2019-11-14T13:16:02-06:00 2018-12-31 990 2018-01-01 382027689 WA Foote Memorial Hospital WAFO 5172054800 205 N East Avenue Jackson MI 49201 Paula Autry President & CEO 5172054800 2019-11-14 150.198.64.200 2019-11-14 14:09:51 ES P AB1DB372B0367D7F6A967A544E38B425EA745858 6A8D99C253AD97DAB86B5D513343FA457C071D3B 2018 2020-04-17 16:48:07Z Henry Ford Allegiance Health Paula Autry 205 N East Avenue Jackson MI 49201 765844700 0 X www.henryford.com/locations/allegiance-health X 1970 MI We lead our community to better health and well-being at every stage of life. 17 11 4870 0 2461737 0 889761 2556493 545560074 588602331 17033958 -8028399 15363778 33287400 578847571 616417825 323378 390633 0 0 295554499 302378836 0 0 169589 292082959 299275503 587960836 602044972 -9113265 14372853 516461443 508997334 305080415 271838627 211381028 237158707 X See Schedule OOur MissionWe lead our community to better health and well-being at every stage of life.Our ValuesCompetence: expertise in carrying out responsibilities and inspiring others to have confidence in you.Integrity: behavior that is honest, fair, trustworthy and sincere, strength of character and respect for others.Teamwork: working together in an environment of mutual respect.Diversity: respect for individual beliefs, uniqueness, and differences.Quality: committment to excellence in care.Compassion: acknowledging the feelings of others with empathy, support, encouragement, and sensitivity. Listening and responding to individual needs in a patient and caring manner.Customer Service: taking pride in providing service beyond expectations.Healing Environment: providing an environment that promotes an atmosphere of trust, comfort, healing and security 0 0 527595746 390633 641981359 See Schedule OThe Hospital devotes substantial efforts and resources to providing health services to people in its communities. The Hospital is engaged in the following activities to ensure that our mission is accomplished:Unreimbursed Services Provided to the Underserved:The Hospital provides a substantial portion of its services to the underserved (elderly and low income residents). During 2018, approximately 51% of the value of services rendered were to elderly patients under the Medicare program, and approximately 18% of the services were provided to patients who were deemed indigent under state, county, or Medicaid Center guidelines.In the spirit of our mission and values, the Hospital has taken proactive steps to address those issues that will affect accessibility, the financing, and the delivery of healthcare services to all persons. In 2018 the hospital recorded a provision for bad debts of $20.3 million. Consistent with Schedule H reporting, charity care at cost for 2018 was $5.8 million.Patient Services:The Hospital serves seven counties with a medical staff of more than 400 physicians. A complete listing of services is available at Henryford.com.The Hospital provides unprofitable health services on behalf of the community including inpatient and outpatient behavioral health and substance abuse services, obstetrics, emergency and trauma services, general medicine, family/general practice, senior services, cardiac and pulmonary rehabilitation, palliative care, wound care, pain clinic and diabetes clinic.Community Benefit Activities:The Hospital is engaged in community programs and services that address identified community health needs regardless of source or availability of payment and provide measurable improvement in health access, health status, and the use of health care resources. These programs address one of the six criteria:Supports the Hospital's community-based missionTargets the problems of the poor or medically underservedImpacts the health status of the identified communityReduces community health costsIs accessible to the entire target community regardless of ability to payStimulates external community partnershipsHealth Improvement Organization:The Health Improvement Organization (HIO) was created by Henry Ford Allegiance Health (HFAH) in 2001 to promote a culture of continuous health improvement in our community and integrate wellness and prevention throughout our services. The HFAH Department of Prevention and Community Health provides staff and infrastructure to facilitate the coordination of local health improvement activities. The HIO Coordinating Council (HIO CC) is a multi-disciplinary stakeholders group led by HFAH with representation from local government, public health, health care, health and human service agencies, nonprofits, school districts, health plans, mental health, employers and the faith community. The HIO CC coordinates efforts among community leaders in health to create unprecedented alignment of goals and resources, as well as a strong community platform for advocacy. The work of the HIO CC has culminated in the completion of a Community Action Plan including goals, objectives and strategies to address physical activity, nutrition, tobacco use, and depression in Jackson County. The Plan is based on assessment and data-driven processes, as well as input from over 30 representatives from local health and human service agencies, and over 100 community stakeholders. The overarching tactics that the Community Action Plan relies upon include evidence-based activities to:Enhance media attention and public recognition of healthy lifestyle practices;Improve access to healthy foods and safe, attractive, affordable places for activity through supportive policies and physical environment changes;Provide social support and services that promote consistent screening, referral and supportive relationships for physical activity, nutrition, mental health and smoking behavior change.The HIO builds upon existing community strengths and infrastructure to support implementation of health initiatives that have been prioritized as part of a community wide plan with significant community engagement and an established infrastructure to support longevity. In addition to operational support for the HIO CC, the HFAH Department of Prevention and Community Health provides subject matter expertise on wellness and prevention at the Board, Service Line and community level, and direct service delivery (including employer-based health management, tobacco treatment services, weight management, faith community nursing, etc.) to a broad base of community members to support the health improvement priorities identified by the HIO. The Department of Prevention and Community Health has an annual budget of around $1 million. Since 2001, the Hospital has committed over $24.4 million of funding to this program.Other Community Benefit Activities:Through Community Education and Outreach, the Hospital provided educational sessions and clinics that reached 33,520 individuals at a cost of $173,771 in 2018. The sessions/clinics included education on asthma, AIDS/HIV, diabetes, family planning, fitness/exercise, overall health, cardiovascular health, nutrition and weight management, pulmonary, smoking cessation and womens health. These educational offerings were located at the Hospital, community fairs, parishes, schools, work sites and by phone. Free Medical Screenings for high blood pressure, diabetes, mental health/depression, vascular disease and womens health served 2,965 community members at a cost of $30,709 in 2018.Free and discounted prescription drug and medical supplies were provided to community members at a cost of $4,164 during 2018. HFAH clinics provided reduced fee medical services at a cost of $1,104,264 in fiscal year 2018.Through Meals on Wheels and other food programs, the Hospital donated $11,728 in food.Patient transportation assistance was provided in 2018, including wheelchair van, ambulance, transport to and from cancer centers and cab service at a cost of $61,614.Partnerships:The Hospital played a leadership role in the establishment of the Center for Family Health, a Federally Qualified Health Center, providing $100,000 in fiscal year 2018 support for the uninsured.The Hospital donates office space to a area non-profit organization, the Enterprise Group of Jackson, Inc. 527595746 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 1 0 0 0 0 0 1 1 1 1 1 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 375 0 1 4870 1 1 1 1 CJ 0 0 0 0 0 0 0 0 0 0 X 17 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X David W Spring 5172054800 205 N East Avenue Jackson MI 49201 Georgia R Fojtasek RN EdD Trustee-President & CEO 58.00 7.00 X X 0 1274944 54700 Martha A Fuerstenau Trustee 1.00 1.00 X 0 0 0 Robert G Riney Trustee 1.00 64.00 X 0 1837361 50013 Adnan R Munkarah MD Physician Trustee 1.00 63.00 X 0 923523 55624 Sandra Kilian MD Trustee 60.00 1.00 X 179151 0 26458 Kevin E Oxley Trustee-President & CEO 1.00 1.00 X 0 0 0 Timothy K Levy Trustee- Chair 2.00 2.00 X X 0 0 0 Aaron S Boatin Trustee 1.00 3.00 X 0 0 0 Neeta M Delaney Trustee- Vice Chair 2.00 2.00 X X 0 0 0 Bradley N Clark Trustee- Secretary/Treasurer 2.00 2.00 X X 0 0 0 David L Halsey MD Trustee 1.00 1.00 X 39092 0 0 Mark Olson Trustee 1.00 1.00 X 0 0 0 Andrew F Caughey MD CMO/CEO HFAHMG 1.00 1.00 X 0 0 0 Steven D Rick Trustee 1.00 1.00 X 0 0 0 John C Nally Trustee 1.00 1.00 X 0 0 0 Gregg A Patten MD Trustee 1.00 2.00 X 0 0 0 Mohan G Kulkarni MD Physician Trustee 60.00 1.00 X 961567 0 91920 Kenneth W Empey General Counsel 55.00 5.00 X 484642 0 49177 Ondrea L Bates RN SVP Patient Care 60.00 5.00 X 497408 0 57324 Mark A Smith MD Chief Medical Officer 55.00 5.00 X 412318 0 60844 Kevin P Leonard VP Finance/ CFO 55.00 5.00 X 370520 0 30097 Azam Basheer MD Physician 60.00 0.00 X 1886335 0 142055 Timothy Ephrian Ekpo DO Physician 60.00 0.00 X 1395253 0 102667 Amritraj G Loganathan MD Physician 60.00 0.00 X 1632231 0 120290 Frank LaMarca MD Physician 60.00 0.00 X 2095373 0 148625 Stephen Lee Kirkner DO Physician 60.00 0.00 X 1325938 0 84721 Karen Chaprnka Former SVP & COO 55.00 5.00 X 156706 0 0 11436534 4035828 1074515 327 1 1 0 CHRISTMAN COMPANY 208 N Capital Avenue Lansing MI 489331357 General Contractor 14958800 Independent Hospitalist Physicians PLLC PO BOX 100 Royal Oak MI 48068 Healthcare Services 10001757 ST JOSEPH MERCY HEALTH SYSTEM PO BOX 992 Ann Arbor MI 48106 Healthcare Services 9822125 Pulmonary Clinics Of Southern MI PC 900 E Michigan Avenue Ste 105 Jackson MI 49201 Healthcare Services 3561764 FOCUSONE SOLUTIONS LLC PO BOX 3037 OMAHA NE 681030037 Staffing Solutions 2174763 51 183750 2372743 2556493 Patient Services 621990 588602331 586621076 1981255 588602331 -30648908 -30648908 227646 0 227646 227646 227646 172047384 149266373 160502 22781011 -160502 22620509 22781011 -160502 Contracted Pharmacy Revenue 621110 22009094 22009094 JHN 621990 3150850 3150850 Cafeteria 900099 2067920 2067920 5831890 5351408 480482 33059754 616417825 641981359 2461737 -30581764 X 238000 238000 152633 152633 5124030 2960926 1993515 169589 686219 330600 355619 251882765 209234039 42648726 8402104 6910361 1491743 19319429 15889381 3430048 16964289 13952382 3011907 399015 328172 70843 235000 235000 60351144 52786879 7564265 1640736 1349433 291303 13697876 11265901 2431975 941497 774340 167157 9313781 7660175 1653606 332537 273497 59040 502453 413246 89207 4620388 3800066 820322 29058016 23898941 5159075 4440957 3652492 788465 Medical Supplies 52700150 52700150 Pharmaceutical Supplies 48118075 48118075 Corp Office Allocation 24427299 24427299 Uncompensated Care 20331439 20331439 28165140 26147319 2017821 602044972 527595746 74279637 169589 2528596 6015197 944248 16846891 911234 68768324 78705782 115000 115000 8053478 8453746 5291637 4035255 306755664 64879699 224765467 241875965 193283776 143221026 4684605 12710917 4132633 516461443 508997334 100503140 53597922 156439744 155513098 135457 48137531 62592150 305080415 271838627 X 211381028 233975313 2439366 744028 211381028 237158707 516461443 508997334 X 14372853 11404826 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 41452 0 0 41452 0 Part II-B, Line 1: Health care is a highly-regulated field, requiring frequent and high-level communication with regulators and elected officials. A small investment in lobbying enables us to remain in contact with legislators and government agencies, maximize the resources with which we are entrusted and assure that we provide the best care to our community. W.A. Foote Memorial Hospital dba Henry Ford Allegiance Health enlists the services of several lobbying consultants, attorneys and healthcare trade associations. In addition, the Hospital employs a corporate accounts specialist. The specialist spends a portion of his time contacting legislators, participating in grass roots advocacy, and other activities closely related to lobbying. 2713012 2074346 -50758 1553207 3183393 2037753 1513373 93086 931200 2713012 1614108 471995 19074 67424 2037753 1451944 463114 12856 313806 1614108 1312432 558781 -4612 414657 1451944 0.23370 0.76630 0 1 1 4034484 4034484 161889620 18953592 142936028 210800 90866 119934 137117198 45835241 91281957 3503562 3503562 241875965 Retirement Plan Liability 36955071 Deferred Comp 6315850 Corporate Reserve 6173223 Liability Insurance 12326008 Workers Comp Liability 821998 62592150 X Part V, Line 4: The Organization's endowment funds are used for various charitable hospital programs including treatment of uninsured patients, community preventative health education, program development and capital improvements. Part X, Line 2: The System does not have any material uncertain tax positions as of December 31, 2018 and 2017. Central America and Carribean Investments 29337965 0 0 0 0 0 0 29337965 0 29337965 1 0 0 0 1 1 1 1 1 X 250.000000000000 0 1 1 0 1 1 5811282 5811282 0.01000 169514153 131451541 38062612 0.06540 175325435 131451541 43873894 0.07540 656312 9200 647112 0.00110 16118833 6527528 9591305 0.01650 18647245 16836981 1810264 0.00310 333006 333006 0.00060 687892 687892 0.00120 36443288 23373709 13069579 0.02250 211768723 154825250 56943473 0.09790 200 8197 8197 0.00000 1574 1574 0.00000 160225 363739 363739 0.00060 160425 373510 373510 0.00060 0 20331439 5082860 171677542 186856154 -15178612 X 1 1 1 Foote Health Center Associates Entity leases medical office space. 0.62000 0.00000 0.38000 1 1 WA Foote Memorial Hospital 205 N East Avenue Jackson MI 49201 www.henryford.com X X X X X WA Foote Memorial Hospital 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X See Part V, Page 8 X www.myhio.org X X 1 16 1 See Part V, Page 8 0 1 X 250.000000000000 X X X X X X 1 1 X X X X 1 X https://www.henryford.com/visitors/billing/financial-assistance X https://www.henryford.com/visitors/billing/financial-assistance X https://www.henryford.com/visitors/billing/financial-assistance X X X X X X 1 X 0 X X X 1 X 0 0 W.A. Foote Memorial Hospital Part V, Section B, Line 2: Effective April 1, 2016, Henry Ford Health System became the sole member of Henry Ford Allegiance Health Group (formerly Allegiance Health Services). Henry Ford Allegiance Health Group is the sole member of W. A. Foote Memorial Hospital d/b/a Henry Ford Allegiance Health. Henry Ford Health System is a non-profit 501(c)(3) organization. This affiliation allows Henry Ford Allegiance Health Group to join forces with one of the largest healthcare providers in Michigan to continue to provide high-quality healthcare services to residents of the community it serves. It also ensures that Henry Ford Allegiance Health Group will have the commitment to capital to continue to pursue growth opportunities and to expand existing healthcare services, with the goal of providing the best care possible. W.A. Foote Memorial Hospital Part V, Section B, Line 5: The Health Improvement Organization Coordinating Council, founded by Henry Ford Allegiance Health (HFAH), is a collaborative of community stakeholders committed to improving the health status of the community through an integrated health improvement infrastructure that addresses Jackson's priority health issues. The HIO Coordinating Council serves as the health strand of the Jackson Collaborative Network which also includes the Cradle to Career Education network and the Financial Stability Network. The scope of the HIO Coordinating Council responsibility includes monitoring community level indicators, identifying specific health priorities and developing community action plans to address common goals.In this model, community stakeholders work with public health experts to develop and complete a community health assessment for Jackson County.This assessment provides a data collection mechanism that better aligns efforts among community partners and creates a more strategic framework for local health improvement activities.Individuals contributing input for HFAH's recent CHNA:Megan Albertson, HFAHKellie Baker, LifeWaysMarilyn Bell, Michigan Purchasers Health AllianceSara Benedetto, Center for Family Health Adam Brown, Jackson County AdministrationCindy Bruner, Meridian Health PlanShelly Bullinger, Jackson County Health DepartmentKathleen Clark, YMCA Storer CampsMark Fall, Henry Ford Allegiance CareLinkAndrew Farmer, AARP of MichiganKevin Ford, MSUTed Hilleary, Community MemberJennifer Johnson, Great Lakes IndustryDavid King, LifeWaysRay King, HFAHDavid Kirk, HFAHIrene LeCrone, United WayKatie Luke, Partnership Park Neighborhood Assoc.Katherine Martin, Community Action AgencyRebecca Mayer, AWAREPamela McCrum, Catholic Charities of Jackson Dani Meier, Jackson Public SchoolsMonica Moser, Jackson Community Foundation Wendy Murdock, United Way of Jackson CountyErin Norton, United WayAmy Pelletier, Marriage MattersRhonda Rudolph, Jackson County Health DepartmentScott Schmidt, United Way of Jackson County Amy Schultz, HFAHSteve Sukta, Intermediate School DistrictScott TenBrink, Fitness Council of Jackson Shaina Tinsey, HFAHJulie Weisbrod, Jackson County Health DepartmentTed Westmeier, Jackson County Health Department W.A. Foote Memorial Hospital Part V, Section B, Line 6a: Henry Ford Specialty Hospital, a Community-Owned Specialty Hospital. HFSH is a related non-profit corporation. W.A. Foote Memorial Hospital Part V, Section B, Line 6b: AARPBig Brothers/Big SistersCenter for Family HealthCommunity Action AgencyCradle to CareerFitness Council of JacksonGreat Lakes IndustryGreat StartJackson Community FoundationJackson County Health DepartmentJackson County Intermediate School DistrictJackson County Parks and RecreationJackson Health NetworkJackson YMCALifeWaysMarriage Matters JacksonMichigan State UniversityPartnership Park Downtown Neighborhood AssociationUnited Way of Jackson CountyUniversity of MichiganYMCA Storer Camps W.A. Foote Memorial Hospital Part V, Section B, Line 7d: The CHNA is posted on the hospital website at the address below. In addition, the CHNA is posted on other community organization websites, presented at public forums, and hard copies of the assessment are available upon request. www.henryford.com/about/community-health W.A. Foote Memorial Hospital Part V, Section B, Line 11: Henry Ford Allegiance Health and its community partners have a comprehensive implementation strategy to meet needs identified in the Community Health Needs Assessment (CHNA). The CHNA implementation strategy is rolled out in stages. Henry Ford Allegiance Health completed a Community Health Needs Assessment with partners across Jackson County. After surveying community stakeholders and analyzing local health data, the following indicates the priority areas of focus for HFAH.IDENTIFIED PRIORITIES / GOALSo Improve the knowledge, attitudes and behaviors of residents of Jackson Countyo Reduce the obesity rate amongst Jackson County residentso Reduce smoking rate and secondhand smoke exposure in Jackson Countyo Improve the behavioral health and emotional wellness of Jackson County residentso Enhance collaborative action planning, resource alignment, and linkages among clinical and social systems to achieve collective population health impactMultiple strategies were adopted to address each identified priority. HFAH serves as the "champions" for multiple strategies. While measuring improvement in health status for every priority can be challenging in the short term, updated data indicates local improvement in a number of areas including:o Proportion of Jackson County residents that received advice about their weight from a health care provider increased from 27% in 2010 CHNA to 39% in 2013 CHNA and 42% in 2016 CHNA.o Number of Jackson residents with low access to fresh food decreased from 19,000 to 12,000 from 2013 CHNA to 2016 CHNA.o Proportion of smokers who report receiving advice from their provider to quit increased from 61% to 68% from 2013 CHNA to 2016 CHNA.o Percent of adults who would 'definitely' seek professional help for a serious emotional problem increased from 54% to 63% from 2013 CHNA to 2016 CHNA.In terms of significant health needs that will not be addressed, Henry Ford Allegiance Health acknowledges the wide range of health concerns that emerged from the CHNA process, and determined it could most effectively focus on those health needs that were determined to be most urgent and essential to the health of the community as well as within its ability to influence. The implementation plan can be accessed on the hospital's website atwww.henryford.com/about/community-health W.A. Foote Memorial Hospital Part V, Section B, Line 15e: Invoice provides patient with a number to call if they believe they may qualify for financial assistance. Patients calling the number are guided through the financial assistance application process by hospital representatives.PART V, SECTION B, LINE 22A:Uninsured patients who do not otherwise qualify for insurance with household incomes at or below 250% of the Federal poverty level may qualify under the Patient Financial Assistance Policy (FAP) for medically necessary services to be provided at no cost.In addition, patients regardless of insurance status with annual medical liabilities to HFHS in excess of 30% of their household income may qualify for discounts on their personal obligations. Patient's personal responsibilities for medically necessary services not covered by insurance or FAP are generally based on the amount generally billed for the service, which approximates 115% of prevailing Medicare rates. 81 1 - Henry Ford Allegiance Occupational Hlth 100 E Michigan Ave Ste 101 Jackson MI 49201 Urgent care, employment screening 2 - Henry Ford Allegiance Physical Rehab-Jac 100 E Michigan Ave Ste 103 Jackson MI 49201 Rehab 3 - Henry Ford Allegiance Substance Abuse Se 2424 W Washington Ave Jackson MI 49201 Outpatient Treatment 4 - Henry Ford Allegiance Home Care 100 E Michigan Ave Ste 400 Jackson MI 49201 Visiting Nurses 5 - Henry Ford Allegiance Personal Care 100 E Michigan Ave Ste 400 Jackson MI 49201 Private duty nursing 6 - Henry Ford Allegiance Tobacco Treatment 100 E Michigan Ave Ste 900 Jackson MI 49201 Outpatient Treatment 7 - Gayle M Jacob Cancer Center 1100 E Michigan Ave Ste 307 Jackson MI 49201 Hematology Oncology practice and infusion center 8 - Allegiance Wellness Center 1100 E Michigan Ave Ste 100 Jackson MI 49201 Wellness Center 9 - Henry Ford Allegiance Cardiac Rehab 1100 E Michigan Ave Ste 102 Jackson MI 49201 Post-surgical Rehab facility 10 - Henry Ford Allegiance Pulmonary Rehab 1100 E Michigan Ave Ste 102 Jackson MI 49201 Post-surgical Rehab facility 11 - Henry Ford Allegiance Diagnostic Center- 1100 E Michigan Ave Ste 104 Jackson MI 49201 Lab and imaging services 12 - Henry Ford Allegiance Outpatient Trauma 1100 E Michigan Ave Ste 201 Jackson MI 49201 Physician specialty practice 13 - Henry Ford Allegiance Thoracic Surgery 1100 E Michigan Ave Ste 201 Jackson MI 49201 Physician specialty practice 14 - Henry Ford Allegiance Pediatric Cardiolo 1100 E Michigan Ave Ste 201 Jackson MI 49201 Physician specialty practice 15 - Henry Ford Allegiance Cardiac Surgery S 1100 E Michigan Ave Ste 201 Jackson MI 49201 Physician specialty practice 16 - Henry Ford Allegiance Radiation Oncology 1102 E Michigan Ave Jackson MI 49201 Radiation therapy 17 - Henry Ford Allegiance ENT 1111 Teneyck St Ste 100 Jackson MI 49201 Physician specialty practice 18 - Henry Ford Allegiance Hearing Center 1111 Teneyck St Ste 200 Jackson MI 49201 Hearing loss treatment; hearing aid sales/service 19 - Henry Ford Allegiance Surgery Center 1125 E Michigan Avenue Jackson MI 49201 Outpatient surgery center 20 - Henry Ford Allegiance Rheumatology 1201 E Michgan Avenue Ste 100 Jackson MI 49201 Physician specialty practice 21 - Henry Ford Allegiance Neurology 1201 E Michgan Avenue Ste 240 Jackson MI 49201 Physician practice 22 - Henry Ford Allegiance Orthopedics 1201 E Michgan Avenue Ste 300 Jackson MI 49201 Physician specialty practice 23 - Henry Ford Allegiance Senior Health Cntr 100 E Michigan Ave Ste 102 Jackson MI 49201 Retail sales of durable medical equipment 24 - Henry Ford Allegiance Osteoporosis Cntr 1201 E Michigan Ave Ste 120 Jackson MI 49201 Physician practice 25 - Allegiance Balance Center 1201 E Michigan Ave Ste 120 Jackson MI 49201 Rehabilitation services 26 - Henry Ford Allegiance Pain Management 1201 E Michigan Ave Ste 200 Jackson MI 49201 Physician practice 27 - Henry Ford Allegiance Neurosurgery 1201 E Michigan Ave Ste 240 Jackson MI 49201 Physician specialty practice 28 - Henry Ford Allegiance Physical Medicine 1201 E Michigan Ave Ste 300 Jackson MI 49201 Physician specialty practice 29 - Henry Ford Allegiance Physical Rehab 1201 E Michigan Ave Ste 300 Jackson MI 49201 Rehabilitation services 30 - Henry Ford Allegiance Diagnostic Center 1201 E Michigan Avenue Jackson MI 49201 Laboratory and imaging services 31 - Henry Ford Allegiance Diagnostic Center- 1310 Greenwood Ave Jackson MI 49203 Laboratory services 32 - Henry Ford Allegiance Neuropsychology 1400 E Michigan Ave Jackson MI 49202 Physician specialty practice 33 - Henry Ford Allegiance Diagnostic Center- 1401 W North Street Jackson MI 49202 Lab and imaging services 34 - Henry Ford Allegiance Family Medicine 1401 W North Street Jackson MI 49202 Family medicine and Extended Hours Clinic 35 - Henry Ford Allegiance CRNA 205 N East Ave Jackson MI 49201 Anesthesiology services 36 - Henry Ford Allegiance EEG 205 N East Ave Jackson MI 49201 Patient testing 37 - Henry Ford Allegiance EKG 205 N East Ave Jackson MI 49201 Patient testing 38 - Henry Ford Allegiance Emergency Care 205 N East Ave Jackson MI 49201 Emergency room and urgent care 39 - Henry Ford Allegiance Health Pharmacy 205 N East Ave Jackson MI 49201 Outpatient pharmacy 40 - Henry Ford Allegiance Sleep Health Cent 205 N East Ave Jackson MI 49201 Diagnostic and testing center 41 - Henry Ford Allegiance Behavioral Health 205 N East Ave Jackson MI 49201 Mental health outpatient services 42 - Henry Ford Allegiance Digestive Health 205 S East Ave Jackson MI 49201 Outpatient GI procedures 43 - Henry Ford Allegiance Behavioral Health 2200 Springport Road Ste 200 Jackson MI 49202 Mental health OP services 44 - Henry Ford Allegiance Infectious Disease 2200 Springport Road Ste 500 Jackson MI 49202 Geriatric services 45 - Henry Ford Allegiance Wound Care Center 2200 Springport Road Ste 500 Jackson MI 49202 Treatment and therapy 46 - Henry Ford Allegiance Diagnostic Center 2200 Springport Road Ste 800 Jackson MI 49202 Laboratory services 47 - Henry Ford Allegiance Medication Therapy 2200 Springport Road Ste 900 Jackson MI 49202 Pharmaceutical counseling services 48 - Henry Ford Allegiance Addiction Recovery 2424 W Washington Ave Jackson MI 49203 Outpatient treatment center 49 - Allegiance Family Medicine - Summit Wood 2585 Spring Arbor Road Jackson MI 49203 Family medicine 50 - Henry Ford Allegiance Vascular Health 300 W Washington Avenue Ste 300 Jackson MI 49201 Physician specialty practice 51 - Henry Ford Allegiance Vascular Laborator 300 W Washington Avenue Ste 350 Jackson MI 49201 Vascular system testing (ultrasound) 52 - Henry Ford Allegiance Health Cardiology 309 Page Avenue Jackson MI 49201 Cardiovascular care, diagnostic testing 53 - Henry Ford Allegiance Family Medicine 3235 E Michigan Avenue Ste 100 Jackson MI 49202 Family medicine 54 - Henry Ford Allegiance Internal Medicine 3235 E Michigan Avenue Ste 150 Jackson MI 49202 Internal medicine 55 - Henry Ford Allegiance Diagnostic Center 3305 Spring Arbor Rd Ste 100 Jackson MI 49203 Lab and imaging services 56 - Henry Ford Allegiance Women's Health Cnt 3305 Spring Arbor Rd Ste 500 Jackson MI 49203 Clinical exams, mammograms, spa services 57 - Henry Ford Allegiance Family Medicine 3333 Spring Arbor Rd Ste 100 Jackson MI 49203 Family medicine (pending, not currently open) 58 - Henry Ford Allegiance Family Medicine 400 Hinckley Blvd Ste 100 Jackson MI 49203 Family medicine 59 - Henry Ford Allegiance Diagnostic Center 400 Hinckley Blvd Ste 200 Jackson MI 49203 Lab and imaging services 60 - Henry Ford Allegiance Family Medicine 4304 Page Ave Michigan Center MI 49254 Family medicine (pending, not currently open) 61 - Henry Ford Allegiance Diagnostic Center 4304 Page Ave Michigan Center MI 49254 Lab and imaging services 62 - Henry Ford Allegiance Physical Rehabilit 4304 Page Ave Ste 100 Michigan Center MI 49254 Rehabilitation services 63 - Henry Ford Allegiance Diagnostic Center 505 N Jackson St Ste 178 Jackson MI 49201 Lab and imaging services 64 - Henry Ford Allegiance Home Medical Equip 700 E Michigan Ave Jackson MI 49201 Retail Sales of durable medical equipment 65 - Phlebotomy - Dr Lynd 724 W Franklin Jackson MI 49203 Phlebotomy office (independent physician practice) 66 - Henry Ford Allegiance General Surgery 744 W Michigan Ave Ste 200 Jackson MI 49201 Physician specialty practice 67 - Henry Ford Allegiance Gastroenterology 744 W Michigan Ave Ste 201 Jackson MI 49201 Physician specialty practice 68 - Henry Ford Allegiance Pediatrics 760 W Franklin Jackson MI 49203 Pediatric medicine 69 - Henry Ford Allegiance Diagnostic Center 12369 E Michigan Ave Grass Lake MI 49240 Lab and imaging services 70 - Henry Ford Allegiance Family Medicine 12369 E Michigan Ave Grass Lake MI 49240 Family medicine 71 - Henry Ford Allegiance Family Medicine 130 N Sherman St Leslie MI 49251 Family medicine 72 - Henry Ford Allegiance Family Medicine 810 Hogsback Rd Ste A Mason MI 48854 Family medicine 73 - Henry Ford Allegiance Health Diagnostic 810 Hogsback Rd Ste B Mason MI 48854 Lab and imaging services 74 - Henry Ford Allegiance Physical Rehab 810 Hogsback Rd Ste B Mason MI 48854 Rehabilitation services 75 - Henry Ford Allegiance Diagnostic Center 153 Wamplers Lake Rd Brooklyn MI 49230 Laboratory services (Jan 2016 adding imaging services) 76 - Henry Ford Allegiance Family Medicine 8958 M-50 Onsted MI 49265 Family medicine 77 - Henry Ford Allegiance Family Medicine 27931 C Drive North Albion MI 49224 Family medicine 78 - Henry Ford Allegiance Family Medicine 7845 Spring Arbor Road Spring Arbor MI 49283 Family medicine 79 - Henry Ford Allegiance Plastic Surgery 3305 Spring Arbor Rd Ste 200 Spring Arbor MI 49283 Plastic Surgery 80 - Henry Ford Allegiance Dermatology 3333 Spring Arbor Rd Ste 500 Spring Arbor MI 49283 Dermatology 81 - Henry Ford Allegiance Podiatry 3333 Spring Arbor Rd Ste 200 Spring Arbor MI 49283 Podiatry Part I, Line 6a: The Hospital prepares an annual community benefit report, which can be accessed at www.Henryford.com/locations/allegiance-health/about/giving-back/report-to-the-community Part I, Line 7: The Hospital used a cost-to-charge ratio to calculate the cost of charity care and Medicaid shortfall. Community Health Improvement Services, Health Professions Education, Research and Contributions are actual amounts. Part I, Ln 7 Col(f): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $20,331,439 Part II, Community Building Activities: The Hospital is involved in numerous community building activities. We believe these activities, such as supporting affordable housing, working in partnership with the local community college to develop skilled nurses and supporting economic development programs directly improve the general health and wellness of the community. Also, staff at every level of the organization are encouraged to serve community groups that promote education, health and economic advocacy for the less fortunate. Part III, Line 2: The organization's bad debt expense is stated in patient gross charges. Part III, Line 4: Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its historical experience and identifies trends for each of its major payor sources to estimate the appropriate allowance for uncollectible accounts and the provision for bad debts. Management regularly reviews data about these major payor sources in evaluating the sufficiency of the allowance for uncollectible accounts. For receivables associated with services provided to patients who have third-party health care coverage, the Hospital analyzes contractually due amounts and provides an allowance for uncollectible accounts and provision for bad debts. For receivables associated with self-pay accounts (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for uncollectible accounts. The amount of bad debt reported for the tweleve months ended Decemember 31,2018 financial statements was $20,331,439. Part III, Line 8: The Organization believes the entire Medicare shortfall reported on Line 7 should be treated as Community Benefit. Henry Ford Allegiance Health is nationally recognized by Healthgrades as being in the top five percent nationally for patient safety (seven years in a row). Henry Ford Allegiance Health also benchmarks favorably on overall cost per case and is deemed to be an efficient provider. The Organization is subsidizing a government program and sustaining significant losses in providing health care to Medicare receipients. By continuing to treat patients eligible for Medicare, hospitals alleviate the federal government's burden for directly providing medical services. Part III, Line 9b: The Hospital does not collect from patients known to qualify for charity care or other financial assistance. Patients having difficulty paying their bills are directed to financial counselors. These counselors review the patient's information in order to see if they qualify for assistance. In addition, bills sent to patients include a number to call for help in providing the required financial information to qualify for charity care. Part VI, Line 2: The Health Improvement Organization (HIO) was founded on the understanding that long-term health improvement requires that we extend beyond acute medical care to affect the social and environmental determinants of health. Since its creation in 2000, the HIO has evolved to become a national best practice model for organizing population health improvement efforts in a region. The Health Improvement Organization Coordinating Council (HIO CC) is the community stakeholder collaborative, led by Henry Ford Allegiance Health, responsible for completing shared needs assessments, identifying high priority health issues, developing and coordinating implementation of collaborative action plans and monitoring progress over time. In FY16, the HIO CC completed an updated Community Health Assessment report and 2016-2017 Community Action Plan. The Community Health Assessment was posted on the Henry Ford Allegiance Health and HIO websites and adopted by the Henry Ford Allegiance Board of Trustees and HIO Coordinating Council in June 2016. This plan reflects significant work of many dedicated organizations and individuals: Over 1200 Jackson County residents responded to our third Community Health Assessment phone survey or participated in focus group discussions to provide insight about local health status, attitudes, beliefs, behaviors and opportunities. More than 30 HIO Coordinating Council representatives from local government, public health, health care, school districts, mental health, employers and other human service sectors spent months reviewing local data, best practice research and community input to revise our Goals and Objectives for 2016-2017. Three existing community initiatives were voted into the Health Improvement Organization, resulting in seven Health Action Teams leading change around priority health issues.Over 20 organizations and individuals stepped up to lead Health Action Teams and champion specific strategies.Our Community Health Assessment gives Jackson a powerful tool to measure health indicators within geographic and demographic subpopulations and to track changes over time. Based on the most recent data, the HIO continues to prioritize obesity, smoking and behavioral health as targets for improvement. Action Teams organized around goals in each of these areas are pursuing evidence-based community strategies such as increasing access to healthy food, enhanced mental health screening, and anti-tobacco policies. In addition to topic-specific teams around improving nutrition, physical activity, smoke-free lifestyles, behavioral health, teen pregnancy prevention, maternal and child health, and substance abuse prevention, the HIO is active in two cross-network initiatives. The Collaborative Council is a stakeholder group comprised of individuals from health, education, and financial stability. The Collaborative Council exists to coordinate the work of all strands and agencies to maximize efficiency across the community. The Community Engagement Committee is a partnership of the HIO and Cradle to Career, Jackson's education network. Leaders from both initiatives recognized parallel goals to engage populations served and made the decision to combine efforts in order to maximize resources.The Community Action Plan (CAP) report approved by the Board of Trustees during FY 2016 clearly communicates Henry Ford Allegiance Health's role and responsibilities relative to implementation of action plans. Part VI, Line 3: Uninsured inpatients and observation patients are referred to a financial counselor (contracted agent/partner) for assistance with Medicaid, SSI, and Henry Ford Allegiance Health program applications. Many outpatients needing or having received hospital services are also referred to the agent/partner for assistance. ER patients are provided with a packet of information at discharge from the department. This packet includes information about how assistance may be obtained through the local Medicaid office and about how to apply for our income structured payment plan and uncompensated care programs. When patients are billed for balances they owe, we solicit them to call the Business Office with any questions or for assistance. Additionally, a series of letters are sent to patients to apprise them of payment and assistance options. Allegiance has a printed brochure that is available through Registration that includes information regarding Medicaid application assistance and our internal programs. The Henry Ford Allegiance Health website includes a series of web pages related to transparency, quality, pricing, and our financial policies, procedures, and programs. Uninsured patients needing mental health services are screened for eligibility through our partnership with the Jackson Community Mental Health Agency, which funds care for indigent, dual diagnosis, and Medicaid patients. Patients seeking substance abuse care are linked with the Mid-South Substance Abuse Commission. Registration and Business Office team members receive direct training on our programs and scripting for ensuring information is provided to the patients and families with whom our staff interact. Education is provided to organizational leaders to ensure that team members outside of Finance are aware of our programs and where to direct patients and families who may need or who are seeking assistance. Part VI, Line 4: Henry Ford Allegiance Health's market is determined geographically by the boundaries of Jackson County. The hospital is a tax exempt Health System that serves the collective health needs of the more than 160,000 residents of Jackson County. The gender distribution of Jackson County residents is 49% female and 51% male. The age distribution of Jackson County is 26% of residents 19 years and under, 18% between 20 and 34 years, 29% between 35 and 54 years, 13% between 55 and 64 years, and 14% of residents are 65 years and older. Racial distribution of Jackson County residents according to the 2011 Census Data is 88.0% as white, 7.9% as African American, 0.7% as Asian, 0.4% as American Indian or Alaska Native, and 3.0% as some other race or two or more races. Of males aged 15 years and over, 33.0% have never married, 50.4% are married, 1.5% are separated, 2.9% are widowed, and 12.3% are divorced. Of females aged 15 and over, 25.0% have never married, 50.4% are married, 1.7% are separated, 9.8% are widowed, and 13.2% are divorced. According to the Bureau of Labor Statistics (2013), Jackson County also experiences a high unemployment rate of 8.8%. With 69,400 individuals in the civilian labor force, 6,100 residents are currently unemployed. Of those employed, major industries represented include educational services, health care, and social assistance (23.9%); manufacturing (18.7%); retail trade (12.1%); professional, scientific, management, administrative, and waste management services (7.7%); and arts, entertainment, recreation, accommodation, and food services (7.5%). Approximately 51% of Allegiance Hospital patients were covered by Medicare, while 27% were on Medicaid and 1% were uninsured. During the 2018 fiscal year, Henry Ford Allegiance Health had 20,466 inpatient discharges, of which 9,939 Medicare discharges and 6,047 Medicaid discharges from inpatient services. Physician practice visits totaled 379,518 during FY 2018, with 178,377 primary care visits and 201,141 visits to specialists. Part VI, Line 5: The mission of Henry Ford Allegiance Health is to improve peoples's lives through excellence in the science and art of healthcare and healing.Recently celebrating a century of providing care to our community, Henry Ford Allegiance Health's success in creating an environment for safe, clinically sound, patient-centered care has earned many accolades from across the health care industry. While these awards recognize our commitment to providing exceptional patient care, they also challenge us toward continuous improvement across the continuum.CMS Four-Star Rating - Henry Ford Allegiance Health has received a four-star rating from the Centers for Medicare & Medicaid Services (CMS), largely reflecting our significant commitment to quality and safety.Fall 2019 "A" for Patient Safety from The Leapfrog Group - The Leapfrog Group, a national patient safety watchdog, once again awarded Henry Ford Allegiance Health with an "A," ranking it among the safest hospitals in the United States. We Honor Veterans - Henry Ford Allegiance Health is proud to have been designated a Level 3 Hospice Partner of the We Honor Veterans program, a collaboration with the National Hospice Palliative Care Organization and the Veterans Administration.Looking Toward our Community's Future: In September 2018, a new three-story, 59,000 square-feet patient tower opened on the hospital campus, creating a total of 66 private rooms. A two-story Center for Health Innovation & Education center-a regional training center for health care professionals that includes leading-edge technology, such as a simulation lab designed to look and feel like real inpatient and outpatient settings.Jackson Health Network is collaborating with Henry Ford Physician Network (comprised of more than 1,800 physicians throughout southeast Michigan) on ways to improve patient care system-wide.Clinicians and administrators are working to identify opportunities to bring new services to the Jackson area. Most recently, patients have been given access to new services related to oncology, rheumatology, urology, cardiovascular health and the neurosciences, including neurosurgery.Promoting Continuous Health Improvement in Our CommunityThe Health Improvement Organization (HIO) was created by our health system in 2000 to promote a culture of continuous health improvement in our community and integrate wellness and prevention throughout our services. The Henry Ford Allegiance Department of Prevention and Community Health provides staff and infrastructure to facilitate the coordination of local health improvement activities. Part VI, Line 6: The Hospital's sole corporate member is Henry Ford Allegiance Health Group, a 501(c)(3) organization. Other affiliates include: Henry Ford Allegiance Health Foundation; Henry Ford Allegiance Hospice; Henry Ford Allegiance Specialty Hospital, a Long Term Acute Care Hospital (LTACH); Volunteers of Henry Ford Allegiance Health. These are all 501(c)(3) non-profit organizations working together to improve healthcare in and around Jackson, MI. Additionally, the Hospital recently formed Jackson Health Network (JHN), a clinically integrated network. The Hospital is also affilated with Henry Ford Allegiance Pharmacy.The Foundation and the Volunteer organization work closely with Henry Ford Allegiance Health Group and the hospital to raise funds for projects and services that benefit the overall well-being of the community. Previous campaigns successfully raised funds to expand and improve our Graduate Medical Education program, cancer care service line and provided free medical care to indigent patients. Jackson Health Network works to improve patient clinical outcomes thru coordinated care and lowering overall health care costs. 1 Center for Family Health 505 N Jackson St Jackson MI 49201 383251354 501(c)(3) 100000 N/A The Center for Family Health grant provides operational support for medically underserved populations. Jackson Symphony Orchestra 215 W Michigan Ave Jackson MI 49201 382146747 501(c)(3) 5000 N/A Contribution to Endowment fund in support of Symphony Operations. Anchor Initiative 141 S Jackson St Jackson MI 49201 472475316 501(c)(3) 50000 N/A Annual Contribution to community growth org. Family Services and Childrens Aid 330 W Michigan Ave Jackson MI 49201 386088382 501(c)(3) 45000 N/A Support Of Jackson County guardianship program. Region II Area Agency on Aging 102 N Main St Brooklyn MI 49230 382056030 501(c)(3) 8000 N/A Support of educational programs Enterprise Group 100 E Michigan Ave 1100 Jackson MI 49201 383326101 501(c)(6) 25000 N/A Annual Contribution to community growth org. Jackson Community Foundation 100 S Jackson St Suite 206B Jackson MI 49201 386070739 501(c)(3) 5000 N/A Contribution to child advocacy fund honoring falle police officer Staff Assistance Fund for Emergencies 125 102658 We Care Patient Needs Fund 50 3053 Womens Health Center Oncology Aesthetics 10 2220 Cancer Patient Immedicate Needs Funds 100 44702 Part I, Line 2: Awards are granted based on an application and review process.The Organization sends out an award letter to all grantee recipents. The letter outlines what the funding may be used for and requests a final report detailing the year's activities. X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 Georgia R Fojtasek RN EdD Trustee-President & CEO 0 644465 0 426550 0 203929 0 26534 0 28166 0 1329644 0 0 Robert G Riney Trustee 0 990589 0 593292 0 253480 0 26535 0 23478 0 1887374 0 0 Adnan R Munkarah MD Physician Trustee 0 734522 0 173026 0 15975 0 23784 0 31840 0 979147 0 0 Sandra Kilian MD Trustee 136053 0 0 0 43098 0 15444 0 11014 0 205609 0 34514 0 Mohan G Kulkarni MD Physician Trustee 456182 0 336034 0 169351 0 63066 0 28854 0 1053487 0 0 0 Kenneth W Empey General Counsel 241414 0 120555 0 122673 0 27999 0 21178 0 533819 0 90008 0 Ondrea L Bates RN SVP Patient Care 277696 0 183048 0 36664 0 23437 0 33887 0 554732 0 0 0 Mark A Smith MD Chief Medical Officer 338742 0 36634 0 36942 0 19690 0 41154 0 473162 0 0 0 Kevin P Leonard VP Finance/ CFO 215434 0 122362 0 32724 0 19201 0 10896 0 400617 0 11616 0 Azam Basheer MD Physician 745205 0 814401 0 326729 0 117217 0 24838 0 2028390 0 0 0 Timothy Ephrian Ekpo DO Physician 692279 0 329179 0 373795 0 78160 0 24507 0 1497920 0 292598 0 Amritraj G Loganathan MD Physician 744140 0 547189 0 340902 0 94394 0 25896 0 1752521 0 0 0 Frank LaMarca MD Physician 1143362 0 600324 0 351687 0 122814 0 25811 0 2243998 0 0 0 Stephen Lee Kirkner DO Physician 444627 0 366591 0 514720 0 64821 0 19900 0 1410659 0 351261 0 Karen Chaprnka Former SVP & COO 143647 0 0 0 13059 0 0 0 0 0 156706 0 0 0 Part I, Line 1a Henry Ford Allegiance Health provides a country club membership to three executives. The executives reimburse the hospital for any personal use of the club. These benefits did not result in taxable compensation during FY 18. Part I, Line 3 The Chief Executive Officer for W.A. Foote Memorial Hospital is an employee of Henry Ford Health System (the sole member of Henry Ford Allegiance Health Group). Henry Ford Health System ("HFHS") has a Compensation Committee of the Board of Trustees consisting of all independent trustees. The committee meets throughout the year and is charged with the approval of the organization's overall compensation and benefit programs as well as the specific review and approval of the compensation of certain employees including the Chief Executive Officer of W.A. Foote Memorial Hospital. The committee directly engages an independent compensation advisor to assist with this process. The process includes evaluation of the individual's performance, utilization of compensation studies of similarly situated positions as well as comparisons to compensation as reported by other health care organizations. The reasonableness of compensation is evaluated based upon these and other factors. The CEO is accountable for ensuring that Allegiance Health's mission is efficiently carried out with the highest levels of quality, safety and service, while at the same time ensuring that the organization is financially healthy. Executive compensation is reviewed annually by the Executive Compensation Committee of the Board of Trustees. This committee works with an independent compensation consultant to ensure that Henry Ford Allegiance Health compensation practices are consistent with industry standards and that compensation levels are fair compared to similar healthcare organizations nationally. The compensation consultant benchmarks Henry Ford Allegiance Health's positions against data from multiple published surveys of health care executive compensation in the national health care labor market. Based upon the consultants recommendations, the Executive Compensation Committee makes a recommendation to the Board of Trustees for approval of the executive compensation program. Only independent Trustees vote on this recommendation. Part I, Line 4b 4b. Certain members of the Organization's senior leadership team participate in supplemental retirement programs that result in reportable taxable income as the benefits accrue, and/or as paid. It is an element of some plan designs to absorb the advance tax impact of these plans for the participants. In such cases the related amounts are reported as taxable income to the individual and included in the determination of reasonable compensation. The following provides the required listing of the participating individuals: Sec 457(f)-Non-Qualified Deferred Compensation Retirement Plan - W.A. FOOTE MEMORIAL HOSPITAL Reportable Accrual Distribution Non-Vested W-2 Amounts Ray King 11,250 20,658 - 20,658 Mohan Kulkarni 63,066 - - - Ondrea Bates 15,875 - - - Mark Smith M.D. 15,565 - - - Ken Empey 13,626 90,008 - 90,008 Kevin Leonard 11,616 11,616 - 11,616 Amritra J Longanathan 94,394 - - - Frank LaMarca 122,814 - - - Stephen Kirkner 64,824 351,261 - 351,261 Azam Basheer 117,217 - - - Timothy E. Ekpo 78,160 292,598 - 292,598 Sandra Kilian 15,444 34,514 - 34,514 Sec 457(f) - Supplemental Executive Retirement Plan (SERP) - HENRY FORD HEALTH SYSTEM Participant Accrual Distribution Non-Vested Reportable W-2 Robert G. Riney 230,078 - - 230,078 Georgia Fojtasek 172,223 - - 172,223 Adnan R. Munkarah - - 154,094 - Sec 457(b)-Non-Qualified Deferred Compensation Retirement Plan - HENRY FORD HEALTH SYSTEM Employee Employer Medicare Reportable 2018 Contr. 20187 Contr. Tax gross-Up W-2 Amounts Robert G. Riney 18,500 - - 18,500 Adnan R. Munkarah 11,072 - - 11,072 Georgia Fojtasek 18,500 - - 18,500 Part I, Line 7 Column B(ii) of Part II, Schedule J includes non-fixed payments to certain physicians based on their productivity and other performance metrics. Patrick Nally Son of John Nally, Chairman of Allegiance Health Employee Recruitment Loan X 115000 115000 0 1 1 115000 Patrick Nally Family Member/Officer 131214 Employee Wages 0 Form 990, Part VI, Section A, line 6 The Corporation is organized on a membership basis. The sole corporate member of the Corporation is Henry Ford Allegiance Health Group (formerly Allegiance Health Services). Form 990, Part VI, Section A, line 7a The sole Member of the organization may elect and remove, with or without cause, the Corporation's Trustees. Form 990, Part VI, Section A, line 7b The following powers are reserved for the sole corporate Member of the hospital. Approve any change in the Articles of Incorporation, purposes or philosophy of the Corporation; Approve changes in those provisions of the Corporation's Bylaws which affect the size, composition, and method of selection of the Board of Trustees, or which affect this Article; Approve plans of merger, consolidation or dissolution of the Corporation; Elect and remove, with or without cause, the Corporation's Trustees, upon a simple majority vote of the Directors then serving on the Board of the Member present at a meeting at which a quorum is present; Approve guarantees by the Corporation of the debt of others in excess of maximum limits established by the Member, upon a simple majority vote of the Directors then serving on the Board of the Member present at a meeting at which a quorum is present; Authorize the sale, lease, mortgage or other disposition of all or substantially all of the assets owned, held or leased by or to the Corporation, approve any decision by the Corporation which would have the net effect of diminution of governance control of the Member, and any decision by the Corporation which would have the net effect of diminution in the Corporation's governance control over it's own subsidiary; Ratify or reject operating and capital budgets developed by the Board and any non-budgetary expenditures or creations of debt in excess of an amount designated by the Member from time to time, upon a simple majority vote of the Directors then serving on the Board of the Member present at a meeting at which a quorum is present; and Authorize the formation or acquisition of new subsidiaries of the Corporation or the sale or other disposition of existing subsidiaries. Form 990, Part VI, Section B, line 11b The organization is an affiliate of Henry Ford Health System (HFHS) and the tax department of HFHS prepares the organization's Form 990. As part of the preparation and review process prior to filing the return, the following review process is conducted: - Reviewed by the Organization's Director and VP of Finance, Chief Executive Officer, General Counsel, and Compliance Officer. - Review of the entire return with the HFHS and organization's Senior Vice President Financial Operations and Chief Financial Officer, - Review of all compensation matters and disclosures with the Compensation Committee of the HFHS Board of directors - Review of the return with the HFHS Audit and Compliance Committee of the Board of director, including the CEO and COO - Final copies of the return are distributed to the Hospital's Board of Trustees before the return is filed. Form 990, Part VI, Section B, line 12c The organization is an affiliate of Henry Ford Health System (HFHS) who oversees the conflict of interest process with regard to the organization. HFHS has a standing Conflict of Interest Committee (the Committee) that is responsible for oversight of all conflict of interest matters. The HFHS Conflict of Interest Policy applies to all Directors and employees. Annually, Directors, employees of a management level, researchers, as well as employees associated with procurement, or in certain other predefined roles must complete an annual disclosure designed to identify activities and relationships that could potentially give rise to a conflict of interest. It is the responsibility of the Committee to review these disclosures and determine the need for any action to manage the potential conflict. The Committee annually reports the results of its activities to the Audit and Compliance Committee of the HFHS Board of Directors. Form 990, Part VI, Section B, line 15 The organization is an affiliate of Henry Ford Health System (HFHS) who has responsibility to oversee the compensation practices of the organization. HFHS has a Compensation Committee of the Board of Directors consisting of all external directors. They meet periodically throughout the year. They are charged with approval of the organization's overall compensation and benefit programs as well as the specific review and approval of the compensation of certain employees including the Chief Executive Officer, all officers and key employees of the organization. They directly engage an independent compensation advisor to assist with this process. The process includes evaluation of the individual's performance, utilization of compensation studies of similarly situated positions, as well as comparisons to compensation as reported by other health care organizations. The reasonableness of compensation is evaluated based upon these and other factors. The Committee also reviews the compensation disclosures to be made on Form 990 in advance of filing. Form 990, Part VI, Section C, line 19 Forms 1023, 990 and 990-T are available upon request. The conflict of interest policy is not available to the public. PART IV, LINE 12 The Organization is an element of the external audit report obtained for the consolidated operations of Henry Ford Health System. FORM 990, PART IV, LINE 24a, TAX-EXEMPT BOND ISSUE: THE ORGANIZATION IS AN AFFILIATE OF HENRY FORD HEALTH SYSTEM. THE ALLOCATED TAX-EXEMPT BOND LIABILITY OF THE ORGANIZATION IS REPORTED UNDER THE FORM 990, SCHEDULE K OF ITS PARENT, HENRY FORD HEALTH SYSTEM. Form 990, Part IX, line 11g Professional Other: Program service expenses 11,228,459. Management and general expenses 0. Fundraising expenses 0. Total expenses 11,228,459. Physican Services: Program service expenses 17,746,119. Management and general expenses 0. Fundraising expenses 0. Total expenses 17,746,119. Purchased Services Other: Program service expenses 23,812,301. Management and general expenses 7,564,265. Fundraising expenses 0. Total expenses 31,376,566. Form 990, Part XI, line 9: PENSION LIABILITY ADJUSTMENT 7,814,030. AFFILIATE EQUITY TRANSFERS 3,590,796. Form 990, Part XII, Line 2C Henry Ford Allegiance Health is included in the consolidated financial statements of Henry Ford Health System (the sole member of Henry Ford Allegiance Health Group). The governing body of Henry Ford Health System has delegated the oversight of its financial statements, including the choice of independent auditors, to its audit committee. FORM 990, PART VII: Average hours per week devoted to related organizations: Many executive employees of Henry Ford Health System and affiliates provide services to multiple affiliated entities. Henry Ford Health System and affiliates use estimates for reporting average hours per week in all sections of Form 990. Generally 60 hours are reported for the hours associated for the organization that the individual has principal responsibility for. Hours associated with other hospitals or affiliates are reported at between 1 to 5 hours per week. Form 5713 - International Boycott Activity: A Form 5713, International Boycott Report, has been filed on our behalf by Henry Ford Health System (sole member of Henry Ford Allegiance Health Group). Henry Ford Allegiance Health did not itself have any activities associated with an international boycott country. Physicians Choice Network LLC 205 N East Avenue Jackson MI 49201 Provider Network MI 116529 54637 Henry Ford Allegiance Health Jackson Health Network L3C 205 N East Avenue Jackson MI 49201 453253643 Clinically Integrated Network MI 3150850 4453366 Henry Ford Allegiance Health Jackson Community Medical Records LLC 205 N East Avenue Jackson MI 49201 371502443 Electronic Medical Records MI 6013063 1640016 Henry Ford Allegiance Health It's Your Life Services LLC 205 N East Avenue Jackson MI 49201 Prevention and Community Health MI 40542 0 Henry Ford Allegiance Health Telehealth Michigan 205 N East Avenue Jackson MI 49201 Electronic Health Monitoring MI 0 0 Henry Ford Allegiance Health Henry Ford Allegiance Health Group 205 N East Avenue Jackson MI 49201 382756428 Exempt Health System MI 501(c)(3) Line 12b, II Henry Ford Health System 1 Allegiance Health Foundation 205 N East Avenue Jackson MI 49201 383607833 Supports Allegiance Health MI 501(c)(3) Line 12b, II Henry Ford Allegiance Health Group 1 Hospice of Jackson dba Allegiance Hospice 205 N East Avenue Jackson MI 49201 382336367 Hospice Care MI 501(c)(3) Line 7 Heathlink 1 The Hospice of Jackson Endowment Fund One Jackson Square Jackson MI 49201 383422146 Raise Funds for Allegiance Hospice MI 501(c)(3) Line 12b, II Allegiance Hospice 1 Healthlink 205 N East Avenue Jackson MI 49201 382756425 Home Health Care MI 501(c)(3) Line 12a, I Henry Ford Allegiance Health Group 1 Henry Ford Allegiance Specialty Hospital 110 North Elm Avenue Jackson MI 49202 381218485 Long Term Acute Care Hospital MI 501(c)(3) Line 3 Henry Ford Allegiance Health Group 1 Henry Ford Health System One Ford Place Detroit MI 48202 381357020 Healthcare Service Provider MI 501(c)(3) Line 3 N/A 0 Henry Ford Wyandotte Hospital 2333 Biddle Ave Wyandotte MI 48192 382791823 Healthcare Service Provider MI 501(c)(3) Line 3 Henry Ford Health System 1 Henry Ford Health System Foundation One Ford Place Detroit MI 48202 237383042 Supporting Organization MI 501(c)(3) Line 12a, I Henry Ford Health System 1 Health Alliance Plan 2850 W Grand Blvd Detroit MI 48202 382242827 Health Maintenance Organization MI 501(c)(4) N/A Henry Ford Health System 1 HFHS Self Funded Liability One Ford Place Detroit MI 48202 386553031 Malpractice Insurance MI 501(c)(4) N/A Henry Ford Health System 1 HFII Corporation One Ford Place Detroit MI 48202 900840304 Scientific Research MI 501(c)(3) Line 7 Henry Ford Health System 1 Henry Ford Health System Government Affairs Services One Ford Place Detroit MI 48202 464064067 Advocacy Services for HFHS and affiliates ME 501(c)(4) N/A Henry Ford Health System 1 Henry Ford Macomb Hospital Corporation One Ford Place Detroit MI 48202 382947657 Healthcare Service Provider DE 501(c)(3) Line 3 Henry Ford Health System 1 Foote Health Center Associates 1100 E Michigan Avenue Jackson MI 49201 383017711 Lessor of Medical Condominiums MI Henry Ford Allegiance Health Related 107489 1107666 0 0 0.62000 Northwest Detroit Dialysis 30100 Telegraph Bingham Farms MI 48025 383232668 Operate Dialysis Clinic MI Henry Ford Health System Related 0 0 Macomb Regional Dialysis Centers 16151 Nineteen Mile Rd Clinton Township MI 48038 260423581 Operate Dialysis Clinic MI Henry Ford Health System related 0 0 Henry Ford Allegiance Pharmacy 205 N East Avenue Jackson MI 49201 383370242 Pharmacy MI Henry Ford Allegiance Health Group C 1 Sha Realy Inc One Ford Place Detroit MI 48202 381378121 Real Estate Holding MI Henry Ford Health System C 1 Fairlane Health Services 30100 Telegraph Bingham Farms MI 48025 382565235 Healthcare Management MI Henry Ford Health System C 1 Alliance Health and Life Insurnace 2850 W Grand Blvd Detroit MI 48202 383291563 Health Insurance Provider MI Health Alliance Plan C 1 HAP Preferred Inc 2850 W Grand Blvd detroit MI 48202 382513504 Provider Network Leasing MI Health Alliance Plan C 1 Onika Insurance Ltd First Carribean House Grand Cayman CJ Captive Insurance CJ Henry Ford Health System C 1 Henry Ford Physician Network One Ford Place Detroit MI 48202 320306774 Physician Network MI Henry Ford Health System C 1 Adminstration Systems Research Corporation 2850 W Grand Blvd detroit MI 48202 382651185 Third Party Insurance Admin. MI Health Alliance Plan C 1 HAP Midwest Health Plan Inc 2850 W Grand Blvd Detroit MI 48202 383123777 Health Insurance Provider MI Health Alliance Plan C 1 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 Hospice of Jackson dba Henry Ford Allegiance Hospice J 126060 Cost Hospice of Jackson dba Henry Ford Allegiance Hospice L 619129 Cost Alliance Health & Life Insurance Co P 1890316 Cost Allegiance Health Foundation S 2756386 Cost CareLink of Jackson L 571783 Cost Volunteers of Henry Ford Allegiance Health R 171312 FMV Health Alliance Plan L 2715820 cost Jackson Community Ambulance M 213750 cost Health Alliance Plan M 1890316 cost Onika Insurance Ltd P 1714894 Cost Onika Insurance Ltd Q 1593061 Cost SCHEDULE R, PART V, LINE 1D & 1E: The Organization is a member of the Henry Ford Health System Obligated Group. Members of the Obligated Group are jointly and severally liable for outstanding obligations issued under the 2016 HFHS Bond Master Indenture.