2020-06-04T10:51:55-05:00 2019-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Suite 2800 Minneapolis MN 554021538 990 2018-07-01 420680391 Mercy Hospital Iowa City Iowa MERC 3193390300 500 East Market Street Iowa City IA 52245 Sean J Williams President/CEO 3193390300 2020-06-04 1 Kristina Rasmussen P00143920 6123974000 139.167.185.46 2020-06-04 02:20:35 US P 4A2558486EEC6DB97E73B1E5FE2049900CCE7E47 C51E840BC3CE956D5D1AE02461DE610D74F443FB 2018 2020-11-06 18:47:13Z Sean J Williams 500 East Market Street Iowa City IA 52245 313212819 0 0928 X www.mercyiowacity.org X 1873 IA To heal and comfort the sick and improve the health of the community in the spirit of Jesus Christ. 14 13 1521 425 6478277 -369233 782642 760710 161265562 160757444 8181158 9050009 1715069 1359361 171944431 171927524 33145 36419 0 0 72203837 74122343 0 0 0 77295701 83087540 149532683 157246302 22411748 14681222 270071844 263566195 160020450 170390276 110051394 93175919 Mercy Iowa City ("Mercy") heals and comforts the sick and works to improve the health of the community in the spirit of Jesus Christ and the Catholic tradition of the Sisters of Mercy. 0 0 110189821 160785596 Hospital Services. In keeping with our mission of healing and comforting the sick, providing hospital medical services is at the heart of what we do. These services are provided in inpatient and outpatient settings, in situations that may be emergent, acute or chronic. Services include a 24 hour emergency unit, intensive and cardiovascular care. We also service a maternity unit and newborn nursery along with other surgical services, cardiac cath lab, cancer care, digestive care, telemetry monitored care, medical care, stroke care and behavioral and hospice care. 334164 215303 Education. The ongoing education of Mercy staff is critical in the fast changing field of health care and it necessary to meet regulations and certifications. Mercy hosts a number of professional continuing education classes each year, which is attended by it's own staff and staff from other institutions. Mercy provides a setting for students who are considering a career in health care including a class of insight to possible careers and preparation for CNA exam. 2512517 36419 Community Benefit. Mercy's community benefits take many forms, beginning with the traditional charity care of ($777 thousand) and the unpaid cost of Medicaid ($5.3 million). Other examples include cash donations to community non-for-profits such as the Free Medical Clinic, leadership time and skills that further the work of the non-for-profits, first aid booth provided at public events including the Johnson Co Fair. These efforts are detailed in Mercy's community health benefit report. As a trusted, longtime member of the community, Mercy plays an important role not only in further community health but the general community good. 113036502 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 63 0 1 1521 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 14 13 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 0 1 1 1 1 1 X Kimberley Rossiter 3193393900 500 East Market Street Iowa City IA 52245 Tim Krumm Chair (Beg 10/18) 1.00 1.00 X 0 0 0 Mark Phillips End 1018 Chair 1.00 1.00 X 0 0 0 Tom McLaughlin Vice Chair (Beg 10/18) 1.00 0.00 X 0 0 0 Tom Clancy Secretary (Beg 7/18) 40.00 0.00 X 36080 0 0 Scott Fisher End 1018 Secretary 1.00 1.00 X 0 0 0 Steven Anderson Beg 119 Board Member 1.00 0.00 X 0 0 0 SR Helen Marie Burns Board Member 1.00 0.00 X 0 0 0 Shari DeMaris Beg 119 Board Member 1.00 1.00 X 0 0 0 Jack Dusenbery Board Member 1.00 0.00 X 0 0 0 Tom Goedken End 1018 Board Member 1.00 0.00 X 0 0 0 SR Patricia Murphy Board Member 1.00 0.00 X 0 0 0 Bob Ritz Board Member 1.00 1.00 X 0 0 0 SR Rita Specht Board Member 1.00 0.00 X 0 0 0 Dave Vellinga Board Member 1.00 0.00 X 0 0 0 Mary Westbrook Board Member 1.00 0.00 X 0 0 0 Madeline Windauer Beg 119 Board Member 1.00 0.00 X 0 0 0 Sean Williams CEO & Administrator 40.00 2.00 X X 0 0 0 Douglas Davenport Treasurer 40.00 2.00 X 0 0 0 Kimberley Rossiter Assistant Treasurer 40.00 2.00 X 154167 0 28851 Casey Greene 1018 - 419 Vice President 40.00 0.00 X 258582 0 26504 Martin Izakovic Beg 419 Vice President 40.00 0.00 X 390146 0 44923 LeAnn Tatman End 1018 Vice President 40.00 0.00 X 0 0 0 Andrew Ashby Physician 40.00 0.00 X 667308 0 38862 Yonas Getachew Physician 40.00 0.00 X 611011 0 39953 Shoba Theivanayagam Physician 40.00 0.00 X 550284 0 20052 Joseph Truszowski Physician 40.00 0.00 X 578532 0 41579 Ankur Vyas Physician 40.00 0.00 X 575396 0 36311 Ronald R Reed Frmr President (CEO) & Administrator 0.00 0.00 X 209949 0 0 Michael Heinrich Former Officer 0.00 0.00 X 378759 0 1256 4410214 0 278291 117 1 1 0 Mercy Health Network PO Box 74008768 Chicago IL 606748768 Management Services 1894879 McComas-Lacina Construction 1310 Highland Ct Iowa City IA 52240 Construction Services 1656400 Progressive Rehabilitation Associates LL 2751 Northgate Dr NE Iowa City IA 52240 Rehabilitation Services 1496613 Allscripts Healthcare LLC 8700 W Bryn Mawr Avenue 700N Chicago IL 60631 IT Services 1482765 Philips Healthcare 3000 Minuteman Road Andover MA 01810 Medical Equipment Supplier 839969 58 760710 760710 Patient Serv. Revenue 621400 86175280 86175280 Medicare/Medicaid 621400 61792685 61792685 Lab Outreach 621511 6478277 6478277 ASC/DIC Income 900099 3653811 3653811 2657391 2657391 160757444 3061708 3061708 1814815 1538612 276203 276203 276203 131517390 14217594 126855665 12891018 4661725 1326576 5988301 5988301 Cafeteria Income 722210 839704 839704 Telephone 517000 159914 159914 Access 621400 9180 9180 74360 74360 1083158 171927524 154522621 6478277 10165916 27440 27440 8979 8979 341794 86025 255769 594212 594212 58218858 45210348 13008510 3884850 2814576 1070274 7032368 5094949 1937419 4050261 2934414 1115847 1636328 1636328 101292 101292 184576 184576 25511 25511 10262795 7871106 2391689 628936 1987 626949 13338428 8131626 5206802 6402278 450321 5951957 2973220 65440 2907780 222483 119402 103081 4424630 1818222 2606408 11011710 9326261 1685449 735782 735782 Medical Supplies 14156698 14153499 3199 Pharmacy Supplies 5431386 5431386 Bad Debt Expense 5136571 5136571 Food Expense 1190218 1190218 5224698 3163732 2060966 157246302 113036502 44209800 0 -279548 6429690 1734264 2261094 34099473 38244282 3797643 4464090 2855429 3603549 267901443 205361259 78187839 62540184 102278033 95118388 -32382843 -46432551 0 79781554 97337469 270071844 263566195 21695170 26112074 73912806 71626482 287691 132892 64124783 72518828 160020450 170390276 X 110051394 93175919 110051394 93175919 270071844 263566195 X 14681222 -2765951 -28790746 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 1 0 1 0 1 25511 25511 0 Part II-B, Line 1: Mercy Hospital, Iowa City, Iowa is a member of the Iowa Hospital Association (IHA) and America Hospital Association (AHA). A percentage of membership dues paid to IHA and AHA relate to lobbying activities. 17286002 14493 377510 533466 17144539 16775239 456231 744957 690425 17286002 15365728 123098 1673119 386706 16775239 15598237 263507 -400097 95919 15365728 16037323 213614 -138094 514606 15598237 0.55800 0.15600 0.28600 0 1 1 4171595 4171595 139325901 100112461 39213440 122797564 104646891 18150673 1606383 601907 1004476 62540184 Beneficial Interest-Foundation 17439968 Due from Affiliates 75546674 2011/2018 Bond Fund 4140827 Non-Compete Agreement Value 210000 97337469 Pension Benefit Liability 70715338 Other Long-Term Liabilities 135900 Professional Liability Claims 1667590 72518828 Part V, Line 4: All Restricted Endowed Funds are used for the benefit of Mercy Hospital Iowa City - capital equipment, employee grants, scholarships, etc. 1 1 1 X 1 X 1 1 0 1 1 779088 779088 0.00510 15490619 10180173 5310446 0.03490 16269707 10180173 6089534 0.04000 399894 399894 0.00260 2225 2225 0.00000 1122384 811274 311110 0.00200 53250 53250 0.00040 1577753 811274 766479 0.00500 17847460 10991447 6856013 0.04500 1693 1693 0.00000 376199 376199 0.00250 525 525 0.00000 378417 378417 0.00250 0 1408961 0 42703366 50100723 -7397357 X 1 1 1 Iowa City Ambulatory Surgery Center Outpatient Surgery Center 0.51000 0.49000 2 Corridor Radiology Outpatient Radiology Services 0.51000 0.49000 1 1 Mercy Hospital 500 East Market Street Iowa City IA 52245 www.mercyiowacity.org X X X Lab Outreach Mercy Hospital Iowa City Iowa 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X See Part V, Section C X 1 18 1 See Part V, Section C 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X See Part V, Page 8 X See Part V, Page 8 X See Part V, Page 8 X X X X X X 1 X 0 X X X X 1 X 0 0 Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 5: The Hospital conducted two focus groups with participants from these organizations, representing broad and deep knowledge of community health needs:- 4 Cs Community Coordinated Child Care- City of Coralville- City of North Liberty- Clear Creek Amana Schools- Coralville Police Department- Iowa City Area Chamber of Commerce- Iowa City Area Development Group- Iowa City Community School District- Iowa City Free Medical and Dental Clinic- Iowa City Police Department- Johnson County Ambulance Service- Johnson County Public Health- Johnson County Social Services- Mercy Hospital Iowa City- Mercy Hospital Emergency Care Unit- Mercy Iowa City- Mercy IC and Mercy Services- Mercy Pediatric Clinic- National Alliance on Mental Illness Johnson County- Rural Health and Safety Clinic of Eastern Iowa- United Action for Youth- United Way- United Way of Johnson and Washington Counties Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 7d: http://www.mercyiowacity.org/upload/docs/2018%20PRC%20CHNA%20Report%20-%20Mercy%20Iowa%20City.pdfPart V, Section B, line 10a, Implementation Strategy Website:http://www.mercyiowacity.org/upload/docs/About%20Mercy/2018CommunityHealthStrategy%20(1).pdf Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 11: The 2018 CHNA summarized twelve areas of opportunity for Community Health Improvement. Mercy Hospital is addressing those needs as follows:Mental Health - Depression and Social Support:Mercy has budgeted an expansion in our outpatient psychiatric clinic from 3 advanced registered nurse practitioners and 1 therapist in 2018 to 4 practitioners and 2 therapists in 2020. We expect this to result in a proportional growth of patient visits and an improvement in timely response. Mercy will continue to offer inpatient and emergency room mental health services at our Johnson county hospital. We have employed 2 nurse navigators in 2018 that are in the process of developing high quality social support referral networks in recognition of the importance of social support services to patients after they return home after hospitalizations. We are also involved in planning meetings with Johnson County which is building an Access Center to provide rapid stabilization to patients experiencing substance abuse or mental health crisis.Nutrition, Physical Activity, Diabetes:We will continue to offer a 12 week program to the public taught by registered dieticians that focuses on behavioral modifications to achieve long-term lifestyle changes to improve overall health.Since 2018, we have employed a board certified physician in endocrinology, diabetes, and metabolism. His ability to effectively treat patients with metabolic disorders advances our ability to address the adult obesity health need. We have increased this department budget for the next fiscal year and expect it to treat 10% more patients than in the previous year.Substance Abuse - Binge Drinking:Our community is home to a major university and excessive drinking has long been an issue. Our Vice President of Population Health attends the Partnership for Alcohol Safety, a joint project of the University of Iowa and the City of Iowa City. Its mission is to identify and advocate for strategies that reduce high-risk drinking and related harms.Access to Primary Care Physicians:Mercy will continue to operate primary care clinics in each of our 5 primary care counties. This is the most direct way to address access, along with a financial aid policy that reduces the financial barriers for the uninsured. Mercy will also continue support of the Free Medical Clinic in Johnson county. This is an important health care access point for those with limited ability to pay.Cancer - Cancer Incidence:Mercy intends to more widely advertise the low dose lung cancer screening program that screens for at-risk patients, especially former heavy smokers. The existing program has resulted in the early identification and treatment of lung cancers, although many more eligible patients have not yet been screened.Heart Disease & Stroke Mortality Rates:Two additional cardiologists will begin treating patients in 2019 and should result in at least 25% increase in patient contacts with our cardiologists. Mercy is also certified as a primary stroke center and intends to maintain that certification.Infant Health - Teen Births:Mercy has budgeted to maintain our Muscatine county clinic staffing levels for the next year. This should maintain patients ability to access health care resources directly from this clinic. Additionally, we partner with independent OBGYN groups to assess the market needs in this county.Injury & Violence - Violent Crime Rate:We intend to take no action as reducing the crime rate is not within the scope of our health care delivery system.Oral Health - Regular Dental Care:We intend to take no action regular dental care is not within the scope of our health care delivery system.Respiratory Disease - Chronic Lower Respiratory Disease:We have employed 2 nurse navigators in 2018, that are focused on reducing hospitalization readmissions and avoidable emergency room visits, especially from patients with chronic conditions. They contact patients after they return home after hospital encounters to ensure that patients have follow-up visits with their normal primary care provider and that they understand and are following the medical advice prescribed for them.Sexually Transmitted Disease and Chlamydia Incidence:Mercy is continuing to monitor chlamydia incidence rates and has seen recent high rates in the eastern portion of our service area. Our Infection Prevention Coordinator plans to provide staff education in the clinic and identify opportunities for community outreach. He will then track the incidence rates to see if those efforts have a significant impact on reducing incidence.Tobacco Use:We continue to provide smoking cessation counseling to a high percentage (85%) of adult smokers who are seen in our clinics. Part V, line 16a, FAP website: http://www.mercyiowacity.org/upload/docs/Patients%20and%20Visitors/Financial%20Assistance%20Docs/Financial%20Assistance%202019%20Updated%20Policy.pdf Part V, line 16b, FAP Application website: http://www.mercyiowacity.org/upload/docs/Patients%20and%20Visitors/Financial%20Assistance%20Docs/Exhibit%20A--Financial%20Assistance%20App%202019.pdf Part V, line 16c, FAP Plain Language Summary website: http://www.mercyiowacity.org/upload/docs/Patients%20and%20Visitors/Financial%20Assistance%20Docs/Exhibit%20B--Plain%20Language%20Summary%202019.pdf 1 1 - Mercy Home Health Care 500 East Market Street Iowa City IA 52245 Home Health and Private Duty Nursing Part I, Line 7: Amounts in the table were derived using a cost accounting system that addresses all patient segments. A cost to charge ratio derived from completing IRS worksheet 2 was used to determine the amounts in Part I, Line 7a, 7b, 7c. and 7g. Part I, Ln 7 Col(f): Bad debt expense of $5,136,571 was subtracted for purposes of calculating the percentage in Schedule H, Part I, Line 7, column (f). Part II, Community Building Activities: Economic Development:Mercy works with such groups as the Iowa City Area Chamber of Commerce and Iowa City Area Development Group to support the business community, welcome innovation to the area, and develop the workforce. It began construction of a new 40-bed Mercy Inpatient Rehabilitation Hospital that will employ approximately 100 health care professionals. Its anticipated completion is May, 2020.Community Support:Mercy has provided support to United Way of Johnson and Washington Counties for more than 30 years. Mercy also supports financially and with colleague time, community agencies such as Iowa City Hospice, Free Medical Clinic, NAMI (National Alliance for the Mentally Ill), American Cancer Society, School-Based Health Clinics now located in four of the Iowa City Community School Districts public schools (another opened at City High School in August), and so on. Mercy also provides staff to provide first aid at community festivals such as Arts Fest, Jazz Fest and Soul Fest, and at the Johnson County Fair. In FY2019, Mercy signed a Memorandum of Understanding with Rural Health and Safety of Eastern Iowa to partner in their efforts to increase health care outreach and reduce injury prevention in the agricultural areas that make up most of its service area. Physical and mental health screenings, injury prevention education and general health information activities are ongoing during the warm weather months in Johnson and five contiguous counties.Mercy continues to be a community leader in ensuring that fewer people experience food insecurity within Johnson County and the State of Iowa. Mercy contributes regularly to Table to Table, a local organization that collects wholesome, edible food from donors (grocery stores, restaurants, and Mercy Iowa City) and redirects it to food pantries and meal sites in the county. Mercy is also a lead organization for Thanksgiving in July, an annual summer food drive whose goal is to fill food pantries at a time of year when they have fewer donations and children are out of school, not receiving free and reduced breakfast and lunch. This program was started at Mercy Iowa City in 1995 and has grown to include many other sites in the State of Iowa including Des Moines, Dubuque and the Quad cities. Mercy has also held additional food drives during the year.Mercy's pastoral care department provides clothing to patients who are discharged with nothing to wear, often because what they had when they were admitted is no longer wearable (cut off in the Emergency Room, etc.) and there is no one to bring them anything. The chaplains also coordinate the Shoes That Fit program to meet clothing and footwear needs for children in area elementary schools who do not have appropriate attire, especially during the cold weather months when they need heavy coats and boots.Mercy's 24-hour "Mercy On Call" service provides medical triage and health information, can schedule provider appointments and refer callers to local supporting services.Environmental Improvements:Mercy has been a good neighbor by maintaining its buildings and landscaping at a high level. Mercy also pursues extensive recycling (including newspapers, office paper, magazines, plastics, batteries, cooking oil, construction materials and more) and programs that reduce energy consumption. Mercy is expanding its recycling program to make it easier for colleagues and visitors to participate throughout the hospital. Mercy has also sold four houses it owned adjacent to its campus to the Iowa City which rehabilitated them for single family use during the last several years.Leadership Development and Training of Community Members:Mercy lends support to the annual Community Leadership program of the Iowa City Area Chamber of Commerce, a nine-month leadership development program for 24 individuals who are increasing their professional and personal commitment to the community and typically sponsors a class member each year. It participates actively in the health care day of education. Mercy also supports an active Clinical Ladder program for nurses, offers Continuing Education Credit (CEU) courses and conferences open to medical professionals across the state on a regular basis, such as those tailored to Emergency care, Hospitalist care and Nursing care. Mercy also offers a location for CEU courses for the local Honoring Your Wishes initiative which encourages all adults to have Advance Directives that are current and reflect their wishes. The CEU courses train individuals to become certified counselors to help individuals with their Advance Directives, and to train certified counselors to assist with IPOST which is the Iowa version of the national POLST directive, a medical order for those with terminal conditions. Honoring Your Wishes is the program used at Mercy, and the hospital offers free assistance to anyone in its service area who needs it to complete their documents.Coalition Building:Mercy is involved in many ways with local citizens and groups that are working to afford all members of our community a good quality of life and to improve overall quality of life. Mercy is a co-sponsor of the Johnson County SAFE Kids Coalition whose mission is to prevent or reduce preventable injuries to children from birth to age 14. SAFE Kids promotes the correct use of child safety restraints in vehicles, bicycle helmets, and safety education to prevent falls, burns, poisoning and more. Mercy is also a lead partner of Safety Village, a two-week summer safety camp for children aged 5-7 held in a miniature village on the grounds of one of our local elementary schools. Each summer, 200 children participate in classes and safety education with local EMS, police, sheriffs and others.Mercy is also a lead partner in a new Health and Rural Safety of Eastern Iowa initiative which works to reduce preventable injuries in the agricultural community such as heavy equipment, large animal, pesticides and more. This partnership also seeks to increase health screenings and referrals to primary and specialty care for this population, that includes Anabaptist, and provide education to improve health. Some of this is accomplished through youth safety camps, FFA (Future Farmers of America) and 4-H programs, county fairs, community events and in cooperation with churches. Part III, Line 2: The amount of bad debt expense reported on line 2 was derived from taking actual bad debt write-offs and applying the cost to charge ratio of .3326 to that amount. Part III, Line 3: Mercy Hospital works with those qualifying for charity care along every step of the process. Every effort is made to work with the patient to provide financial assistance when appropriate. While there are people who do not cooperate with Mercy Hospital regarding payment plans, financial assistance or with those trying to get help from Government programs. For individuals not providing necessary information, it is impossible to know the reason for not cooperating and therefore know whether they will qualify for charity care. Mercy Hospital is unable to reasonably determine whether any amount of bad debt could have been classified as charity care if the individuals do not provide the necessary information to evaluate their situation to determine qualifications with the charity care policy. Part III, Line 4: Mercy Hospital's Audited Financial Statements includes a footnote for the Provision of Uncollectible Accounts on page 11 of the Audited Financial Statements. Part III, Line 8: Total revenue was determined using charges per the CMS Provider Statistical Reimbursement System reports for Fee Reimbursed Services for the fiscal year ended 6/30/19. Costs calculated using the Cost to Charge Ratio for the appropriate services from the submitted Medicare Cost Report Form 2552-96 for the fiscal year ended 06/30/19. Part III, Line 9b: Mercy Hospital has two policies related to debt collection. The Financial Assistance Policy provides guidelines for forgiving all or part of a patient's financial responsibility for healthcare services received at Mercy Hospitals. Patient may be given a financial assistance application at the time of service, be offered financial assistance during the normal collection process or learn of the option on the Hospital website. All patients with no insurance are offered financial assistance via billing statements & follow-up telephone calls. Any patient that is known to qualify for financial assistance is provided assistance. The payment plan policy enables those who qualify for patient financial assistance to establish payment plans of the remaining balance of their bill. Part VI, Line 2: The most recent community health needs assessment was conducted in December 2018. The organization engaged Professional Research Consultants to conduct the assessment. The community health survey is a systematic, data-driven approach to determining the health status, behaviors, and needs of residents in the communities the organization serves. The survey instrument used for the assessment is based largely on the Centers for Disease Control (CDC), Behavioral Risk Factor Surveillance System (BRFS), as well as various other public health surveys and customized questions addressing gaps in indicator data, relative to nation health promotion and disease prevention objectives and other recognized health issues. Part VI, Line 3: Evaluation for Medicaid, disability, and other types of coverage is provided for uninsured patients for inpatient stays as well as high dollar outpatient services. Part VI, Line 4: Mercy Hospital is located in the community of Iowa City, Iowa, in Johnson County along the east central part of the state. The county's population in 2018 was approximately 147,000. Mercy Hospital services 10 counties in southeast Iowa, with the primary service area being Johnson County. The secondary service areas includes: Cedar, Iowa, Muscatine and Washington counties. The tertiary service area includes Henry, Jefferson, Keokuk, Lee and Louisa counties. The population of the service area is approximately 340,200.Iowa City is home to the University of Iowa, which has an enrollment of approximately 32,000 for the 2017-2018 academic year. Johnson County is well-educated, of individuals 25 and older, 95.3 percent are high school graduates and 53 percent hold a bachelors degree or higher. The University of Iowa also provides the foundation for an economy that has particular strengths in education, health care, services, technology, agribusiness and manufacturing. According to the U.S. Census Bureau, 17.7 percent of the Johnson County population lived below the poverty line between 2017 and 2018, compared to 10.7 percent for the entire state. Part VI, Line 5: Mercy Iowa City is faith-based institution that provides services based on the ethical and religious directives of the Catholic Church. An important part of Mercy's mission is to improve the health of the community. Mercy does so by: Ensuring that the medical staff is open to all qualified physicians; ensuring that the hospital is accredited and in good standing with the Joint Commission; ensuring that the board of directors is comprised of diverse, independent individuals, not employees of the hospital, representing the community and also providing necessary expertise; establishing and carrying out a conflict of interest policy; providing a site for clinical experience for a variety of health care professionals; providing charity care and financial assistance with medical bills as needed to community members; participating in such programs as Medicare, Medicaid, and Hawk-i, an insurance program for needy Iowa children; absorbing unreimbursed costs for such government programs; ensuring that account collections are carried out in compliance with state and federal guidelines; providing emergency room services and working with local and state officials in community preparedness issues; treating emergency patients according to EMTALA guidelines and service all patients regardless of their ability to pay; investing surplus funds in services, technology, and personnel that will further the benefit of the community. Part VI, Line 7, Reports Filed With States IA 1 Iowa City Area Development Group Inc 136 S Dubuque Street Iowa City IA 52240 421234837 501(c)(6) 12000 General Support 0 1 Temporary Assistance Program 15 8979 Part I, Line 2: All organizations Mercy provides assistance to are local organizations. Therefore, Mercy is in frequent contact with the organizations and is generally aware of their use of Mercy's assistance. However, there is no formal mechanism in place to track specific uses of the assistance. Mercy Hospital offers a Temporary Assistance Program (TAP) for emergency financial needs that employees may have. This confidential program offers crisis assistance and health benefit assistance. X X X X X 1 1 0 0 0 0 0 1 0 Kimberley Rossiter Assistant Treasurer 118360 0 31732 0 4075 0 0 0 28851 0 183018 0 0 0 Casey Greene 1018 - 419 Vice President 207610 0 50003 0 969 0 0 0 26504 0 285086 0 0 0 Martin Izakovic Beg 419 Vice President 352729 0 21644 0 15773 0 7626 0 37297 0 435069 0 0 0 Andrew Ashby Physician 550229 0 79345 0 37734 0 0 0 38862 0 706170 0 0 0 Yonas Getachew Physician 590715 0 0 0 20296 0 0 0 39953 0 650964 0 0 0 Shoba Theivanayagam Physician 550014 0 0 0 270 0 0 0 20052 0 570336 0 0 0 Joseph Truszowski Physician 577242 0 0 0 1290 0 0 0 41579 0 620111 0 0 0 Ankur Vyas Physician 433627 0 141322 0 447 0 0 0 36311 0 611707 0 0 0 Ronald R Reed Frmr President (CEO) & Administrator 209949 0 0 0 0 0 0 0 0 0 209949 0 63743 0 Michael Heinrich Former Officer 378759 0 0 0 0 0 0 0 1256 0 380015 0 0 0 Part I, Lines 4a-b Ronald R. Reed, former CEO retired from the organization in early 2016. He had a written severance agreement with Mercy Hospital that was to pay him his salary for a term of 24 months after separation. In calendar year 2018, he was paid $146,206. Michael Heinrich, former Treasurer/CFO separated from the organization in July 2017. He had a written severance agreement with Mercy Hospital that was to pay him his salary for a term of 24 months after separation. In calendar year 2018, he was paid $378,759. Part I, Line 4b: Mercy established an IRC Section 457(f) plan as a way of retaining executive, officers and select groups of highly compensated employees with supplemental retirement benefits. The following individuals participated in and received payments from the plan. - Ronald R. Reed - $63,743 Part I, Line 7 Non-fixed payments were provided to administrators and physicians who met stated criteria that included meeting certain RVU (Relative Value Unit), productivity levels, specified CMS/JACHO performance core indicators and certain patient satisfaction and/or nursing satisfaction survey scores. A City of Hills Iowa 420920947 000000000 2018-05-10 40501771 Refund Bonds issued 04/29/08 0 0 0 B City of Hills Iowa 420920947 431669AW0 2011-11-30 44742571 Build and Equip Facility; Refund Bonds issued 7/16/1998 0 0 0 A 515000 40501771 4057022 2131594 34320000 2018 1 0 1 1 B 11880000 44743882 589874 20002570 24151438 2012 1 0 1 1 A 0 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 B 0 0 0 1 0 0 0 1 1 A 1 B 1 Schedule K, Part II, Line 3: Differences between the issue price (Part I) and total proceeds (Part II, line 3) are due to investment earnings. Schedule K, Part IV, Line 2c, Column B: Rebate calculation was performed 5/21/14. Schedule K, Part IV, Line 6, Column B: Such amounts were appropriately yield restricted. Form 990, Part VI, Section A, line 2 Sister Helen Marie Burns, board member; and Sister Patricia Murphy, board member; are both members of the Sister of Mercy of the Americas West Midwest Community. Form 990, Part VI, Section A, line 6 Mercy's sole member is the Sisters of Mercy of the Americas West Midwest Community, Inc. Form 990, Part VI, Section A, line 7b Mercy's sole member, Sisters of Mercy of the Americas West Midwest Community, Inc., maintains a number of "reserved powers" including but not limited to approval of annual budgets, approval of amendments to the articles of incorporation and bylaws, approval of real property transactions and approval of long term borrowing. Form 990, Part VI, Section B, line 11b The Form 990 is prepared and reviewed by Mercy Hospital management and is also reviewed by Deloitte Tax LLP. In addition, a board resolution was established that provides that each board member be (i) provided a copy of the Form 990 as it is intended to be filed, and (ii) given a reasonable opportunity before filing to provide to the Audit Committee any comments, corrections, concerns or other inputs on the proposed Form. The Audit Committee's review process shall be intended to reasonable verify that the Form 990 has been fully and accurately completed, including but not limited to, all inquiries therein relating to corporate governance. After completing its review, the Audit Committee, on the Board's behalf, shall have the authority to authorize the filing of the annual Form 990. Form 990, Part VI, Section B, line 12c A conflict of interest statement is signed at the beginning of Board members term and on an annual basis there after. Any abstention from a vote is recorded in Board minutes. After the fiscal year end a "look back" questionnaire is distributed to all Board members to disclose any conflicts of interest that may have taken place in the previous year. Form 990, Part VI, Section B, Line 13: Per IRS guidance, because the board had not formally adopted the whistleblower policy as of 6/30/19, the organization has answered "No" to this question, Mercy Hospital has an Executive Leadership Team (ELT) which is made up of Vice Presidents and the CEO that has been delegated by the board of directors to manage and approve policies. The ELT has approved the whistleblower policy. Form 990, Part VI, Section B, line 15 Compensation for all executives and other key employees is determined based on national or regional market data for comparable positions at comparatively sized hospitals. The Executive Committee of the Board of Directors uses this market-based information to set the President and CEO's compensation. In turn, the CEO uses this same information to set compensation for officers and key employees, which is also approved by the board. Form 990, Part VI, Section C, line 19 Mercy's governing documents and conflict of interest policy are not available to the public. Form 990, Part XI, line 9: Change in Unrecognized Pension Actuarial Gain -10,929,635. Change in Beneficial Interest in Foundation -119,039. Change in Beneficial Interest of Services -17,662,072. Transfer to Self Insured Trust -80,000. Mercy Foundation 500 East Market Street Iowa City IA 52245 237040506 Foundation/Fundraising IA 501(c)(3) 12-I Mercy Hospital 1 Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust 500 East Market Street Iowa City IA 52245 426591803 Self Insurance IA 501(c)(3) 12-I Mercy Hospital 1 Sisters of Mercy of the Americas West Midwest Community Inc 7262 Mercy Road Omaha NE 68124 262400800 Religious Order NE 501(c)(3) N/A 0 Mercy Hospital Guild 500 East Market Street Iowa City IA 52245 426099912 Fundraising IA 501(c)(3) 12-III-FI N/A 0 Iowa City Ambulatory Surgical Center LLC 2963 Northgate Drive Iowa City IA 52245 208503424 Outpatient Surgery IA Mercy Hospital Related 3651250 3840945 0 1 0.51000 Corridor Radiology LLC 2769 Heartland Drive Suite 307 Coralville IA 52241 430635070 Radiology Services IA Mercy Hospital Related 540067 2060260 0 0 0.51000 Eastern Iowa Rehabilitation Hospital LLC 680 S 4th Street Louisville KY 40202 831589139 Inpatient Rehabilitation Care IA Mercy Hospital Related 3049973 0 0 0.51000 Mercy Services Iowa City Inc 500 East Market Street Iowa City IA 52245 421241044 Medical Clinic Services IA Mercy Hospital C -18085439 10106816 1.00000 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 Mercy Foundation C 760710 Cost Mercy Services Iowa City Q 59070 Cost Mercy Services Iowa City A 1402181 Cost Mercy Services Iowa City R 3500000 Cost Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust R 80000 Cost Eastern Iowa Rehabilitation Hospital LLC B 3130000 Cost Mercy Services Iowa City S 325000 Cost