2016-08-12T12:29:26-05:00 2015-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2014-10-01 010234189 Northern Maine Medical Center NORT 2078343155 194 East Main Street Fort Kent ME 04743 Cindy Daigle CFO 2078343155 2016-08-12 1 Barbara J McGuan CPA P00219457 2077752387 2016-08-12 2014 2016-09-27 15:27:22Z Peter J Sirois 194 East Main Street Fort Kent ME 04743 48497511 0 X www.nmmc.org X 1948 ME Acute care & long term care hospital and mental health services facility. 11 9 567 65 8842 -10762 1493063 267936 45079671 47112667 -28811 203603 -1102134 386266 45441789 47970472 0 0 0 0 28081024 29106154 0 0 0 17003967 17611228 45084991 46717382 356798 1253090 42813880 46534755 17399129 19885645 25414751 26649110 The mission of Northern Maine Medical Center is to provide, coordinate, or support access to high quality, affordable health care and to positively impact our communities' quality of life by improving health status. 0 0 41358101 47212078 Medical care & ancillary services, nursing home & skilled services, physician services. 41358101 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 1 0 0 1 146 0 1 567 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 ME X Cindy Daigle 2078343155 194 East Main Street Fort Kent ME 04743 Norman Fournier President 2.00 1.00 X X 0 0 0 John Ezzy Vice President 1.00 0.50 X X 0 0 0 Glenn Lamarr Past Treasurer 1.00 0.50 X X 0 0 0 Mark Morneault Treasurer 1.00 0.50 X X 0 0 0 James Thibodeau Secretary 1.00 0.50 X X 0 0 0 Ronald Daigle Director 1.00 0.50 X 0 0 0 Dan Vaillancourt Director 1.00 0.50 X 0 0 0 Robert Bellefleur Director 1.00 0.50 X 0 0 0 Mark Chamberland Director 1.00 0.50 X 0 0 0 Michael Sullivan MD Director 50.00 0.50 X 649732 0 29659 David Desjardins Director 1.00 0.50 X 0 0 0 Don Guimond Director 1.00 0.50 X 0 0 0 Peter J Sirois CEO 50.00 1.00 X 249593 0 29526 Cindy L Daigle CFO 50.00 1.00 X 144257 0 25183 Mark Overton MD Psychiatrist 50.00 0.00 X 612101 0 19743 John Hallberg MD Orthopedic Surgeon 50.00 0.00 X 490557 0 25622 James Harris MD Physician 50.00 0.00 X 471795 0 29082 Baharak Bagheri MD Radiologist 50.00 0.00 X 455338 0 12615 David Coffman MD Surgeon 50.00 0.00 X 454732 0 14339 3528105 0 185769 37 0 1 0 The Sheridan Corporation PO Box 359 Fairfield ME 04937 Building Contractor 903715 Medhost of Tennessee Inc 2739 Momentum Place Chicago IL 60689 Software & Support Services 462449 Quest Diagnostics 12436 Collections Center Drive Chicago IL 60693 Off-Site Laboratory Services 415894 Erik St Pierre 194 East Main St Fort Kent ME 04743 Physician Services 382612 Cary Medical Center 163 Van Buren Rd Suite 1 Caribou ME 04736 Off-Site Laboratory Services 289469 14 267936 155000 267936 Patient Service Revenue 623000 77578327 77578327 Miscellaneous Revenue 623000 2080481 1945122 8842 126517 Meaningful Use Revenue 623000 167373 167373 Provision for Bad Debt 623000 -1571529 -1571529 Contractual/Char. Adj. 623000 -31141985 -31141985 47112667 40582 40582 101676 0 101676 101676 101676 164854 503500 108850 396483 56004 107017 163021 163021 71526 21706 49820 49820 Insurance Captive 900099 234770 234770 234770 47970472 47212078 8842 481616 1127950 679391 448559 23692482 20814063 2878419 352285 315116 37169 2367212 2088174 279038 1566225 1359033 207192 103634 89925 13709 49565 43008 6557 1642 1642 1645609 1427916 217693 49558 43002 6556 3148299 2731819 416480 2016661 1749882 266779 91594 79477 12117 370316 321328 48988 2630836 2282809 348027 1212386 1052003 160383 Medical Supplies 4846285 4846285 Health Care Provider Ta 981988 981988 Valley Medical Associat 387463 387463 Dues & Subscriptions 75392 65419 9973 46717382 41358101 5359281 0 X 121350 207129 9291835 7753926 5881188 6645339 6796 60060 24571 742033 831013 214423 324342 45860827 24954877 19695317 20905950 216322 2005563 489785 6094771 7836922 42813880 46534755 4756508 7330411 7895738 8239594 4746883 4315640 17399129 19885645 X 25056693 26302703 358058 346407 25414751 26649110 42813880 46534755 1253090 -18731 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8058 8058 0 Part II-B, Line 1: The Hospital pays dues to various organizations, a portion of which is attributable to lobbying expenses. 145224 145224 24992008 9852958 15139050 17293150 15101919 2191231 3430445 3430445 20905950 Deferred Compensation 798260 Cash Surrender Value of Life Insurance 201262 Interest in Synernet Reinsurance 905593 Meaningful Use Receivables 157037 Estimated Third-Party Payor Settlements 2511219 Insurance Claim Receivable 2775000 Due from Related Parties 488551 7836922 Deferred Compensation 798260 Estimated Third-Party Payor Settlements 3517380 4315640 X Part X, Line 2: The Medical Center and VMA are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the Code), and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Medical Center's tax positions and concluded the Medical Center has maintained its tax-exempt status, does not have any significant unrelated business income and has taken no uncertain tax positions that require adjustment or disclosure in the consolidated financial statements. 2015 Cancer Fund Tour 24528 24528 4971 240 2266 Emergency Room Fundraiser 46998 46998 600 5188 2994 5448 71526 71526 600 10159 3234 7714 21707 49819 1 1 X 1 X 1 X 0 1 0 1 1 394152 394152 0.00840 2949217 1893789 1055428 0.02260 3343369 1893789 1449580 0.03100 21850878 17691653 4159225 0.08900 21850878 17691653 4159225 0.08900 25194247 19585442 5608805 0.12000 1 884614 18461838 17705836 756002 X 1 0 2 1 Northern Maine Medical Center 194 East Maine Street Fort Kent ME 04743 www.nmmc.org 38126 X X X 2 Forest Hill 20 Bolduc Avenue Fort Kent ME 04743 X Licensed Hospital Related Facility Northern Maine Medical Center 1 0 0 1 X X X X X X X X X 13 1 1 0 1 X www.nmmc.org X 1 14 0 1 0 1 X 150.000000000000 200.000000000000 1 1 X X X 1 X http://www.nmmc.org/billing/ X http://www.nmmc.org/billing/ X X X X 1 X 0 X X X X 1 X 0 0 Northern Maine Medical Center Part V, Section B, Line 3j: Northern Maine Medical Center (NMMC) is located in Fort Kent, Maine (Aroostook County). Aroostook County is considered rural by the State of Maine and the United States Census Bureau. The hospital service area is primarily the St. John Valley. The following towns make up the St. John Valley region: Allagash, Eagle Lake, Fort Kent, Fort Kent Mills, Frenchville, Grand Isle, Madawaska, St. Agatha, St. David, St. Francis, Sinclair, Wallagrass, Winterville Plt., Van Buren and several surrounding towns and unorganized territories. In 2009, the percentage of Fort Kent residents with income below the poverty level was 36.4%. The percentage of children below the poverty level was 36.7% in 2009. The percentage of the population aged 65 and over was 18% in Aroostook County. The unemployment rate in Aroostook County was 9.3% in 2011, which was higher than the State's rate of 7.8%. Of the individuals 25 years or older in Aroostook County, 23% do not have a high school diploma compared to 15% overall in the State.Northern Maine Medical Center utilizes an electronic medical record system and its related physician practices abstract data for reporting to the ACO they are now a part of, which provides a vast amount of data relative to patients in care. The needs assessment provides a much broader picture of the community as a whole, including the health status of individuals not in care, as well as functional health status and social demographics (such as employment, income and education levels). The local units of the State's public health infrastructure (known as "Healthy Maine Partnerships") are also integrated into the process so that their data relative to health, environmental and social measures are part of the community dissemination process.Northern Maine Medical Center distributed the EMHS Qualitative Stakeholder survey link to their employees, volunteers, board members, donors, and other stakeholders. In the Fort Kent service area, key collaborators going forward will include: Northern Maine Medical Center and its owned physician practices, Cary Medical Center, The Aroostook Medical Center, Fish River Rural Health Center, local schools, Aroostook Home Health Services/Valley Home Health Services, Aroostook Mental Health Center, UMFK, and Twin Rivers.EMHS, the primary tertiary center utilized by Northern Maine Medical Center, routinely conducts a community health needs assessment (hereafter referred to simply as "needs assessment") across the service area of all of its member hospitals. The most recent assessment, published in 2014, was developed by EMHS to support their member organizations and community partners in their work to develop strategies that will improve the health of the people they all serve. The report's findings were analyzed and compiled by representatives of Hart Consulting, Inc. The report relates findings from three data sources: The Qualitative Stakeholder Survey conducted by EMHS with its stakeholders (June 2014), the University of Wisconsin Population Health Institute's County Health Rankings (2014), and OneMaine Health's Community Health Needs Assessment (2011). Northern Maine Medical Center Part V, Section B, Line 5: The 2014 Community Health Needs Assessment was developed by the Eastern Maine Health System (EMHS) to support member organizations and community partners' work to develop strategies that will improve the health of the people we serve. The consultants who developed the survey tool worked with individuals from a broad spectrum of backgrounds as follows: the Maine Center for Disease Control and Prevention, the District Public Health Liaisons, Federally Qualified Health Centers, Bangor Public Health and Community Services, Portland Public Health, and others who provided generous support and insights.Target audience was anyone with a vested interest in public health and healthcare including medical staff, community board members, volunteers, donors and members of the general public. The online survey was distributed as a website link via email across the eight participating Maine Counties of Aroostook, Cumberland, Hancock, Kennebec, Penobscot, Piscataquis, Somerset, Washington) by 17 partnering Maine Hospitals, 5 local Public Health Districts and 11 Healthy Maine Partnerships.On January 7, 2016, the Northern Aroostook Community Engagement Forum was held jointly with the area Public Health District Coordinating Council. A total of 33 individuals participated in the session. The following sectors were represented at the public forum:- Healthy Aroostook- Northern Maine Medical Center- Public Health Nursing- Aroostook Mental Health Services- Wabanaki Public Health- Town of Madawaska- UMFK Student- Power of Prevention- Fish River Rural Health - Maine Quality Counts- U. Maine Cooperative Extension- Visiting Nurses of Aroostook- Town of Fort Kent- The Aroostook Medical Center- Fiddlehead Focus News- Maine CDC- Pines Health Services- University of Maine at Fort Kent- Northern Maine Development Commission- Community Voices- Community Members Northern Maine Medical Center Part V, Section B, Line 6a: The following hospitals were included in the collaborative community health assessment: Cary Medical Center, Down East Community Hospital, Houlton Regional Hospital, Maine Coast Memorial Hospital, Mayo Regional Hospital, Millinocket Regional Hospital, Mount Desert Island Hospital, Northern Maine Medical Center, Redington-Fairview General Hospital. Northern Maine Medical Center Part V, Section B, Line 7d: The St. John Valley assessment was posted on the NMMC website in late 2014, as soon as it became available. The report is also available upon request. In 2015, a news article was published to inform the public that the report is available and how they can access it. The report is on the NMMC website and in addition, contact information is provided on the website for individuals who wish to request a free paper copy. Additionally, individuals may call NMMC to request a free copy. Northern Maine Medical Center Part V, Section B, Line 11: NMMC adopted an implementation strategy to address the health needs of the hospital facility's community and prioritized the health needs of its communities using the St. John Valley and Aroostook County Community Health Needs Assessment of 2014 conducted by EMHS. A Steering Committee composed of Northern Maine Medical Center administrative leadership and governing board was formed to evaluate the findings from the 2014 Community Health Needs Assessment survey for the St. John Valley and Aroostook County. The Committee was educated in the principles to be considered when assessing the survey findings. A summary of the Affordable Care Act provisions aimed at improving community health through direct investments in wellness and prevention at the individual and community level was also provided to members. The Committee identified priorities which were approved by the full governing board that subsequently designated responsibility to two separate work groups to develop a plan to address the prioritized needs over the next three years. 2015 CHNA overarching goals:1. Identify key stakeholders and harness resources to form partnerships with existing St. John Valley and Aroostook County groups who may be sharing similar goals that benefit the communities served.2. Educate members of the communities and other key personnel such as medical providers regarding available resources Prioritization of health needs in its community.Priority #1 Substance AbuseThe 2014 CHNA survey results for the St. John Valley demonstrated mental health and substance abuse as one of the top unmet healthcare needs and so it was chosen as priority number one. a. Affordable options for people who are uninsured or under insuredb. Pain management alternatives to prescription drugs/opioidsc. Substance abuse treatment providersPreventive screenings that survey respondents did not feel were very accessible in this category included:- Alcohol misuse screening - Social concerns in the survey findings included substance abuse. - Gaps were identified by respondents in healthcare services related to substance abuse treatment & detoxification.Action plan for Priority #12015-20161. Actions are being addressed in three distinct categories: prevention, screening and treatment. 2. The hospital Chief Operating Office, in collaboration with community partners (Power of Prevention and the Aroostook Mental Health Center) is coordinating educational opportunities which will be offered to local schools and civic groups on the effects of substance abuse.3. The Power of Prevention is working with law enforcement to increase checkpoints to screen for drunk driving.4. The Medication Lock Boxes, in collaboration with the Healthy Maine Partnerships, were launched in Madawaska through the Primary Care offices. The program was introduced at a public event in November of 2015. Coordination to provide the boxes in the Fort Kent provider offices is in progress.5. Discussions were held with Power of Prevention representatives to plan for formal training of primary care practice employees on SBIRT, Screening, Brief Intervention, Referral and Treatment. The training is planned for Spring of this year (2016). SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. The SBIRT model, developed by the Institute of Medicine, is a recommendation that promotes community-based screening for health risk behaviors, including substance abuse. The next step will be to implement the screening process in the Emergency Department and inpatient units. 6. NMMC fosters the community support group AA, Alcoholics Anonymous, in regards to their assistance with aftercare by allowing them to use physical meeting space at Forest Hill to hold meetings. Information about the support group is also provided to surrounding communities and included on NMMC's master list of support groups. 7. With a full complement of hospital social workers in 2016, there will be further collaboration with community partners to address the substance abuse priority as identified in the Community Health Needs Assessment. Specifically, an evidence- based tool will be adopted to screen patients for substance abuse in the hospital's inpatient Child and Adolescent Psychiatric Unit., (such as AC-OK which screens adolescents for co-occurring disorders). Priority #2 Healthy Food and NutritionThe 2014 CHNA survey results for the St. John Valley demonstrated top barriers that prevent healthy eating and thus was chosen as priority number two. a. Affordability of healthy food optionsb. Access to healthy food options in school/work environmentc. knowledge, attitudes and beliefs regarding nutritionPreventive screenings that survey respondents did not feel were very accessible included obesity screening.Action plan for Priority #22015-20161. Participation in the Let's Go! Program was pursued as planned. A meeting was held with the new Northern Aroostook County Let's Go! Program coordinator, Colette Thompson on 2/10/15. All three program components were considered for implementation: Healthy Workplace, Childhood Obesity Reduction, Support Healthy Families. It was determined that all three components add value and would be phased in over time to ensure the best success in each section and to create sustainability. By beginning with the Healthy Workplace, the benefit of engaging employees who will take home the message was seen as a first step to contributing to the community impact.2. A work session took place on 4/16/15 to define the level of commitment NMMC was prepared to undertake with the implementation of the Let's Go! Program. A formal training session was held for NMMC Department Directors and Supervisors as the first step. A Policy was drafted outlining nonfood or healthy food options for rewards. The philosophies of Let's Go are also supported in the community by offering healthy choices at events and making outdoor physical activity events available twice a year.3. Coordinate presentation to NMMC providers by Let's Go! Program director, Dr. Tory Rogers -Growing and Sustaining Let's Go! In Maine.Pediatrician, Dr. Tory Rogers, is scheduled to provide a CME program on 3/31/16 for NMMC Medical Staff related to the Let's Go! Childhood Obesity Reduction Program. If we decide to participate in the program, we may be able to utilize EHR data for tracking the impact of the program on reducing obesity. Dr. Rogers will also be meeting with the Chief Executive Officer on 3/31/16. 4. In January and February of 2016, partnerships continued to be developed with local organizations such as the Cooperative Extension Service, the University of Maine at Fort Kent, Healthy Maine Partnerships, the Power of Prevention, Public Health and the local food coop. 5. The Public Relations Director has become a member of the Clinical Community Linkages, a committee of the Power of Prevention. The committee is working on strategies to address food insecurities in the surrounding communities with the support of PICH, Partners in Community Health.6. A partnership was also created with Farm to Institution New England to begin a dialogue with local farmers to discuss strategies for affordability and access to fresh foods. Conference calls were held February 9, 16 & 24th. These calls were to identify key stakeholders in preparation for a roundtable presentation scheduled for March 9, 2016 where local institutions will identify needs and develop a plan to work with local farmers. Programs or resources to be used to address Priority #2Partners in Community HealthPower of Prevention, Clinical Community LinkagesHealthy Maine PartnershipLet's Go! MaineFarm to Institution Food ProgramSee continuation of Part V, Section B, Line 11 narrative on next page. Northern Maine Medical Center Part V, Section B, Line 22d: Individuals are billed at gross amounts and charges are adjusted accordingly, if they qualify for assistance. Northern Maine Medical Center Part V, Section B, Line 24: Individuals are billed at gross amounts and charges are adjusted accordingly, if they qualify for assistance. Part V, Section B, Line 11 Priority #3 Cardiovascular HealthThe 2014 CHNA survey results for the St. John Valley demonstrated top barriers that prevent people from being physically active. Aroostook County has the second highest prevalence of heart disease in Maine and so this need was selected as priority number three. a. Personal barriers (i.e., lack of time, motivation, values and beliefs)b. Weather conditionsc. Insufficient facilities or lack of access to facilities for exercisingAction plan for Priority #32015 -20161. A partnership was created with the Aroostook Area Agency on Aging to offer a Bone Builders class to local seniors. Bone Builders is a fitness program for people over the age of 50 which focuses on strength training, balance and includes such topics as fall prevention, osteoporosis, and nutrition. The partnership also involves the local Senior Citizen Center who will provide the space to offer the classes free of charge. The agreement was signed with the Aroostook Area Agency on Aging in early 2015. NMMC is providing hand and ankle weights free of charge to class participants. 2. A partnership was created with the Madawaska School system and the Recreation Department to open a Wellness Center which is open to the public. NMMC provided the equipment and start-up funds for renovating the physical space needed for the program. There are currently approximately 80 members.3. There is also a partnership in place with the Fort Kent School for a Wellness Center. The Center was open to the public for a period of time but is temporarily only open to school youth, school system staff and NMMC employees. The obstacle at this time is funding. The intent is to reopen to the public as soon as resources can be accessed.4. The NMMC Website upgrade was completed in the Spring of 2015. The site now offers a variety of health and wellness resources for members of the community. An electronic newsletter is also now available to subscribers on a quarterly basis. Two newsletters have been published. The NMMC website has over 80 subscribers to the electronic newsletter in addition to the distribution through a chamber of commerce database. An additional resource is also in the planning stages. The resource provides the public access to a user friendly, up to the day health, wellness and disease information site called Your Care Everywhere which links directly with NMMC's website and patient portals. 5. On a weekly basis, OffUGoAroostook, a service of the Aroostook Power of Prevention, circulates physical activity opportunities to subscribers to assist in broadening the availability of the health and wellness activities available around the St. John Valley and Aroostook County. NMMC's support comes in the form of expanding the circulation of the information to a broader population. 6. We are currently convening a community group to create a partnership that would offer more options to local seniors for free access to exercise facilities, especially for use during winter months. 7. NMMC Patient Educator was trained in February of 2015 along with two other RN's by the Pfizer Company to be able to offer 'Beat the Pack' smoking cessation program. The program has been offered twice since the training was completed. Advertising of the support is posted on the NMMC website and information about the program was offered at two community events in 2015; Twin Rivers Paper Company August 2015 and the Acadia Family Health Center Open House in November where they spoke with the public about smoking cessation opportunities.Programs or resources to be used to address Priority #3Aroostook Area Agency on AgingTown of Madawaska School SystemTown of Madawaska Recreation DepartmentTown of Fort Kent School SystemPower of Prevention, Off-U-Go AroostookNMMC believes the following community health needs are important however they were prioritized as secondary level priorities for various reasons. It is also important to note, as will be outlined further in this section, some work is being done to positively impact these needs. 1. Social concerns that include -Unemployment/economic opportunity -Domestic violence -Physical and social isolation -began partnering with the Aroostook Area Agency on Aging's Thrive in Place program for elders. On 1/29/15, clinical staff was trained to broaden their knowledge in the area of home environmental assessments which can also provide some socialization. We are working closely with the Aroostook Area Agency on Aging to address some of the physical and social isolation identified. -Affordable housing2. Preventive screenings and immunizations that survey respondents did not feel were very accessible. Those include: -Oral health -Depression screening - All primary care providers are using the PHQ depression screening tool as a first line depression screening. -Aging related screening - We have begun working with the Power of Prevention, Healthy Aroostook Coalition to address aging related screening and the possibility of educating providers on the use of CMS screening tools. -Tobacco use screening -this screening is done organization wide; the NMMC Patient Educator was trained last year along with two other RN's by the Pfizer Company to be able to offer 'Beat the Pack' smoking cessation program. The program has been offered twice since the training was completed. Advertising of the support is posted on the NMMC website and information about the program was offered at two community events in 2015. 3. Gaps in Healthcare Services: -Dental care -'First Tooth' program has been presented to the Family Practice Team for their consideration of adding this assessment tool to their patient visits. -Behavioral/mental health services for adults4. Issues Preventing Access to Care: -Out of pocket costs associated with insurance plans -Lack of insurance and unable to pay for the carea. A new section was added to the NMMC website to provide more access to information to assist the public. The website includes the Charity Care Eligibility and application and other resources to assist the public. A Patient Financial Counselor position was added as a means of support to patients as well. -Transportation -NMMC is partnering with the Aroostook Area Agency on Aging to address the issue of transportation. -Don't understand or value the importance of seeking care -Negative prior experiences -several initiatives have been undertaken to provide transparency to the people served by NMMC and to encourage open communication. a. Community Liaison Committee of the Board of Trustees was convened and is in its second year. b. We're Listening Campaign was launched in 2015 to inform the public of the importance of their feedback directly to NMMC. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Northern Maine Medical Center Part V, Section B, line 16b website: http://www.nmmc.org/billing/ Northern Maine Medical Center Part V, Section B, line 16c website: http://www.nmmc.org/billing/ Part I, Line 7: The amounts reported on Lines 7a & 7b were computed using a cost-to-charge ratio. Amounts on line 7g are derived from internal financial/cost accounting systems. Part I, Line 7g: Subsidized health services on line 7g include physician clinics, rural health centers, a skilled nursing facility, and emergency room. Part II, Community Building Activities: N/A Part III, Line 4: In evaluating the collectibility of accounts receivable, the Medical Center analyzes past results and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for doubtful accounts. Management regularly reviews data about these major payor sources in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Medical Center analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for doubtful accounts, if necessary. For receivables associated with self-pay patients (which include both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Medical Center records a provision for doubtful accounts in the period of service based on past experience, which indicates that many patients are unable or unwilling to pay amounts for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated or eligible) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged against the allowance for doubtful accounts. Part VI, Line 2: Please see Schedule H, Part V, Section B, Line 5 for a description of NMMC's assessment process. Part VI, Line 3: We notify patients and customers about access to assistance in various ways. The simplest way is the signage, pamphlets, and educational material located around the Organization and in various offices. In every patient access/patient financial services area is a sign explaining the availability of free/discounted care and the Federal Poverty Guidelines. There are also pamphlets located in the outpatient areas explaining free/discounted care and providing information on Mainecare. For inpatients, there is a book in each room which provides all the information on all programs available.Through the patient accounting department, we provide information aboutthese statements. We also counsel patients on the phone about all theprograms available whether it is Medicaid or a hospital program. Part VI, Line 4: Northern Maine Medical Center is a 94 licensed bed (29 A&P which includes swing beds, 6 ICU beds, 14 Psych beds, and 45 SNF beds), full-service, acute-care, not-for profit hospital located in Fort Kent, Maine (Aroostook County). The Hospital is accredited by the joint commission and its mission is to serve its communities with excellence in health care. Its services include acute inpatient, psych inpatient, SNF, 24-hour emergency center, diagnostic, and surgical services. Along with these hospital services, the Hospital employs/contracts with the majority of primary and specialty care physicians in the area. Part VI, Line 5: Northern Maine Medical Center is a local, not-for-profit hospital that serves its local communities and people regardless of their ability to pay. Northern Maine provides financial assistance and sliding scale discounts to self-pay and low-income patients. Also the Hospital participates in government-sponsored health care programs including Medicare, Medicaid, CHAMPUS, and Tricare. The volunteer board of trustees sets the strategic direction for the Hospital and is comprised of community members from the Hospital's service area. This group is made up of local business owners, professionals, and retirees. Northern Maine's non-profit status allows the Hospital to reinvest any excess of revenues over expense back into the Hospital to continuously improve the medical care it delivers. The Hospital allows access to healthcare that would otherwise be difficult. The Hospital is the main employer for the local physicians, including specialty physicians that would otherwise have to be accessed out of the area. X X X 0 0 0 0 0 0 0 1 0 Michael Sullivan MD Director 607232 0 25000 0 17500 0 7800 0 21859 0 679391 0 0 0 Peter J Sirois CEO 225593 0 24000 0 0 0 7667 0 21859 0 279119 0 0 0 Cindy L Daigle CFO 139257 0 5000 0 0 0 4394 0 20789 0 169440 0 0 0 Mark Overton MD Psychiatrist 612101 0 0 0 0 0 0 0 19743 0 631844 0 0 0 John Hallberg MD Orthopedic Surgeon 490557 0 0 0 0 0 5878 0 19744 0 516179 0 0 0 James Harris MD Physician 454295 0 0 0 17500 0 7800 0 21282 0 500877 0 0 0 Baharak Bagheri MD Radiologist 455338 0 0 0 0 0 2854 0 9761 0 467953 0 0 0 David Coffman MD Surgeon 454732 0 0 0 0 0 0 0 14339 0 469071 0 0 0 Part I, Line 7 The bonus paid to Peter Sirois, CEO, has set point criteria for earning specific bonus levels/amounts. The Board awards points based on the accomplishment of pre-established objectives/targets. Points are tabulated with the final score determining bonus level achieved. The Board meets with the CEO to discuss performance including those objectives/targets and based on that meeting award the points and derive the bonus amount. The bonus payment made to Cindy Daigle, CFO, was paid at the discretion of the Organization's CEO. The CEO communicates the bonus and amount directly with the Human Resources Director. The bonus paid to Michael Sullivan, M.D. was for reaching the goal of improving Accountable Care Organization measures by 25%. Daigle Oil Company Entity of which Dan Vaillancourt, Board Member, is an officer 123249 Independent Contractor Arrangement 0 Nola Sirois Family member of Peter Sirois, Hospital CEO 24008 Employment 0 Michelle L Plourde Family member of Peter Sirois, Hospital CEO 69033 Employment 0 Nicole Marquis Family member of Peter Sirois, Hospital CEO 39367 Employment 0 Robin Werntgen Family member of Glenn Lamarr, Past Board Treasurer 59153 Employment 0 James Daigle Family member of Cindy Daigle, CFO 13819 Employment 0 X 1 155000 Appraisal 1 0 1 0 Form 990, Part VI, Section A, line 2 Peter Sirois and Glenn Lamarr have a family relationship. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by the Organization's independent public accounting firm and thoroughly reviewed by the CFO and Controller. The completed form was sent electronically to Board members prior to the form being filed. Form 990, Part VI, Section B, line 12c The enforcement of the conflict of interest policy is achieved through annual reporting and ongoing monitoring. Form 990, Part VI, Section B, line 15 The Board of Directors determines the compensation of the CEO using compensation studies and comparability data. The CEO determines the compensation of other officers and key employees in a similar manner. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Northern Maine Medical Center 194 East Main Street Fort Kent, ME 04743 EIN: 01-0234189 Northern Maine Medical Center is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Valley Medical Association 194 East Maine Street Fort Kent ME 04743 223245434 Medical Physician Practice ME 501(c)(3) Line 3 Northern Maine Medical Center 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 Valley Medical Association R 387463 Actual Outlay