 1 1 10610935 4867717 5743218 0.023 15822798 8164939 7657859 0.03 0 0 0 0 0 0 26433733 13032656 13401077 0.053 559146 173463 385683 0.002 231131 0 231131 0.001 741022 0 741022 0.003 0 0 1531299 173463 1357836 0.006 0 0 27965032 13206119 14758913 0.059 35758 0 35758 0 8671 0 8671 5000 0 5000 140257 0 140257 0 0 0 189686 0 189686 0 1 8561083 1 42492496 53177233 -10684737 X 1 1 Boulder Community Musculoskeletal Surgery Center LLC Outpatient Surgery Center 0.5 0 0.5 Endoscopy Center of the Rockies LLC Outpatient Endoscopy Center 0.5 0 0.5 Boulder Community Sleep Services LLC Sleep Lab Services 0.5 0 0.5 2 1 Boulder Community Hospital

1100 Balsam Avenue Boulder CO 80304

X X X Rehab DPU, Psych DPU 2 Boulder Community Foothills Hospital

4747 Arapahoe Avenue Boulder CO 80303

X X X Boulder Community Hospital 1 0 1 1 250 1 800 1 X X X X X 1 1 X X X X X X 1 X X X 1 X X X X X X X 1 X 0 1 Boulder Community Foothills Hospital 2 0 1 1 250 1 800 1 X X X X X 1 1 X X X X X X 1 X X X 1 X X X X X X X 1 X 0 1 24 Community Medical Center

1000 W South Boulder Road Lafayette CO 80026

Urgent-care center Mapleton Center

311 Mapleton Boulder CO 80304

Outpatient clinic for rehabilitation, sports medicine, mental health and home health BCH at Boulder Medical Center

2750 Broadway Boulder CO 80304

laboratory and imaging services Boulder Community Musculoskeletal Surgery LLC

1136 Alpine Avenue Boulder CO 80304

Ambulatory Surgical Center BCH Cyberknife Services

905 Alpine Boulder CO 80304

outpatient cyberknife services Endoscopy Center of the Rockies in Lafayette

1000 W South Boulder Road Suite 202 Lafayette CO 80026

Endoscopic Ambulatory Surgery Center Endoscopy Center of the Rockies in Boulder

1755 48th Street Suite 110 Boulder CO 80303

Endoscopic ambulatory surgical center Family Medical Associates

1000 W South Boulder Rd Suite 110 Lafayette CO 80026

Physician clinic Table Mesa Family Medicine

1755 48th St Suite 200 Boulder CO 80303

Physician clinic Endoscopy Center of the Rockies in Longmont

1551 Professional Lane Suite 295 Longmont CO 80501

Endoscopic ambulatory surgical center Boulder Community Hospital Occupational Medicine

4745 Arapahoe Ave Suite G40 Boulder CO 80303

Occupational Medicine Clinic Gunbarrel Medical Center

6685 Gunpark Drive Suite 110 Boulder CO 80301

Physician clinic Internal Medicine Associates

1155 Alpine Unit 360 Boulder CO 80304

Physician clinic Internal Medicine Associates Foothills

4745 Arapahoe Ave Suite G50 Boulder CO 80303

Physician clinic Beacon Clinic

1136 Alpine Ave Suite 205 Boulder CO 80304

Infectious Disease Clinic Boulder Community Sleep Services LLC

1000 Alpine Ave Suite 201 Boulder CO 80304

Sleep study center Boulder Community Sleep Services LLC

13654 Xavier Lane Suite 210A Broomfield CO 80020

Sleep Study Center Internal Medical Associates of Lafayette

100 W South Boulder Rd Suite 214 Lafayette CO 80026

Physician clinic Sports Medicine East

400 S McCaslin Blvd Louisville CO 80027

Sports medicine clinic Foothills Gynecology

4745 Arapahoe Suite G50 Boulder CO 80303

Physician clinic Buffalo Ridge Medical Center

16677 Lowell Blvd Broomfield CO 80023

Physician clinic Center for Integrative Care

4715 Arapahoe Unit 100 Boulder CO 80303

Outpatient Integrative Care for Cancer patients Broomfield Imaging

36 Golden Center Broomfield CO 80020

Laboratory and Imaging Services Boulder Community Internal Medicine

2880 Folsom Street Suite 212 Boulder CO 80304

Physician clinic SchH_P01_S00_L07 Schedule H, Part I, Line 7 Ratio of Patient Care Costs to Patient Care Charges SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f $20,752,755 SchH_P02_S00_L00 Schedule H, Part II Community Building Activities include disaster readiness training in conjunction with numerous local agencies (fire, police, sheriff, other counties, other hospitals) to ensure coordinated and effective response to a disaster. Also reported are the hopsitals participation in the development of the Colorado Regional Health Information Organization (CORHIO) and Boulder County Health Information Exchange (BCHIE)--both are electronic health exchanges aimed at promoting effective and efficient health care delivery, and also at providing information for community health needs assessments. Community health improvement includes support of the Boulder Valley School District healthy food project to encourage development of life-long healthy eating habits in children. The workforce development includes physician recruitment--Boulder is a Medically Underserved Area for low income and Medicare. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Audit statement footnote: on balance sheet Accounts receivable from patient services, net of allowances for uncollectible accounts of approximately $10,670,000. The net AR amount on the balance sheet is $33,865,301. To determine the cost of bad debts reflected on Part III, Section A, Line 2, the hospital applied the Ratio of Patient Care Costs to Charges to 85% of the Bad Debts and included 100% of 15% of the Bad Debts (patient responsibilities for copays, deductibles and coinsurance after insurance contractual allowances). The hospital does not have a mechanism to reasonably estimate the amount of bad debt cost that would reasonably relate to patients who would qualify for financial assistance under the hospital's financial assistance policy, but for whom sufficient information was not obtained to make a determination of their eligibility. However, surely there are bad debt dollars that would qualify for charity if the information were known. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 100%, and more, of Line 7 Medicare shortfall should be treated as community benefit. Boulder county has a demonstrated community need for physicians who accept Medicare. (Many physician providers do not.) The hospital not only serves the Medicare population for hospital services, it also employs numerous primary care and internal medicine providers who accept Medicare in order to provide our community with adequate coverage. The Cost Report shortfall reported on Line 7 excludes Medicare HMO enrollee shortfalls, excludes shortfalls from ancillary procedures which are paid by fee schedule and are therefore not included in the Cost Report, and excludes the shortfall related to employed physicians serving the Medicare population. The hospitals total Medicare shortfall, including these programs, is actually $21,600,045. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The hospital employs financial counselors to assist patients in determining eligibility for Medicaid, Colorado Indigent Care Program (CICP), or the hospital's charity program (WeCare). Financial arrangements with Emergency Room patients are not discussed until the patient has been assessed and treated in accordance with EMTALA. The hospital's debt collection policy contains a Communications section addressing courtesy, confidentiality, cultural sensitivity, and primary language of a patient. It contains a section on Billing and Collection Practices which addresses when an account will be referred to a licensed collection agency and that those agencies will treat all ptients with dignity, compassion and respect, as well as adhering to Colorado State Laws and the Fair Debt Collection Act. Patients may apply/reapply for financial assistance before, during or after care, or after collection agency assignment. SchH_P05_S0B_L19 Schedule H, Part V, Section B, Line 19 All patients without insurance are eligilbe for a 50% prompt pay discount. Those patients who qualify for financial assistance receive a discount rate that exceeds the lowest negotiated commercial discount rate. SchH_P05_S0B_L21 Schedule H, Part V, Section B, Line 21 A person who does not have insurance, but has means (does not qualify under the financial assistance policies), would be charged for services at the gross charge rate. However a 50% prompt-pay discount is available if the person pays at time of service, and a 40% discount if paid within 30 days of service. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 The hospital collaborated with the Boulder County Public Health Department, the Community Foundation Serving Boulder County and over 50 other community organizations who participated in community health focus groups to prepare a Community Health Needs Assessment. The report was issued February 22, 2011. In 2010 a comprehensive facilities study was performed to evaluate each of the existing hospital campuses and determine the most efficient and effective methods of delivering the safest, highest quality and efficient health care. The Hospital's Board Planning Committee uses the Community Health Needs Assessment, the Comprehensive Facilities study, as well as market and demographic studies to ensure the Hospital meets the future health care needs of our community. The Hospital is embarking on a 10 year transitional strategy to consolidate health care delivery in order to meet the needs of the community in a safe and sustainable manner. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Hospital employs financial counselors to assist patients in determining eligibility for Medicaid, Colorado Indigent Care Program (CICP), or the Hospital's charity program (WeCare). The hospital employs Spanish speaking financial counselors and would utilize interpreter services for other languages. Financial Assistance programs are referenced in patient discharge information, billing statements, and on the hospital's web site. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The Corporation provides comprehensive health services to a diverse population of more than 300,000 people who reside in Boulder County and an adjacent portion of the City and County of Broomfield. The Corporation has refined delineation of its primary and secondary service areas based on its market share by zip code. The primary service area includes the Cities of Boulder, Lafayette (approximately 15 miles east of the Broadway Campus and 11 miles southeast of the Foothills Campus), and Louisville (approximately 11 miles southeast of the Broadway Campus) as well as the western portion of the City and County of Broomfield. The secondary service area encompasses the rest of Boulder County, including the City of Longmont, which is approximately 15 miles northeast of the Broadway Campus. According to the Community Foundation's Boulder County Trends report published in 2009, the Boulder community enjoys good health which appears to be related directly to the community's higher-than-average education and economic levels. However, the Foundation Trends Report estimates that 15% to 20% of adults in Boulder County are without health insurance and a disproportionate number of the uninsured are Latino. The community's teen fertility rate is low compared to state and national benchmarks, but 70% of teen mothers are Latina and Latinas also lag in receiving prenatal care. The Trends study states that Boulder County children are generally rather fortunate, since 91% of the estimated 69,000 children under age 18 have access to health insurance. However, just 45% of Boulder County residents report having dental insurance coverage. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Hospital is governed by a volunteer community board. The Hospital has an open medical staff. All surplus funds are reinvested in the hospital to fund charity, subsidize under performing health programs, develop new health programs, or as an investment in plant, equipment and technology. 1 Boulder County Fire Fighters Assoc Sunshine Fire Protection District 311 County Road 83 Boulder CO 80302 846000600 501 (c) 3 26000 FMV support for local fire association Special Transit 4880 E Pearl St Boulder CO 80301 840777296 501 (c)3 10000 FMV Support for transportation for the disabled. Boulder Valley Women's Health Center 2855 Valmont Boulder CO 803011374 840645786 501 (c) 3 10000 FMV Support community women's health clinic. Clinica Campesina Family Health Services 2000 W South Boulder Rd Lafayette CO 80026 840743432 501 (c) 3 50000 FMV support for low income community health clinic Boulder Valley School District 6500 E Arapahoe Boulder CO 80303 846014683 501 (c) 3 65346 FMV Athletic trainer services Provide an athletic trainer to the school district to support high school athletics and help to reduce injuries to student athletes. 5 0 Healthcare educational scholarships 25 48000 FMV Assistance fund for for IP rehab patients to be used to support patient and family with living and medical expenses 39 27860 FMV Assistance with chemotherapy treatment expenses 91 21600 FMV Assistance with mammography professional fees for indigent patients 4 379 Cost of service Charity drugs and medical supplies given after discharge 270 6520 Cost Pharmaceutical prescriptions filled at cost for patients discharged with inability to pay, as well as medical supplies at cost. Bike helmets for school safety program 307 6200 Cost Bike helmets purchased for distribution at school safety programs. Transportation, housing and nursing home assistance for indigent patients 50 11381 Cost SchI_P01_S00_L02 Schedule I, Part I, Line 2 Grants are only made to non profit agencies supporting our local community with health and welfare services. Grants in excess of $10,000 are specifically approved by the hospital board of directors during the budget process. The CEO has a discretionary budget allocation for which he may approve disbursements less than $10,000. Monitoring of grants over $10,000 is done by having representation on their non profit board. Scholarship applications for healthcare education are reviewed by a committee, and payments are sent directly to the schools on the student's behalf with a letter indicating the money should be returned to the hospital if the student does not register. X 0 1 X X X X X 1 1 0 0 0 0 0 1 0 David Gehant 824443 0 0 0 38500 0 14271 0 18118 0 895332 0 0 0 William A Munson Jr 196851 0 23691 0 32985 0 75327 0 28531 0 357385 0 23691 0 Gail Osterbur 182708 0 20563 0 38500 0 87467 0 15355 0 344593 0 0 Paul Kenneth Lewis Jr 201727 0 15784 0 6497 0 81666 0 21903 0 327577 0 0 Sarah E Meshak 175810 0 4750 0 16500 0 85380 0 1485 0 283925 0 4750 0 James Peters 159223 0 0 0 29500 0 63847 0 26060 0 278630 0 0 0 Michael D Moran 131962 0 0 0 111202 0 25250 0 1022 0 269436 0 94702 0 Linda S Minghella 144167 0 14454 0 15470 0 58876 0 1238 0 234205 0 14454 Ronald Secrist 158903 0 8658 0 22000 0 27712 0 13816 0 231089 0 8658 0 Valerie E Lipetz 218766 0 0 0 6909 0 13485 0 25231 0 264391 0 0 0 James M Oberwetter 181995 0 0 0 38500 0 13095 0 25307 0 258897 0 0 0 Benjamin J Keidan 198881 0 0 0 6239 0 12185 0 21410 0 238715 0 0 0 Mark D King 179121 0 0 0 16484 0 11754 0 24887 0 232246 0 0 0 Todd D Turner 179447 0 0 0 12000 0 11162 0 2323 0 204932 0 0 0 Margaret Van Cleave 0 0 0 0 207544 0 0 0 9953 0 217497 0 107682 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a The hospital pays for board member companion travel at its annual educational conference. Companion travel is reported as Misc Income on the board members 1099. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b Travel for companions is only provided for spouse/significant other of board members attending the annual educational conference. Companion travel is reimbursed based upon substantiated receipts and is reported as Miscellaneous Income on a 1099 to the Board Member. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Margaret Van Cleave, former VP & COO Foothills, received $107,682 in severance pay offered in conjunction with an early retirement incentive plan designed to reduce staffing. The hospital contributes to a supplemental non-qualified retirement plan for the benefit of its executive leadership. Participants include: William A. Munson Jr, VP & CFO ($31,824 contributed;$0 paid out), Michael Moran, VP & Chief Quality Officer ($16,628 contributed; $94,702 paid out), Gail Osterbur, VP & Chief Nursing Officer ($33,129 contributed; $0 paid out), James Peters, VP ($18,744 contributed; $0 paid out), Linda S. Minghella, VP & CIO ($29,961 contributed; $0 paid out), Paul Kenneth Lewis Jr, VP and Chief Medical Officer ($25,058 contributed; $0 paid out), Sarah E. Meshak, VP & General Counsel ($39,953 contributed; $0 paid out), Margaret VanCleave, former VP & COO Foothills ($0 contributed; $85,206 paid out). SchJ_P01_S00_L07 Schedule J, Part I, Line 7 The hospital has an Incentive Compensation Plan for Vice Presidents and Directors whereby a percentage of base salary is paid out if goals are met and if authorized by the Board of Directors. For Vice-Presidents, one-third of their incentive is based upon the Hospital meeting at least 85% of its budgeted net operating income before interest expense. One-third VP incentive is based on Safety goals and one-third is based on Performance Goals. The one-third financial goal for Directors is based on meeting their departmental financial targets, as well as a one-third safety goal and a one-third performance goal. Colorado Health Facilities Authority 840752932 19648AVF9 2010-12-01 93535431 Foothills expansion; balance for debt refunding 0 0 0 0 0 93535431 0 0 0 1013609 0 0 0 67458941 25067002 2013 1 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 0 0 1 SchK_P02_S00_L03 Schedule K, Part II, Line 3 Pt II, Lns 4 through 12 exceed Pt II Ln 3 by 4,121, the amount transferred into the 2010 Cost of Issuance Bond Trust Fund from the close-out of the 2003 Bond Interest Trust Fund. Boulder Valley Pathology PC Dr. John Meyer is a Board member and also is a member of Boulder Valley Pathology PC -202610 BVP has an exclusive agreement to provide Anatomical and Pathology Services at Boulder Community Hospital. Payment to BVP ans (reimbursements from) BVP are as follows: Lab medical directorship, $84,890; payment of professional component of global fee arrangements, $288,000; reimb. of the per slide cost of private BVP pathology services done at the hospital, ($552,000); reimb. of space costs, ($23,500) per year. 0 Boulder Emergency Physicians PC Dr. Paul Lewis is the VP & Chief Medical Officer for BCH; he is also a member of Boulder Emerg Phys 406375 The hospital has an agreement with Boulder Emergency Physicians to provide ER services. Under this agreement, the hospital paid the group $28,375 for medical directorship of ER, $36,000 for a quality incentive, and $342,000 as an annual coverage payment for the Foothills ER. 0 Boulder Medical Center PC (BMC) Dr. Fries is a Board member and a pediatrician with BMC. 356047 Dr. Fries was paid $2,400 as a Pediatric Rehab Medical Director and $5,700 for call coverage. The hospital paid BMC $297,947 under a lab and imaging space lease agreement. The hospital has an agreement with BMC to provide on-site lab and imaging services to BMC patients. All lab and imaging charges are billed directly to patients and third party insurance by the hospital. The hospital loaned BMC $50,000 for the recruitment of an OB; this loan will be forgiven as long as the OB serves the community for at least 18 months. 0 Mako Shimoda MD Bd. Member 29400 The hospital paid Dr. Shimoda $29,400 for call coverage. This is consistent with the hospital practice of paying OB's for call coverage. 0 F990_P06_S0A_L04 Form 990, Part VI, Section A, Line 4 The bylaws were amended 9/2/2008 to establish a Patient Safety Committee as a Standing Commitee. Section V.E. and V.K. establish the composition and function of the Patient Safety Committee. This change has not previously been reported on the tax return. F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a Form 990 is prepared by the Controller based upon audited financial statements. The 990 is reviewed by the nonprofit tax manager of our external audit firm, by the CEO, CFO, VP & General Counsel, Compliance Officer, and the Audit Committee of the Board of Directors. Final copies are provided to each voting Board member electronically before filing with the IRS. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The hospital has a Conflict of Interest policy for staff, a Conflict of Interest policy for Board Members, and a Conflict of Interest disclosure form for physicians serving on committees. Board members complete an annual Statement of Interest form which discloses employment, family member employment, business relationships, service on other Boards or governance positions and identifies other conflicts of interest. The Statement of Interest also identifies transactions requiring disclosure. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The hospital has a Compensation Committee as specified by the bylaws of the hospital (Article V, D). The Compensation Committee is comprised of the Chairman, Vice Chairman, Secretary and a member of the Finance Committee. The committee meets approximately three times per year to review the CEO compensation and approve annual contract changes. Compensation and contract changes are reported to the Board. The Committee engages a consulting firm to provide comparative compensation studies for similarly qualified persons in functionally comparable positions at similarly situated organizations. Compensation study and performance review are considered in developing the compensation decision. Compensation ranges and Benefit changes for Vice President level employees are reviewed and approved by the Compensation Committee if they are outside of hospital wide treatment. Compensation studies are also used for VP level assessment. All Compensation Committee meetings are formally documented through minutes. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The hospital's web site is www.bch.org. The web site includes the hospital's Mission, Vision and Beliefs Statement. It also includes the Annual Report which contains the hospital Board members, key financial data, and information on new programs, patient safety and quality, and community benefits. The web site also has a section for Compliance policies including the Code of Conduct and Conflict of Interest. Annual audited financial statements are made available to the public at the Annual Meeting of The Community Hospital Association. The tax return is made available to anyone who requests the return through our Public Information Office. F990_P11_S00_L05 Form 990, Part XI, Line 5 Other Change in Net Assets of -1,216,734 = Change in Foundation Net Assets of 1,725,628 plus Unrealized gain on investments of 6,571,422 less unrealized loss on interest rate swaps of 7,413,064 less charge for Minimum pension liability of 2,100,722 plus rounding of 2. Boulder Community Hospital Foundation 1155 Alpine Avenue Suite G40 Boulder CO 80304 840772664 Fundraising for the hospital CO 509(c)3 509(a)3 N/A 0 Boulder Community Musculoskeletal Surgery Center LLC 1136 Alpine Avenue Boulder CO 80304 201391702 Outpatient surgery center CO N/A Related 2103408 1066046 0 0 1 0.5 Endoscopy Center of the Rockies LLC 382 S Arthur Ave Ste 140 Louisville CO 80027 841562782 Outpatient Endoscopy CO N/A Related 3643892 1047892 0 0 1 0.5 Boulder Community Sleep Services LLC 1136 Alpine Avenue Boulder CO 80304 262429064 Sleep Lab Services CO N/A Related 74511 61871 0 0 1 0.5 1 1 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 Boulder Community Musculoskeletal Surgery Center LLC a-iv 671650 Rental Agreement Boulder Community Musculoskeletal Surgery Center LLC p 64420 Recap of contracted amounts Boulder Community Sleep Services LLC a-iv 48083 Rent recapped by Property Mangement firm Boulder Community Sleep Services LLC l 764416 Contract for Services Boulder Community Sleep Services LLC p 345969 Recap of contract Extension to November 15, 2011 approved on Notice No. CP211A dated September 19, 2011.