2016-08-03T13:48:14-05:00 2015-09-30 440160260 BKD LLP 2800 POST OAK BLVD STE 3200 HOUSTON TX 77056 990 2014-10-01 751041154 THE GOOD SHEPHERD HOSPITAL INC GOOD 9033152000 700 E MARSHALL AVENUE LONGVIEW TX 75601 TIM PILEGGI CFO 9033152440 2016-08-03 1 PAIGE GERICH P00226776 7134994600 2014 2016-12-15 16:53:06Z GOOD SHEPHERD MEDICAL CENTER TIM PILEGGI 700 EAST MARSHALL AVENUE LONGVIEW TX 75601 399674260 0 X WWW.GSMC.ORG X 1959 TX GOOD SHEPHERD MEDICAL CENTER IS A NOT-FOR-PROFIT COMMUNITY HOSPITAL DEDICATED TO CREATING A HEALTHIER FUTURE FOR THE RESIDENTS OF LONGVIEW AND NORTHEAST TEXAS. TO ENSURE THE CONTINUED WELL-BEING OF THE COMMUNITY, THE MEDICAL CENTER STRIVES TO PROVIDE QUALITY, COMPASSIONATE AND COMPREHENSIVE HEALTHCARE SERVICES TO THE WHOLE PERSON: BODY, MIND AND SPIRIT.GOOD SHEPHERD EXISTS TO CARE FOR ALL THOSE WHO PRESENT THEMSELVES, WHATEVER THEIR NEED, REGARDLESS OF RACE, CREED OR GENDER. THE MEDICAL CENTER PROVIDES HEALTH SERVICES TO THE MEDICALLY UNDERSERVED AS FAR AS RESOURCES PROVIDE, WHILE MAINTAINING THE LONG-TERM INTEGRITY OF SERVICE TO THE COMMUNITY.THE LEADERSHIP WILL REMAIN EVER COGNIZANT OF THE MEDICAL CENTER'S INTEGRAL ROLE IN THE COMMUNITY AND ITS RESPONSIBILITY TO DEMONSTRATE GOOD STEWARDSHIP OF THE HEALTH OF ITS RESIDENTS WHILE PROVIDING SERVICES AT COMPETITIVE COSTS. INHERENT WITHIN THIS MISSION IS A RESPONSIBILITY TO MAINTAIN THE ORGANIZATION'S FINANCIAL SOLVENCY. 13 11 2314 160 5446550 -194809 156326 242766 327516624 396033354 619175 337057 2241004 2379236 330533129 398992413 752708 949582 0 0 107251485 113882193 0 0 0 229582557 287481662 337586750 402313437 -7053621 -3321024 147684765 160345805 173548629 188024148 -25863864 -27678343 X GOOD SHEPHERD MEDICAL CENTER PROVIDES SERVICES TO PATIENTS QUALIFYING UNDER THE CHARITY POLICY AND PROVIDES QUALITY TERTIARY HEALTH SERVICES TO THE RESIDENTS OF NORTHEAST TEXAS. 0 0 333423805 949582 390586804 GOOD SHEPHERD MEDICAL CENTER IS IMPACTED BY THE SIGNIFICANT CHANGES IN HEALTHCARE TODAY. TO ENSURE THAT GOOD SHEPHERD MEDICAL CENTER IS STRONGLY POSITIONED FOR THE FUTURE, THE FOLLOWING MAJOR STRATEGIES HAVE BEEN ADOPTED:- IMPROVE CLINICAL QUALITY OUTCOMES AND CUSTOMER SERVICE- IMPROVE OPERATING PERFORMANCE AND REDUCE COSTS- DEVELOP A HEALTH SYSTEM THAT PROVIDES A FULL CONTINUUM OF HOSPITAL, PHYSICIAN AND INSURANCE SERVICES- IMPROVE THE HEALTH STATUS OF THE SERVICE AREA- IMPROVE THE CAPABILITY AND ADAPTABILITY OF EMPLOYEESGOVERNED BY A VOLUNTARY BOARD OF DIRECTORS, GOOD SHEPHERD MEDICAL CENTER HAS A DIRECT LINK TO SOLICIT COMMUNITY INVOLVEMENT IN DECISION MAKING. THE BOARD OF DIRECTORS IS COMPOSED OF GOOD SHEPHERD MEDICAL CENTER'S PRESIDENT AND CHIEF EXECUTIVE OFFICER AND TWELVE MEMBERS OF THE COMMUNITY WHO SERVE ON A VOLUNTARY BASIS TO FURTHER THE MISSION OF GOOD SHEPHERD MEDICAL CENTER. THESE MEMBERS REPRESENT LOCAL BUSINESS, INDUSTRY, EDUCATION, MEDICAL SERVICES AND CONSUMERS-AT-LARGE. THE BOARD OF DIRECTORS PROVIDES PERPETUAL COMMUNICATION OF THE CONCERNS AND HEALTHCARE NEEDS OF THE GREATER LONGVIEW COMMUNITY.AS PART OF OUR ONGOING COMMITMENT TO THE UNDERSERVED POPULATION OF GOOD SHEPHERD'S SERVICE AREA, THE BOARD OF DIRECTORS ESTABLISHED CRITERIA FOR FINANCIAL ASSISTANCE CONSISTENT WITH THE ORGANIZATION'S MISSION AND FINANCIAL RESOURCES.FINANCIAL ASSISTANCE IS PROVIDED TO ALL PATIENTS, WITHOUT REGARD TO RACE, CREED, GENDER OR NATIONAL ORIGIN, WHO ARE CLASSIFIED AS FINANCIALLY INDIGENT ACCORDING TO GOOD SHEPHERD'S ELIGIBILITY GUIDELINES AND WHO PRESENT THEMSELVES FOR CARE AT GOOD SHEPHERD MEDICAL CENTER AND ITS REGIONAL SYSTEM OF SERVICES. MANY FACTORS SUCH AS ALL SOURCES OF INCOME, EMPLOYMENT STATUS, FAMILY SIZE, AMOUNT OF THE PATIENT'S ACCOUNT AND HEALTHCARE NEEDS ARE ALL TAKEN INTO CONSIDERATION WHEN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. GOOD SHEPHERD MEDICAL CENTER MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF FINANCIAL ASSISTANCE IT PROVIDES TO THE COMMUNITIES IT SERVES.- IN FISCAL YEAR 2015, CHARITY CARE BASED ON ESTABLISHED RATES WAS RENDERED IN THE AMOUNT OF $33,124,798. THIS AMOUNT ENCOMPASSES THE CARE OF MORE THAN 6,000 PATIENT VISITS AND REPRESENTS APPROXIMATELY 2.38 PERCENT OF GROSS PATIENT REVENUE.- GOOD SHEPHERD PROVIDED CHARITY CARE, GOVERNMENT-SPONSORED INDIGENT HEALTHCARE AND OTHER COMMUNITY BENEFITS COSTING $23,646,519 OR MORE THAN 8.15 PERCENT OF THE TOTAL OPERATING EXPENSES.GOOD SHEPHERD MEDICAL CENTER ALSO PARTICIPATES IN THE MEDICARE AND MEDICAID PROGRAMS, AS WELL AS OTHER FEDERAL, STATE AND LOCAL HEALTHCARE REIMBURSEMENT PROGRAMS FOR THOSE IN FINANCIAL NEED. THESE PROGRAMS ACCOUNT FOR MORE THAN 61 PERCENT OF THE MEDICAL CENTER'S GROSS PATIENT REVENUE. 333423805 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 147 0 1 2314 1 1 1 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DIANNE HALFORD 9033155177 700 E MARSHALL AVE LONGVIEW TX 75601 STEVE ALTMILLER PRESIDENT - CEO 2.00 51.00 X X 0 595121 20817 KELLYN DRAYER CHAIR 2.00 X X 0 0 0 WILLIAM M HOLDA EDD TRUSTEE 2.00 X 0 0 0 MARK BOON TRUSTEE 2.00 X 0 0 0 CR MARTIN MD TRUSTEE 2.00 X 0 0 0 THOMAS P TIBILETTI TRUSTEE 2.00 X 0 0 0 STAN UPCHURCH MD TRUSTEE 2.00 X 0 0 0 KEITH HONEY TRUSTEE 2.00 X 0 0 0 LESTER LUCY TRUSTEE 2.00 X 0 0 0 GAYLE ENGLISH VICE CHAIR 2.00 X X 0 0 0 HOMER ROCKMORE TRUSTEE 2.00 X 0 0 0 SUSHAMA BRIMMER PHYSICIAN 2.00 41.00 X 0 494535 25637 MARK BOGLE FINANCE CHAIRMAN 2.00 X X 0 0 0 TIM PILEGGI INTERIM CFO 2.00 51.00 X 0 273924 0 DANIEL D SMITH CRNA 40.00 X 249000 0 17877 RICHARD LEE HOLLADAY CRNA 40.00 X 330380 0 12728 ROGER BRYANT JR CRNA 40.00 X 255008 0 26041 LEE ALLEN HOLLADAY CRNA 40.00 X 248166 0 17807 RICHARD HINSON CRNA 40.00 X 254853 0 20987 KENNETH CUNNINGHAM FORMER-INTERIM CEO 0.00 46.00 X 0 300110 24332 LEORA WILLIAMS FORMER-SECRETARY 0.00 0.00 X 0 125765 11117 PAT KEEL FORMER CFO 0.00 0.00 X 0 192475 6556 1337407 1981930 183899 74 1 1 0 LONGVIEW EMERGENCY MEDICINE 700 EAST MARSHALL LONGVIEW TX 75601 PROFESSIONAL FEES 10301427 MORRIS AND DICKSON CO LLC PO BOX 51367 SHREVEPORT LA 71135 PHARMACY SERVICES 7628915 MORRISON MANAGEMENT SPECIALIST PO BOX 102289 ATLANTA GA 303682289 MEDICAL SERVICES 5770190 ARAMARK HEALTHCARE 12483 COLLECTIONS CENTER DR CHICAGO IL 60693 CAFETERIA SERVICES 5493798 HOSPITAL HOUSEKEEPING SYSTEMSLTD POBOX 826 SAN ANTONIO TX 78293 HOUSEKEEPING SERVICES 5007723 69 242766 242766 NET PATIENT REVENUE 621110 357621655 357621655 GOVERNMENT DSH AND TRAUMA FUNDING 900099 28422173 28422173 LAB OUTREACH REVENUE 621500 4923697 4923697 WELLNESS CENTER REVENUE 624100 3661100 3138247 522853 LEASE REVENUE 532420 1287446 1287446 117283 117283 396033354 97543 97543 545661 567439 -21778 -21778 -21778 353922 114408 239514 239514 239514 CAFETERIA 722210 2191278 0 2191278 VENDING 722210 51023 0 51023 158713 158713 2401014 398992413 390586804 5446550 2716293 X 949582 949582 94262971 87124922 7138049 2086971 1920013 166958 10848023 9980181 867842 6684228 6149490 534738 14037016 14037016 198466 198466 6405878 6405878 4652 4652 42951413 27024686 15926727 1958637 1133 1957504 2452501 2256301 196200 7888639 1854 7886785 2252658 2041784 210874 110248 89973 20275 6404387 6404387 5099901 4678613 421288 1232403 1133692 98711 PROVISION FOR BAD DEBTS 112967416 110970700 1996716 MEDICAL SUPPLIES & EQUI 35011833 35011833 LEASES AND RENTALS 9419597 8567061 852536 HOUSEKEEPING 6846141 6298450 547691 32239876 29223537 3016339 402313437 333423805 68889632 0 19747 3982292 60139048 60325472 10624823 9875299 878555 560165 188232766 134879459 56686726 53353307 9643997 18874725 7403188 9084299 1550321 2644639 738360 1645607 147684765 160345805 25127971 28553890 357212 207618 126402763 116375286 861250 666250 20799433 42221104 173548629 188024148 X -32798027 -35095675 6934163 7417332 -25863864 -27678343 147684765 160345805 X -3321024 1506545 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 4652 0 0 0 4652 0 PART II-B, LINE 1: THE AMOUNT REPRESENTS THE PERCENTAGE OF DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION THAT THE AHA DETERMINED WAS FOR LOBBYING EXPENSES. 614744 614744 103266598 61509942 41756656 7239533 5802072 1437461 74543393 67567445 6975948 2568498 2568498 53353307 INVESTMENT IN CHAMPION EMS 1666965 C INVESTMENT IN GS FOUNDATION 7417334 F 9084299 INTERCOMPANY PAYABLES 24134488 ESTIMATED SELF-INSURANCE COSTS 3458287 DUE TO AFFILIATES 8570798 NOTE PAYABLE TO GSMC FOUNDATION 6057531 42221104 X 288066944 567439 567439 287499505 111492908 111492908 398992413 289913460 567439 567439 289346021 112967416 112967416 402313437 PART X, LINE 2: THE SYSTEM, GSHS ASO, THE MEDICAL CENTER, GSMC LINDEN, GSMC MARSHALL, THE GSMC FOUNDATION AND THE GSMC - LINDEN FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THESE ENTITIES ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. ENTERPRISES IS A TAXABLE CORPORATION. CSC IS TAXED AS A PARTNERSHIP. DEFERRED TAX ASSETS AND LIABILITIES ARE RECOGNIZED FOR ENTERPRISES FOR THE TAX EFFECTS OF DIFFERENCES BETWEEN THE FINANCIAL STATEMENTS AND TAX BASES OF ASSETS AND LIABILITIES. A VALUATION ALLOWANCE IS ESTABLISHED TO REDUCE DEFERRED TAX ASSETS IF IT IS MORE LIKELY THAN NOT THAT A DEFERRED TAX ASSET WILL NOT BE REALIZED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 567,439. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 112,967,416. INVESTMENT RETURN 97,543. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP -171,148. OTHER 283,856. JOINT VENTURE INVESTMENT LOSS -1,684,759. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 567,439. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 112,967,416. 1 1 X 1 X 1 X 500.000000000000 1 1 1 0 1 1 7367450 3601279 3766171 0.01300 46108818 33704304 12404514 0.04290 456194 196371 259823 0.00090 53932462 37501954 16430508 0.05680 389807 27980 361827 0.00130 7712569 1913075 5799494 0.02000 949582 949582 0.00330 9051958 1941055 7110903 0.02460 62984420 39443009 23541411 0.08140 1 102918907 86417282 70058116 16359166 X 1 1 1 1 GOOD SHEPHERD MEDICAL CENTER 700 EAST MARSHALL AVE LONGVIEW TX 75601 WWW.GSMC.ORG 000029 X X X X THE GOOD SHEPHERD HOSPITAL INC 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X WWW.GSMC.ORG X 1 12 1 WWW.GSMC.ORG 0 0 1 X 100.000000000000 500.000000000000 X X X X 1 1 X X X 1 X WWW.GSMC.ORG X WWW.GSMC.ORG X X X 1 X 0 X X X 1 X 0 0 THE GOOD SHEPHERD HOSPITAL INC PART V, SECTION B, LINE 5: GSMC RECEIVED INPUT FROM REPRESENTATIVES OF THE COMMUNITY WHICH INCLUDES THE FOLLOWING INDIVIDUALS WITH; A.)SPECIALIZED KNOWLEDGE OR EXPERTISE IN PUBLIC HEALTH B.)AFFILIATION WITH LOCAL GOVERNMENT,SCHOOLS AND INDUSTRYC.)INVOLVEMENT WITH UNDERSERVED AND MINORITY POPULATIONS.INTERVIEWS WERE CONDUCTED BOTH AT THE MEDICAL CENTER AND IN LOCATIONS MORE CONVENIENT FOR THE INFORMANT. ALL INTERVIEWS WERE CONDUCTED BY BKD PERSONNEL USING A STANDARD QUESTIONNAIRE.THE FOLLOWING INDIVIDUALS PARTICIPATED IN OUR KEY INFORMANT INTERVIEW PROCESS:LETOURNEU UNIVERSITY/NEW LIFE ASSEMBLY OF FED, ASSOCIATE PROFESSOR/PASTORGOOD SHEPHERD HEALTH SYSTEM, EXECUTIVE DIRECTORGOOD SHEPHERD HEALTH SYSTEM, DIRECTOR OF REIMBURSEMENTEASTMAN ESTATES, COMMUNITY RELATIONS DIRECTORGOOD SHEPHERD HEALTH SYSTEM, DIRECTOR OF INFECTION PROTECTIONGOOD SHEPHERD HEALTH SYSTEM, DIVISION CONTROLLERGOOD SHEPHERD HEALTH SYSTEM, CHIEF NURSING OFFICERCITY OF LONGVIEW, ASSISTANT CITY MANAGERUT HEALTH AND SCIENCE, DIRECTOR PROGRAM PLANNINGCOMMUNITY HEALTHCORE, PROGRAM DIRECTORKILGORE COLLEGE OF NURSING, DIRECTORUPSHER COUNTY, JUDGELONGVIEW INTERFAITH HOSPITALITY NETWORK, EXECUTIVE DIRECTORTEXAS ONCOLOGY, DIRECTORUT HEALTH AND SCIENCE, DIRECTOR OF OCCUPATIONAL HEALTH SCIENCESCOUNTY HEALTH AUTHORITY, DIRECTORGOOD SHEPHERD MEDICAL ASSOCIATES, ETGA PHYSICIANGOOD SHEPHERD HEALTH SYSTEM, PHYSICAL THERAPY DIRECTORCITY OF LONGVIEW, EMS CHIEFFRIENDS OF PARTNERS IN PREVENTION, DIRECTORCOMMUNITY HEALTHCARE, EXECUTIVE DIRECTORGOOD SHEPHERD HEALTH SYSTEM, SYSTEM CONTROLLEREAST TEXAS LITERACY COUNCIL, EXECUTIVE DIRECTORLONGVIEW SHERIFF DEPARTMENT, DEPUTYCITY OF LONGVIEW, FIRE CHIEFGREGG COUNTY, JUSTICE OF THE PEACEGREGG COUNTY, JUDGE COMMISSIONERS COURTGOOD SHEPHERD HEALTH SYSTEM, EXECUTIVE VPCITY OF LONGVIEW, DIRECTOR OF COMMUNITY SERVICESGOOD SHEPHERD HEALTH SYSTEM, EXECUTIVE DIRECTOR HEALTH & PREVENTION SERVICESSALVATION ARMY, MAJORGOOD SHEPHERD HEALTH SYSTEM, DIRECTOR OF QUALITY CONTROLGOOD SHEPHERD HEALTH SYSTEM, DIRECTOR RESIDENCY PROGRAMGOOD SHEPHERD HEALTH SYSTEM, PHYSICIAN GOOD SHEPHERD HEALTH SYSTEM, EMPLOYEEGOOD SHEPHERD HEALTH SYSTEM, CFOGOOD SHEPHERD HEALTH SYSTEM, VP ORGANIZATIONAL EXECUTIVEGOOD SHEPHERD HEALTH SYSTEM, VP ANCILLARY SERVICESLONGVIEW COMMUNITY MINISTRIES, ASSISTANT DIRECTORLONGVIEW CHILD DEVELOPMENT, DIRECTORGREGG COUNTY, SHERIFFSEE SAW CHILDREN'S PLACE, DIRECTORGOOD SHEPHERD HEALTH SYSTEM, SYSTEM DIRECTOR OF MENTAL CARECHAMPION EMS, CEOGSHS, DIRECTOR OF FINANCIAL PLANNINGGOOD SHEPHERD HEALTH SYSTEM, DIVISION DIRECTOR CRITICAL CAREGOOD SHEPHERD HEALTH SYSTEM,PARENTING RESOURCE CENTER, DIRECTORGOOD SHEPHERD HEALTH SYSTEM, MARKETING DIRECTOR THE GOOD SHEPHERD HOSPITAL INC PART V, SECTION B, LINE 11: GSMC - LONGVIEW COMPLETED A CHNA AND CHNA IMPLEMENTATION PLAN IN 2013 WHICH FOUND AND ADDRESSED TEN PRIORITY HEALTH NEEDS IN THE COMMUNITY. THE NUMBER ONE PRIORITY ITEM IDENTIFIED IN THE CHNA IS "UNINSURED/LACK OF ACCESS TO SERVICES". THE MEDICAL CENTER CONTINUES TO PROVIDE SIGNIFICANT VOLUMES OF INPATIENT, EMERGENCY AND OTHER SERVICES TO UNINSURED PATIENTS, MANY OF WHOM QUALIFY FOR HELP UNDER THE SYSTEM'S FINANCIAL ASSISTANCE POLICY. THE HOSPITAL IS A MEDICAID DISPROPORTIONATE SHARE (DSH) PROVIDER AND COMPLETES A MEDICAID DSH SURVEY EACH YEAR WHICH QUANTIFIES UNINSURED VOLUMES AND DETERMINES MEDICAID DSH QUALIFICATION.IN ADDITION, THE MEDICAL CENTER HAS DEVELOPED A NUMBER OF PROGRAMS TO ADDRESS EACH OF THE REMAINING NINE PRIORITY HEALTH NEEDS. SERVICES PROVIDED AND OTHER ACTIVITIES RELATED TO THESE PROGRAMS ARE TRACKED DURING THE YEAR AND SUMMARIZED IN AN ANNUAL COMMUNITY BENEFIT REPORT. THE GOOD SHEPHERD HOSPITAL INC PART V, SECTION B, LINE 22D: THE FINANCIAL ASSISTANCE ELIGIBILITY DISCOUNT GUIDELINES STATES ALL UNINSURED PATIENTS WHO QUALIFY FOR LESS THAN 68% FINANCIAL ASSISTANCE AND COMPLETE THE NECESSARY APPLICATION PROCESS, WILL RECEIVE THE DISCOUNT UNDER THE UNINSURED ADJUSTMENT. THIS AMOUNT IS BASED ON AN AVERAGE OF GSHS MANAGED CARE CONTRACTS DEEPEST DISCOUNTS. THIS AMOUNT WILL BE REVIEWED ANNUALLY BY THE FAP COMMITTEE TO ADJUST FOR CHANGES AS APPROPRIATE. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY THE GOOD SHEPHERD HOSPITAL INC PART V, SECTION B, LINE 16A WEBSITE: WWW.GSMC.ORG THE GOOD SHEPHERD HOSPITAL INC PART V, SECTION B, LINE 16B WEBSITE: WWW.GSMC.ORG PART I, LINE 7: ALLOCATION OF MEDICAID SUPPLEMENTAL PAYMENTSDURING THE CURRENT REPORTING PERIOD, THE STATE OF TEXAS PARTICIPATED IN A SPECIAL 1115 MEDICAID WAIVER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS). VARIOUS SUPPLEMENTAL HOSPITAL PAYMENTS UNDER THE WAIVER ARE INTENDED TO HELP HOSPITALS OFFSET MEDICAID AND UNINSURED LOSSES AND/OR CREATE NEW PROGRAMS DESIGNED TO IMPROVE THE PATIENT CARE EXPERIENCE, ENHANCE HEALTH OUTCOMES AND REDUCE COSTS FOR THESE SAME PATIENT POPULATIONS. SUPPLEMENTAL PAYMENTS ARE CAPPED BY MEDICAID AND UNINSURED LOSSES DETERMINED FROM A SPECIAL UNCOMPENSATED CARE (UC) TOOL DESIGNED BY THE TEXAS HEALTH AND HUMAN SERVICES COMMISSION (HHSC). IN FISCAL YEAR 2015, THE HOSPITAL RECOGNIZED $28,422,173 OF SUPPLEMENTAL PAYMENT INCOME UNDER THE MEDICAID WAIVER. THE PAYMENTS WERE PARTIALLY FUNDED THROUGH INTER-GOVERNMENT TRANSFER (IGT) PAYMENTS FROM A NEW LOCAL PROVIDER PARTICIPATION FUND (LPPF) ENABLED BY A LAW PASSED BY THE 84TH TEXAS LEGISLATURE IN 2015. THE NEW LPPF WAS FUNDED BY HOSPITAL TAX ASSESSMENTS TOTALING $8,039,611 IN 2015. FOR PURPOSES OF IRS FORM 990 SCHEDULE H REPORTING, THE MEDICAID SUPPLEMENTAL PAYMENTS AND TAX ASSESSMENTS HAVE BEEN ALLOCATED BETWEEN FINANCIAL ASSISTANCE (CHARITY), MEDICAID AND BAD DEBT USING RATIOS DERIVED FROM THE UC TOOL AND OTHER INTERNAL DOCUMENTS USED FOR PURPOSES OF PREPARING MEDICARE COST REPORT WORKSHEET S-10 "HOSPITAL UNCOMPENSATED AND INDIGENT CARE DATA".MORE INFORMATION ON THE MEDICAID WAIVER MAY BE FOUND AT HTTP://WWW.HHSC.STATE.TX.US/1115-WAIVER.SHTML PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 112,967,416. PART III, LINE 4: THE INFORMATION IS PROVIDED IN THE ATTACHED AUDITED FINANCIAL STATEMENT ON PAGES 10 AND 11 TITLED PATIENT ACCOUNTS RECEIVABLE. PART III, LINE 8: SOURCE OF INFORMATION ON LINE 6 IS THE FYE 09/30/15 MEDICARE COST REPORT. THE SUM OF MEDICARE PART A ALLOWABLE COSTS REPORTED ON WORKSHEET D-1, PART II (FOR BOTH INPATIENT ACUTE PPS AND INPATIENT REHAB FACILITY) AND WORKSHEET DV, COLUMN 9.01 FOR MEDICARE OUTPATIENT PPS SERVICES. SINCE ALLOWABLE COSTS ARE NOT DETERMINED FOR SERVICES RENDERED TO MEDICARE PATIENTS ENROLLED IN MEDICARE ADVANTAGE (MEDICARE PART C) OR FOR PHYSICIAN SERVICES (SUCH AS EMERGENCY ROOM DOCTORS) BILLED UNDER MEDICARE PART B, NEITHER THE REVENUES OR COSTS RELATED TO THESE SERVICES HAVE BEEN INCLUDED ON LINES 5 OR 6.MEDICARE ALLOWABLE COSTS WERE DERIVED FROM THE FYE 9/30/2015 FILED COST REPORT. THE COST REPORT USES FINANCIAL AND STATISTICAL DATA TO DEVELOP PER DIEMS AND COST TO CHARGE RATIOS THAT ULTIMATELY DETERMINE ALLOWABLE MEDICARE INPATIENT AND OUTPATIENT COSTS AND REIMBURSEMENTS. PART III, LINE 9B: ALL PATIENTS WHO ARE UNDERINSURED OR UNINSURED WILL BE EVALUATED FOR GOVERNMENT PROGRAMS, PAYMENT PLANS, AND FINANCIAL ASSISTANCE. IF ALL ATTEMPTS FAIL, WE WILL CONSIDER EACH ACCOUNT MEETING CERTAIN CRITERIA FOR FINANCIAL ASSISTANCE. ANY ACCOUNT THAT HAS A BALANCE GREATER THAN $10,000 AND HAS NOT QUALIFIED FOR MEDICAID OR COUNTY PROGRAMS WILL BE REVIEWED ON A CASE BY CASE BASIS FOR CHARITY CONSIDERATION. CREDIT REPORTS WILL BE RUN AND SUBMITTED FOR REVIEW. WRITE-OFFS WILL BE MONITORED THROUGH A SPECIFIC CODE, TO MONITOR AND EVALUATE AS NEEDED FOR CHANGES OR UPDATES. IF AT ANYTIME RECOVERIES ARE OBTAINED AFTER WRITE-OFF, THE CHARITY ADJUSTMENT WILL BE REVERSED AND ADDITIONAL REVIEW OF THE ACCOUNT WILL BE REQUIRED. PART III, LINE 2 AND LINE 3 BAD DEBT FROM THE AUDITED FINANCIAL STATEMENT REDUCED BY ALLOCATED MEDICAID SUPPLEMENTAL PAYMENTS OF $14,012,000, PLUS ALLOCATED PROVIDER TAXES OF $3,963,491. WE DID NOT INCLUDE ANY BAD DEBT AMOUNTS IN COMMUNITY BENEFITS. PART VI, LINE 2: THE UNITED WAY CONDUCTS A NEEDS ASSESSMENT SURVEY EVERY TWO YEARS TO DETERMINE THE HEALTH NEEDS OF THE COMMUNITY. GOOD SHEPHERD USES THIS DATA TO AUGMENT INFORMATION GATHERED BASED ON UTILIZATION OF SERVICES. PART VI, LINE 3: AS PATIENTS ENTER OUR FACILITY, SIGNAGE IS POSTED IN DESIGNATED AREAS WHICH STATE OUR POLICY TO PROVIDE CHARITY CARE TO THOSE PATIENTS WHO MEET ELIGIBILITY REQUIREMENTS. BUSINESS OFFICE AND REGISTRATION STAFF DISCUSS PAYMENT OPTIONS AND FINANCIAL ASSISTANCE AVAILABLE TO PATIENTS USING VERBAL AND WRITTEN COMMUNICATION. PATIENTS ARE CONTACTED PRIOR TO SERVICES WITH AN ESTIMATED COST AND OUT OF POCKET EXPENSES. CASH PRICES AND PAYMENT OPTIONS ARE DISCUSSED AND FINANCIAL ASSISTANCE SCREENING IS AVAILABLE UPON REQUEST. GOOD SHEPHERD MEDICAL CENTER EVALUATES PATIENT APPLICATIONS AND UTILIZES A SLIDING SCALE TO QUALIFY PATIENTS BASED ON GOVERNMENT POVERTY GUIDELINES. ADDITIONALLY, OUR ELIGIBILITY VENDOR SCREENS FOR GOVERNMENT AGENCY PROGRAMS AND OFFERS FINANCIAL ASSISTANCE APPLICATIONS TO THOSE WHO DO NOT QUALIFY FOR GOVERNMENT PROGRAMS. BUSINESS OFFICE AND REGISTRATION PERSONNEL ARE AVAILABLE TO ANSWER ANY FINANCIAL QUESTIONS AND ASSIST THE PUBLIC WITH THEIR FINANCIAL OBLIGATIONS. PART VI, LINE 4: GOOD SHEPHERD MEDICAL CENTER SERVES AN 11-COUNTY REGION INCLUDING THE FOLLOWING COUNTIES: GREGG, HARRISON, MARION, MORRIS, PANOLA, RUSK, UPSHUR, CAMP, CASS, WOOD, AND TITUS. GOOD SHEPHERD MEDICAL CENTERS IN LONGVIEW AND MARSHALL OFFER A TRUE SYSTEM OF HEALTHCARE THAT ENCOMPASSES THE REACH OF OUR REGION. TO MEET THE EVERYDAY HEALTHCARE NEEDS OF THE RESIDENTS IN OUR REGION, GOOD SHEPHERD HEALTH SYSTEM OPERATES FAMILY HEALTH CENTERS IN THE COMMUNITIES OF LONGVIEW, GLADEWATER, HENDERSON AND KILGORE. THE PRIMARY 6 COUNTIES POPULATION'S ARE GREGG - 124,108, HARRISON-66,746, MARION-10,160, UPSHUR-40,603, RUSK-53,070 AND PANOLA-23,766 AND TOTAL 318,453. PART VI, LINE 5: GOVERNED BY A VOLUNTARY BOARD OF DIRECTORS, GOOD SHEPHERD MEDICAL CENTER HAS A DIRECT LINK TO SOLICIT COMMUNITY INVOLVEMENT IN DECISION MAKING. THE BOARD OF DIRECTORS IS COMPOSED OF GOOD SHEPHERD MEDICAL CENTER'S PRESIDENT AND CHIEF EXECUTIVE OFFICER AND TWELVE MEMBERS OF THE COMMUNITY WHO SERVE ON A VOLUNTARY BASIS TO FURTHER THE MISSION OF GOOD SHEPHERD MEDICAL CENTER. THESE MEMBERS REPRESENT LOCAL BUSINESS, INDUSTRY, EDUCATION, MEDICAL SERVICES, AND CONSUMERS-AT-LARGE. THE BOARD OF DIRECTORS PROVIDES PERPETUAL COMMUNICATION OF THE CONCERNS AND HEALTHCARE NEEDS OF THE GREATER LONGVIEW COMMUNITY.GOOD SHEPHERD MEDICAL CENTER MAINTAINS A PRESENCE TO PROVIDE HEALTHCARE INFORMATION TO COMMUNITIES THROUGHOUT THE REGION. IN ADDITION, THE ORGANIZATION HOSTS AN ANNUAL HEALTH FAIR OFFERING FREE HEALTH SCREENINGS. GOOD SHEPHERD ALSO OFFERS DISCOUNTED MAMMOGRAMS EACH MONTH, FREE PROSTATE SCREENINGS ANNUALLY, AND WAS INTEGRALLY INVOLVED IN ESTABLISHING THE MAYOR'S FITNESS COUNCIL. PART VI, LINE 6: GOOD SHEPHERD HEALTH SYSTEM OPERATES HOSPITALS IN LONGVIEW AND MARSHALL. IN EACH OF THE COMMUNITIES, THE HOSPITAL OFFERS FREE SCREENINGS TO IDENTIFY EARLY DISEASE, EDUCATIONAL OFFERINGS FEATURING PHYSICIAN SPEAKERS AND CONTINUOUSLY PARTICIPATE IN COMMUNITY ACTIVITIES WHERE PREVENTION AND WELLNESS INFORMATION CAN BE SHARED. PART VI, LINE 7 TEXAS 1 SERVICE ORGANIZATION OF GOOD SHEPHERD 2950 50TH STREET LUBBOCK TX 79413 383914883 501(C)(3) 949582 0 HEALTHCARE SERVICES 1 SCHEDULE I PART I LINE 2 AFTER A NEED IS DETERMINED FOR ASSISTANCE, A REQUEST FROM THE SERVICE ORGANIZATION OF GOOD SHEPHERD IS SUBMITTED, IDENTIFYING THE FUNDS NEEDED FOR THE PROGRAM AND/OR PATIENT. THE REQUEST IS REVIEWED AND APPROVED BY THE CFO BEFORE FUNDS ARE TRANSFERRED. A SERVICE LOG IS SUBMITTED TO THE CFO TO DOCUMENT HOURS INCURRED ON PROJECTS AND SUPPORT USE OF FUNDS. 0 0 0 0 0 0 0 0 0 STEVE ALTMILLER PRESIDENT - CEO 0 595121 0 0 0 0 0 8834 0 11983 0 615938 0 0 SUSHAMA BRIMMER PHYSICIAN 0 438285 0 56250 0 0 0 7993 0 17644 0 520172 0 0 TIM PILEGGI INTERIM CFO 0 273924 0 0 0 0 0 0 0 0 0 273924 0 0 DANIEL D SMITH CRNA 249000 0 0 0 0 0 1419 0 16458 0 266877 0 0 0 RICHARD LEE HOLLADAY CRNA 330380 0 0 0 0 0 10400 0 2328 0 343108 0 0 0 ROGER BRYANT JR CRNA 255008 0 0 0 0 0 10131 0 15910 0 281049 0 0 0 LEE ALLEN HOLLADAY CRNA 248166 0 0 0 0 0 7180 0 10627 0 265973 0 0 0 RICHARD HINSON CRNA 254853 0 0 0 0 0 8543 0 12444 0 275840 0 0 0 KENNETH CUNNINGHAM FORMER-INTERIM CEO 0 300110 0 0 0 0 0 6688 0 17644 0 324442 0 0 LEORA WILLIAMS FORMER-SECRETARY 0 121992 0 3773 0 0 0 5032 0 6085 0 136882 0 0 PAT KEEL FORMER CFO 0 192475 0 0 0 0 0 3782 0 2774 0 199031 0 0 PART I, LINE 3 GSMC DOES NOT HAVE A CEO THAT IT EMPLOYS WHO IS PAID DIRECTLY OR INDIRECTLY BY THE FILING ORGANIZATION OR A RELATED ORGANIZATION. A GREGG COUNTY HEALTH FACILITIES DEVELOPMENT CORPORATION 751865828 39753MDU9 2006-11-08 99276418 ADVANCE REFUNDING OF BONDS 0 0 0 B GREGG COUNTY HEALTH FACILITIES DEVELOPMENT CORPORATION 751865828 39753MFF0 2012-09-05 33033015 CAPITAL IMPROVEMENTS 0 0 0 C GREGG COUNTY HEALTH FACILITIES DEVELOPMENT CORPORATION 751865828 39753MDT2 2015-02-01 88000000 REFINANCING 0 0 0 A 99276418 96480044 636501 2159873 2012 0 1 1 1 B 33033015 2176874 8338548 660660 14045280 7811653 2014 0 1 0 1 C 77682622 87286972 8800000 804350 2015 0 1 0 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 1 0 0 0 1 0 0 0 0 0 C 0 1 0 0 1 0 0 0 0 A 0 B 0 C 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: GREGG COUNTY HEALTH FACILITIES DEVELOPMENT CORPORATION DATE THE REBATE COMPUTATION WAS PERFORMED: 11/07/2011 PART II LINE 3 $87,286,972 IS THE $88,000,000 LESS $713,028 UNDERWRITERS DISCOUNT FORM 990, PART VI, SECTION A, LINE 6 GSHS INC IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B A NUMBER OF DECISIONS OF THE ORGANIZATION ARE SUBJECT TO APPROVAL OF THE MEMBER OF THE ORGANIZATION. THESE RESERVED POWERS ARE STATED BELOW: A) BEGINNING JANUARY 1, 2007, APPROVE THE MEMBERS OF THE BOARD; B) BEGINNING JANUARY 1, 2007, REMOVE MEMBERS FROM THE BOARD AND SET SIZE OF BOARD; C) APPROVE THE ELECTION AND REMOVAL OF OFFICERS OF THE CORPORATION AND ESTABLISH, TERMINATE AND/OR REVISE ALL EMPLOYMENT CONTRACTS, COMPENSATION, AND BENEFIT PACKAGES OF THE OFFICERS OF THE CORPORATION; D) DESIGNATE THE FISCAL YEAR; E) APPROVE THE SELECTION AND REMOVAL OF INDEPENDENT AUDITORS, OUTSIDE GENERAL LEGAL COUNSEL, AND OUTSIDE INVESTMENT ADVISORS; F) AMEND THE ARTICLES OF INCORPORATION; G) AMEND OR REPEAL THE BYLAWS; H) APPROVAL OF ALL MERGERS, ACQUISITIONS, CONSOLIDATIONS, OR AFFILIATIONS WITH OTHER ENTITIES, THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION, OR THE SALE, MORTGAGE, OR ENCUMBRANCE OF ANY REAL PROPERTY OWNED BY THE CORPORATION; I) APPROVE THE DISSOLUTION OR LIQUIDATION OF THE CORPORATION; J) APPROVE CAPITAL PLANS, STRATEGIC PLANS, AND ANNUAL OPERATING AND CAPITAL BUDGETS; K) APPROVE ANY EXCEPTION TO THE CAPITAL BUDGET FOR A SINGLE ITEM OR RELATED ITEM THAT IS $500,000 OR MORE, AND APPROVE ANY OPERATING EXPENSE THAT EXCEEDS THE BUDGET BY $500,000 OR MORE; L) SELECT OFFICIAL DEPOSITORIES FOR THE CORPORATION'S FUNDS; M) CREATING OR INVESTING IN ANY SUBSIDIARY ENTITY OR ENTERING ANY PARTNERSHIP OR JOINT VENTURE; N) AUTHORIZATION OF ANY LOANS, GUARANTEES, OR INCURRENCE OF DEBT; O) THE COMMENCEMENT OF ANY LITIGATION OR OTHER LEGAL PROCEEDING, OR THE SETTLEMENT, DISPOSITION, OR TERMINATION OF ANY SUCH LITIGATION OR OTHER LEGAL PROCEEDING OR OF ANY CLAIM OR THREAT OF LITIGATION OR OTHER LEGAL PROCEEDING NOT FULLY COVERED BY INSURANCE; AND P) APPROVAL OF THE ADMISSION OF ADDITIONAL MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION HAS AN EXTERNAL ACCOUNTING FIRM AUDIT ON A CONSOLIDATED BASIS. INTERNAL ACCOUNTING PREPARES THE 990. THE 990 IS REVIEWED BY AN EXTERNAL ACCOUNTING FIRM. THE RETURN IS THEN REVIEWED BY INTERNAL ACCOUNTANTS AND EXECUTIVES PRIOR TO FILING. THE BOARD OF DIRECTORS WILL REVIEW BEFORE THE SUBMISSION DATE. FORM 990, PART VI, SECTION B, LINE 12C DISCLOSURES ARE OBTAINED ANNUALLY. THE BOARD REVIEWS AND APPROVES THE BOARD MEMBERS' DISCLOSURES, AND THE CEO REVIEWS AND APPROVES THE EMPLOYEES' DISCLOSURES. BOARD MINUTES REFLECT WHEN A BOARD MEMBER DECLARES A CONFLICT AND DOES NOT VOTE. FORM 990, PART VI, SECTION B, LINE 15 A COMPENSATION SUBCOMMITTEE OF THE BOARD NEGOTIATES CONTRACTS WITH EXECUTIVES THROUGH LONGNECKER & ASSOCIATES. THIS SUBCOMMITTEE OF THE BOARD REVIEWS AND APPROVES COMPENSATION AND BONUSES ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 GOOD SHEPHERD MEDICAL CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 14,696,745. MANAGEMENT AND GENERAL EXPENSES 15,886,750. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 30,583,495. PROFESSIONAL FEES CONSULTING: PROGRAM SERVICE EXPENSES 484,660. MANAGEMENT AND GENERAL EXPENSES 39,977. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 524,637. PROFESSIONAL FEES PHYSICIAN: PROGRAM SERVICE EXPENSES 11,843,281. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,843,281. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 865,353. CHANGE IN INTEREST IN NET ASSETS OF THE FOUNDATION 483,169. CONTRIBUTIONS OF OR FOR PROPERTY AND EQUIPMENT 158,023. GSHS INC 700 E MARSHALL AVE LONGVIEW TX 75601 752027157 SUPPORT GSMC TX 501(C)(3) LINE 11B, II N/A 0 GOOD SHEPHERD HOSPITAL AUXILIARY 700 E MARSHALL AVE LONGVIEW TX 75601 237203364 SUPPORT TX 501(C)(3) LINE 9 THE GOOD SHEPHERD HOSPITAL INC 1 GOOD SHEPHERD FOUNDATION INC 700 E MARSHALL AVE LONGVIEW TX 75601 752056700 SUPPORT TX 501(C)(3) LINE 11A, I THE GOOD SHEPHERD HOSPITAL INC 1 GSHS ADMINISTRATIVE SERVICES ORGANIZATION 700 E MARSHALL AVE LONGVIEW TX 75601 861132471 ADMIN SUPPORT TX 501(C)(3) LINE 11A, I GSHS INC 1 HARRISON COUNTY HOSPITAL ASSOCIATION 811 SOUTH WASHINGTON AVE MARSHALL TX 75670 752605699 HEALTHCARE TX 501(C)(3) LINE 3 GSHS INC 1 GOOD SHEPHERD MEDICAL CENTER - LINDEN 404 N KAUFMAN STREET LINDEN TX 75563 010829282 HEALTHCARE TX 501(C)(3) LINE 3 GSHS INC 1 GSMC - LINDEN FOUNDATION INC 404 N KAUFMAN STREET LINDEN TX 75563 200845127 SUPPORT TX 501(C)(3) LINE 11B, II GSHS INC 1 MARSHALL HOSPITAL FOUNDATION INC 811 SOUTH WASHINGTON AVE MARSHALL TX 75670 752605699 SUPPORT TX 501(C)(3) LINE 7 HARRISON COUNTY HOSPITAL ASSOCIATION 1 MARSHALL HEALTH SERVICES INC 811 SOUTH WASHINGTON AVE MARSHALL TX 75670 752580686 HEALTHCARE TX 501(C)(3) LINE 3 HARRISON COUNTY HOSPITAL ASSOCIATION 1 GS AMBULATORY SURGICAL CENTER 700 E MARSHALL AVE LONGVIEW TX 75601 900259782 SURGERY TX GSHS ENTERPRISES OPERATING #2 INC RELATED 0 0 GSHS ENTERPRISES INC 700 E MARSHALL AVE LONGVIEW TX 75601 752027162 HEALTHCARE TX GSHS INC C 1 GOOD SHEPHERD HEALTH NETWORK 700 E MARSHALL AVE LONGVIEW TX 75601 752554695 INACTIVE TX THE GOOD SHEPHERD HOSPITAL INC C 1 NORTHEAST TEXAS PHYSICIAN SE 700 E MARSHALL AVE LONGVIEW TX 75601 752712245 MGMT SERVICES TX GSHS ENTERPRISES INC C 1 GS PHYSICIAN SERVICES INC 700 E MARSHALL AVE LONGVIEW TX 75601 752762417 MEDICAL SERVICES TX GSHS ENTERPRISES INC C 1 GSHS ENTERPRISES HOLDING INC 700 E MARSHALL AVE LONGVIEW TX 75601 510412465 HOLDING COMPANY DE GSHS ENTERPRISES INC C 1 GSHS ENTERPRISES OPERATING 1 700 E MARSHALL AVE LONGVIEW TX 75601 752954772 HEALTHCARE DE GSHS ENTERPRISES INC C 1 GSHS ENTERPRISES OPERATING 2 700 E MARSHALL AVE LONGVIEW TX 75601 752954777 HEALTHCARE DE GSHS ENTERPRISES INC C 1 0 0 1 0 1 0 0 0 0 1 1 1 1 1 1 1 1 1 1 GOOD SHEPHERD FOUNDATION INC C 98340 CASH METHOD GOOD SHEPHERD FOUNDATION INC E 6057531 CASH METHOD GOOD SHEPHERD AUXILIARY C 144426 CASH METHOD