2016-05-11T10:14:20-05:00 2015-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Ste 2800 Minneapolis MN 554021538 990 2014-07-01 420680391 Mercy Hospital Iowa City Iowa MERC 3193390300 500 East Market Street Iowa City IA 52245 Michael G Heinrich Executive VP of Finance & CFO 3193390300 2016-05-05 1 Chris Meskimen P01314196 6123974000 2014 2016-08-17 19:52:53Z Michael G Heinrich 500 East Market Street Iowa City IA 52245 189376716 0 0928 X www.mercyiowacity.org X 1873 IA To heal and comfort the sick and improve the health of the community in the spirit of Jesus Christ. 13 12 1391 433 3582507 -501695 556006 658002 141590917 147218080 28997330 5994848 4167177 2841810 175311430 156712740 71237 53737 0 0 75169111 74930042 0 0 0 68828870 72771260 144069218 147755039 31242212 8957701 318244873 333980445 144201548 177920414 174043325 156060031 X Mercy Iowa City ("Mercy") heals and comforts the sick and works to improve the health of the community in the spirit of Jesus Christ and the Catholic tradition of the Sisters of Mercy. 0 0 102017081 148341299 Hospital Services. In keeping with our mission of healing and comforting the sick, providing hospital medical services is at the heart of what we do. These services are provided in inpatient and outpatient settings in situations that may be emergent, acute, or chronic. Services include a 24-hour emergency unit, intensive care, cardiovascular care and the services of a cardiac cath lab, maternity unit and newborn nursery, surgical services, cancer care, orthopedic care, digestive care, telemetry monitored care, medical care, stroke care, behavioral health care, skilled nursing, and hospice care. 799576 245405 Education. The ongoing education of Mercy staff members is critical in the fast-changing field of health care and is necessary to meet regulation and certification. Mercy hosts a number of professional continuing education conferences each year, attended by its own staff as well as staff from other institutions. In addition, Mercy provides a setting for many students who are considering or pursuing health care careers. For high school students, a health careers class gives students insight into possible careers and options; it also prepares students for the certified nursing assistant exam. Mercy works with students from health education programs that include the University of Iowa, Kirkwood Community College, and other local colleges, offering such options as a paid summer nursing internship program, a lab student rotation opportunity, and job shadow opportunities. The support and education of future health care providers is critical not only for Mercy but for the entire community. Mercy also hosts free community education seminars for the public. 3836946 53737 Community Benefit. Mercy's community benefits take many forms, beginning with traditional charity care of $1.6 million, and the unpaid cost of Medicaid ($2.2 million). Other examples are varied; they include cash donations to community non-for-profits such as the Free Medical Clinic, free meeting space to valued community organizations, leadership time and skills that further the work of community non-for-profits, first aid booths provided at public events. These efforts are detailed in Mercy's community benefit report, prepared annually. As a trusted, longtime member of the community, Mercy plays an important role not only in furthering community health but the general community good. 106653603 1 1 0 1 0 0 0 0 0 1 1 0 1 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 61 0 1 1391 1 1 1 0 0 0 0 0 0 0 0 0 0 X 13 12 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 0 1 1 1 1 1 X Kim Rossiter 3193393900 500 East Market Street Iowa City IA 52245 Mark Phillips Chair 1.00 1.00 X 0 0 0 Tim Krumm Vice Chair 1.00 1.00 X 0 0 0 Scott Fisher Secretary 1.00 0.00 X 0 0 0 Robert Beckman MD Board Member 1.00 1.00 X 0 0 0 SR Helen Marie Burns Board Member 1.00 0.00 X 0 0 0 Mark Danielson Board Member 1.00 1.00 X 0 0 0 Tom Goedken Board Member 1.00 0.00 X 0 0 0 Chuck McComas Board Member 1.00 0.00 X 0 0 0 Tom McLaughlin Board Member 1.00 0.00 X 0 0 0 SR Patricia Murphy Board Member 1.00 0.00 X 0 0 0 Mary Westbrook Board Member 1.00 0.00 X 0 0 0 SR Margaret Wright Board Member 1.00 0.00 X 0 0 0 Ronald R Reed President (CEO) & Administrator 40.00 2.00 X X 580440 0 71609 Jean M Berge Assistant Treasurer 40.00 1.00 X 167469 0 45631 Michael G Heinrich Treasurer 40.00 2.00 X 365363 0 55576 Cindy Penney Vice President 40.00 0.00 X 225945 0 34143 Andrew R Ashby MD Physician 40.00 0.00 X 451146 0 32131 Anjana Aggarwal MD Physician 40.00 0.00 X 472364 0 14585 Joseph Truszkowski MD Physician 40.00 0.00 X 531817 0 39234 RJoe Ewing MD Physician 40.00 0.00 X 682494 0 40120 Thomas Shreves MD Physician 40.00 0.00 X 686993 0 39131 4164031 0 372160 83 0 1 0 Cross Medical Laboratories 2406 Towncrest Drive Iowa City IA 52244 Laboratory Services 368150 Rohrbach Associates PC 325 E Washington Iowa City IA 52244 Engineering 233824 Iowa City Heart Center PC 540 E Jefferson Street Suite 303 Iowa City IA 52244 Physician Office 202330 Deloitte and Touche LLP 50 South 6th Street Minneapolis MN 55402 Audit Services 196773 Maquet Medical Systems 3615 Solutions Center Chicago IL 606773006 Medical Equipment Supplier 141885 7 658002 658002 Patient Serv. Revenue 621400 81019236 81019236 Medicare/Medicaid 621400 57818227 57818227 Lab Outreach 621511 3583722 3583722 ASC Income 900099 3331577 3331577 Program Relat. Revenue 621400 800411 800411 664907 664907 147218080 2982163 2982163 2892849 2159986 732863 732863 -1633 734496 33421659 95016 30258388 245602 3163271 -150586 3012685 3012685 Meaningful Use 900099 1047953 1047953 Cafeteria Income 722210 730755 730755 Access 621400 122788 122788 207451 197883 418 9150 2108947 156712740 145002982 3582507 7469249 41600 41600 12137 12137 1476215 771137 705078 58759242 43893454 14865788 3509689 2602434 907255 7009641 5197649 1811992 4175255 3095952 1079303 267341 267341 194532 194532 27253 27253 6949400 5194656 1754744 630120 3435 626685 12724996 7755748 4969248 4893514 642692 4250822 2389588 74250 2315338 325446 213864 111582 3094449 2279003 815446 12197611 10113965 2083646 1301616 1301616 Medical Supplies 15581000 15575759 5241 Pharmacy Supplies 3329076 3329076 Bad Debt Expense 2746430 2746430 Food Expense 1222072 1222072 4896816 1888290 3008526 147755039 106653603 41101436 0 9417152 3687475 3130700 2053343 25571518 26750967 73963 81085 4507969 4446770 4397784 2711765 283296830 172605964 92528099 110690866 136598047 139492346 23693233 19483592 691447 18326408 23890789 318244873 333980445 16082330 26053937 77931079 87225937 317634 139643 49870505 64500897 144201548 177920414 X 174043325 156060031 174043325 156060031 318244873 333980445 X 8957701 -3424762 -23516233 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED X 0 0 0 0 1 0 1 0 1 27253 27253 0 Part II-B, Line 1: Mercy Hospital, Iowa City, Iowa is a member of the Iowa Hospital Association (IHA) and American Hospital Association (AHA). A percentage of membership dues paid to IHA and AHA relate to lobbying activities. 16037323 213614 -138094 514606 15598237 14220862 324729 1990532 498800 16037323 12544119 779016 1391252 493525 14220862 12951892 165736 -117757 455752 12544119 10653690 451005 2031685 184488 12951892 0.56000 0.17000 0.27000 0 1 1 10234386 10234386 155314688 87999667 67315021 636656 580820 55836 72783984 55282082 17501902 44327116 28743395 15583721 110690866 Mercy Services Paid in Capital 1541821 C Investment in Mercy Services -837961 C Equity Investment in Joint Ventures 18779732 C 19483592 Beneficial Interest-Foundation 15959852 Due From Affiliates 6472326 Cash Value Life Insurance 239833 Deferred Financing Cost Other Assets 438760 Non-Compete Agreement Value 770000 2008/2011 Bond Funds 10018 23890789 Pension Benefit Liability 61682403 Fair Value of Interst Rate SWAP 2584494 Other Long-Term Liabilities 234000 64500897 X Part V, Line 4: All Restricted Endowed Funds are used for the benefit of Mercy Hospital Iowa City - capital equipment, employee grants, scholarships, etc. Part X, Line 2: As a result of the implementation of ASC 740, "As of June 30, 2015 and 2014, the Company recorded no liabilities for unrecognized tax benefits." 1 1 1 X 1 X 1 1 1 0 1 1 1605702 1605702 0.01110 9503637 7282320 2221317 0.01530 22693 12766 9927 0.00010 11132032 7295086 3836946 0.02650 450974 16807 434167 0.00300 4209 4209 0.00000 2715825 1760813 955012 0.00660 198527 198527 0.00140 3369535 1777620 1591915 0.01100 14501567 9072706 5428861 0.03750 25739 0 25739 0.00020 25739 25739 0.00020 0 885449 0 41905685 57494542 -15588857 X 1 1 1 Iowa City Ambulatory Surgery Center Outpatient Surgery Center 0.51000 0.49000 2 Corridor Radiology Outpatient Radiology Services 0.51000 0.49000 1 1 Mercy Hospital 500 East Market Street Iowa City IA 52245 X X X Skilled Nursing and Lab Outreach Mercy Hospital Iowa City Iowa 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X http://www.mercyiowacity.org/community_health X 1 12 0 1 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X 1 X http://www.mercyiowacity.org/patient-financial-assistance X http://www.mercyiowacity.org/patient-financial-assistance X X X X 1 X 0 X 1 X 0 0 Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 5: The hospital conducted two focus groups with participants from these organizations, representing broad and deep knowledge of community health needs:- Center on Aging, University of Iowa College of Public Health- United Way of Johnson County- Shelter House Homeless Shelter and Transition Services- Iowa City Area Development Group- Iowa City Community School District- Consultation of Religious Communities- Chamber of Commerce Secretary- Woofables Dog Biscuit Company- Iowa City Area Development Group- Johnson County Public Health Department- City of North Liberty- City of Iowa City- Consultation of Religious Communities- Iowa City Free Medical Clinics. Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 6a: As a non-for-profit and faith-based health care organization, Mercy Iowa City expresses its mission through a wide variety of activities. These activities include charity care, the unpaid cost of Medicaid, the unpaid cost of the State Children's Health Insurance Program (SCHIP), subsidized health services and community programs. These programs include varied activities, from providing medications and x-ray exams provided to Free Medical Clinic patients to resources that help high school and college students further their health care studies. Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 11: The 2012 CHNA summarized seven areas of opportunity for Community Health Improvement. Mercy Hospital is addressing those needs as follows:Access to Health Services:- Evaluate a mobile primary care clinic- Evaluate extended office hours in clinics- Use a more assertive approach to scheduling annual visitsAdvocate for Medicaid Expansion:- Expand access to Iowa Health and Wellness Plan participantsCancer:- Provide information to patients on colorectal and prostate cancerHeart Disease & Stroke:- Increase health survey and biometric screeningMental Health & Mental Disorders:- Increase awareness for NAMI and participate in the NAMI Walk fundraiser- Support United Way agencies focused on crisis intervention and mental healthNutrition, Physical Activity & Weight:- Support Blue Zones- Support community efforts to become a Blue Zone- Become a Blue Zone certified employerSubstance Abuse:- Support United Way agencies focused on helping individuals with substance abuse problems. Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 22d: Mercy Hospital determines on an individual basis based on the patient's ability to pay for the maximum amounts that can be charged to FAP-Eligible individuals for emergency and other medically necessary care. Patients, who fall under the 200% Federal Poverty Guidelines, are eligible for free care. Mercy Hospital uses the following factors to determine the amount to charge FAP-eligible patients for individuals who earn more than 200% of the FPG: Income level, Asset level, medical indigency, insurance status, uninsured discount, Medicaid/Medicare. In addition to the financial assistance policy, all uninsured patients are eligible for discounts ranging from 30-10% based on timeliness of payment. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Mercy Hospital, Iowa City, Iowa Part V, Section B, line 16b website: http://www.mercyiowacity.org/patient-financial-assistance Mercy Hospital, Iowa City, Iowa Part V, Section B, line 16c website: http://www.mercyiowacity.org/patient-financial-assistance 1 Mercy Home Health Care 500 East Market Street Iowa City IA 52245 Home Health & Private Duty Nursing Part I, Line 7: Amounts in the table were derived using a cost accounting system that addresses all patient segments. A cost to charge ratio derived from completing IRS worksheet 2 was used to determine the amounts in Part I, Line 7a, 7b, 7c, and 7g. Part I, Ln 7 Col(f): Bad debt expense of $2,746,430 was subtracted for purposes of calculating the percentage in Schedule H, Part I, Line 7, column (f). Part II, Community Building Activities: Economic development:Mercy works with such groups as the Iowa City Area Chamber of Commerce and Iowa City Area Development Group to support the business community, welcome innovation to the area, and develop the workforce. Community support:Mercy has provided extensive support for more than 20 years to United Way of Johnson County. Mercy holds its own United Way campaign with employees each autumn (typically raising more than $100,000 each year) and provides much staff time and support to the local United Way organization. Mercy is also a location for SHIIP (Senior Health Insurance Information Program) counseling with trained volunteers who provide the service.Mercy has been a community leader in helping others achieve food parity and regularly directs excess food to Table to Table, a local organization that collects wholesome, edible food from donors and redirects it to local shelters and agencies to serve the hungry, homeless and at-risk population.Environmental improvements:Mercy has been a good neighbor for its closest neighbors by maintaining its buildings and landscaping at a high level. Mercy also pursues extensive recycling (including newspapers, magazines, office paper, plastics, batteries, cooking oil, construction materials, and more) and programs that reduce energy consumption. Mercy regularly holds silent auctions open to employees to sell equipment that is no longer needed, rather than sending it into the trash stream. Mercy has a Sustainability Committee to further and standardize these efforts.Leadership development and training for community members:Mercy lends support to the Iowa City Area Chamber of Commerce annual Community Leadership Program. In this nine-month program, 24 members of the civic community receive an in-depth look at the workings of local government, public works, education system, health care, arts community, and more. This program gives participants a better understanding and appreciation of the entire community and develops fellowship among members from diverse backgrounds and settings.Coalition building:Mercy is involved in many ways with local citizens and groups that are working to afford all members of our community a good quality of life and to improve the overall quality of life. Beginning in January 2014, Mercy provided the use of a small building on its campus to the Iowa City Blue Zones project group. Their four staff members from Blue Zones Project/Wellmark worked in Iowa City for 18 months to advance community health initiatives.Mercy is a cosponsor of and provides leadership for the 23-year-old Johnson County Safe Kids Coalition, a grass-roots effort to reduce unintentional injuries to children from birth to age 14. Since its inception, the coalition has been active in promoting bike helmet use, bike safety, and safety education events.Mercy is also involved with the local effort Honoring Your Wishes, whose mission is to promote and sustain a community-wide advanced care planning process. The effort that resulted in Honoring Your Wishes began in December 2010 and Mercy has been involved since the beginning. Community health improvement advocacy:Healthy Kids Community Care is a school-based clinic that provides health care to children who have no other access to it. Mercy made large cash donations over a period of five years to help launch this initiative and provided key leadership as the program developed. Mercy has also provided financial support to the Free Medical Clinic, which saw more than 1,900 unique patients in almost 5,500 clinic visits in FY2015. Those who seek care of the Free Medical Clinic typically have no other access to health care services. As noted under "Coalition Building," Mercy is also closely involved with the Blue Zones Project in Iowa City. Part III, Line 2 The amount of bad debt expense reported on line 2 was derived from taking actual bad debt write-offs and applying the cost to charge ratio of .3224 to that amount. Part III, Line 3 Mercy Hospital works with those qualifying for charity care along every step of the process. Every effort is made to work with the patient to provide financial assistance when appropriate. While there are people who do not cooperate with Mercy Hospital regarding payment plans, financial assistance or with those trying to get help from government programs. For individuals not providing necessary information it is impossible to know the reason for not cooperating and therefore know whether they will qualify for charity care. Mercy Hospital is unable to reasonably determine whether any amount of bad debt could have been classified as charity care if the individuals do not provide the necessary information to evaluate their situation to determine qualifications with the charity care policy. Part III, Line 4: Mercy Hospital's Audited Financial Statements includes a footnote for the Provision of Uncollectible Accounts on page 12 and 13 of the Audited Financial Statements. Part III, Line 8: Mercy Hospital does not include Medicare shortfalls as part of its community benefit. Total revenue was determined using charges per the CMS Provider Statistical Reimbursement System reports for Fee Reimbursed Services for the fiscal year ended 6/30/15. Costs calculated using the Cost to Charge Ratio for the appropriate services from the submitted Medicare Cost Report form 2552-96 for the fiscal year ended 6/30/15. Part III, Line 9b: Mercy Hospital has two policies related to debt collection. The Financial Assistance Policy provides guidelines for forgiving all or part of a patient's financial responsibility for healthcare services received at Mercy Hospital. Patients may be given a financial assistance application at the time of service, be offered financial assistance during the normal collection process or learn of the option on the Hospital website. All patients with no insurance are offered financial assistance via billing statements & follow up telephone calls. Any patient that is known to qualify for financial assistance is provided assistance. The payment plan policy enables those who qualify for partial financial assistance to establish payment plans of the remaining balance of their bill. Part VI, Line 2: The most recent community health needs assessment was conducted in Fall 2012. The organization engaged Professional Research Consultants to conduct the assessment. The community health survey is a systematic, data-driven approach to determining the health status, behaviors and needs of residents in the communities the organization serves. The survey instrument used for the assessment is based largely on the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS), as well as various other public health surveys and customized questions addressing gaps in indicator data relative to national health promotion and disease prevention objectives and other recognized health issues. Part VI, Line 3: Evaluation for Medicaid, disability, and other types of coverage is provided for uninsured patients for inpatient stays as well as high dollar outpatient services. The evaluation is conducted during the children called hawk-i. Information about hawk-i is provided at registration points. Part VI, Line 4: Mercy Hospital is located in the community of Iowa City, Iowa, in Johnson County in the east central part of the state. The county's population in 2014 was approximately 139,000. From 2000 to 2008 Johnson County experienced strong population growth of 15.4 percent, compared to 2.6 percent for the entire state. Mercy Hospital serves 10 counties in southeast Iowa, with the primary service area being Johnson County. The secondary service area includes Cedar, Iowa, Muscatine and Washington counties. The tertiary service area includes Henry, Jefferson, Keokuk, Lee and Louisa counties. The population of the service area is approximately 330,000.Iowa City is home to the University of Iowa, which has an enrollment of approximately 31,000 for the 2015-2016 academic year. Johnson County is well-educated; of individuals 25 and older, 95.3 percent are high school graduates and 50.6 percent hold a bachelor's degree or higher.The University of Iowa also provides the foundation for an economy that has particular strengths in education, health care, services, technology, agribusiness, and manufacturing.According to the U.S. Census Bureau, 17.6 percent of the Johnson County population lived below the poverty line between 2008 and 2012, compared to 12.2 percent for the entire state. Part VI, Line 5: Mercy Iowa City is a faith-based institution that provides services based on the ethical and religious directives of the Catholic Church. An important part of Mercy's mission is to improve the health of the community. Mercy does so by: Ensuring that the medical staff is open to all qualified physicians; ensuring that the hospital is accredited and in good standing with The Joint Commission; ensuring that the board of directors is comprised of diverse, independent individuals, not employees of the hospital, representing the community and also providing necessary expertise; establishing and carrying out a conflict of interest policy; providing a site for clinical experience for a variety of health care professionals; providing charity care and financial assistance with medical bills as needed to community members; participating in such programs as Medicare, Medicaid, and hawk-i, an insurance program for needy Iowa children; absorbing unreimbursed costs for such government programs; ensuring that account collections are carried out in compliance with state and federal guidelines; providing emergency room services and working with local and state officials in community prepardness issues; treating emergency patients according to EMTALA guidelines and serving all patients regardless of their ability to pay; investing surplus funds in services, technology, and personnel that will further the benefit of the community. Part VI, Line 7, Reports Filed With States IA 1 American Heart Association-Midwest Affiliate PO Box 4002902 Des Moines IA 503402902 135613797 501(c)(3) 7500 Iowa City Events Sponsor Iowa City Free Medical Clinic 2440 Towncrest Drive Iowa City IA 52240 420960955 501(c)(3) 13000 General Support Iowa City Area Development Group 316 East Court Iowa City IA 52240 421234837 501(c)(6) 12000 General Support 2 1 Temporary Assistance Program 20 12137 Part I, Line 2: All organizations Mercy provides assistance to are local organizations. Therefore, Mercy is in frequent contact with the organizations and is generally aware of their use of Mercy's assistance. However, there is no formal mechanism in place to track specific uses of the assistance. Mercy Hospital offers a Temporary Assistance Program (TAP) for emergency financial needs that employees may have. This confidential program offers crisis assistance and health benefit assistance. X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 Ronald R Reed President (CEO) & Administrator 442400 0 72725 0 65315 0 31607 0 40002 0 652049 0 39791 0 Jean M Berge Assistant Treasurer 158546 0 4177 0 4746 0 29169 0 16462 0 213100 0 0 0 Michael G Heinrich Treasurer 299666 0 49896 0 15801 0 15812 0 39764 0 420939 0 14345 0 Cindy Penney Vice President 179057 0 30661 0 16227 0 11404 0 22739 0 260088 0 11805 0 Andrew R Ashby MD Physician 450856 0 0 0 290 0 0 0 32131 0 483277 0 0 0 Anjana Aggarwal MD Physician 412226 0 60000 0 138 0 0 0 14585 0 486949 0 0 0 Joseph Truszkowski MD Physician 511213 0 19894 0 710 0 0 0 39234 0 571051 0 0 0 RJoe Ewing MD Physician 654943 0 25834 0 1717 0 0 0 40120 0 722614 0 0 0 Thomas Shreves MD Physician 650691 0 24449 0 11853 0 0 0 39131 0 726124 0 0 0 Part I, Line 1a Health club membership dues were paid for Mercy's CEO, Ronald Reed in the amount of $890.40 and were included as taxable income on his W-2. Part I, Line 4b Mercy established an IRC Section 457(f) plan as a way of retaining executives, officers and select groups of highly compensated employees with supplemental retirement benefits. The following individuals participated in and received payments from the plan. - Ronald Reed - $39,791 - Cindy Penney - $11,805 - Michael Heinrich - $14,345 Part I, Line 7 Non-fixed payments were provided to administrators and physicians who met stated criteria that included meeting certain RVU (Relative Value Unit) productivity levels, specified CMS/JCAHO performance core indicators and certain patient satisfaction and/or nursing satisfaction survey scores. A City of Hills Iowa 420920947 431669AA8 2008-04-29 39235000 Refund Bonds issued 10/19/2005 0 0 0 B City of Hills Iowa 420920947 431669AW0 2011-11-30 44742571 Build and Equip Facility; Refund Bonds issued 7/16/1998 0 0 0 C Iowa Finance Authority 521699886 2010-12-22 9375000 Construct Medical Office Building 0 0 0 A 3180000 39325000 278380 96759 38859861 1 0 1 1 B 4675000 44744001 589874 19972014 24151438 30675 1 0 0 1 C 803102 9375000 9375000 0 0 1 1 A 0 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 C 1 1 1 0 0 0.00000 0.00000 1 0 1 A 0 0 1 0 1 1 Piper Jaffray 27.000000000000 0 0 0 0 1 B 0 1 0 0 0 0 0 1 1 C 0 0 1 0 1 1 Bankers Trust Company 10.000000000000 0 0 0 0 1 A 1 B 1 C 1 Schedule K, Part II, Line 3: Differences between the issue price (Part I) and total proceeds (Part II, line 3) are due to investment earnings. Schedule K, Part III, Lines 4 and 7, Column C: A substantial portion of the proceeds of the bonds was used for private activity purposes. These bonds are Midwest Disaster Area Bonds, which are exempt facility bonds under IRC section 142 as provided by section 702 of the Heartland Disaster Tax Relief Act of 2008. Such bonds, while expected to have up to 100% private business use and to meet the private security or payment test, are qualified bonds by statute. Schedule K, Part IV, Line 6, Column B: Such amounts were appropriately yield restricted. Michael G Heinrich Officer Split Dollar Life Insurance Policy X 26194 26194 0 0 0 Ronald R Reed Officer Split Dollar Life Insurance Policy X 52696 52696 0 0 0 Cindy L Penney Officer Split Dollar Life Insuarnce Policy X 2195 2195 0 0 0 81085 Form 990, Part VI, Section A, line 2 Sister Helen Marie Burns, board member; Sister Patricia Murphy, board member; and Sister Margaret Wright, board member; are all members of the Sisters of Mercy of the Americas West Midwest Community. Form 990, Part VI, Section A, line 6 Mercy's sole member is the Sisters of Mercy of the Americas West Midwest Community, Inc. Form 990, Part VI, Section A, line 7b Mercy's sole member, Sisters of Mercy of the Americas West Midwest Community, Inc., maintains a number of "reserved powers" including but not limited to approval of annual budgets, approval of amendments to the articles of incorporation and bylaws, approval of real property transactions and approval of long term borrowing. Form 990, Part VI, Section B, line 11 The Form 990 is prepared and reviewed by Mercy Hospital management and is also reviewed by Deloitte Tax LLP. In addition, a board resolution was established that provides that each board member be (i) provided a copy of the Form 990 as it is intended to be filed, and (ii) given a reasonable opportunity before filing to provide to the Audit Committee any comments, corrections, concerns or other input on the proposed Form. The Audit Committee's review process shall be intended to reasonably verify that the Form 990 has been fully and accurately completed, including but not limited to, all inquiries therein relating to corporate governance. After completing its review, the Audit Committee, on the Board's behalf, shall have the authority to authorize the filing of the annual Form 990. Form 990, Part VI, Section B, line 12c A conflict of interest statement is signed at the beginning of Board members term and on an annual basis there after. Any abstention from a vote is recorded in Board minutes. After the fiscal year end a "look back" questionnaire is distributed to all Board members to disclose any conflicts of interest that may have taken place in the previous year. Form 990, Part VI, Section B, Line 13: Per IRS guidance, because the board had not formally adopted the whistleblower policy as of 6/30/15, the organization has answered "No" to this question. Mercy has an Administrative team "A Team" which is made up of Vice Presidents and the CEO that has been delegated by the board of directors to manage and approve policies. The A Team has approved the whistleblowers policy. Form 990, Part VI, Section B, line 15 Compensation for all executives and other key employees is determined based on national or regional market data for comparable positions at comparatively sized hospitals. The Executive Committee of the Board of Directors uses this market-based information to set the President and CEO's compensation. In turn, the CEO uses the same information to set compensation for officers and key employees, which is also approved by the board. Form 990, Part VI, Section C, line 19 Mercy's governing documents and conflict of interest policy are not available to the public. Form 990, Part XI, line 9: Change in Unrecognized Pension Actuarial Loss -13,641,730. Change in Beneficial Interest in Foundation -496,894. Change in Beneficial Interest in Services -9,377,609. UDM LLC 500 East Market Street Iowa City IA 52245 271456513 Health Clinics Building IA 63471 14964804 Mercy Hospital Mercy Foundation 500 East Market Street Iowa City IA 52245 237040506 Foundation/Fundraising IA 501(c)(3) 11-I Mercy Hospital 1 Mercy Hospital Iowa City Iowa Self Insurance Plan & Trust 500 East Market Street Iowa City IA 52245 426591803 Self Insurance IA 501(c)(3) 11-I Mercy Hospital 1 Sisters of Mercy of the Americas West Midwest Community Inc 7262 Mercy Road Omaha NE 68124 262400800 Religious Order NE 501(c)(3) N/A 0 Mercy Hospital Guild 500 East Market Street Iowa City IA 52245 426099912 Fundraising IA 501(c)(3) 11-III-FI N/A 0 Cancer Care of Iowa City LLC 613 East Bloomington Suite 100 Iowa City IA 52245 421460774 Oncology Services IA Mercy Hospital Related -235658 230140 0 0 0.53360 Iowa City Ambulatory Surgical Center LLC 2963 Northgate Drive Iowa City IA 52245 208503424 Outpatient Surgery IA Mercy Hospital Related 3733589 5301034 0 1 0.51000 Corridor Radiology LLC 2769 Heartland Drive Suite 307 Coralville IA 52241 460635070 Radiology Services IA Mercy Hospital Related -317759 2405719 0 0 0.51000 Mercy Services Iowa City Inc 500 East Market Street Iowa City IA 52245 421241044 Medical Clinic Services IA Mercy Hospital C -9330404 8711604 1.00000 1 1 1 1 0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 Cancer Care of Iowa City A 124472 Cost Mercy Foundation C 658002 Cost Mercy Services Iowa City Q 3449047 Cost Mercy Services Iowa City R 5000000 Cost Mercy Foundation Q 259995 Cost