2017-11-14T13:44:22-06:00 2016-12-31 ERNST & YOUNG US LLP 800 YARD STREET SUITE 200 COLUMBUS OH 43212 990 2016-01-01 310537095 Upper Valley Medical Center % J MICHAEL SIMS UPPE 9374999942 110 N Main St Suite 500 Dayton OH 45402 TIMOTHY D SNIDER VP-CFO 9374999942 2017-11-08 true DIANE L BEAN P00104972 6142245678 208.102.97.33 31499120173185000015 2017-11-14 P 582F47EFACDD6166E52205D1FBFEA2601660FA18 8EFF0C77748B9BD402565CEF41270569F54FE33A 2016 2017-02-10 21:41:12Z REBECCA A RICE 3130 N COUNTY RD 25 A TROY OH 45373 173507415 false X www.premierhealth.com X 1926 OH WE WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTH SERVICES. 7 1 1594 156 199663 -25650 183580 172769 141924880 147916213 2311629 2070570 2369812 1738653 146789901 151898205 771390 550292 0 0 74933197 76668833 0 0 0 61062476 67469708 136767063 144688833 10022838 7209372 182294753 187350287 97392118 105229559 84902635 82120728 X WE WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTH SERVICES. false false 133652161 550292 147916213 See Schedule H and Schedule O. 133652161 true true false true false false false false false false true true false false true true false true false false true false false false false false true true true false true true false false false false false false false false false false false false false false false true true true false false true 105 0 true 1594 true true true false false false false false false false false false X 7 1 false true true false true true true true true false false true true true true true true true true false OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 Dayton OH 45402 X ROWAN R NICKOL MD BOARD CHAIR 0.5 0.5 X X 0 0 0 REBECCA A RICE PRESIDENT & CEO 38.0 2.0 X X 511177 0 54827 RAFAY ATIQ TRUSTEE 0.5 39.5 X 0 464432 38479 DANIEL S BAILEY MD TRUSTEE & CMO (TO AUG) 39.5 0.5 X 244544 0 32606 DONALD D DELCAMP MD TRUSTEE & PRES MEDICAL STAFF 0.5 39.5 X 0 513201 35778 JENNIFER J HAULER MD TRUSTEE & CMO (FROM AUG) 39.5 0.5 X 98459 0 1152 RONAL MANIS JR MD TRUSTEE (TO JAN) 0.5 0.5 X 55800 0 0 JAMES R PANCOAST TRUSTEE & PREMIER CEO 7.5 8.5 X 0 0 0 SCOTT SWABB DO TRUSTEE 0.5 0.0 X 15417 0 0 DALE E CREECH BOARD SECRETARY 7.5 31.5 X 0 708171 62021 DIANE L PLEIMAN COO 39.5 0.5 X 284925 0 33132 TIMOTHY D SNIDER-SEE SCH O BOARD TREASURER & CFO 18.0 2.0 X 267607 0 40198 BENJAMIN A WATSON BOARD RECORDING SECRETARY 0.5 2.0 X 0 0 0 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 8.0 31.0 X 0 293603 61061 GARY G GINTER SYSTEM VP - CIO 8.0 32.0 X 0 537399 73246 BARBARA A JOHNSON SYS VP - HR OPERATIONS 8.0 32.0 X 0 523006 30879 TAMMY S LUNDSTROM MD SYSTEM VP - CMO 8.0 32.0 X 0 716856 59414 THOMAS R PARKER SYS VP- CHF EXPERIENCE OFFICER 8.0 32.0 X 0 496641 54594 CRAIG SELF SYS VP -CHIEF STRATEGY OFFICER 8.0 32.0 X 0 497273 39370 MARK W SHAW SYSTEM VP - MANAGED CARE 8.0 32.0 X 0 458030 61038 SCOTT A SHELTON SYSTEM VP - CPO 8.0 32.0 X 0 358074 32224 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 8.0 31.0 X 0 398678 35691 THOMAS D BIGLEY DIRECTOR - PHARMACY 40.0 0.0 X 208518 0 103171 ROBERT H BLYTHE STAFF PHARMACIST 40.0 0.0 X 147228 0 33256 TERRY R FRY VP - CNO 40.0 0.0 X 234309 0 33824 KATHLEEN J SCARBROUGH PRESIDENT, UVMC FOUNDATION 10.0 30.0 X 115034 39000 37429 MELISSA M TALMAGE DIR-NRS SURG/ICU/PCU 40.0 0.0 X 167995 0 32059 RENEE P GEORGE FORMER KEY EMPLOYEE 0.0 40.0 X 0 324102 24786 J NICK LAIR FORMER KEY EMPLOYEE 0.0 40.0 X 0 324961 56822 MICHAEL J MAIBERGER FORMER KEY EMPLOYEE 0.0 40.0 X 0 887043 94748 2351013 7540470 1161805 35 true true false COMPUNET CLINICAL LABORATORIES 2308 SANDRIDGE DR MORAINE OH 45349 CLINICAL LAB 1157285 PDT ARCHITECTS LLC 300 W 4TH ST CINCINNATI OH 45202 ARCHITECTURAL DESIGN 257108 BLACK BOX NETWORK SERVICES 1000 PARK DR LAWRENCE PA 15055 COMMUNICATIONS UPDAT 222576 FIRSTSOURCE SOLUTIONS USA LLC 1661 LYNDON FARM CT LOUISVILLE KY 40223 COLLECTIONS 215959 POWER SOLUTIONS GROUP LTD 425 KERR RD TIPP CITY OH 45371 ELECTRICAL MAINT 209830 9 172769 172769 NET PATIENT CARE REVENUE 621110 77313674 77124817 188857 MEDICARE/MEDICAID 621110 67468487 67468487 HOSPITAL FRANCHISE TAX RECOVERIES 900099 3060269 3060269 MEDICAL RECORDS 900099 37169 37169 HEALTH EDUCATION 900099 1740 1740 34874 34874 147916213 759947 759947 89533 89533 0 2438358 1949546 488812 0 488812 488812 20410622 154798 19225405 118925 1185217 35873 1221090 1221090 0 0 0 0 0 0 306670 315334 -8664 -8664 CAFETERIA SALES 721210 705360 705360 PURCHASE DISCOUNTS 900099 41044 41044 ALL OTHER REVENUE 900099 512101 10806 501295 1258505 151898205 147727356 199663 3798417 550292 550292 0 0 0 1639844 1495537 144307 0 0 58391615 53253153 5138462 3651873 3330508 321365 8933538 8147387 786151 4051963 3695390 356573 93659 85417 8242 164703 150209 14494 60563 60563 12608 11498 1110 0 127657 127657 7573339 6906885 666454 943664 943664 855344 780074 75270 4161065 3794891 366174 0 2333913 2128529 205384 143855 131196 12659 0 243 222 21 1555699 1555699 0 10729000 9784848 944152 0 OPERATING SUPPLIES 16065775 16065775 JOINT OPERATING AGREEMENT 10507000 9582384 924616 PURCHASED SERVICES 7318456 6674432 644024 HOSPITAL FRANCHISE TAX 2107327 2107327 2715838 2476844 238994 144688833 133652161 11036672 0 2860 2860 5545712 3808655 0 0 22070179 21116723 0 0 0 0 71597 0 743192 503818 2463932 1493024 200775621 109290028 83562100 91485593 48408530 48768299 13072143 14696404 0 0 0 0 6354508 5474911 182294753 187350287 11776297 10782754 357735 279110 149856 51388 38982492 63100490 0 0 0 0 899595 350903 0 0 45226143 30664914 97392118 105229559 X 84902635 82120728 0 0 0 0 84902635 82120728 182294753 187350287 X 7209372 1275947 -11267226 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 10178 false false true 2430 12608 false false PART II-B, LINE 1F: PAYMENTS FOR LOBBYING ACTIVITIES INCLUDE DUES PAID TO GREATER DAYTON AREA HOSPITAL ASSOCIATION, DAYTON DEVELOPMENT COALITION, AMERICAN HOSPITAL ASSOCIATION, AND OHIO HOSPITAL ASSOCIATION. PART II-B, LINE 1I: THE HOSPITAL CONTRACTS WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 1284133 1284133 114324654 62232179 52092475 69381027 47057849 22323178 15785807 15785807 91485593 ALTERNATIVE INVESTMENTS 14696404 F 14696404 0 PENSION OBLIGATION 12645341 JOINT OPERATING AGREEMENT 10507000 MALPRACTICE INSURANCE 3150466 DEFERRED COMPENSATION 2117953 CONSTRUCTION RESERVE 758885 SETTLEMENT - 3RD PARTY PAYORS 328504 WORKER'S COMP RESERVE 985852 OTHER 170913 30664914 X PART X, LINE 2: THE FOLLOWING FOOTNOTE IS FROM THE AUDITED COMBINED FINANCIAL STATEMENTS FOR PREMIER HEALTH AND AFFILIATES. UVMC IS THE PARENT ORGANIZATION OF UPPER VALLEY MEDICAL CENTER: PREMIER HEALTH (PREMIER), MEDAMERICA HEALTH SYSTEMS (MAHS), samaritan health partners (shp), ATRIUM HEALTH SYSTEM (AHS), AND UVMC have been determined by the Internal Revenue Service to be tax-exempt nonprofit corporations and public charities under Sections 501(c)(3) and 509(a), respectively, of the Internal Revenue Code. As tax-exempt organizations, their income is exempt from federal income tax except to the extent of any unrelated business activities. PREMIER, SHP, AND UVMC ALSO OWN OR CONTROL CERTAIN SUBSIDIARIES, WHICH ARE FOR-PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. Taxes payable at December 31, 2016 and 2015, for such unrelated business activities are not significant. Management annually reviews the tax positions and has determined that there are no material uncertain tax positions. Central America and the Caribbean Investments 10390000 Europe (Including Iceland and Greenland) Investments 4868000 Central America and the Caribbean Program Services INSURANCE 25000 15283000 15283000 false false false false false false true true true X true X true true false true true 5083000 2458000 2625000 0.01810 26261269 17856269 8405000 0.05810 1011000 896000 115000 0.00080 32355269 21210269 11145000 0.07700 393000 393000 0.00270 10000 10000 0.00010 2692000 2692000 0.01860 109000 109000 0.00080 3204000 3204000 0.02220 35559269 21210269 14349000 0.09920 17000 17000 0.00010 14000 14000 0.00010 4500 4500 900 900 268000 268000 0.00190 304400 304400 0.00210 true 3067251 0 28169000 30749000 -2580000 X true true 1 1 UPPER VALLEY MEDICAL CENTER 110 N MAIN ST 500 DAYTON OH 45402 WWW.PREMIERHEALTH.COM SEE PART V SECT C X X X UPPER VALLEY MEDICAL CENTER 1 false false true X X X X X X X X X 16 true true true true X See Part V, Section C X true 17 true See Part V, Section C false true X 200. 400. X X true true X X X true X SEE PART V, SEC C X SEE PART V, SEC C X SEE PART V, SEC C X X X X X X X true X false X X X X true X false false Part V, Section B, Line 1: THE STATE OF OHIO DOES NOT LICENSE HOSPITALS, BUT THE OHIO DEPARTMENT OF HEALTH DOES REGISTER HOSPITALS. AS PART OF THIS REGISTRATION PROCESS, HOSPITALS IN THE STATE OF OHIO ARE REQUIRED TO COMPLETE AND SUBMIT THE ANNUAL HOSPITAL REGISTRATION AND PLANNING REPORT (AHR) EACH CALENDAR YEAR. UPPER VALLEYS REGISTRATION NUMBER IS 1036. PART V, SECTION B, LINE 5: PARTNERING IN THE DATA REVIEW PROCESS AND IN THE PROCESS FOR IDENTIFYING AND PRIORITIZING COMMUNITY HEALTH NEEDS AND SERVICES WERE THE BOARD OF TRUSTEES AND EXECUTIVE LEADERSHIP OF UPPER VALLEY MEDICAL CENTER, The Health Collaborative in Cincinnati, Ohio, Miami County Public Health District, Shelby County Health Department, Darke County General Health District, and the Greater Dayton Area Hospital Association with its member hospitals. The participating hospitals invited a broad range of nonprofit agencies and organizations, which serve the medically underserved, low-income and minority populations, to attend community meetings and complete surveys. PART V, SECTION B, LINE 6A & 6B: UPPER VALLEY MEDICAL CENTER partnered with member hospitals of the Greater Dayton Area Hospital Association, The Health Collaborative in Cincinnati, Ohio, Miami County Public Health District, Shelby County Health Department, Darke County General Health District, and The Greater Dayton Area Hospital Association, Xavier University and an independent consultant to prepare the community health needs assessment. PART V, SECTION B, LINE 7A & 10A: The direct website address where the 2016 CHNA and the 2017 Community Health Improvement Plan can be accessed is: http://www.premierhealth.com/Our-Community/Making-a-Difference/ Community-Health-Improvement/ PART V, SECTION B, LINE 11: Upper Valley Medical Center (Upper Valley), as a member of the Premier Health system, was part of a collaboration in 2016 with member hospitals of the Greater Dayton Area Hospital Association, Miami County Public Health District, Shelby County Health Department, Darke County General Health District, and The Health Collaborative in Cincinnati, Ohio, The Greater Dayton Area Hospital Association, Xavier University and an independent consultant to prepare the community health needs assessment. Based on the results of this assessment, Upper Valley Medical Center has adopted an implementation strategy to address the following prioritized needs: * Behavioral Health/Substance Abuse * Chronic Diseases Health issue: Behavioral Health ----------------- Upper Valley Medical Center (Upper Valley) is working with the local ADAMHS board to improve access to, and integration of, primary care and behavioral health in the tri-county area. One Wellness Place is a planned new facility on County Road 25-A between Troy and Piqua. Developed by the ADAMHS Tri-County Board of Recovery and Mental Health Services, it will house mental health and addiction treatment providers, public health, and an array of wraparound support services in an integrated, easy-to-navigate facility. There may be an opportunity to house Upper Valleys proposed Federally Qualified Health Center in this facility to support both physical and behavioral health issues. Upper Valley shares many of these clients with the agencies contractually supported by the ADAMHS board. Additional partners in this project include Community Housing Inc., NAMI of Darke, Miami and Shelby counties, Recovery & Wellness Center of Midwest Ohio, Miami County Recovery Council, Miami County Dental Clinic, Miami County Public Health, and Safehaven Inc. Upper Valley also supports the local county schools in their efforts to combat bullying and violence in the school setting through Rachels Challenge. Rachels Challenge is a program designed to make schools safer, more connected places where bullying and violence are replaced with kindness and respect. Upper Valley supports delivery of this K-12 program in eight school districts, plus two faith-based schools, for a total of 29-36 school buildings participating, depending upon the year. For the 2017-2018 school year, the hospital is planning for Chain Reaction Days (all-day training programs for adults and students) at middle and high schools in the eight public school districts. Upper Valley has pledged to continue funding this program in area schools through the 2018-2019 academic year. Upper Valleys affiliate, Samaritan Behavioral Health, Inc., also provides three full-time mental health therapists who work in Piqua and Milton Union schools to provide behavioral health services for students covered by Medicaid. Health issue: Behavioral Health and Substance Abuse ------------------------------------- Upper Valley Medical Center will provide education that addiction is a disease and as a result, change perceptions, first of hospital personnel and medical professionals, and then of the community. The objectives are 1) to provide CEU's to front-line staff and physicians for education on this topic, with curriculum delivered by ADAMHS; and 2) to offer education in the community. In addition to assistance from the ADAMHS Board, resources will be obtained from Samaritan Behavioral Health, physician practices, and the Heroin Coalitions of Darke, Miami, and Shelby counties. Health issue: Chronic Diseases ---------------- Upper Valley will partner with local school districts to plan two Wellness initiatives aimed at reducing obesity in school-aged children. In one program, the hospital will build on its existing relationship with the Miami County Dental Clinic and their Traveling Smiles Program to introduce the Drinking Water Challenge initiative. The Drinking Water challenge (also known as "cavity-free kids") is a public oral health educational campaign focused on drinking water instead of sugar-sweetened beverages (soft drinks, sports drinks, and fruit juices). The Public Education Campaign includes billboards, news articles, local radio stations, PSA's, and flyers. The initiative will engage schools, local dentists, dental clinics, pediatricians and family practice physicians, local communities, etc. The second program, known as CATCH (Coordinated Approach To Child Health), is an evidence-based, coordinated school health program designed to promote physical activity and healthy food choices and to prevent tobacco use in children from preschool through grade eight. By teaching children that eating healthy and being physically active every day can be fun, the CATCH program has proven that establishing healthy habits in childhood can promote behavior changes that can last a lifetime. For more than 25 years, the CATCH platform has been proven to launch kids and communities toward healthier lifestyles. CATCH is supported by more than 120 academic papers, indicating as much as an 11 percent decrease in overweight and obese individuals in the environments in which it has been implemented. Upper Valley will collaborate with eight local public school districts, two faith-based schools, and the Miami County Dental Clinic in the planning and implementation of this program. In the broader community, Upper Valley Medical Center will implement a strategy to increase the amount of healthy food available for people with health related nutritional needs. The short-term objectives are 1) to ensure that all eligible patients are signed up for Supplemental Nutritional Assistance Program (SNAP) and/or Women Infant Children (WIC) benefits; and 2) to increase the availability of fresh produce in partnership with local food pantries, area farmers, and/or community gardens. The hospital may begin screening for hunger to ascertain the scope of the problem. If determined feasible, the hospital, along with its affiliates in Premier Health, would like to create a food pharmacy, or similar prescription for food program by 2019. A food pharmacy accepts people with a physician referral and offers two to three days worth of food per visit. Patients can return to the food pharmacy once per month for up to six months, at which time they can return to their physician for another referral if they are still in need. Other services may include nutrition counseling, cooking classes, and connection to community resources. Major local food pantries in Miami County will be used as resources to implement this strategy. Upper Valley Medical Center is one of five hospitals in the Premier Health system. All five hospitals participated with other health care organizations to create a collaborative Community Health Needs Assessment (CHNA). Based on the results of the Assessment, the five Premier hospitals jointly identified three shared health care need priorities that are critical throughout the Premier service area: Birth Outcomes, Chronic Diseases and Behavioral Health/Substance Abuse. The remaining health care needs identified in the Assessment are shared with many local health departments in our region, as well as state agencies. These include Access to Care, Social Determinants, Provider Shortages, Transportatio 6 HYATT CENTER 450 HYATT ST TIPP CITY OH 45371 LABORATORY, IMAGING, SPORTS MEDICINE, SURGERY OUTPATIENT CARE CENTER NORTH 280 LOONEY RD PIQUA OH 45356 LABORATORY, IMAGING, REHABILITATIVE THERAPY OUTPATIENT CARE CENTER SOUTH 998 S DORSET RD TROY OH 45373 LABORATORY, IMAGING OCCUPATIONAL HEALTH REHABILITATIVE THERAPY STANFIELD PLACE 31 STANFIELD RD TROY OH 45373 IMAGING JACOB DETTMER BUILDING 3130 N COUNTY RD 25A TROY OH 45373 Behavorial Health VERSAILLES CENTER 471 MARKER RD VERSAILLES OH 45380 LABORATORY Part I, line 6a: THE COMMUNITY BENEFIT REPORT FOR UPPER VALLEY MEDICAL CENTER IS PART OF THE PREMIER HEALTH REPORT (EIN# 31-1446699). PART I, LINE 7: A COST TO CHARGE RATIO WAS USED TO CALCULATE THIS FINANCIAL ASSISTANCE AT COST. THIS CALCULATION TAKES TOTAL OPERATING EXPENSES LESS OTHER OPERATING REVENUES DIVIDED BY TOTAL GROSS REVENUES. UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENTAL PROGRAMS WERE CALCULATED USING A COST ACCOUNTING SYSTEM. THIS SYSTEM ADDRESSES ALL PATIENT SEGMENTS AND INCLUDES FULLY LOADED COSTS. FOR THE REMAINING ITEMS THE ORGANIZATION USED SPECIFIC NUMBERS FOR EXPENSE PAID DIRECTLY FOR THESE SERVICES. PART I, LINE 7G: UPPER VALLEY MEDICAL CENTER provides subsidized emergency services by operating a 24-hour emergency room 365 days per year. This emergency room is open to all individuals regardless of their ability to pay. The hospital incurs expenses related to call time and physician subsidies due to the large number of indigent patients coming through the emergency room. FOR 2016, THE AMOUNTS PAID FOR CALL TIME AND SUBSIDIES WERE $2,644,000. PART II, LINE 2: Upper Valley Medical Center (Upper Valley) is committed to improving the health of the communities it serves through a variety of prevention, health improvement and engagement programs. As part of its overall commitment to the community, Upper Valley focuses on four areas of service: --Investing in the community --Prevention and wellness --Commitment to the under-served --Community engagement Some of the programs supported by Upper Valley during 2016 include: 1) Ongoing efforts to improve the economic condition in Dayton and the Miami Valley. A total of $14,000 was contributed toward a capital campaign project to build and develop a new community center. The center will be located in an under-privileged community where approximately 30% of the families live below the poverty level. The community center will reinforce early learning, inter-generational and family engagement, population health and advocacy and workforce development. 2) Funding of $5,000 was contributed towards the economic development and revitalization of an urban community within the hospitals service area. This project includes construction of a performing arts pavilion that will provide free concerts to the surrounding communities. 3) Providing free healthcare to uninsured and underinsured residents of Miami County, Ohio through a local clinic. Services provided at the clinic include appointments with physicians and other health care professionals, diagnostic lab testing, pharmacy and prescription assistance, nursing visits, and medication reviews. Upper Valley provided $93,000 in support of this program in 2016. 4) Contributions of $65,000 to a local dental clinics program which provides education and prevention for local children who have limited or no access to dental care. Preventative and restorative dental care is provided to the uninsured, underinsured and low-income children in Miami County in the local school setting. Participating children are treated regardless of their ability to pay. 5) support of the local hospice program totaling $25,000 in their mission to improve the quality of life for people and families facing life-limiting illnesses, regardless of the patients insurance coverage or ability to pay. 6) Funding of local charitable organizations through the hospitals Board Charitable Credit Fund. As part of Upper Valley's community partnership activity, board members of the hospital are granted charitable credits to be donated in the name of the board member with priorities to not-for-profit, tax-exempt 501(c)(3) health and human services organizations, arts and culture organizations, as well as other community activities in the hospital systems area. Also suggested are organizations that focus on supporting youth, education, underserved groups, and safe neighborhoods. The amount of support provided in 2016 was $81,000. PART III, LINE 2 & 3: Bad debt expense is incurred when an account is taken out of accounts receivable and turned over to a collection agency. This action may occur if a patient refuses payment arrangements, refuses to apply for financial assistance, and there is not an insurance balance being contended. An account is written off to bad debt after 130 days if an attempt to collect from the patient is made within our collection policy. The collection agency attempts to collect the account in accordance with established guidelines. Collection attempts are ceased and the account returned back to the organization if the patient applies for financial assistance. Any amounts collected from these accounts are credited back against bad debt expense. The organization recognizes that there are accounts written off to bad debt that may have qualified for charity care if the patient had provided the necessary financial information. In order to resolve this, the organization has engaged a third-party vendor to analyze data based on credit scores to reallocate some of this expense to charity care. A representative sample of these accounts is then sent to our third-party vendor who gathers external credit data that presents the account as less than 100% federal poverty level or not enough information (typically indicative of indigent). These accounts are reclassed from bad debt expense to charity expense on our income statement. Any credit score that presents the accounts as greater than 100% federal poverty level remains in bad debt expense. Due to this process, the organization has used best efforts to not report bad debt expense for patients eligible under the organization's charity care policy. PART III, LINE 4: THE ORGANIZATION DOES NOT HAVE A FOOTNOTE IN THE AUDITED FINANCIAL STATEMENTS WHICH DISCUSSES THIS CALCULATION. PART III, SECTION B, LINES 5, 6, AND 7: THE AMOUNTS REPORTED ON LINES 5, 6, AND 7 DO NOT INCLUDE CERTAIN MEDICARE PROGRAM REVENUES AND COSTS, AND THUS DO NOT REFLECT ALL OF THE ORGANIZATION'S REVENUES AND COSTS ASSOCIATED WITH ITS PARTICIPATION IN MEDICARE PROGRAMS. IN ADDITION TO THE AMOUNTS REPORTED ON LINE 5, 6, AND 7, THE ORGANIZATION RECEIVED REVENUE OF $17,937,000 AND INCURRED COST OF $23,425,000, FOR AN ADDITIONAL NET SHORTFALL OF $5,488,000 ASSOCIATED WITH THESE PROGRAMS. BELOW IS A RECONCILIATION OF THE AMOUNTS ASSOCIATED WITH MEDICARE PROGRAMS. ALLOWABLE MEDICARE REVENUE PER MEDICARE COST REPORT (PART III, SECTION B) $28,169,000 MEDICARE REVENUE NOT REPORTED IN PART III, SECTION B $17,937,000 TOTAL MEDICARE ASSOCIATED REVENUE $46,106,000 ALLOWABLE MEDICARE COST PER MEDICARE COST Report (PART III, SECTION B) $30,749,000 MEDICARE COST NOT REPORTED IN PART III, SECTION B $23,425,000 TOTAL MEDICARE ASSOCIATED COST $54,174,000 MEDICARE SHORTFALL PER PART III, SECTION B $2,580,000 ADDITIONAL SHORTFALL NOT INCLUDED IN PART III, SECTION B $5,488,000 TOTAL MEDICARE SHORTFALL $8,068,000 PART III, LINE 8: THE ORGANIZATION'S SHORTFALL SHOULD BE CONSIDERED CHARITY CARE BECAUSE IT IS PROVIDING HIGH-QUALITY CARE IN EXCESS OF THE COST TO OUR COMMUNITY RESIDENTS THAT NEED CARE. THE MEDICARE POPULATION AT THE ORGANIZATION IS IN EXCESS OF 42% OF NET PATIENT REVENUE. THE ORGANIZATION USED A COST ACCOUNTING SYSTEM TO CALCULATE THE MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: THE ORGANIZATION MAKES REASONABLE EFFORTS TO DETERMINE WHETHER OR NOT AN INDIVIDUAL IS ELIGIBLE FOR ASSISTANCE UNDER THE STATE OR HOSPITAL FINANCIAL ASSISTANCE POLICY BEFORE ENGAGING IN EXTRAORDINARY COLLECTIVE ACTIONS AGAINST THAT INDIVIDUAL. PATIENTS WHO ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE ARE OFFERED REASONABLE PAYMENT PLAN ARRANGEMENTS FOR ANY REMAINING BALANCES. ANY THIRD PARTY COLLECTING SELF-PAY RECEIVABLES ON OUR BEHALF IS REQUIRED TO MAKE REASONABLE EFFORTS TO DETERMINE IF THE INDIVIDUAL MEETS THE QUALIFICATIONS OF THE STATE OR OF OUR HOSPITAL FINANCIAL ASSISTANCE PROGRAMS. REASONABLE EFFORTS INCLUDE: A. VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD PARTY PAYMENT HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL. B. DOCUMENTING THAT THE ORGANIZATION HAS OR HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR CHARITY CARE UNDER ITS FINANCIAL ASSISTANCE POLICY. C. DOCUMENT THAT THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. D. DOCUMENT THAT THE PATIENT HAS BEEN OFFERED AND ACCEPTED TERMS FOR A PAYMENT PLAN, BUT HAS NOT HONORED THE TERMS OF THAT PLAN. THE FINANCIAL COUNSELORS MEET WITH INPATIENT, OUTPATIENT SELF-PAY, AND OTHER PATIENTS UPON REQUEST WHO MAY NEED FINANCIAL ASSISTANCE. IN ADDITION TO ASSISTING PATIENTS WHO WANT TO APPLY FOR ASSISTANCE THROUGH THE MEDICAID PROGRAM, THE FINANCIAL COUNSELOR WILL PROVIDE THE PATIENT WITH A FINANCIAL ASSISTANCE APPLICATION. PART VI, LINE 2: THE ORGANIZATION WORKS WITH THE COMMUNITY ON PROGRAMS THAT ADDRESS THE UNDERLYING CAUSES OF PERSISTENT HEALTH PROBLEMS AS PART OF A COMPREHENSIVE STRATEGY TO IMPROVE THE HEALTH STATUS AND QUALITY OF LIFE FOR IDENTIFIED MEMBERS OF THE COMMUNITY WHO true HEALTH PARTNERS FREE CLINIC 1300 N CO RD 25A TROY OH 45373 311596731 501(C)(3) 107000 SUPPORT SAMARITAN BEHAVIORAL HEALTH INC 601 S EDWIN C MOSES BLVD DAYTON OH 45408 020633634 501(C)(3) 91325 SUPPORT MIAMI COUNTY DENTAL CLINIC 1364 W MAIN ST TROY OH 45373 204901192 501(C)(3) 67500 SUPPORT MIAMI COUNTY RECOVERY COUNCIL INC 1059 N MARKET ST TROY OH 45373 310917327 501(C)(3) 62983 SUPPORT HOSPICE OF MIAMI COUNTY INC 550 SUMMIT AVE 101 TROY OH 45373 311031277 501(C)(3) 36500 SUPPORT UVMC FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311581859 501(C)(3) 17863 SUPPORT TROY COMMUNITY DEVELOPMENT 405 SW PUBLIC SQUARE 330 TROY OH 45373 311736034 501(C)(3) 15000 SUPPORT MIAMI VALLEY HOSPITAL 110 N MAIN ST 500 DAYTON OH 45402 310537504 501(C)(3) 14667 MAHOGANY CHILD & BRIDGE PROGRAM EDISON FOUNDATION 1973 EDISON DR PIQUA OH 45356 311379781 501(C)(3) 13500 SUPPORT OMEGA COMMUNITY DEVELOPMENT 1800 HARVARD BLVD DAYTON OH 45406 311561713 501(C)(3) 13500 CAPITAL RENOVATION REACH OUT MONTGOMERY COUNTY 25 E FORAKER ST DAYTON OH 45409 311434282 501(C)(3) 10753 RX ASSISTANCE FOR INDIGENT BRUKNER NATURE CENTER 5995 HORSESHOE BEND RD TROY OH 45373 310732613 501(C)(3) 10295 SUPPORT THE BARN MINISTRY INC 2140 N RENCH RD PLEASANT HILL OH 45359 311671150 501(C)(3) 10000 SUPPORT MIAMI COUNTY FOUNDATION 317 N WAYNE ST PIQUA OH 45356 311142558 501(C)(3) 10000 SUPPORT GALA OF HOPE FOUNDATION - 3500 PENTAGON BLVD 500 BEAVERCREEK OH 45431 464277044 501(C)(3) 9000 SUPPORT MIAMI COUNTY YMCA 223 W HIGH ST PIQUA OH 45356 310537179 501(C)(3) 7500 SUPPORT GOODWILL EASTER SEALS MIAMI VALLEY 660 S MAIN ST DAYTON OH 45402 310537112 501(C)(3) 6930 SUPPORT DAYTON ART INSTITUTE 456 BELMONTE PARK N DAYTON OH 45405 310537480 501(C)(3) 6554 SUPPORT TROY FOUNDATION 216 W FRANKLIN ST TROY OH 45373 316018703 501(C)(3) 6000 SUPPORT HABITAT FOR HUMANITY INTERNATIONAL INC 115 W RIVERVIEW DAYTON OH 45405 311352522 501(C)(3) 5500 SUPPORT PIQUA EDUCATION FOUNDATION 719 E ASH ST PIQUA OH 45356 311117501 501(C)(3) 5500 SUPPORT 21 0 PART I, LINE 2: 1) DISBURSEMENTS ARE ANALYZED MONTHLY THROUGH VARIOUS REPORTS AND COMMITTEE MEETINGS. 2) INVOICES ARE RECEIVED IN ACCOUNTS PAYABLE AND APPROVED AND DISBURSED PER ORGANIZATIONAL POLICY. 3) GRANT SPENDING IS MONITORED AGAINST BUDGETED AMOUNTS ON AN ONGOING BASIS. X X X X true true false false false false false false false REBECCA A RICE PRESIDENT & CEO 317890 0 161267 0 32020 0 40939 0 13888 0 566004 0 0 0 RAFAY ATIQ TRUSTEE 0 350804 0 111645 0 1983 0 9730 0 28749 0 502911 0 0 DANIEL S BAILEY MD TRUSTEE & CMO (TO AUG) 174568 0 59747 0 10229 0 11149 0 21457 0 277150 0 0 0 DONALD D DELCAMP MD TRUSTEE & PRES MEDICAL STAFF 0 489806 0 0 0 23395 0 7541 0 28237 0 548979 0 0 DALE E CREECH BOARD SECRETARY 0 384517 0 157999 0 165655 0 35724 0 26297 0 770192 0 0 DIANE L PLEIMAN COO 223032 0 56968 0 4925 0 27386 0 5746 0 318057 0 0 0 TIMOTHY D SNIDER-SEE SCH O BOARD TREASURER & CFO 198405 0 68205 0 997 0 14231 0 25967 0 307805 0 0 0 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 0 217200 0 73402 0 3001 0 31381 0 29680 0 354664 0 0 GARY G GINTER SYSTEM VP - CIO 0 371557 0 162212 0 3630 0 47670 0 25576 0 610645 0 0 BARBARA A JOHNSON SYS VP - HR OPERATIONS 0 358532 0 148857 0 15617 0 21090 0 9789 0 553885 0 0 TAMMY S LUNDSTROM MD SYSTEM VP - CMO 0 511262 0 200578 0 5016 0 57992 0 1422 0 776270 0 0 THOMAS R PARKER SYS VP- CHF EXPERIENCE OFFICER 0 369275 0 103016 0 24350 0 42604 0 11990 0 551235 0 0 CRAIG SELF SYS VP -CHIEF STRATEGY OFFICER 0 361101 0 134279 0 1893 0 12640 0 26730 0 536643 0 0 MARK W SHAW SYSTEM VP - MANAGED CARE 0 297362 0 94038 0 66630 0 35596 0 25442 0 519068 0 0 SCOTT A SHELTON SYSTEM VP - CPO 0 241172 0 85638 0 31264 0 28797 0 3427 0 390298 0 0 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 0 317525 0 78603 0 2550 0 9718 0 25973 0 434369 0 0 THOMAS D BIGLEY DIRECTOR - PHARMACY 154583 0 25479 0 28456 0 92663 0 10508 0 311689 0 0 0 ROBERT H BLYTHE STAFF PHARMACIST 143583 0 0 0 3645 0 7944 0 25312 0 180484 0 0 0 TERRY R FRY VP - CNO 172026 0 41652 0 20631 0 24978 0 8846 0 268133 0 0 0 KATHLEEN J SCARBROUGH PRESIDENT, UVMC FOUNDATION 78462 26601 26701 9052 9871 3347 13567 4801 14112 4949 142713 48750 0 0 MELISSA M TALMAGE DIR-NRS SURG/ICU/PCU 147098 0 20220 0 677 0 13917 0 18142 0 200054 0 0 0 RENEE P GEORGE FORMER KEY EMPLOYEE 0 248408 0 74875 0 819 0 12854 0 11932 0 348888 0 0 J NICK LAIR FORMER KEY EMPLOYEE 0 221875 0 74484 0 28602 0 25951 0 30871 0 381783 0 0 MICHAEL J MAIBERGER FORMER KEY EMPLOYEE 0 363714 0 239684 0 283645 0 65488 0 29260 0 981791 0 0 PART I LINE 4A: THE FOLLOWING INDIVIDUAL ELECTED TO PARTICIPATE IN A VOLUNTARY RETIREMENT PROGRAM, AND RECEIVED THE FOLLOWING PAYMENTS: Thomas Bigley $6,808 in 2016, and will receive $81,696 in 2017. Part I, Line 4B: DUE TO RESTRICTIONS IMPOSED BY THE INTERNAL REVENUE CODE, CERTAIN PERSONS ARE LIMITED IN THE AMOUNT OF BENEFIT THAT CAN BE EARNED UNDER A QUALIFIED RETIREMENT PLAN. LIKE MANY EMPLOYERS, UPPER VALLEY MEDICAL CENTER (UPPER VALLEY) AND ITS AFFILIATED ORGANIZATIONS COMPENSATE FOR THIS LIMITATION AND SUPPLEMENTS THE AFFECTED EXECUTIVES' QUALIFIED PENSION THROUGH CERTAIN NONQUALIFIED PLANS. UPPER VALLEY SUPPLEMENTS THE AFFECTED EXECUTIVES THROUGH A PENSION RESTORATION PLAN AND A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE BENEFITS UNDER THESE SUPPLEMENTAL NONQUALIFIED PLANS ARE SUBJECT TO MULTI-YEAR VESTING AND A PARTICIPANT CAN FORFEIT BENEFITS EARNED IF VESTING REQUIREMENTS ARE NOT SATISFIED. UNDER THE TERMS OF THE SUPPLEMENTAL PLANS, AND BECAUSE OF TAX RULES PERTAINING TO TAXATION OF THE EARNED BENEFITS UPON VESTING, CERTAIN INDIVIDUALS RECEIVED A PAYOUT OF THE CUMULATIVE VESTED BENEFITS UNDER THEIR SUPPLEMENTAL PLAN DURING 2016. THE INDIVIDUALS LISTED BELOW HAVE MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE PENSION RESTORATION PLAN AND RECEIVED THE ASSOCIATED PAYMENT IN 2016: Dale Creech $159,735; J. Nick Lair $9,782; Diane Pleiman $3,376; Mark Shaw $53,557; Scott Shelton $28,038. THE INDIVIDUALS LISTED BELOW HAVE MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE SERP AND RECEIVED THE ASSOCIATED PAYMENT IN 2016: Daniel Bailey, M.D. $7,699; Barbara Johnson $10,303; Michael Maiberger $34,406; Rebecca Rice $6,314. In addition, the following SERP amounts were deferred on the participants behalf during the year and will be held until the incremental amounts are vested and paid to the SERP participants: Danny Bailey, M.D. $668; Thomas Curtin $1,493; Renee George $1,610; Gary Ginter $18,847; Barbara Johnson $10,811; Tammy Lundstrom $49,100; Michael Maiberger $50,476; Thomas Parker $14,575; Rebecca Rice $9,476; Craig Self $1,462; Timothy Snider $594. BASED ON THE GUIDANCE PROVIDED IN THE INSTRUCTIONS TO THE FORM 990, ANY PAYMENTS TO THE PARTICIPANTS RELATED TO THESE PLANS THAT WERE MADE WITHIN 2-1/2 MONTHS AFTER THE END OF THE ORGANIZATION'S TAX YEAR ARE NOT TREATED AS DEFERRED COMPENSATION FOR PURPOSES OF SCHEDULE J. SUCH AMOUNTS ARE PROPERLY REPORTED AS COMPENSATION FOR FORM 990 PURPOSES WHEN INCLUDED IN THE PARTICIPANTS' FORM W-2 WAGES. ANY PAYMENTS MADE AFTER THE 2-1/2 MONTHS WERE PROPERLY REPORTED ON PRIOR YEARS' FILED IRS FORM 990 RETURNS, DISCLOSING COMPENSATION EARNED BY THESE INDIVIDUALS UNDER THE PLANS FOR EACH SUCH YEAR. Part II, Line 7: TIMOTHY SNIDER SERVES AS AN OFFICER FOR BOTH UPPER VALLEY MEDICAL CENTER AND ANOTHER UNRELATED HOSPITAL. HOWEVER, 100% OF HIS COMPENSATION IS PAID BY UPPER VALLEY MEDICAL CENTER. MR. SNIDER SPENDS APPROXIMATELY ONE-HALF OF HIS WORKING HOURS AT EACH HOSPITAL. THE COMPENSATION REPORTED ON PART VII & SCHEDULE J INCLUDES ALL OF HIS REPORTABLE COMPENSATION, EVEN THOUGH UPPER VALLEY MEDICAL CENTER IS REIMBURSED BY THE UNRELATED HOSPITAL FOR HIS TIME SPENT AT THAT INSTITUTION. A County of Miami Ohio 316000055 2016-08-31 33210000 SEE PART VI false false false A 0 0 33210000 0 0 0 111568 0 0 0 33098432 0 2009 true false true true A false true true true false 0.00050 0.00230 0.00280 false false false true A false true false false true true BOAML 0. true true false 0 true true A true SCHEDULE K, PART I, LINE A, COLUMN F PURPOSE OF BOND: THE BOND ISSUE OF 08/31/2016 WAS USED TO CURRENTLY REFUND THE 2006 SERIES BOND. Form 990, PART III, LINE 4A: THE PRIMARY EXEMPT PURPOSE OF UPPER VALLEY MEDICAL CENTER IS TO PROVIDE COMPREHENSIVE INPATIENT, OUTPATIENT, AND EMERGENCY HEALTH CARE SERVICES TO THE RESIDENTS OF MIAMI AND THE SURROUNDING COUNTIES. THE HOSPITAL FURTHERS ITS TAX-EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY IN MANY WAYS. SEE SCHEDULE H FOR MORE INFORMATION. FORM 990, PART VI, SECTION A, LINE 3: PREMIER HEALTH (PREMIER) AS THE OPERATOR OF UPPER VALLEY MEDICAL CENTER (UPPER VALLEY), DEVELOPS AND OVERSEES THE IMPLEMENTATION OF THE STRATEGIC PLAN FOR UPPER VALLEY, WHICH INCLUDES (BUT IS NOT LIMITED TO) SUCH MATTERS AS LOCATION OF CLINICAL AND ADMINISTRATIVE EXPENSES AND THE CONSOLIDATION OF SUCH SERVICES. UPPER VALLEY SHALL COMPLY WITH AND IMPLEMENT THIS PLAN AND SHALL NOT TAKE ANY ACTION THAT MATERIALLY DEPARTS FROM THIS PLAN WITHOUT PREMIER'S APPROVAL. UPPER VALLEY SHALL IMPLEMENT ANY CAPITAL AND OPERATING BUDGET SO APPROVED AND/OR REVISED FOR IT BY PREMIER. UPPER VALLEY SHALL IMPLEMENT THE BUSINESS PLAN APPROVED BY PREMIER. PREMIER IS THE SOLE AGENT TO NEGOTIATE ALL RELATIONSHIPS WITH PAYORS ON BEHALF OF UPPER VALLEY WITH ALL THIRD PARTY PAYORS AND ALTERNATIVE DELIVERY SYSTEMS INCLUDING, BUT NOT LIMITED TO INSURERS. UPPER VALLEY MUST HAVE APPROVAL FROM PREMIER TO BORROW IN ANY FISCAL YEAR, GUARANTEE IN ANY YEAR, OR INCUR ANY LIEN OR OTHER ENCUMBRANCE ON ANY PROPERTY IN AN AMOUNT EQUAL TO OR GREATER THAN $1,000,000. UPPER VALLEY MUST SEEK PREMIER'S APPROVAL FOR ANY ACQUISITIONS, SALE OR TRANSFER OF ANY MATERIAL ASSET USED IN PREMIER'S ACTIVITIES. FORM 990, PART VI, SECTION A, LINE 4: In 2016, Upper Valley Medical Centers Code of Regulations were modified. Listed below are the significant changes: * An attendance requirement was added for the Trustees, requiring at least 75% attendance of the board meetings or is considered to have resigned. In addition, the board members must attend at least 75% of each meeting, with an exception for Physicians addressing urgent patient care needs. In such an event, the physician must attend at least 50% of the meeting to be considered present. * No Trustee shall be entitled to receive compensation for services provided as a Trustee, other than reasonable, out-of-pocket expenses incurred in connection with his/her service as a Trustee. * All actions taken by the Executive Committee must be by unanimous vote. * The officers of the Corporation shall be: (a) a Chair of the Board of Trustees, (b) a President and Chief Executive Officer, (c) a Secretary, (d) a Treasurer, and (e) other such officers, including one (1) or more Assistant Secretaries and one (1) or more Assistant Treasurers. FORM 990, PART VI, SECTION A, LINE 6: UPPER VALLEY MEDICAL CENTER HAS TWO CORPORATE MEMBERS. ONE MEMBER IS UVMC. THE SECOND MEMBER IS PREMIER HEALTH, AN OHIO NONPROFIT CORPORATION, FORMED PURSUANT TO THE JOINT OPERATING AGREEMENT. UVMC HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES OF THE CORPORATION. PREMIER HAS THE GENERAL AUTHORITY TO OPERATE AND MANAGE THE OPERATIONAL ACTIVITIES OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A & 7B: UVMC HAS THE SOLE AUTHORITY TO ELECT THE BOARD OF TRUSTEES FOR UPPER VALLEY MEDICAL CENTER FROM AMONG THOSE RECOMMENDED BY THE NOMINATING COMMITTEE SET FORTH IN THE JOINT OPERATING AGREEMENT. UVMC HAS THE AUTHORITY TO REMOVE SUCH TRUSTEES AT ANY REGULAR OR SPECIAL BOARD MEETING OR BY WRITTEN CONSENT. FORM 990, PART VI, SECTION B, LINE 11B: THIS 990 TAX RETURN AND ATTACHED SCHEDULES (THE RETURN) ARE PREPARED BY A STAFF MEMBER IN THE PREMIER HEALTH (PREMIER) TAX DEPARTMENT, OF WHICH UPPER VALLEY MEDICAL CENTER IS AN AFFILIATE. THE RETURN IS REVIEWED BY THE TAX MANAGER AND DIRECTOR OF TAX COMPLIANCE OF PREMIER. THE RETURN IS CONCURRENTLY SENT TO ERNST & YOUNG U.S. LLP FOR THEIR REVIEW. AFTER ALL CHANGES FROM THE ABOVE GROUPS ARE MADE, THE RETURN IS REVIEWED BY THE VICE-PRESIDENT/CONTROLLER OF PREMIER AND THE CHIEF FINANCIAL OFFICER OF THIS ENTITY. A FINAL VERSION OF THE RETURN IS SENT TO ERNST & YOUNG U.S. LLP FOR A FINAL REVIEW AND THEN PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW. AT A BOARD OF TRUSTEES MEETING, THE VICE PRESIDENT/CONTROLLER OF PREMIER (OR DESIGNEE) SHARES DETAILED INFORMATION ON COMPENSATION AND OTHER KEY AREAS, AS WELL AS ADDRESSES ANY QUESTIONS FROM THE BOARD OF TRUSTEES, PENDING THEIR REVIEW. THE 990 TAX RETURN IS ALSO SHARED WITH THE AUDIT COMMITTEE OF PREMIER. FORM 990, PART VI, SECTION B, LINE 12C: PREMIER HEALTH (PREMIER), WITH WHICH UPPER VALLEY MEDICAL CENTER IS AN AFFILIATE, REQUIRES ALL BOARD MEMBERS, OFFICERS, EXECUTIVE DIRECTORS, VICE PRESIDENTS, DIRECTORS, PURCHASING DEPARTMENT STAFF, AUTHORIZED PURCHASERS, MEDICAL DIRECTORS, DEPARTMENT AND SECTIONS CHAIRS, AND ALL EMPLOYED PHYSICIANS TO ANNUALLY REVIEW THE PREMIER COMPREHENSIVE CONFLICT OF INTEREST STATEMENT, AN EXPLANATORY MEMORANDUM, THE ANTITRUST COMPLIANCE POLICY, AND COMPLETE AN INDIVIDUAL QUESTIONNAIRE DISCLOSING ANY POTENTIAL CONFLICTS AS DEFINED IN THE CONFLICT OF INTEREST POLICY. THIS IS ACCOMPLISHED EITHER BY WAY OF AN ELECTRONIC COMMUNICATION SENT OUT DIRECTLY BY THE CORPORATE COMPLIANCE DEPARTMENT OR BY WAY OF A MEMO SENT OUT FROM THE CHAIRMAN OF THE BOARD AND CHIEF EXECUTIVE OFFICER OF PREMIER. IT ALSO INCLUDES AN EXPLANATORY MEMORANDUM OF SPECIFIC ACTIVITIES THAT MIGHT GIVE CAUSE TO A CONFLICT AND AN INDIVIDUAL QUESTIONNAIRE TO DISCLOSE ALL SUCH ACTIVITIES. THIS QUESTIONNAIRE MUST BE COMPLETED AND SIGNED BY THE INDIVIDUAL. THIS CORRESPONDENCE INCLUDES A COPY OF THE ANTITRUST COMPLIANCE POLICY THAT MUST BE SIGNED BY THE INDIVIDUAL. ALL OF THESE DOCUMENTS ARE SENT TO THE CORPORATE COMPLIANCE DEPARTMENT. THE CORPORATE COMPLIANCE DEPARTMENT ENSURES ALL FORMS ARE RETURNED AND RETAINS THE DOCUMENTS FOR FIVE YEARS. IN ADDITION, AT EACH MEETING OF THE BOARD OR ANY BOARD COMMITTEE, FOLLOWING APPROVAL OF THE PREVIOUS MEETING'S MINUTES, THE BOARD OR COMMITTEE CHAIR SHALL REQUEST ANY BOARD MEMBER WHO PERCEIVES A POTENTIAL CONFLICT OF INTEREST ON ANY OF THE MEETING'S AGENDA ITEMS TO DISCLOSE THE POTENTIAL CONFLICT. ADDITIONALLY, AT ANY BOARD OR BOARD COMMITTEE MEETING WHERE THE SUBJECT OF CONFLICT OF INTEREST IS DISCUSSED, THE MINUTES SHALL CONTAIN THE NAME OF THE PARTY DISCUSSING A POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE POTENTIAL CONFLICT OF INTEREST AND WHETHER A CONFLICT OF INTEREST WAS FOUND TO EXIST. IF A CONFLICT OF INTEREST IS DETERMINED BY THE BOARD TO EXIST, THE MEMBER WILL BE EXCUSED FROM PARTICIPATING IN ANY DISCUSSION OR VOTING ON THE PARTICULAR AGENDA ITEM. THE CHIEF COMPLIANCE AND ENTERPRISE RISK OFFICER REPORTS THE RESULTS OF THE PREMIER CONFLICT OF INTEREST QUESTIONNAIRES NO LESS THAN ANNUALLY TO THE BOARD OF TRUSTEES BY WAY OF THE COMPLIANCE AND AUDIT COMMITTEE. THIS REVIEW IS DOCUMENTED IN THE MINUTES OF THE MEETING. PERIODICALLY, THE INTERNAL AUDIT DEPARTMENT WILL REVIEW A SAMPLE OF COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND REPORT THE RESULTS TO THE COMPLIANCE AND AUDIT COMMITTEE. THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE INDIVIDUALLY SUMMARIZED IN A DOCUMENT AND SENT ELECTRONICALLY TO THE FINANCE DEPARTMENT FOR ANY NECESSARY DISCLOSURES REQUIRED ON THE 990 TAX RETURN. FORM 990, PART VI, SECTION B, LINE 15A & 15B: COMPENSATION FOR UPPER VALLEY MEDICAL CENTERS (UPPER VALLEY) CEO IS REVIEWED AND APPROVED BY PREMIER HEALTH (PREMIER), OF WHICH UPPER VALLEY IS AN AFFILIATE, ON AN ANNUAL BASIS. THE REVIEW PROCESS PERFORMED BY PREMIER FOLLOWS A MARKET BASED COMPENSATION PHILOSOPHY DESIGNED TO ATTRACT AND RETAIN THE EXECUTIVE TALENT REQUIRED TO MEET THE HIGH-PERFORMANCE STANDARDS OF OUR BOARD AND OUR COMMUNITY. PREMIER ANNUALLY REVIEWS EXECUTIVE COMPENSATION SURVEY DATA FOR A REGIONAL PEER GROUP OF SYSTEMS AND HOSPITALS THAT ARE SIMILAR IN SIZE AND COMPLEXITY TO PREMIER AND ITS AFFILIATES. THE DATA FOR THE SURVEY IS PROVIDED BY A THIRD-PARTY CONSULTANT GROUP THAT IS INDEPENDENT OF PREMIER. THIS REPORT INCLUDES COMPARABILITY FOR KEY EXECUTIVES, VICE PRESIDENTS, AND DIRECTOR LEVEL POSITIONS. THE INDEPENDENT COMPARABILITY DATA IS REVIEWED BY THE EXECUTIVE COMPENSATION COMMITTEE ON AN ANNUAL BASIS. THIS COMMITTEE IS COMPRISED OF THREE MEMBERS, ALL OF WHOM ARE INDEPENDENT. THIS COMMITTEE REVIEWS IN DETAIL THE COMPENSATION FOR THE PREMIER CEO, COO, CFO, CHIEF STRATEGY OFFICER, CHIEF INTEGRATION OFFICER AND THE HOSPITAL CEOS. OTHER POSITIONS ARE REVIEWED AT A HIGH LEVEL FOR REASONABLENESS. ALL THE MEETING MINUTES ARE DOCUMENTED AND KEPT ON FILE ALONG WITH ANY COMPARABILITY DATA AND THE CONSULTANT REPORT. AFTER THE COMPENSATION COMMITTEE REVIEWS AND APPROVES THE COMPENSATION ACTIONS, THE PROCESS IS AUDITED BY THE INTERNAL AUDIT DEPARTMENT. THE EXECUTIVE COMPENSATION COMMITTEE PRESENTS THE COMPENSATION ACTIONS TO THE PREMIER BOARD ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19A: THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC WHEN REQUIRED BY LAW OR FOR ACCREDITATION PURPOSES. THE CONFLICT OF INTEREST POLICY IS AVAILABLE ON WWW.PREMIERHEALTH.COM. FORM 990, PART VII, LINE 1A, ITEM 12: TIMOTHY SNIDER SERVES AS AN OFFICER FOR BOTH UPPER VALLEY MEDICAL CENTER AND ANOTHER UNRELATED HOSPITAL. HOWEVER, 100% OF HIS COMPENSATION IS PAID BY UPPER VALLEY MEDICAL CENTER. MR. SNIDER SPENDS APPROXIMATELY ONE-HALF OF HIS WORKING HOURS AT EACH HOSPITAL. THE COMPENSATION REPORTED ON PART VIII INCLUDES ALL OF HIS REPORTABLE COMPENSATION, EVEN THOUGH UPPER VALLEY MEDICAL CENTER IS REIMBURSED BY THE UNRELATED HOSPITAL FOR HIS TIME SPENT AT THAT INSTITUTION. Form 990, Part XI, Line 9: EQUITY TRANSFERS (11,879,845) FOUNDATION ADJUSTMENT (172,769) PHG EQUITY TRANSFER (118,639) CHANGE IN UVMC AUXILIARY CASH POSITION (20,954) OTHER 9,882 GAIN ON SALE-DIALYSIS CENTER 126,000 TRANSFER FROM AFFILIATE 143,480 PENSION FASB 158 ADJUSTMENT 645,619 ----------- TOTAL (11,267,226) UVMC 110 N Main St 500 DAYTON OH 45402 341850683 PARENT OH 501(c)(3) 12C III FI NA false UVMC FOUNDATION 110 N Main St 500 DAYTON OH 45402 311581859 FOUNDATION OH 501(c)(3) 7 NA false PREMIER HEALTH 110 N MAIN ST 500 DAYTON OH 45402 311446699 JOA PARENT OH 501(c)(3) 12A I NA false UPPER VALLEY PROFESSIONAL CORP (UVPC) 110 N MAIN ST 500 DAYTON OH 45402 311400963 HEALTH CARE OH 501(c)(3) 10 UVMC true UVPC SPECIALISTS INC 110 N MAIN ST 500 DAYTON OH 45402 203687536 HEALTH CARE OH 501(c)(3) 10 UVPC true UVMC NURSING CARE INC 110 N MAIN ST 500 DAYTON OH 45402 311224064 NURSING HOME OH 501(c)(3) 10 UVMC true UVMC MANAGEMENT CORPORATION 110 N MAIN ST 500 DAYTON OH 45402 311360489 MGT COMPANY OH UVMC C CORP 0 0 0.00000 true AFTER HOURS FAMILY CARE 110 N MAIN ST 500 Dayton OH 45402 311269483 Health Care OH UVPC C Corp 0 0 0.00000 true false true true false false false false false false true false true false false true true true true true UVMC FOUNDATION C 316249 FMV UVMC FOUNDATION Q 414480 FMV UVMC FOUNDATION R 332368 FMV UPPER VALLEY PROFESSIONAL CORP J 65525 FMV UPPER VALLEY PROFESSIONAL CORP O 118942 FMV UPPER VALLEY PROFESSIONAL CORP Q 5880607 FMV UPPER VALLEY PROFESSIONAL CORP S 380635 FMV AFTER HOURS FAMILY CARE P 244756 FMV UVPC SPECIALISTS INC O 1106580 FMV UVPC SPECIALISTS INC P 585059 FMV UVPC SPECIALISTS INC Q 2689196 FMV UVMC MANAGEMENT CORP B 148741 FMV UVMC MANAGEMENT CORP O 849073 FMV UVMC MANAGEMENT CORP Q 784400 FMV UVMC NURSING CARE INC Q 55532 FMV PREMIER HEALTH B 108473 FMV UVPC SPECIALISTS INC B 5385519 FMV UPPER VALLEY PROFESSIONAL CORP B 6616394 FMV AFTER HOURS FAMILY CARE B 574587 FMV UVMC C 696654 CASH