2016-11-15T13:50:31-06:00 2015-12-31 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 4200 INDIANAPOLIS IN 462045108 990 2015-01-01 351974765 GOSHEN HEALTH SYSTEM INC GOSH 5745352665 200 HIGH PARK AVENUE GOSHEN IN 46526 AMY FLORIA CFO 5745352665 2016-11-15 1 SHAWNA M JIMENEZ P01222873 3174648600 2015 2017-02-10 21:41:12Z IU HEALTH GOSHEN RANDAL CHRISTOPHEL 200 HIGH PARK AVENUE GOSHEN IN 46526 39782224 0 X WWW.IUHEALTH.ORG/GOSHEN X 1997 IN TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES. 19 15 441 15 -29381 -113538 13216717 13765920 24581614 25382830 -48471 -55544 1125367 689018 38875227 39782224 0 0 0 0 28793218 29916090 0 0 0 10278605 10069986 39071823 39986076 -196596 -203852 3733452 4258932 5574504 6100167 -1841052 -1841235 X THE MISSION OF IU HEALTH GOSHEN IS TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICES, THROUGH EXCEPTIONAL PEOPLE DOING EXCEPTIONAL WORK. 0 0 36445497 25820817 IU HEALTH GOSHEN IS A NON-DENOMINATIONAL NOT-FOR-PROFIT ORGANIZATION PROVIDING HEALTH CARE SERVICES FOR THE GENERAL PUBLIC. SEE SCHEDULE O FOR ADDITIONAL DETAIL.THE MISSION OF IU HEALTH GOSHEN IS TO IMPROVE THE HEALTH OF OUR COMMUNITIES BY PROVIDING INNOVATIVE, OUTSTANDING CARE AND SERVICE, THROUGH EXCEPTIONAL PEOPLE DOING EXCEPTIONAL WORK. THE SYSTEM'S VALUES INCLUDE: COMPASSION - AND COMMITMENT TO SERVICE WITH EMPATHY. ACCOUNTABILITY - WITH INTEGRITY AND ACTION. RESPECT - THROUGH TREATING OTHERS AS YOU WISH TO BE TREATED. EXCELLENCE - IN ALL WE DO.BUILDING UPON OUR MISSION AND VALUES, IU HEALTH GOSHEN WILL DELIVER EXCEPTIONAL HEALTHCARE TO THE COMMUNITIES WE SERVE USING AN INTEGRATED MODEL OF CARE AND ACHIEVING EXCELLENCE THROUGH A COMMITMENT TO QUALITY, LEADERSHIP, AND INNOVATION. BY 2020, WE WILL ACHIEVE THIS VISION BY FOCUSING ON THE FOLLOWING STRATEGIC PRIORITIES: - LEAD THE REGION IN CLINICAL INTEGRATION AND MANAGEMENT OF POPULATION HEALTH. - DELIVER HIGH VALUE TO OUR PATIENTS, PROVIDERS, PAYERS AND COLLEAGUES.- GOSHEN'S ONCOLOGY AND HEART & VASCULAR SERVICE LINES BECOME THE DESTINATION OF CHOICE IN OUR BROADER REGION.- CULTIVATE A CULTURE FOR COLLEAGUES WHERE PERSONAL AND PROFESSIONAL MISSIONS ARE ALIGNED.- INSPIRE A SPIRIT OF PARTNERSHIP AND GENEROSITY BY ENGAGING OUR COMMUNITY WITH OPPORTUNITIES THAT MEET REGIONAL HEALTH NEEDS.KEY COMPONENTS OF IU HEALTH GOSHEN INCLUDE THE OPERATIONS OF A MULTI-SPECIALTY PHYSICIAN NETWORK OR IU HEALTH GOSHEN PHYSICIANS. THE PHYSICIAN NETWORK EMPLOYS HEALTHCARE PROVIDERS DEDICATED TO MEETING THE HEALTH CARE NEEDS OF AREA RESIDENTS, YOUNG AND OLD. THE NETWORK OF BOTH PRIMARY CARE AND SPECIALTY PROVIDERS ENHANCES THE SYSTEM'S ABILITY TO CARE FOR THE COMMUNITY. IU HEALTH GOSHEN PHYSICIANS REPRESENT THE FOLLOWING CARE AREAS: FAMILY PRACTICE, NEUROLOGY, CARDIOLOGY, ADULT INTERNAL MEDICINE, PEDIATRICS, ORTHOPEDICS, OBSTETRICS AND GYNECOLOGY, BARIATRICS, GASTROENTEROLOGY, INFECTION CONTROL, AND ONCOLOGY.IU HEALTH GOSHEN EXCELS AT MEETING THE HEALTH CARE NEEDS OF ITS PATIENTS AS MEASURED BY PRESS GANEY AND NRC PICKER, NATIONALLY RECOGNIZED COMPANIES THAT PARTNER WITH HEALTHCARE FACILITIES TO MEASURE THE LEVEL OF CUSTOMER SATISFACTION AND IMPROVE THEIR QUALITY OF HEALTH CARE DELIVERY. IN 2012, IU HEALTH GOSHEN PHYSICIANS RANKED ABOVE THE 90TH PERCENTILE IN OVERALL PATIENT SATISFACTION. IU HEALTH GOSHEN EARNED THE 2013 APEX WORKPLACE OF DISTINCTION AWARD FROM MOREHEAD ASSOCIATES. THE APEX AWARD RECOGNIZES THE INDUSTRY'S TOP EMPLOYERS, DETERMINED BY OBJECTIVE DATA GATHERED FROM EMPLOYEE SURVEYS. OUR NATIONAL HEALTH CARE PERCENTILE RANKING FOR WORKFORCE COMMITMENT IN 2013 WAS 69TH. IU HEALTH GOSHEN HAS BEEN NAMED ONE OF INDIANA'S BEST PLACES TO WORK BY THE INDIANA CHAMBER OF COMMERCE, AND WAS NAMED TO THE LIST OF "100 BEST PLACES TO WORK IN HEALTHCARE" BY MODERN HEALTHCARE AND BECKER'S HOSPITAL REVIEW. IU HEALTH GOSHEN PHYSICIANS PROVIDES HEALTH CARE SERVICES TO ALL MEMBERS OF THE COMMUNITIES REGARDLESS OF THEIR ABILITY TO PAY. THE NETWORK OFFERS FINANCIAL ASSISTANCE TO THOSE PATIENTS UNABLE TO PAY ALL OR A PORTION OF THEIR BILL AND WHO ARE UNABLE TO QUALIFY FOR ASSISTANCE THROUGH FEDERAL AND STATE GOVERNMENT ASSISTANCE PROGRAMS. PATIENTS ARE ASKED TO PROVIDE FINANCIAL INFORMATION TO ASSESS THEIR FINANCIAL POSITION. IN 2015, THE NETWORK PROVIDED APPROXIMATELY $842,174 OF CHARITY CARE TO PATIENTS. 36445497 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 64 0 1 441 1 1 1 0 0 0 0 0 0 0 0 0 X 19 15 1 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 1 1 IN X DIRECTOR OF FINANCE 5745352665 200 HIGH PARK AVE GOSHEN IN 46526 RANDAL CHRISTOPHEL PRESIDENT AND CEO 1.00 41.00 X X 0 733020 123565 EDWARD BOYTS MD TREASURER 40.00 0.00 X X 269069 0 37725 RICHARD B HOSTETTER MD SECRETARY 40.00 0.00 X X 511525 0 44998 DELMAR G GOOD PHD DIRECTOR 1.00 0.00 X 0 0 0 GERALD A TROLZ DIRECTOR 1.00 0.00 X 0 0 0 GEORGE E MARLOW DIRECTOR 1.00 1.00 X 0 0 0 ALAN R TEHAN DIRECTOR 1.00 0.00 X 0 0 0 STEPHEN FIDLER DIRECTOR 1.00 0.00 X 0 0 0 PARIS BALL-MILLER DIRECTOR 1.00 1.00 X 0 0 0 DENISE DAVIS ESQ DIRECTOR 1.00 0.00 X 0 0 0 WES HERSCHBERGER CHAIR 1.00 0.00 X X 0 0 0 JAMES ALVAREZ DIRECTOR 1.00 0.00 X 0 0 0 SHERYL EAKINS DIRECTOR 1.00 0.00 X 0 0 0 JOHN LEAVITT DIRECTOR 1.00 1.00 X 0 0 0 DERALD BONTRAGER VICE CHAIR 1.00 1.00 X X 0 0 0 MARK KING PHD DIRECTOR 1.00 0.00 X 0 0 0 BETSY WENZ DIRECTOR - IU HEALTH 1.00 0.00 X 0 0 0 DANIEL DIENER MD DIRECTOR 1.00 0.00 X 0 0 0 DANIEL NAFZIGER MD DIRECTOR 40.00 1.00 X 152724 0 13461 MARK DICKEN DIRECTOR 1.00 0.00 X 0 0 0 AMY FLORIA CFO 1.00 40.00 X 0 409953 49311 RANDALL CAMMENGA MD COO 1.00 40.00 X 0 620599 17174 LARRY ALLEN MD CMO 1.00 40.00 X 0 377752 51381 ALAN WELDY VP OF HR AND CORPORATE COMPLIANCE 1.00 40.00 X 0 456271 54704 MARGARET S FRANGER VP OF CANCER SERVICES 1.00 40.00 X 0 292140 47260 PAM KARSEN VP OF NURSING 1.00 40.00 X 0 328138 23538 STEVE GARBODEN VP PLANNING AND MANAGED CARE 1.00 40.00 X 0 256680 30005 MARK PODGORSKI VP OF HOSPITAL OPERATIONS 1.00 40.00 X 0 276565 43373 VLADIMIR RADIVOJEVIC VP OF SURGICAL SERVICES 1.00 40.00 X 0 211480 37128 RICK TARSKE VP OF GOSHEN PHYSICIANS 1.00 40.00 X 0 186008 30345 MARK SMUCKER MD PHYSICIAN 40.00 0.00 X 741286 0 38907 PETER KIM MD PHYSICIAN 40.00 0.00 X 683934 0 27005 JAMES WHEELER MD PHYSICIAN 40.00 0.00 X 563984 0 33417 ABDUL BASIT MD PHYSICIAN 40.00 0.00 X 615224 0 34562 CHRISTOPHER OWENS MD PHYSICIAN 40.00 0.00 X 656414 0 40215 4194160 4148606 778074 63 0 1 0 GNKL PROPERTIES 1824 DORCHESTER COURT GOSHEN IN 46526 RENT 371420 QUEST DIAGNOSTICS PO BOX 12989 CHICAGO IL 60693 MEDICAL SERVICES 320047 LARRY ALLEN MD 13275 N EAST SHORE DRIVE SYRACUSE IN 46567 RENT 185442 AJJM LLC 2523 MESSICK DRIVE GOSHEN IN 46526 RENT 108720 4 13765920 13765920 HEALTHCARE SERVICES 621110 25338742 25338742 EKG REVENUES 621110 44088 44088 25382830 -55544 -29381 -26163 110544 0 110544 110544 73508 37036 BILLINGS 561000 213995 213995 TEAM BARIATRICS 621110 29266 29266 SPECIALIST X-RAY 621500 16295 16295 318918 318918 578474 39782224 25820817 -29381 224868 1029502 1029502 22729066 20728985 2000081 1488769 1359647 129122 3377855 2819473 558382 1290898 1136888 154010 55800 55800 2556680 2556680 1892638 1818377 74261 300308 226270 74038 647721 478139 169582 536321 536119 202 CLINICAL SUPPLIES 2574181 2572729 1452 PURCHASED SERVICES 1506337 1126888 379449 39986076 36445497 3540579 0 1683589 2052273 552707 572307 8142087 6507735 1497156 1634352 3733452 4258932 5574504 6100167 5574504 6100167 X -1841052 -1841235 -1841052 -1841235 3733452 4258932 X -203852 203669 X 0 1 X 1 0 X X 1 GOSHEN HOSPITAL ASSOCIATION INC 356001540 3 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X 1 1 SCHEDULE A, PART IV, SECTION D, LINE 3: GOSHEN HEALTH SYSTEM, INC. IS ORGANIZED TO OPERATE FOR THE BENEFIT OF, TO PERFORM FUNCTIONS OF, AND TO CARRY OUT THE PURPOSES OF GOSHEN HOSPITAL ASSOCIATION, INC. (THE "HOSPITAL"). GOSHEN HEALTH SYSTEM, INC. AS THE PARENT AND SUPPORTING ORGANIZATION OF AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, MANAGES AND DIRECTS THE HOSPITAL'S DELIVERY OF HEALTH CARE SERVICES, PROVIDES LONG-RANGE AND STRATEGIC PLANNING, AND UPHOLDS FINANCIAL CONTROLS. ANNUAL OPERATING BUDGETS ARE SUBMITTED BY THE HOSPITAL TO THE GOSHEN HEALTH SYSTEM BOARD OF DIRECTORS FOR APPROVAL DETAILING CAPITAL EXPENDITURES AND KEY INVESTMENTS IN HOSPITAL OPERATIONS. GOSHEN HEALTH SYSTEM, INC.'S BOARD OF DIRECTORS IS COMPOSED OF AT LEAST TWO BOARD MEMBERS FROM THE HOSPITAL BOARD OF DIRECTORS. IN ADDITION, OVERLAP EXISTS OF OFFICES HELD BY KEY COLLEAGUES OF GOSHEN HEALTH SYSTEM, INC. AND THE HOSPITAL. THIS SHARED LEADERSHIP ENSURES THERE IS A CLOSE AND CONTINUOUS WORKING RELATIONSHIP WITH A SET OF COMMON STRATEGIC GOALS AND OBJECTIVES BETWEEN THE ORGANIZATIONS. SCHEDULE A, PART IV, SECTION E, LINE 3A: GOSHEN HEALTH SYSTEM, INC., HAS THE POWER TO ELECT A MAJORITY OF THE OFFICERS AND DIRECTORS OF GOSHEN HOSPITAL ASSOCIATION, INC. SCHEDULE A, PART IV, SECTION E, LINE 3B: GOSHEN HEALTH SYSTEM, INC. IS ORGANIZED TO OPERATE EXCLUSIVELY FOR THE BENEFIT OF, TO PERFORM THE FUNCTIONS OF, AND TO CARRY OUT THE PURPOSES OF GOSHEN HOSPITAL ASSOCATION, INC. ("THE HOSPITAL"). GOSHEN HEALTH SYSTEM, INC. AS THE PARENT AND SUPPORTING ORGANIZATION OF AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, MANAGES AND DIRECTS THE HOSPITAL'S DELIVERY OF HEALTH CARE SERVICES, INCLUDING PROVIDING LONG-RANGE AND STRATEGIC PLANNING, FINANCIAL CONTROL, AND PROGRAMS AND POLICIES THAT CAUSE THE HOSPITAL TO FUNCTION AS AN INTEGRATED HEALTH CARE DELIVERY SYSTEM. GOSHEN HEALTH SYSTEM, INC. IS RESPONSIBLE FOR THE APPROVAL OF THE HOSPITAL BUDGET, STRATEGIC PLANNING, RESOURCE ALLOCATION, AND COMMUNITY BENEFIT ACTIVITIES. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7945351 6507735 1437616 196736 196736 1634352 1 1 0 0 0 0 0 0 0 RANDAL CHRISTOPHEL PRESIDENT AND CEO 0 457011 0 239300 0 36709 0 116140 0 7425 0 856585 0 0 EDWARD BOYTS MD TREASURER 152581 0 116488 0 0 0 28840 0 8885 0 306794 0 0 0 RICHARD B HOSTETTER MD SECRETARY 432443 0 60982 0 18100 0 38701 0 6297 0 556523 0 0 0 DANIEL NAFZIGER MD DIRECTOR 56383 0 91234 0 5107 0 13163 0 298 0 166185 0 0 0 AMY FLORIA CFO 0 308793 0 88003 0 13157 0 43582 0 5729 0 459264 0 0 RANDALL CAMMENGA MD COO 0 256742 0 213802 0 150055 0 10600 0 6574 0 637773 0 0 LARRY ALLEN MD CMO 0 294131 0 75353 0 8268 0 46885 0 4496 0 429133 0 0 ALAN WELDY VP OF HR AND CORPORATE COMPLIANCE 0 341903 0 100946 0 13422 0 49709 0 4995 0 510975 0 0 MARGARET S FRANGER VP OF CANCER SERVICES 0 227971 0 62974 0 1195 0 37269 0 9991 0 339400 0 0 PAM KARSEN VP OF NURSING 0 249555 0 69747 0 8836 0 21439 0 2099 0 351676 0 0 STEVE GARBODEN VP PLANNING AND MANAGED CARE 0 168036 0 51716 0 36928 0 23828 0 6177 0 286685 0 0 MARK PODGORSKI VP OF HOSPITAL OPERATIONS 0 215549 0 56890 0 4126 0 40323 0 3050 0 319938 0 0 VLADIMIR RADIVOJEVIC VP OF SURGICAL SERVICES 0 163302 0 42990 0 5188 0 30753 0 6375 0 248608 0 0 RICK TARSKE VP OF GOSHEN PHYSICIANS 0 167575 0 11773 0 6660 0 28246 0 2099 0 216353 0 0 MARK SMUCKER MD PHYSICIAN 689936 0 51350 0 0 0 28840 0 10067 0 780193 0 0 0 PETER KIM MD PHYSICIAN 623234 0 17700 0 43000 0 18240 0 8765 0 710939 0 0 0 JAMES WHEELER MD PHYSICIAN 484570 0 61314 0 18100 0 28840 0 4577 0 597401 0 0 0 ABDUL BASIT MD PHYSICIAN 594274 0 20850 0 100 0 28840 0 5722 0 649786 0 0 0 CHRISTOPHER OWENS MD PHYSICIAN 563621 0 56838 0 35955 0 28840 0 11375 0 696629 0 0 0 PART I, LINE 3 GOSHEN HOSPITAL ASSOCIATION, INC., A RELATED TAX-EXEMPT ORGANIZATION OF GOSHEN HEALTH SYSTEM, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4A: AS PER OUR EMPLOYMENT AGREEMENT, UPON QUALIFYING TERMINATION DEFINED AS AN INVOLUNTARY SEPARATION FROM SERVICE OTHER THAN FOR CAUSE, THE EMPLOYEE IS ENTITLED TO SEVERANCE PAY BASED UPON YEARS OF SERVICE. THE TERMS AND CONDITIONS TO RECEIVE SEVERANCE PAYMENTS REQUIRE THE EMPLOYEE TO SIGN A RELEASE OF CLAIMS FORM THAT COVERS ALL SITUATIONS SURROUNDING THE EMPLOYEE'S EMPLOYMENT AND SEPARATION FROM IU HEALTH GOSHEN. RANDALL CAMMENGA $108,570 PART I, LINE 4B: ELIGIBLE EXECUTIVES PARTICIPATE IN VARIOUS NON-QUALIFIED DEFERRED COMPENSATION PLANS ORGANIZED UNDER CODE SECTION 457(F). THE EXACT PURPOSE OF EACH PLAN VARIES, BUT THEY INCLUDE: COMPENSATION LIMITATION MAKE-UP PLANS, VOLUNTARY DEFERRAL PLANS, DEFERRAL OF A PORTION OF INCENTIVE BONUS TYPE PLANS, ETC. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. NO NON-QUALIFIED PLAN PAYMENTS WERE MADE DURING THE YEAR TO ANY LISTED PERSONS IN PART VII. FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE EMPLOYEES OF IU HEALTH GOSHEN OR ITS RELATED ORGANIZATIONS, AND SERVE ON OTHER RELATED TAXABLE BOARDS: RANDY CHRISTOPHEL AMY FLORIA ALAN WELDY FORM 990, PART VI, SECTION A, LINE 6 IU HEALTH IS THE SOLE MEMBER OF IU HEALTH GOSHEN. FORM 990, PART VI, SECTION A, LINE 7A IU HEALTH, AS THE SOLE MEMBER OF IU HEALTH GOSHEN, HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF IU HEALTH GOSHEN. FORM 990, PART VI, SECTION A, LINE 7B ITEMS THAT REQUIRE APPROVAL OF IU HEALTH GOSHEN INCLUDE ANY AMENDMENT OF THE OPERATING AGREEMENT, DISSOLUTION OF THE ORGANIZATION OR THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND THE AUDIT COMMITTEE IN OCTOBER FOR REVIEW AND QUESTIONS BEFORE THE RETURN IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER COMPLETES AN ANNUAL DISCLOSURE OF KNOWN OR POTENTIAL CONFLICTS. THE DISCLOSURES ARE REVIEWED BY THE VP-LEGAL. ADDITIONALLY, WHEN AGENDA ITEMS ARE DISCUSSED AT MEETINGS, IT IS ASKED IF THERE ARE ANY KNOWN OR POTENTIAL CONFLICTS OF INTEREST, AND CONFLICTED PARTIES MUST RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15 IU HEALTH GOSHEN'S TOP MANAGEMENT OFFICIALS AND OTHER OFFICERS ARE COMPENSATED BY IU HEALTH GOSHEN HOSPITAL, A RELATED TAX-EXEMPT ORGANIZATION. AN INDEPENDENT COMMITTEE APPROVES THE COMPENSATION WHICH IS DETERMINED TO BE REASONABLE BASED UPON INDEPENDENT COMPARABILITY DATA. APPROVAL OF AMOUNTS ARE DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION C, LINE 19 IU HEALTH GOSHEN WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. FORM 990, PART XI, LINE 9: EQUITY TRANSFER 203,669. 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