2016-11-12T12:45:00-06:00 2015-12-31 ERNST & YOUNG US LLP 800 YARD STREET SUITE 200 GRANDVIEW HEIGHTS OH 43212 990 2015-01-01 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 2016-11-02 true DIANE L BEAN P00104972 6142245678 2015 2017-02-10 21:41:12Z REBECCA A RICE 3130 N COUNTY RD 25 A TROY OH 45373 170552216 false X www.premierhealth.com X 1926 OH WE WILL BUILD HEALTHIER COMMUNITIES WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTH CARE SERVICES. 7 2 1583 147 245211 -18791 85580 183580 132638850 141924880 2478084 2311629 1195415 2369812 136397929 146789901 749788 771390 0 0 71524918 74933197 0 0 0 57224086 61062476 129498792 136767063 6899137 10022838 182859293 182294753 102184144 97392118 80675149 84902635 X WE WILL BUILD HEALTHIER COMMUNITIES WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-COMPETITIVE HEALTH CARE SERVICES. false false 125680398 771390 141924880 See Schedules H and O. 125680398 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 101 0 true 1583 true true true false false false false false false false false false X 7 2 false true false false true true true true true false false true true true true true true true true false X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 Dayton OH 45402 X ROWAN R NICKOL MD BOARD CHAIR 0.5 2.0 X X 0 0 0 REBECCA A RICE PRESIDENT & CEO 38.0 2.0 X X 462890 0 43415 DANNY S BAILEY MD TRUSTEE & CMO (EX OFFICIO) 40.0 0.0 X 361891 0 30850 CHRISTOPHER A GROVE MD MED STAFF 1ST VP (EX OFFICIO) 0.5 39.5 X 0 328759 34530 RONAL MANIS JR MD TRUSTEE 0.5 0.5 X 41083 0 0 JAMES R PANCOAST TRUSTEE & PREMIER CEO 7.5 8.5 X 0 0 0 SCOTT SWABB DO TRUSTEE 0.5 0.5 X 8333 645 0 TIMOTHY D SNIDER - SEE SCH O BOARD TREASURER & CFO 18.0 2.0 X 239326 0 34962 JENNA M DOWNEY ESQ RECORDING SECRETARY 0.5 2.0 X 0 0 0 JAMES A HURAK VP HOSPITAL OPERATIONS 40.0 0.0 X 205743 0 45906 DALE E CREECH SYSTEM VP - CLO 8.0 32.0 X 0 624758 60638 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 8.0 32.0 X 0 276277 37323 GARY G GINTER SYSTEM VP - CIO 8.0 32.0 X 0 493377 53719 BARBARA A JOHNSON SYSTEM VP - HR OPERATIONS 8.0 32.0 X 0 491255 17489 TAMMY S LUNDSTROM MD SYSTEM VP - CMO 8.0 32.0 X 0 656668 10493 THOMAS R PARKER SYS VP -CHF EXPERIENCE OFFICER 8.0 32.0 X 481498 0 38310 DIANE L PLEIMAN VP - OPERATIONS (FROM APR) 40.0 0.0 X 273529 0 28528 CRAIG SELF SYSTEM VP - CSO 8.0 32.0 X 0 380470 37955 MARK W SHAW SYSTEM VP - MANAGED CARE 8.0 32.0 X 0 393525 61180 SCOTT A SHELTON SYSTEM VP - CPO 8.0 32.0 X 0 313527 29282 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 8.0 32.0 X 0 386458 17725 THOMAS D BIGLEY DIRECTOR PHARMACY 40.0 0.0 X 194304 0 20573 TERRY R FRY VP & CNO 40.0 0.0 X 221977 0 23522 RYAN E MCELDOWNEY STAFF PHARMACIST 40.0 0.0 X 146959 0 31099 DELORES A MULLEN DIRECTOR - EMERGENCY SERVICES 40.0 0.0 X 147341 0 64177 KATHLEEN J SCARBROUGH PRESIDENT, UVMC FOUNDATION 30.0 10.0 X 115305 39000 40936 MICHAEL J MAIBERGER FORMER TRUSTEE & OFFICER 0.0 39.0 X 0 664955 82531 RENEE P GEORGE FORMER KEY EMPLOYEE 0.0 40.0 X 0 300232 21000 J NICK LAIR FORMER KEY EMPLOYEE 0.0 40.0 X 0 294314 46572 2900179 5644220 912715 39 true true false VALLEY ANESTHESIA INC PO BOX 63437 CINCINNATI OH 45263 MEDICAL SERVICES 3554333 CATHOLIC HEALTH INITIATIVES 3900 OLYMPIC BLVD 400 ERLANGER KY 41018 CLINICAL ENGINEERING 1196606 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 MEDICAL SERVICES 959684 ESCO COMMUNICATIONS INC PO BOX 1243 INDIANAPOLIS IN 46206 COMPUTER SERVICES 875353 COMPUNET CLINICAL LABORATORIES PO BOX 714132 CINCINNATI OH 45271 LABORATORY SERVICES 804030 22 183580 183580 NET PATIENT CARE REVENUE 621110 72470912 72238740 232172 MEDICARE/MEDICAID 621110 66628727 66628727 HOSPITAL FRANCHISE TAX RECOVERIES 900099 2733959 2733959 MEDICAL RECORDS 900099 37754 37754 HEALTH EDUCATION 900099 1456 1456 52072 52072 141924880 815812 815812 19823 19823 0 1080213 1144201 -63988 0 -63988 -63988 22354484 363724 21173831 68383 1180653 295341 1475994 1475994 0 0 1280611 1375900 -95289 -95289 GAIN ON INTEREST SWAP ADJ 900099 803022 803022 CAFETERIA SALES 721210 731054 731054 ALL OTHER REVENUE 900099 995013 13039 981974 2529089 146789901 141692708 245211 4668402 771390 771390 0 0 0 2296264 2076740 219524 0 0 55480781 50176818 5303963 4042942 3656437 386505 9118804 8247046 871758 3994406 3612541 381865 19000 17184 1816 156771 141784 14987 84177 84177 11853 10720 1133 0 161976 161976 6440913 5825162 615751 1003679 1003679 1051825 951271 100554 4081931 3691698 390233 0 2343816 2119747 224069 178650 161571 17079 0 971 878 93 2190341 2190341 0 10012760 9055540 957220 223149 201816 21333 OPERATING SUPPLIES 16989451 16989451 JOINT OPERATING AGREEMENT 6532000 5907541 624459 PURCHASED SERVICES 5353009 4841261 511748 HOSPITAL FRANCHISE TAX 2171580 2171580 2054624 1858202 196422 136767063 125680398 11086665 0 3110 2860 16549780 5545712 0 0 18916002 22070179 0 0 0 0 139333 71597 747916 743192 2454126 2463932 189201580 105639480 85400226 83562100 38612803 48408530 11785627 13072143 0 0 0 0 8250370 6354508 182859293 182294753 15441507 11776297 193850 357735 72018 149856 41671466 38982492 0 0 0 0 2268545 899595 0 0 42536758 45226143 102184144 97392118 X 80675149 84902635 0 0 0 0 80675149 84902635 182859293 182294753 X 10022838 -2704097 -3091255 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 29153 false false true 2700 31853 false PART II-B, LINE 1F: PAYMENTS FOR LOBBYING ACTIVITIES INCLUDE DUES PAID TO GREATER DAYTON AREA HOSPITAL ASSOCIATION, DAYTON DEVELOPMENT COALITION, AND OHIO HOSPITAL ASSOCIATION. FUNDS WERE ALSO GRANTED TO CITIZENS FOR SINCLAIR IN SUPPORT OF THE SINCLAIR COMMUNITY COLLEGE LEVY CAMPAIGN. PART II-B, LINE 1I: THE HOSPITAL CONTRACTS WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 1314171 1314171 114915901 62480490 52435411 60229 60229 0 66288098 43098761 23189337 6623181 0 6623181 83562100 ALTERNATIVE INVESTMENTS 13072143 F 13072143 0 PENSION OBLIGATION 29229337 JOINT OPERATING AGREEMENT 6532000 MALPRACTICE INSURANCE 3376554 DEFERRED COMPENSATION 2312510 MEDICAL SERVICES 2194399 WORKER'S COMP RESERVE 913688 HOSPITAL FRANCHISE PAYABLE 524016 OTHER 143639 45226143 X Schedule D, 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), 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. SAMARITAN HEALTH PARTNERS (SHP) IS TAX-EXEMPT UNDER SECTION 501(C)(3) AND IS A PUBLIC CHARITY BY REASON OF BEING INCLUDED IN THE GROUP RULING ISSUED TO THE U.S. CATHOLIC CHURCH. AS TAX-EXEMPT ORGANIZATIONS, THEIR INCOME IS EXEMPT FROM FEDERAL INCOME TAX EXCEPT TO THE EXTENT OF ANY UNRELATED BUSINESS ACTIVITIES. PREMIER, MAHS, SHP, AHS, AND UVMC ALSO OWN OR CONTROL CERTAIN SUBSIDIARIES, WHICH ARE FOR PROFIT CORPORATIONS SUBJECT TO FEDERAL INCOME TAXES. TAXES PAYABLE AT DECEMBER 31, 2015 AND 2014, 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 11251000 Central America and the Caribbean Program Services INSURANCE 25000 11276000 11276000 false false false false false false true true true X true X true true false true true 4758000 1697000 3061000 0.02200 25696000 17296000 8400000 0.06040 341000 266000 75000 0.00050 30795000 19259000 11536000 0.08290 425000 425000 0.00310 91000 91000 0.00070 3036000 15000 3021000 0.02170 347000 347000 0.00250 3899000 15000 3884000 0.02800 34694000 19274000 15420000 0.11090 28000 28000 0.00020 2000 2000 0.00000 25000 25000 0.00020 55000 55000 0.00040 true 3161299 0 28617000 31471000 -2854000 X true true 1 1 UPPER VALLEY MEDICAL CENTER 110 N MAIN ST 500 DAYTON OH 45402 WWW.PREMIERHEALTH.COM OHIO REG # 1036 X X X UPPER VALLEY MEDICAL CENTER 1 false false true X X X X X X X X X 13 true true true true X See Part V, Section C X true 14 true See Part V, Section C false false true X 200. 400. X X true true X X X true X www.premierhealth.com X www.premierhealth.com X www.premierhealth.com 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, community health collaboratives featuring community, health, and business stakeholders/advocates organized by both Upper Valley Medical Center, and the greater Dayton Area Hospital Association with its member hospitals. Part V, Section B, Line 6A & 6B: Upper Valley Medical Center partnered with member hospitals of the Greater Dayton Area Hospital Association and Wright State University to prepare their Community Health Needs Assessment. PART V, Section B, Line 7A: THE DIRECT WEBSITE ADDRESS WHERE THE CHNA CAN BE ACCESSED IS: HTTP://WWW.UVMC.COM/WORKAREA/DOWNLOADASSET.ASPX?ID=76905 PART V, Section B, Line 10A: The direct website address where the implementation strategy can be accessed is: http://www.premierhealth.com/our-community/making-a-difference/community-h ealth-improvement-plan/uvmc/ PART V, Section B, Line 11: Premier Health was part of a collaboration in 2013 with the Greater Dayton Area Hospital Association and hospitals throughout Southwestern Ohio to conduct a regional Community Health Needs Assessment. Identified Priorities: --------------------- In the Community Health Assessment, researchers identified priority areas for community health improvement using a variety of criteria. The priorities that are included and excluded in the plan are outlined here. Priorities that are included in the plan are not listed in order of importance. Priorities Included in the Plan: ------------------------------- Through the Community Health Risk Assessment, the identified priorities with an improvement plan Upper Valley Medical Center are: Primary and Chronic Diseases: 1. Hypertension - from 2004 to 2012, the rate of hospital inpatient hypertension discharge diagnoses increased from 96 to 130 per 1,000 adults. 2. Melanoma of the skin - The cancer rate has increased from 35.4 to 88.0 per 100,000 from 2000 to 2011. Priorities Addressed Through Collaboration: ------------------------------------------- All identified priorities are important elements of improving the health of our community. In some instances priorities are already being targeted by collaborative groups of which Upper Valley Medical Center is a part. Additional strategies will not be developed independent of these efforts. Because of the importance of these community-wide efforts, the following identified priorities are not included in the Community Health Improvement Plan. Maternal and Infant Priorities: 1. First trimester prenatal care 2. Teen pregnancy 3. Low birth weight 4. Tobacco use in pregnant women Upper Valley Medical Center is involved in several state-wide initiatives addressing these issues. As part of these collaborations, it will share the goals and objectives developed by those groups for program implementation and measurement. Ohio Perinatal Quality Collaborative. Upper Valley Medical Center is a non-charter member of this organization as a maternity hospital. The mission of the Collaborative is, "Through collaborative use of improvement science methods, reduce preterm births and improve outcomes of pre-term newborns in Ohio as quickly as possible." Projects of the collaborative include: * 39 Weeks Delivery Charter Project - To reduce elective unnecessary scheduled births before 39 weeks gestational age. (Reduce infant mortality and low birth weights.) * 39 Weeks Dissemination and Birth Registry Accuracy Project - This project was to address inaccuracies in birth certificate data within the Quality Improvement framework. * Obstetrics Antenatal Corticosteroids Project- This project focuses on increasing the use of antenatal corticosteroids to reduce mortality and morbidity among preterm infants. (Reduce infant mortality.) * Progesterone Project - This project intends to help raise awareness about the need for screening and intervention for progesterone, provide support to teams to implement screening, identification and treatment, develop the capacity and capability of skilled ultrasound technicians and remove administrative barriers to the administration of progesterone. (Reduce infant mortality and low birth weights.) Ohio Hospital Association (OHA). OHA has developed a plan to reduce infant mortality (which also addresses low infant birth weight and first trimester care) in Ohio which includes: * Safe sleep (infant mortality) * Eliminating elective deliveries before 39 weeks (infant mortality) * Progesterone for high risk mothers (infant mortality) * Eliminating health disparities * Safe spacing (infant mortality and low birth weight) * Access to prenatal care (First trimester care, infant mortality and low birth weight) * Promote breast milk * These program areas also then address increasing first trimester care, improving low birth weight and decreasing infant mortality. Upper Valley Medical Center is concerned about the data showing the use of tobacco among pregnant women. It is further researching this issue to identify potential resources to address this issue. Primary and Chronic Diseases 5. Department alcohol and drug discharge diagnoses The Tri-County Board of Recovery and Mental Health Services Serving Darke, Miami and Shelby Counties coordinates alcohol and substance abuse services in Miami County. According to its 2014-2016 strategic plan, it intends to expand funding for programs that treat addictions, development and implement a community behavioral health prevention plan and establish a new behavioral health "one stop shop" model program in Miami County. Key Health Priorities by Objective: Priority Area 1: Reduce the incidence and complications from adult hypertension. Blood pressure is how hard blood pushes against the walls of our arteries when our heart pumps blood. When someone has high blood pressure, which is also called hypertension, the increased pressure against the arteries causes damage. Hypertension is called the silent killer because usually those who have it do not feel anything. High blood pressure increases risk for heart disease, stroke, heart failure, kidney disease and blindness. In many cases hypertension can be prevented by maintaining a healthy weight, being active, eating healthy, not using tobacco and limiting alcohol. Most people who are diagnosed with high blood pressure can be controlled. Those with high blood pressure should take the same steps that may prevent high blood pressure. If medication is needed, it is imperative to take it every day. From 2004 to 2012, the rate of hospital inpatient hypertension discharge diagnoses increased from 96 to 130 per 1000 adults. Because of the significant health threat posed by hypertension, a community-focused, population health improvement strategy would benefit all parts of the community. Priority Area 1: Reduce the proportion of adults with hypertension. Objective 1.1: Increase the proportion of adults with hypertension whose blood pressure is under control. Evidence-based Strategies: * Coordinate a hypertension education health communications campaign that will include communications tactics; free, community-based screenings and free online education. * Promote lectures about high blood pressure prevention and control in worksites, congregations, senior centers and other community based venues. * Identify an educational brochure targeted to those who already have high blood pressure about the importance of medication adherence and healthy lifestyle. Make collateral available through system websites, Facebook pages, at employer and community events and other outlets to be identified. These will include how to get more information by telephone and/or online. Outcome Indicators Short and Intermediate Term: To have communications at least once a year in existing hospital communications vehicles that highlights hypertension and how it can be prevented/treated successfully. Long Term: Increase the proportion of adults with hypertension whose blood pressure is under control. Objective 1.2: Increase the proportion of adults who have had their blood pressure measured within the preceding two years and can state whether their blood pressure was normal or high. Evidence-based Strategies: * Upper Valley Medical Center will conduct blood pressure screenings on at least 250 individuals per year at worksites, congregations, senior centers and other community-based venues. * Attempt telephone follow-up with 100% of those who have a stage 2 hypertension result, do not opt out of follow-up and have a working telephone. * We 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. 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: Included in subsidized health services are revenues and expenses related to an obstetrics clinic which is subsidized by both the Miami County Health Department and Upper Valley Medical Center. This clinic serves the prenatal, delivery, and postnatal medical needs of women in the hospital's Miami County service area. Also included in subsidized health services are revenues and expenses related to an outpatient behavioral health clinic which serves the mental and behavioral health needs of area residents. The clients in both of these clinics include those who either have no medical insurance or qualify for Medicaid services. The total community benefit expense for these clinics in 2015 was $55,000, with direct offsetting revenues of $15,000. The net community benefit expense was $40,000. Also included in subsidized health services are the expenses the hospital incurs related to the call time and physician subsidies due to the large number of indigent patients coming through the emergency room. The hospital operates a 24-hour emergency room 365 days per year. This emergency room is open to all individuals regardless of their ability to pay. For 2015, the amounts paid for call time and subsidies were $2,981,000. PART II, LINE 2: Upper Valley contributed $15,000 to the Troy Development Council (TDR) in 2015 to support the advancement of economic development interests of the Troy community and the businesses within the community. The TDC offers site location assistance and related services to domestic and international companies planning new or expanded facilities. Other initiatives include retention of existing business, outreach marketing, workforce development and data services. In ongoing efforts to improve the economic condition in Dayton and the Miami Valley, the UPPER VALLEY MEDICAL CENTER supported the Omega Community Development Corporations capital campaign project to build and develop a new community center 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. UPPER VALLEY MEDICAL CENTER contributed $10,000 to this project in 2015. PART II, LINE 9: Upper Valley MEDICAL CENTER (Upper Valley) PARTICIPATES IN THE FOLLOWING COMMUNITY BENEFIT ACTIVITIES: 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 Miami and Montgomery County Areas. ALSO SUGGESTED ARE ORGANIZATIONS THAT FOCUS ON SUPPORTING YOUTH, EDUCATION, UNDERSERVED GROUPS, AND SAFE NEIGHBORHOODS. THE AMOUNT OF SUPPORT PROVIDED IN 2015 WAS $24,000. 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 $17,246,000 AND INCURRED COST OF $23,537,000, FOR AN ADDITIONAL NET SHORTFALL OF $6,291,000 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) $28,617,000 MEDICARE REVENUE NOT REPORTED IN PART III, SECTION B $17,246,000 TOTAL MEDICARE ASSOCIATED REVENUE $45,863,000 ALLOWABLE MEDICARE COST PER MEDICARE COST Report (PART III, SECTION B) $31,471,000 MEDICARE COST NOT REPORTED IN PART III, SECTION B $23,537,000 TOTAL MEDICARE ASSOCIATED COST $55,008,000 MEDICARE SHORTFALL PER PART III, SECTION B $2,854,000 ADDITIONAL SHORTFALL NOT INCLUDED IN PART III, SECTION B $6,291,000 TOTAL MEDICARE SHORTFALL $9,145,000 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 43% 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. DOCUMENTED THAT THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. D. DOCUMENT THAT THE PATIENT HAS BEEN OFFERED 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 programs as part of a comprehensive strategy to improve the health status and quality of life for identified members of the community who are economically disadvantaged, disenfranchised and/or who have disproportionate unmet health needs. The organization strives to work with Premier Health, the Good Samaritan Hospital Board of Directors, executive management, managers, staff members, community groups, and individuals to provide a collaborative approach to the governance and management of community benefit a true SAMARITAN BEHAVIORAL HEALTH 601 S EDWIN C MOSES BLVD DAYTON OH 45408 020633634 501(C)(3) 114728 SUPPORT HEALTH PARTNERS FREE CLINIC 1300 N COUNTY RD 25A TROY OH 45373 311596731 501(C)(3) 91600 SUPPORT SINCLAIR COMMUNITY COLLEGE FOUNDATION 444 W 3RD STREET DAYTON OH 45402 310723444 501(C)(3) 80900 CAPITAL RENOVATION & EXPANSION MIAMI COUNTY RECOVERY COUNCIL 1059 N MARKET ST TROY OH 45373 310917327 501(C)(3) 68125 SUPPORT MIAMI COUNTY DENTAL CLINIC 1364 WEST MAIN ST TROY OH 45373 204901192 501(C)(3) 60250 SUPPORT UNIVERSITY OF DAYTON 300 COLLEGE PARK DAYTON OH 45469 310536715 501(C)(3) 50000 CYBERSECURITY & DATA INTELLIGENCE VICTORIA THEATRE ASSOCIATION 138 N MAIN ST DAYTON OH 45402 310897638 501(C)(3) 45350 SUPPORT AMERICAN HEART ASSOCIATION 5211 MADISON RD CINCINNATI OH 45227 135613797 501(C)(3) 33900 SUPPORT AIDS RESOURCE CENTER 15 W FOURTH ST 200 DAYTON OH 45402 311126780 501(C)(3) 28760 VARIOUS MIAMI VALLEY HOSPITAL 110 N MAIN ST 500 DAYTON OH 45402 310537504 501(C)(3) 27948 MAHOGANY CHILD & BRIDGE PROGRAM HOSPICE OF MIAMI COUNTY 550 SUMMIT AVE 101 TROY OH 45373 311031277 501(C)(3) 25900 SUPPORT REACH OUT MONTGOMERY COUNTY 25 E FORAKER ST DAYTON OH 45409 311434282 501(C)(3) 24742 RX ASSISTANCE FOR INDIGENT PATIENTS CITIZENS FOR SINCLAIR 120 W SECOND ST 614 DAYTON OH 45402 611529465 NONE 20000 SUPPORT TROY COMMUNITY DEVELOPMENT 405 SW PUBLIC SQUARE 330 TROY OH 45373 311736034 501(C)(3) 15000 SUPPORT MIAMI VALLEY HOSPITAL FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311040231 501(C)(3) 10320 SUPPORT OMEGA COMMUNITY DEVELOPMENT 1800 HARVARD BLVD DAYTON OH 45406 311561713 501(C)(3) 10250 SUPPORT EDISON FOUNDATION 1973 EDISON DR PIQUA OH 45356 311379781 501(C)(3) 10150 SUPPORT GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON 110 N MAIN ST 500 DAYTON OH 45402 237296923 501(C)(3) 6275 SUPPORT ATRIUM MEDICAL CENTER FOUNDATION 110 N MAIN ST 500 DAYTON OH 45402 311079213 501(C)(3) 6010 SUPPORT 18 1 SCHEDULE I, 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 300596 0 134088 0 28206 0 29447 0 13968 0 506305 0 0 0 TIMOTHY D SNIDER - SEE SCH O BOARD TREASURER & CFO 205275 0 32892 0 1159 0 10730 0 24232 0 274288 0 0 0 DANNY S BAILEY MD TRUSTEE & CMO (EX OFFICIO) 308783 0 48115 0 4993 0 7456 0 23394 0 392741 0 0 0 CHRISTOPHER A GROVE MD MED STAFF 1ST VP (EX OFFICIO) 0 310185 0 0 0 18574 0 7069 0 27461 0 363289 0 0 JAMES A HURAK VP HOSPITAL OPERATIONS 156940 0 27961 0 20842 0 20163 0 25743 0 251649 0 0 0 DALE E CREECH SYSTEM VP - CLO 0 395325 0 127297 0 102136 0 34542 0 26096 0 685396 0 0 THOMAS R CURTIN SYSTEM VP - REVENUE CYCLE 0 217857 0 55160 0 3260 0 8232 0 29091 0 313600 0 0 GARY G GINTER SYSTEM VP - CIO 0 351975 0 139106 0 2296 0 26339 0 27380 0 547096 0 0 BARBARA A JOHNSON SYSTEM VP - HR OPERATIONS 0 372517 0 106120 0 12618 0 7701 0 9788 0 508744 0 0 TAMMY S LUNDSTROM MD SYSTEM VP - CMO 0 519002 0 131441 0 6225 0 8908 0 1585 0 667161 0 0 THOMAS R PARKER SYS VP -CHF EXPERIENCE OFFICER 369184 0 87253 0 25061 0 26354 0 11956 0 519808 0 0 0 DIANE L PLEIMAN VP - OPERATIONS (FROM APR) 226682 0 43961 0 2886 0 22001 0 6527 0 302057 0 0 0 CRAIG SELF SYSTEM VP - CSO 0 314509 0 64068 0 1893 0 11333 0 26622 0 418425 0 0 MARK W SHAW SYSTEM VP - MANAGED CARE 0 282789 0 65769 0 44967 0 35804 0 25376 0 454705 0 0 SCOTT A SHELTON SYSTEM VP - CPO 0 250217 0 50865 0 12445 0 25280 0 4002 0 342809 0 0 SYLVAIN TREPANIER DNP RN CENP SYSTEM VP - CNO 0 329769 0 55449 0 1240 0 7971 0 9754 0 404183 0 0 THOMAS D BIGLEY DIRECTOR PHARMACY 153981 0 22008 0 18315 0 7514 0 13059 0 214877 0 0 0 TERRY R FRY VP & CNO 164818 0 37317 0 19842 0 22609 0 913 0 245499 0 0 0 RYAN E MCELDOWNEY STAFF PHARMACIST 146095 0 200 0 664 0 6342 0 24757 0 178058 0 0 0 DELORES A MULLEN DIRECTOR - EMERGENCY SERVICES 85025 0 15903 0 46413 0 39425 0 24752 0 211518 0 0 0 KATHLEEN J SCARBROUGH PRESIDENT, UVMC FOUNDATION 80658 27281 24118 8157 10529 3562 13430 4083 17879 5544 146614 48627 0 0 MICHAEL J MAIBERGER FORMER TRUSTEE & OFFICER 0 383247 0 116670 0 165038 0 52762 0 29769 0 747486 0 26344 RENEE P GEORGE FORMER KEY EMPLOYEE 0 253960 0 45640 0 632 0 9526 0 11474 0 321232 0 0 J NICK LAIR FORMER KEY EMPLOYEE 0 224436 0 41191 0 28687 0 21914 0 24658 0 340886 0 0 SCHEDULE J, PART I LINE 4A: DELORES MULLEN RECEIVED $45,293 OF SEVERANCE PAYMENTS. Schedule J, 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 2015. THE INDIVIDUALS LISTED BELOW HAVE MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE PENSION RESTORATION PLAN AND RECEIVED THE ASSOCIATED PAYMENT IN 2015: DALE CREECH $94,589; BARBARA JOHNSON $5,674; NICK LAIR $9,733; DIANE PLEIMAN $1,154; REBECCA RICE $996; MARK SHAW $37,161; SCOTT SHELTON $8,625. THE INDIVIDUAL LISTED BELOW HAS MET THE MULTI-YEAR VESTING REQUIREMENT UNDER THE SERP AND RECEIVED THE ASSOCIATED PAYMENT IN 2015: MICHAEL MAIBERGER $26,344. 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. IN ADDITION, THE FOLLOWING INDIVIDUAL HAS NOT YET MET THE MULTI-YEAR VESTING REQUIREMENTS UNDER THE SERP. THE FOLLOWING AMOUNT WAS DEFERRED ON HIS BEHALF UNTIL THE MULTI-YEAR VESTING HAS BEEN MET; MICHAEL MAIBERGER $41,820. Schedule J, Part II, line 2: 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 593328EV5 2006-06-29 57502248 SEE PART VI false false false A 15015000 0 62184334 5394383 0 0 663253 0 0 19589170 36537528 0 2009 true false true true A false true true true false 0.00050 0.00230 0.00280 false false false true A false false false true false true BOAML 9.67 false false false 0 true true A true SCHEDULE K, PART I, LINE A, COLUMN F PURPOSE OF BOND: THE BOND ISSUE OF 6/29/2006 WAS USED TO CURRENTLY REFUND THE 1996A, 1996B AND 1996C SERIES BONDS AND TO PROVIDE CAPITAL FOR HOSPITAL IMPROVEMENTS AND EQUIPMENT PURCHASES. SCHEDULE K, PART II, LINE 3: TOTAL PROCEEDS OF ISSUE-INCLUDES SALES PROCEEDS OF $57,502,248 PLUS $2,548,945 EARNINGS ON DEBT SERVICE RESERVE FUND AND $2,133,141 EARNINGS ON PROJECT FUND. SCHEDULE K, PART II, LINE 11: OTHER SPENT PROCEEDS INCLUDES $34,109,391 SALE PROCEEDS USED TO CURRENTLY REFUND THE 1996A, 1996B AND 1996C BONDS AND $2,428,137 OF EARNINGS ON THE DEBT SERVICE FUND USED TO PAY DEBT SERVICE ON THE 2006 SERIES BONDS. SCHEDULE K, PART IV, LINE 1: AN ARBITRAGE REBATE CALCULATION AND YIELD RESTRICTION CALCULATION WERE PERFORMED IN 2011 BY A REBATE ANALYST AND IT WAS DETERMINED THAT NO ARBITRAGE REBATE OR YIELD RESTRICTIONS LIABILITY WERE OWED. THEREFORE, FORM 8038-T WAS NOT REQUIRED TO BE FILED. SCHEDULE K, PART IV, LINE 5: GROSS PROCEEDS INVESTED BEYOND AN AVAILABLE TEMPORARY PERIOD. A PORTION OF THE PROCEEDS RECEIVED FROM THE SALE OF THE 2006 SERIES BONDS, AND THE EARNING THEREON, WHICH WERE HELD IN THE PROJECT FUND WERE NOT EXPENDED PRIOR TO JUNE 29, 2009, THE END OF THE 3 YEAR TEMPORARY PERIOD DESCRIBED IN TREAS. REQ. 1.148-2(E) (2). THOSE AMOUNTS WERE FULLY SPENT AS OF DECEMBER 24, 2009. A YIELD RESTRICTION CALCULATION WAS PERFORMED BY A REBATE ANALYST ON THE FIVE-YEAR ANNIVERSARY DATE OF THE ISSUANCE OF THE 2006 SERIES BONDS AND IT WAS DETERMINED THAT NO YIELD REDUCTION PAYMENTS WERE OWED. 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 6: Upper Valley Medical Center has two corporate members. One member is UVMC, the parent company of the hospital. The second member is Premier Health (Premier), 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: UVMC has the sole authority to elect the board of trustees of Upper Valley Medical Center. UVMC has the authority to remove trustees at any regular or special board meeting or by written consent. Premier Health (Premier) has the right to request that UVMC remove a trustee of Upper Valley Medical Center if Premier has determined that such trustee is frustrating the goals and purposes of Premier's network. Such request shall not be unreasonably refused by UVMC. Form 990, Part VI, Section A, Line 7B: SEE THE RESPONSE ABOVE FOR FORM 990, PART VI, SECTION A, QUESTION 3. 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), OF 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 TO 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, 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 17: 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. Part VII, Section A, System Key Employees: The System Key Employees' total compensation amount is accurately reported on the various entities they serve. If the System Key Employee's compensation is paid by an unrelated organization, their compensation is being reported as related compensation to avoid the erroneous perception that these individuals are being paid identical amounts by multiple parties. Form 990, Part XI, Line 9: EQUITY TRANSFERS (3,937,160) PENSION FASB 158 ADJUSTMENT (2,420,559) PHG EQUITY TRANSFER (200,171) FOUNDATION ADJUSTMENT (183,580) CHANGE IN UVMC AUXILIARY CASH POSITION (10,628) TRANSFER FROM AFFILIATE 3,660,843 ----------- TOTAL (3,091,255) UVMC 110 N Main St 500 DAYTON OH 45402 341850683 PARENT OH 501(c)(3) 11C 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) 11A I NA false UPPER VALLEY PROFESSIONAL CORP (UVPC) 110 N MAIN ST 500 DAYTON OH 45402 311400963 HEALTH CARE OH 501(c)(3) 9 UVMC true UVPC SPECIALISTS INC 110 N MAIN ST 500 DAYTON OH 45402 203687536 HEALTH CARE OH 501(c)(3) 9 UVPC true UVMC NURSING CARE INC 110 N MAIN ST 500 DAYTON OH 45402 311224064 NURSING HOME OH 501(c)(3) 9 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 INC 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 true true false false true true true true true UPPER VALLEY PROFESSIONAL CORP J 65525 FMV UPPER VALLEY PROFESSIONAL CORP Q 18521476 FMV UVPC SPECIALISTS INC Q 2367867 FMV UVMC FOUNDATION C 183580 FMV UVMC FOUNDATION Q 415806 FMV UVMC NURSING CARE Q 53665 FMV AFTER HOURS FAMILY CARE C 492285 FMV AFTER HOURS FAMILY CARE Q 220315 FMV PREMIER HEALTH B 200171 FMV UPPER VALLEY PROFESSIONAL CORP C 235281 FMV UVPC SPECIALISTS INC B 5840880 FMV UVPC SPECIALISTS INC O 282481 FMV UVMC C 3660843 FMV UVMC Q 1174160 FMV UPPER VALLEY PROFESSIONAL CORP P 72331 FMV