2015-11-13T16:24:12-06:00 2014-12-31 420714325 RSM US LLP 1001 Lakeside Ave Suite 200 Cleveland OH 441141152 990 2014-01-01 341425870 Lake Hospital System Inc LAKE 4403541991 7590 Auburn Road Concord OH 44077 Michael E Kittoe Senior VP Finance & CFO 4403541991 2015-11-13 1 ZACHARY FORTSCH P00052725 2165231900 2014 2016-04-25 22:37:26Z Lake Health Cynthia Moore-Hardy 7590 Auburn Road Concord OH 44077 514014984 0 X www.lakehealth.org X 1983 OH To provide health care services to the residents of Lake County and neighboring communities in partnership with those who share a commitment to local access, healing with compassion and superior quality. 11 11 3042 926 1518121 0 1399033 2673507 334131502 357227642 5173201 10369637 9901395 8814622 350605131 379085408 0 0 0 0 137000217 135754688 0 0 0 208126992 224911350 345127209 360666038 5477922 18419370 538843712 552445897 278825573 296169541 260018139 256276356 X It is Lake Hospital System's mission to provide comprehensive health care services to the residents of Lake County and neighboring communities in partnership with those who share a commitment to local access, healing with compassion and superior quality. 0 0 314162665 357803642 As an independent, community-based hospital system, Lake Hospital System, Inc., DBA Lake Health, has had a long-standing tradition of providing services and programs based on the health care needs of the communities that we serve. We are guided by our mission to provide local access, healing with compassion and superior quality and our core values - respect, innovation, teamwork, stewardship, and integrity. Lake Health's growth as a community-based health care system continues to build on its long history of providing progressive, personalized care that you normally wouldn't expect to find at a community hospital. Guided by a collaborative health needs assessment conducted in cooperation with the Lake County General Health District, Lake Health has developed (refer to Sch O, pg. 74 for additional information)program services and partnerships to address the most pressing health issues. The high priority areas include obesity, inactive lifestyles, and smoking. Lake Health is comprised of 12 facilities in Lake, Geauga, and Cuyahoga counties, which include the following:1. TriPoint Medical Center (full-service, acute care hospital)2. West Medical Center (full-service, acute care hopsital)3. Mentor Campus (outpatient lab and diagnostics, physician offices, cancer services)4. Chardon Campus (urgent care, outpatient lab and diagnostics, physician offices)5. Willowick Campus (urgent care, outpatient lab and diagnostics, physician offices)6. Tyler Blvd. Urgent Care (urgent care, occupational health)7. Madison Campus (free-standing ER, outpatient lab and diagnostics, physician offices, physical therapy)8. Clinic at Madison (walk-in care located in Walmart Supercenter)9. Painesville Quick Care Center (walk-in care)10. Willoughby Hills Diagnostics (outpatient imaging)11. Mentor Physical Therapy (physical therapy)12. Willoughby Physical Therapy (physical therapy)Accessibility is key to our mission. We have contracted with most insurance providers to ensure a vast array of primary care physicians and specialists. Lake Health also operates three full-service emergency departments within Lake County at TriPoint Medical Center in Concord Township, West Medical Center in Willoughby, and the free-standing Madison Emergency Department within the Madison Campus. These emergency departments are open to all persons, regardless of ability to pay. For the twelfth year in a row, we were honored as one of Northcoast 99's "Best Places to Work in Northeast Ohio." Our growth as a hospital system reflects the many ways we are building on our mission and how we aspire to be more than your typical community hospital. We want our patients to receive superior patient care without having to leave the community, and that's why we are committed to bringing the best resources together to provide an expanded level of community care. Lake Health provides services and programs based on the health care needs of the communities we serve. In fact, taking health programs and screenings to where people live, work and play is fundamental to our mission. In 2014, we provided just under $23,200,000 in financial assistance and certain other community benefits at cost through our health system operations in Lake and Geauga counties. This includes over 250 community education programs. We also contributed over $348,000 in 2014 in cash and in-kind donations to civic and community events, programs, and partnerships with a health and wellness focus. Some of the programs and events are highlighted below. Many of them are facilitated through our Health Promotion Department and/or our community outreach coordinator. Community Programs and Events:-American Heart Walk-Hands-only CPR training-Cardiac Health Education Programs-Baby Talk programs including Childbirth Preparation, Infant Care, Breastfeeding Program, Sibling Program, Infant and Child CPR, TEEN Childbirth Preparation, Caring for Kids, and Car Seat Checks. -Get Healthy Lake County B Fit 4 Life-Healthy Heart Program-LifeCycles for Women lectures-Senior Connection Lunch & Learn programs-Support Groups which include Breast Cancer, Diabetes, Mended Hearts Cardiac, Pulmonary, and Stroke-Participation in the United Way Day of Caring-Women's Health Screening ProjectLake Health joined forces with Lake Metroparks, Lake County YMCA, and the Lake County General Health District again in 2014 to continue B Fit 4 Life (formerly Get Healthy Lake County), a countrywide initiative that features education, prevention, and wellness programs to enhance and improve the quality of life in Lake County and neighboring communities. The initiative includes the B Fit 4 Life Corporate Challenge in which area businesses vie for the most points as their employees exercise their way to better health. 314162665 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 1 308 0 1 3042 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 OH X Lisa Mothersbaugh 4403541984 7590 Auburn Road Concord OH 44077 Thomas P Jubeck Chair 0.10 X X 0 0 0 Michael E Mayher Vice Chair 0.10 X X 0 0 0 Paul C Sirko Secretary/Treasurer 0.10 X X 0 0 0 Kathleen Bates Trustee 0.10 X 0 0 0 I James Hackenberg Esq Trustee 0.10 X 0 0 0 Frank Myers DO Trustee 0.10 X 0 0 0 Susan Tullai-McGuinness RN PhD Trustee 0.10 X 0 0 0 John F Platz Trustee 0.10 X 0 0 0 Robert G Schiebli Trustee 0.10 X 0 0 0 Richard S Morrison Trustee 0.10 X 0 0 0 Don Brinberg MD Trustee 0.10 X 0 0 0 Cynthia Moore-Hardy President & CEO 40.00 X 699316 0 496827 Michael E Kittoe Senior VP Finance & CFO 38.00 2.00 X 397371 0 101202 Steven R Karns Senior VP Administrative Services 40.00 X 285524 0 215416 Richard D Cicero Senior VP Business Development 37.00 3.00 X 249087 0 97437 Michael Goler MD Senior VP Medical Affairs 39.00 1.00 X 363256 0 19888 Mary L Ogrinc Chief Nursing Officer 40.00 X 270123 0 170593 Joyce A Taylor VP Quality Services 40.00 X 218829 0 27185 Cynthia J Racer VP Clinical Services 40.00 X 173366 0 9695 Craig J Ghidotti VP Human Resources 40.00 X 160374 0 16449 Andrea Wasdovich-Duffner VP Perioperative & Acute Care 40.00 X 166582 0 19981 Jerrold Peters VP Information Technology 40.00 X 162818 0 42162 3146646 0 1216835 54 0 1 0 Siemens Corporation PO Box 120001 Dept 0733 Dallas TX 75312 Medical Services 5201295 Sodexo Inc & Affiliates PO Box 905374 Charlotte NC 28290 Facilities Services 3011474 Crothall Healthcare Inc 13028 Collections Drive Chicago IL 60693 Facilities Services 2815985 Community Hospitalist LLC 30680 Bainbridge Road Solon OH 44139 Medical Services 1399524 Paris Healthcare Linen Service PO Box 1043 DuBois PA 15801 Hospital Linen Services 1301292 223 2097507 576000 900000 2673507 Patient Care 621110 357227642 355846346 1381296 357227642 6523981 6523981 230585 230585 2481678 0 2481678 2481678 136825 2344853 138544647 134929576 3615071 3615071 3615071 CMS Incentive Payments 621110 1849405 1849405 Related Sales and Services 621110 1250376 1250376 Purchase Discounts 621110 563132 563132 2670031 2670031 6332944 379085408 355846346 1518121 19047434 X 2650725 2650725 110226820 95166825 15059995 2290952 1931497 359455 12702316 10980008 1722308 7883875 6646879 1236996 4124510 1176218 2948292 1433931 860359 573572 110824 110824 1293083 1293083 50610351 41931908 8678443 3155751 2640865 514886 7580095 6582816 997279 8304441 7125029 1179412 14666884 13218961 1447923 753271 645956 107315 113977 55732 58245 5309291 5196269 113022 25374500 18790339 6584161 4878004 4309605 568399 Medical Supplies 47284062 47284062 Bad Debt 43988130 43988130 Hospital Franchise Fee 4638037 4638037 Membership Dues 769387 697345 72042 522821 295825 226996 360666038 314162665 46503373 0 4052187 6255246 37957265 43502059 3683797 4365790 11417365 11907809 516102902 278486204 241593845 237616698 225600779 234599585 14538474 14198710 538843712 552445897 27414562 31092559 689036 558402 213176282 209877015 37545693 54641565 278825573 296169541 X 260018139 256276356 260018139 256276356 538843712 552445897 X 18419370 -1384163 -20776990 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 0 1 21347 21347 0 Part II-B, Line 1b Paid wages of VP, Governmental Affairs and Public Relations, in the context of networking and maintaining relationships with individuals and entities that create, influence, vote, or otherwise determine policy for the healthcare industry and hospitals specifically. Part II-B, Line 1g Occurs in the routine course of business for educational, compliance, and policy issues relative to Lake Health for the VP, Governmental Affairs and Public Relations. Part II-B, Line 1i Membership dues paid to Hospital industry Associations and Organizations, the percentage of which is reported under IRS rules as lobbying expense. 4690654 318956 123314 10000 624402 4498522 4014355 919340 479684 24327 698398 4690654 4906425 271543 209789 1373402 4014355 5629760 403229 -24347 1102217 4906425 6225581 262613 104682 963116 5629760 0.65180 0.34820 0 1 1 12956999 12956999 187717122 55210648 132506474 2481715 1334043 1147672 283291560 214849634 68441926 29655506 7091879 22563627 237616698 Third Party Settlements 2765198 Workers Compensation Liability 1972978 Deferred Compensation 2981662 Lease Obligation 2384338 Accrued Self-Insurance 1041692 Physician Agreements 344798 Interest Rate Swap 43150899 54641565 Part V, Line 4: Lake Health's permanent endowment and temporarily restricted endowment funds are held by the Lake Hospital Foundation, Inc. dba Lake Health Foundation (the "Foundation), a related organization. The Foundation's mission is to secure financial and non-financial support to use in realizing Lake Health's vision of providing health care for the community. The Foundation's sole member is Lake Health. Central America and the Caribbean - Antigua & Barbuda, Aruba, Bahamas, Investment 120000 0 0 0 0 0 0 120000 0 120000 0 0 1 0 0 0 1 1 X 1 X 250.000000000000 1 X 1 1 0 1 1 5845766 2189426 3656340 0.01010 33364037 16218550 17145487 0.04750 39209803 18407976 20801827 0.05760 2406626 2406626 0.00670 397552 397552 0.00110 2804178 2804178 0.00780 42013981 18407976 23606005 0.06540 1 43988131 80730204 80038517 691687 X 1 1 1 Mentor Surgery Center LLC Outpatient surgical center 0.42000 0.00000 0.58000 2 Lake West Medical Specialists LLC Medical Office Building 0.12000 0.00000 0.88000 3 Concord Medical Campus Physician Building LLC Medical Office Building 0.51470 0.00000 0.48530 4 Mentor Medical Campus Physician Building LLC Medical Office Building 0.40390 0.00000 0.39610 5 Lake PHO Inc Physician services 0.50000 0.00000 0.50000 2 1 LakeWest Medical Center 36000 Euclid Avenue Willoughby OH 44094 X X X 2 TriPoint Medical Center 7590 Auburn Rd Concord OH 44077 X X X LakeWest & TriPoint Medical Centers 1 0 0 1 X X X X X X X X X 13 1 1 0 1 X http://www.lakehealth.org/about/health-needs-assessment X 1 13 1 https://www.lakehealth.org/About/Health-Needs-Assessment 0 0 1 X 250.000000000000 250.000000000000 X X X X X 1 1 X X X 1 X X X X 1 X 0 X 1 X 0 0 LakeWest & TriPoint Medical Centers Part V, Section B, Line 5: Lake Health identified community health needs by undergoing a needs assessment process. This process incorporated a comprehensive review by Lake Health's Senior Leadership Team along with secondary and primary data input compiled using the expertise of Dixon Hughes Goodman, LLP ("DHG") and Artower Advisory Services, LLC ("Artower"). The collective Community Health Needs Assessment ("CHNA") team reviewed several sources of quantitative health, as well as social and demographic data specific to Lake Health's service area. Lake Health also took advantage of this opportunity to collaborate with its administrators, physicians, public health agencies, and local organizations in identifying and addressing the needs of the community. LakeWest & TriPoint Medical Centers Part V, Section B, Line 6a: As allowed by IRS guidelines, Lake Health decided to produce a joint CHNA report for its two Lake County hospitals, West Medical Center and TriPoint Medical Center. Guidelines state that collaborating facilities must define their communities to be the same and conduct a joint CHNA process. LakeWest & TriPoint Medical Centers Part V, Section B, Line 11: In acknowledging the wide range of priority health issues that emerged from the CHNA process, Lake Health will focus on those most within its immediate ability to influence. LakeWest & TriPoint Medical Centers Part V, Section B, Line 22d: Uninsured patients who do not qualify for Lake Health's financial assistance program are billed for gross charges and are offered a 30% prompt pay discount if payment is received within 30 days of the first patient statement or a payment plan is agreed upon. The maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care are the amounts generally billed to individuals who have insurance covering such care. Part V, Section B, Line 16 Financial Assistance Policy Website Availability LakeWest & TriPoint Medical Centers Part V, Section B, line 16b website: https://www.lakehealth.org/Patients/Financial-Information/Financial-Aid-App 46 Mentor Medical Campus 9485 Mentor Avenue Suite 101 Mentor OH 44060 General Medical & Surgical Center-Outpatient Madison Medical Campus 6270 North Ridge Rd Madison OH 44057 General Medical & Emergency Department Lake County Family Practice 9500 Mentor Avenue Suite 100 Mentor OH 44060 Physician Office Willowick Urgent Care 29804 Lakeshore Blvd Willowick OH 44095 Urgent Care Center Lyndhurst Diagnostic Center 5183 Mayfield Rd Lyndhurst OH 44124 Diagnostic Center Tyler Urgent Care 7956 Tyler Blvd Mentor OH 44060 Urgent Care Center LHPG OBGYN Women's Health Specialist 35040 Chardon Rd Bldg VII Suite 205 Willoughby Hills OH 44094 Physician Office Willoughby Hills Diagnostic Center 34600 Chardon Rd Unit H Willoughby Hills OH 44094 Diagnostic Center Mentor Diagnostic Center 8401 Mentor Ave Suite B Mentor OH 44060 Diagnostic Center LHPG Mentor IMED 9485 Mentor Avenue Suite 210 Mentor OH 44060 Physician Office LHPG Mentor Pediatrics 9485 Mentor Avenue Suite 101 Mentor OH 44094 Physician Office LHPG North Coast Family Practice 7580 Auburn Rd Suite 202 Concord OH 44077 Physician Office Chardon Urgent Care 510 Fifth Avenue Chardon OH 44024 Urgent Care Center LHPG Madison Family Practice 6270 North Ridge Rd Madison OH 44057 Physician Office LHPG OBGYN - Willow Medical 36001 Euclid Avenue Suite C-10 Willoughby OH 44094 Physician Office LHPG Willoughby IMED 36100 Euclid Avenue Suites 240 260 Willoughby OH 44094 Physician Office Lake Wellness and Rehabilitation 9170 Mentor Avenue Mentor OH 44060 Rehabilitation Clinic LHPG Willoughby Pediatrics 36100 Euclid Avenue Suite 300 Willoughby OH 44094 Physician Office LHPG Madison Pediatrics 6270 North Ridge Rd Madison OH 44057 Physician Office LHPG Willoughby Hills IMED 2747 SOM Center Rd Unit D Willoughby Hills OH 44094 Physician Office LHPG Chardon Family Practice 510 Fifth Avenue Suite 130 Chardon OH 44024 Physician Office LHPG Mentor Family Practice 6990 Lindsay Drive 3 Mentor OH 44060 Physician Office LHPG Mentor General Surgery 9500 Mentor Avenue Suite 300 Mentor OH 44060 Physician Office LHPG Willowick Family Practice 29804 Lakeshore Blvd Willowick OH 44095 Physician Office Madison Quick Clinic 6067 North Ridge Rd Madison OH 44057 Quick Clinic LHPG Plastic Surgery 9500 Mentor Avenue Suite 200 Mentor OH 44060 Physician Office LHPG General Surgery 36060 Euclid Avenue Suite 204 Willoughby OH 44094 Physician Office LHPG Thomas Family Practice - Mentor 8316 Yellowbrick Rd Mentor OH 44060 Physician Office LHPG Chardon Pediatrics 510 Fifth Avenue Suite 120 Chardon OH 44024 Physician Office Lake Wellness and Rehabilitation 34881 Euclid Ave Willoughby OH 44094 Rehabilitation Clinic LHPG Orthopedic Surgery 36060 Euclid Avenue Suite 203 Willoughby OH 44094 Physician Office Painesville Quick Clinic 74 S Park Place Painesville OH 44077 Quick Clinic LHPG Thomas Family Practice - Euclid 26151 Euclid Ave Euclid OH 44132 Physician Office LHPG West Cardio Electrophysiology 36100 Euclid Avenue Suite 400 Willoughby OH 44094 Physician Office LHPG West IMED 36100 Euclid Avenue Suite 210 Willoughby OH 44094 Physician Office Middlefield Quick Clinic 15050 S Springdale Avenue Middlefield OH 44062 Quick Clinic LHPG Mentor OBGYN 9485 Mentor Avenue Suite 202 Mentor OH 44060 Physician Office Painesville IMED 1223 Mentor Ave Painesville OH 44077 Physician Office LHPG Sports Medicine & Rehab 36060 Euclid Avenue Suite 105 Willoughby OH 44094 Physician Office LHPG Integrative Medicine 9500 Mentor Avenue Suite 360 Mentor OH 44060 Physician Office Mentor Medical Physician Building 9485 Mentor Avenue Suites 200 203 Mentor OH 44060 Physician Office Hackett Medical Building 8300 Tyler Rd Mentor OH 44060 Physician Office LHPG OBGYN 36001 Euclid Avenue Suite C-7 Willoughby OH 44094 Physician Office LHPG Bariatric Surgery 36100 Euclid Avenue Suite 170 Willoughby OH 44094 Physician Office LHPG Orthopedic Surgery 7580 Auburn Rd Suite 202 Concord OH 44077 Physician Office LHPG Vascular Surgery 36001 Euclid Avenue Suite B-1 B-3 Willoughby OH 44094 Physician Office Part I, Line 3c: The following steps will be followed to evaluate patient's requests for consideration under the Uninsured/Uncompensated Care Guidelines: Financial Interview: A hospital representative will discuss with patients their individual financial position and obtain from them information regarding their finances. This information will be recorded on the HCAP application. Patients will be requested to supply copies of their two most recent pay stubs for all family members employed, copies of the previous year's tax return and any other pertinent documentation supporting their financial position. Evaluation Process: The hospital representative will complete the Financial Interview Form. The hospital representative will evaluate the application to determine whether the patient may be eligible for welfare or Medicaid coverage. If this coverage is available, the representative will make arrangements with the patient for completion of the Medicaid eligibility forms. If welfare or Medicaid eligibility is not available, the patient will be sent an application and will be considered for uncompensated care. A copy of the application will be forwarded to the Patient Accounting department. Determination of Eligibility: The Patient Accounting department will review the application and the patient's qualification status under the uninsured/uncompensated care guidelines. If the patient qualifies for uninsured/uncompensated care and services are provided, then the adjustment will be recorded as an adjustment from charges for Lake Hospital's Uninsured/Uncompensated Charity Care. Patients Not Eligible: Patients who are determined not to be eligible under the guidelines will be requested to pay a deposit equal to 50% of the estimated patient responsibility for either the elective inpatient or outpatient services, and to make arrangements for a payment plan to satisfy the remaining balance after services are provided. Eligibility: Each admission represents a separate financial encounter and will be evaluated with new data to determine if a change has taken place. Each outpatient application will be reviewed to determine if there has been any change in financial status. A new application will be required each month. Part I, Line 7: A cost-to-charge ratio is used. This ratio takes the total costs, including allocated costs from overhead departments, of providing patient care divided by total gross revenue. Part I, Line 7g: Subsidized health services include various free community screening events for health conditions such as blood pressure, cholesterol, bone density, prostate cancer, skin cancer, heart disease and obesity.Part I, Line 7, Column (f):Explanation: An estimated provision for uncollectible accounts is recorded that results in net patient service revenue being reported at the estimated amounts expected to be collected. Patient accounts receivable are reduced by an allowance for uncollectible accounts. The estimation of the allowance for uncollectible accounts is based primarily on the type and age of the patient accounts receivable and the effectiveness of collection efforts. The policy is to reserve a portion of all self-pay receivables, including amounts due from the uninsured and amounts related to co-payments and deductibles, as these charges are recorded. Patient accounts receivable balances and the effectiveness of the reserve policies are reviewed on a monthly basis, and various analytics support the basis for the estimates. Routine hindsight procedures are performed to evaluate historical write-off and collection experience to determine the reasonableness of the process for estimating the allowance for bad debt. Charity care and other community benefits as a percentage of expense is calculated using total expenses from Form 990, Part IX less bad debt expense of $43,988,130 from Part IX. Part II, Community Building Activities: Community advisory groups have been in place for 10 years. These distinct groups represent women, seniors and past patients of the system. Each group is made up of approximately 20 members. Quarterly meetings are held in which education is followed by input on specific programs or improvements being considered. The groups are moderated by a third-party facilitator to avoid biasing the groups. The information from these groups has been used to inform Lake Health management on issues ranging from way-finding to program needs. Coalition BuildingLake Health is involved in many community coalitions and partnerships to improve the health of individuals in the service area. Some of these include participation in the Lake County Strategic Plan, ACHIEVE (a community coalition to improve the environment in Lake County), and United Way programs designed to improve health, particularly in vulnerable communities. Part III, Line 2: Bad debt is estimated using a hind sight analysis on previous years accounts receivable. Those percentages are then applied to current year accounts receivable by payor to estimate the amount of uncollectible. Anything over 365 days is fully reserved. Part III, Line 4: The allowance for uncollectible accounts was approximately $24.2 million and $22.8 million at December 31, 2014 and 2013, respectively. The System's allowance for uncollectible accounts covered approximately 80.6% and 79.6% of combined self-pay and self-pay after insurance patient accounts receivable at December 31, 2014 and 2013, respectively. Write-offs were $42.7 million in 2014 compared to $49.1 million in 2013. Part III, Line 8: Based on a cost to charge ratio determined in accordance with Medicare cost report requirements, the costs of providing care to the Medicare population in 2014 was $80,038,517. The payments related to these services were $80,730,204 leaving a Medicare surplus of $691,687 for the year. Part III, Line 9b: Provisions On Collection Practices For Qualified Patients:Patients who do not have the means to pay for services provided at Lake Hospital System request to be considered under the Uninsured/Uncompensated Charity Care Guidelines. These guidelines define Lake Hospital System's commitment to providing care to patients who are in the greatest financial need. Patients who do not have insurance coverage, or whose out of pocket responsibility is substantial after insurance coverage, or whose income level is at or below 250% of the Federal Income Poverty Guidelines, are eligible to apply for uninsured charity care assistance. The uninsured/uncompensated charity care program does not relieve nor forgive point-of-service copayments that the patient may be required to pay under the terms of their insurance benefit plan. Per visit copayments will be collected at the point of service in compliance with the insurance benefit terms. ProcedureEligibility for Lake's uninsured/uncompensated care is determined by the following two-part test. The Lake Hospital Systems Uninsured/Uncompensated Care Program requires patients to meet at least one condition in both part one and part two: Part One: Insurance Test1. Patient does not have governmental or private insurance coverage; or2. Patient's insurance does not cover the medically necessary service; or3. Patient's insurance benefits are exhausted (i.e. Lifetime Reserve Days, Medicare); or4. Patient has or will obtain medically necessary services from the Hospital for which they do not have the financial means to pay; or5. Patient is responsible for co-payments and deductibles, carries no secondary insurance coverage and only source of income is Social Security.Part Two: Income test (relative to Lake Hospital charges)1. Family income is compared to the Federal Poverty Income Guidelines (family includes patient, patient's spouse, and all of the patient's children, natural or adoptive, under the age of eighteen who live in the home). The schedule shown below will be used to compare family income to a sliding scale based upon the Federal Poverty Income Guidelines. If family income is at or below the designated threshold, the patient is eligible for the percent charity discount associated with that level of income; or 2. The relationship between the patient's medical bills, family income and family assets (including, but not limited to such items as bank accounts, trusts, property, home equity, estate or investments) indicates that the pursuit of payment would adversely affect the well being of the patient and family members, and where the payment of Lake Hospital's bill would result in undue hardship; or3. Patient's family income exceeds 250% of the Federal Income Poverty Guidelines, however patient has supplied information to support exceptional living circumstances (i.e. terminal illness, excessive medical bills and/or medications, etc.) or 100% of incurred charges greater than 25% of annual family income (including bank accounts, trusts and investments, but excluding primary residence). Before Uninsured/Uncompensated Care can be awarded, the following conditions must be met: 1. If Lake Hospital determines that the patient is potentially eligible for medical assistance, the patient must cooperate with Lake Hospital's efforts to establish eligibility for government assistance programs. 2. If Lake Hospital awards Uninsured/Uncompensated Care, it will only cover the services provided under the account number(s) shown on the accompanying application. 3. Proof of income and financial documentation will be requested. (See Hospital Care Assurance Policy.) Part VI, Line 2: As an independent, community-based hospital system, Lake Health has had a long-standing tradition of providing services and programs based on the health care needs of the communities we serve. We are guided by our mission to provide local access, healing with compassion and superior quality and our core values - respect, innovation, teamwork, stewardship and integrity. Guided by a collaborative health needs assessment conducted in cooperation with the Lake County General Health District, Lake Health has developed programs, services and partnerships to address the most pressing health issues. The high priority areas include obesity, inactive lifestyles, and smoking. Programs designed to address weight management span from early childhood through mature adults. Get Healthy Lake County is now in its tenth year of operation and has nearly 2,500 members. Our growth as a health system reflects the many ways we are building on our mission and how we aspire to be more than your typical community hospital. We want our patients and their families to receive superior care without having to leave the community. That's why we are committed to offering the best resources to provide an expanded level of care to meet the needs of the community. Part VI, Line 3: 1. Signage posted at facility access points for patients who cannot afford to pay for medical care. 2. Charity/HCAP application forms given to self-pay patients at time of registration. Explanation of assistance provided to complete application if needed. 3. Uninsured inpatients are visited bedside to assist with the completion of the Charity/HCAP application and also to provide application assistance with other programs such as Medicaid, food stamps, etc. 4. Uninsured patients who receive outpatient services are contacted by phone to assist with the Charity/HCAP application and other programs listed above. 5. Charity/HCAP application appears on the back of all patient statements. 6. Charity/HCAP application appears on Lake Health website Part VI, Line 4: Lake Health's primary service area is Lake County (population about 230,000) and selected zip codes in its secondary service areas (Cuyahoga, Ashtabula, and Geauga counties with a population in the defined zip codes of 268,113). Part VI, Line 5: Prior to 1985, Lake Health's facilities were publicly operated as Lake County Memorial Hospitals. However, in 1985 the board of county commissioners and hospital trustees agreed to privatize the hospital to ensure the viability of a technologically progressive hospital system for Lake County residents. County commissioners serve as members of the Lake Hospital Corporation and, as such, appoint the community leaders who serve on the system's governing board. Lake Health has an open medical staff with privileges available to all qualified physicians in the area. Over 550 physicians comprise Lake Health's medical staff. Lake Health's commitment to the community is readily apparent in the Board of Trustees which is comprised solely of community members, appointed by the County Commissioners. All proceeds are reinvested in capital or other programs and services designed to meet the communities we serve. Lake Health provides services and programs based on the health care needs of the communities we serve. In fact, taking health programs and screenings to where people live, work, and play is fundamental to our mission. In 2013, we provided just under $23,844,000 in financial assistance and certain other community benefits at cost through our health system operations in Lake, Geauga, and Cuyahoga counties. This includes community education programs, excluding blood drives. During these community events and health fairs, we performed over 2,268 blood pressure checks, cholesterol screenings, glucose, heel screenings, skin cancer screenings, and prostate cancer screenings for free or at low cost. Lake Health's commitment to health improvement services that provide a demonstrated community benefit can be broadly categorized into three areas: Community Health Education, Community-Based Clinical Services, and Cash and In-Kind Gifts. Some of the programs and events are highlighted below. Community Health EducationLake Health has an extensive community health program that provides health screenings, physician lectures, self-help, and exercise programs in multiple community locations throughout Lake County and surrounding areas. Our support groups help meet educational and emotional needs related to a variety of conditions. We also partner with many local organizations, including the United Way, the American Red Cross, the American Heart Association, the Arthritis Foundation, the Lake County Y, and the Lake Metroparks to inrease awareness of health issues in the community. These programs and services include:A. Community Calendars and Newsletters:The Best of Health MagazineCalendar of Events in the News-HeraldHealth Talks in the News-Herald (weekly)B. Education on Specific Disease Conditions:Senior Connection Lunch and LearnsCommunity Health Lecture SeriesLifeCycles for Women Lecture SeriesRunner's ClinicOrthopedic and Spine Center SymposiumArthritis ExpoKnow Your Numbers (cardiac event)Diabetes Education eventC. Health Promotion and Wellness Programs:B Fit 4 LifeD. Education to the Public about Health Issues:Information through media releasesE. School Health Education Programs:Healthy Heart School ProgramF. Web-based Consumer Health Information:Regarding Health E-NewsletterConstant Contact E-blastsG. Social Media Consumer Health Information:Facebook posts and remindersTwitter posts and remindersYouTube videosI. Self-Help:Boning Up on OsteoporosisWeight 4 Life Weight Management ProgramOne of the many ways Lake Health is building the community is through strong partnerships with others who share our commitment to local access, healing with compassion, and superior quality. Lake Health joined forces with Lake Metroparks, Lake County YMCA, and the Lake County Health District to launch B Fit 4 Life. Part VI, Line 6: Lake Hospital System, Inc. dba Lake Health is the primary healthcare-providing entity which operates two hospital facilities and several other outpatient, urgent care and physician clinics throughout Lake County and the surrounding community. Lake Health is the sole member of Lake Health Foundation, Inc. dba Lake Health Foundation, a not-for-profit organization which is the fundraising arm of Lake Health. Lake Health is also the sole member of PrimeHealth, Inc. dba Lake Health Physician Grouop ("LHPG") which employs Lake Health's network of physicians. Lake Health is a 50% shareholder in Lake PHO, Inc. dba Lake Health PHO ("the PHO") which is a physician credentialing and membership organization. Physicians must be a member of the PHO in order to practice medicine at a Lake Health hospital or physician clinic. The Lake Health / University Hospitals Seidman Cancer Center is a joint venture between Lake Health and University Hospitals Health System of Cleveland that provides cancer treatment in Mentor, Ohio. Mentor Surgery Center, LLC, Mentor Medical Campus Physician Building, LLC, Lake West Medical Specialists, Inc., and Concord Medical Campus Physicians Building, Inc. are entities in which Lake Health owns a minority stake. These entities lease medical office space at which both Lake Health and non-affiliated practitioners practice. Part VI, Line 7, Reports Filed With States OH X 1 1 X X X X X 1 1 0 0 0 0 0 1 0 Cynthia Moore-Hardy President & CEO 682235 0 0 0 17081 0 487654 0 9173 0 1196143 0 0 0 Michael E Kittoe Senior VP Finance & CFO 376762 0 9993 0 10616 0 95308 0 5894 0 498573 0 0 0 Steven R Karns Senior VP Administrative Services 275469 0 0 0 10055 0 210217 0 5199 0 500940 0 0 0 Richard D Cicero Senior VP Business Development 239585 0 0 0 9502 0 89724 0 7713 0 346524 0 0 0 Michael Goler MD Senior VP Medical Affairs 338512 0 0 0 24744 0 11960 0 7928 0 383144 0 0 0 Mary L Ogrinc Chief Nursing Officer 259569 0 0 0 10554 0 165927 0 4666 0 440716 0 0 0 Joyce A Taylor VP Quality Services 196451 0 15662 0 6716 0 23000 0 4185 0 246014 0 0 0 Cynthia J Racer VP Clinical Services 167622 0 0 0 5744 0 2597 0 7098 0 183061 0 0 0 Craig J Ghidotti VP Human Resources 154741 0 0 0 5633 0 8215 0 8234 0 176823 0 0 0 Andrea Wasdovich-Duffner VP Perioperative & Acute Care 160886 0 0 0 5696 0 13000 0 6981 0 186563 0 0 0 Jerrold Peters VP Information Technology 157490 0 0 0 5328 0 35743 0 6419 0 204980 0 0 0 Part I, Line 1a Lake Hospital System, Inc.'s CEO, Cynthia Moore-Hardy, received the following taxable benefit in 2014: -Social club dues of $10,481 Part I, Lines 4a-b Line 4a: Michael Goler received a severance payment of $17,500 Line 4b: The following people were credited with the listed contributions to their respective 457(f) accounts in 2014. The amounts reflected on this schedule relate to an employee retention program that vest over a three year period: - Cynthia Moore-Hardy, President & CEO: $452,987 - Michael E. Kittoe, Senior VP Finance & CFO: $60,573 - Steven R. Karns, Senior VP Administrative Services: $184,482 - Richard D. Cicero, Senior VP Business Development: $77,256 - Mary L. Ogrinc, Chief Nursing Officer: $129,870 - Jerrold Peters, VP Information Technology: $33,300 Part I, Line 7 Michael E. Kittoe received a discretionary bonus of $9,333 determined by Leadership. Joyce A. Taylor received a discretionary bonus of $15,662 determined by Leadership. A County of Lake Ohio Series 2008 346001618 50943PBL2 2008-06-26 187820719 See Part VI 0 0 0 B County of Lake Ohio Series 2012 346001618 NoneAvail 2012-06-15 145275000 See Part VI 0 0 0 A 121011290 188051290 2057642 1808396 57940 183896741 2009 1 0 1 1 B 3060000 145275000 511289 144763711 2012 1 0 1 1 A 0 0 1 1 0 0 0 1 B 0 0 1 1 0 0 0 1 A 0 0 0 1 1 0 0 0 1 B 0 1 0 0 1 0 0 0 1 A 1 B 1 Date Rebate Computation Performed Issuer Name: County of Lake, Ohio Series 2008 Date the Rebate Computation was Performed: 10/01/2012 Schedule K, Part I, Line A, Column (f) Description of purpose: Construct a hospital; refunding of Series 2004 (issued on 08/15/2004) and Series 2007 (issued on 08/15/2007). Schedule K, Part I, Line B, column (f) Description of purpose: Construct a hospital; refunding of Series 2002 (issued on 12/01/2002), Series 2008A (issued on 08/15/2008) and Series 2008B (issued on 08/15/2008). Schedule K, Part I, Column (e) & Schedule K, Part, II, Line 3: The difference between issue price in Part I, Column (e) and the total proceeds of issue in Part II, Line 3 is investment income earned on bond escrow before the bond proceeds were expended. X Capital Equipment 1 900000 Book Value 0 0 0 0 Part I, Column (b): is the number of contributions. Form 990, Part VI, Section B, line 11 The process followed before filing the Lake Hospital Systems, Inc. Form 990 includes a detailed review completed by an independent outside CPA firm, presentation to and review by the LHS CFO and CEO, presentation and review by the LHS Finance Committee, and presentation to the LHS Board of Trustees. Form 990, Part VI, Section B, line 12c The Lake Hospital System, Inc. Board of Trustees completes a conflict of interest questionnaire annually, which is then reviewed by the LHS CFO and Director of the Board of Trustees. Board Members will excuse themselves from the Board Meeting when a topic of potential conflict is presented and return to the meeting following the completion of discussion, motion, and vote. Compliance with the LHS Conflict of Interest Policy is monitored and enforced by the Board Chair, Committee Chairs, and the Director responsible for Board of Trustees matters. Form 990, Part VI, Section B, line 15 The process for determining compensation of the Lake Hospital System, Inc. CEO, other officers, and key employees includes market research, review, and assessment by an independent consulting firm to make a recommendation to the LHS Board of Directors. The Board reviews the report provided in conjunction with annual performance assessments, and utilizes this information to determine compensation level. In addition, the procedure for other officers and key employees includes review by the CEO. Form 990, Part VI, Section C, line 19 Lake Hospital System, Inc. makes its Form 990, Form 990-T, and Form 1023 available to the public upon request, for the same period of time as set forth in the Internal Revenue Code section 6104(d). Lake Hospital System, Inc. makes available governing documents, conflict of interest policy, and financial statements to the public upon request, for the same period of time as set forth in the Internal Revenue Code section 6104(d), in addition to filing quarterly financial information with Nationally Recognized Municipal Securities Information Repositories for compliance with bond issues and annual financial information with the Attorney General of the State of Ohio. Governing documents for LHS are available through the website of the Ohio Secretary of State. Form 990, Part IX, line 11g Medical Services: Program service expenses 41,931,908. Management and general expenses 8,678,443. Fundraising expenses 0. Total expenses 50,610,351. Form 990, Part XI, line 9: Net change in unrealized gain/loss on other than trading investments 572,778. Net loss from affiliated entities -450,949. Derivative instruments loss -16,546,152. Cash payments on swaps -5,304,709. Underwriting support of Foundation -485,318. hey 1,437,360. Lake Health IPHE 7590 Auburn Rd Concord OH 44077 Physician services OH 0 0 Lake Hospital System Inc Lake Health University Hospitals Seidman Cancer Center 9485 Mentor Avenue Mentor OH 44060 311565964 Treatment of cancer patients OH 501(c)(3) Line 3 Lake Hospital System Inc 1 Lake Hospital Foundation 7590 Auburn Rd Concord OH 44077 341425872 Fundraising for benefit of Lake Hospital System, Inc. OH 501(c)(3) Line 11a, I Lake Hospital System Inc 1 PrimeHealth Inc 7590 Auburn Rd Concord OH 44077 341778204 Physician corporation OH 501(c)(3) Line 3 Lake Hospital System Inc 1 Mentor Surgery Center LLC 9485 Mentor Avenue Mentor OH 44060 341863257 Outpatient Surgery OH Lake Hospital System Inc Related 249226 1473471 0 1 0.42000 Lake West Medical Specialists LLC 180-A Mentor Avenue Painesville OH 44077 341964657 Office Space OH Lake Hospital System Inc Excluded 30460 511201 0 1 0.12000 Concord Medical Campus Physician Building LLC 7580 Auburn Road Suite 103 Concord OH 44077 260550261 Office Space OH Lake Hospital System Inc Excluded 218262 8290506 0 218262 0 0.51470 Interlake Health Corporation 7590 Auburn Rd Concord OH 44077 341510475 Healthcare OH Lake Hospital System Inc C 186 186199 1.00000 1 LHS Assurance Ltd 23 Lime Tree Bay Ave Governors Sq Grand Cayman CJ 980456229 Insurance company CJ Lake Hospital System Inc C 3864843 19684508 1.00000 1 Lake PHO Inc 7590 Auburn Rd Concord OH 44077 341696001 Physician services OH N/A C 257355 1209176 0.50000 0 1 0 1 0 0 0 0 0 0 1 1 0 1 1 0 1 1 0 0 Concord Medical Campus Physician Building LLC A 101235 Book value Lake Hospital Foundation C 1597507 Book value LHS Assurance Ltd C 500000 Book value Lake Health University Hospitals Seidman Cancer Center J 851341 Book value Mentor Surgery Center LLC J 480804 Book value Concord Medical Campus Physician Building LLC K 1219707 Book value Lake Health Foundation M 313875 Book value Prime Health Inc P 25877954 Book value Mentor Surgery Center LLC Q 72502 Book value Lake Health University Hospitals Seidman Cancer Center Q 51877 Book value Lake West Medical Specialists Q 150572 Book value