2015-05-13T13:34:13-05:00 2014-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2013-07-01 480559088 Hays Medical Center Inc HAYS 7856235000 2220 Canterbury Drive Hays KS 67601 John Jeter MD CEO 7856235000 2015-05-12 1 Heather R Eichem P01515553 7852334226 2015-05-12 2013 2016-02-25 16:41:14Z John Jeter MD 2220 Canterbury Drive Hays KS 67601 192987694 0 X www.haysmed.com X 1944 KS Hays Medical Center is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facilities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Organization is to help people be healthy. The Organization is striving to become the best tertiary care center in rural America. 15 10 1718 193 2786 0 130706 1766093 188373548 185509035 4636554 5348353 259211 252636 193400019 192876117 0 0 0 0 97190789 98444246 0 0 0 87289896 86310380 184480685 184754626 8919334 8121491 262721462 262539752 99540527 81603570 163180935 180936182 X Hays Medical Center is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facilities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Organization is to help people be healthy. The Organization is striving to become the best tertiary care center in rural America. 0 0 155126482 185509035 Patient Care Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as defined in Section 501(c)(3) of the IRS code. Admissions: Acute-5,151, Newborn ICU-61, Newborn-638, Skilled-98, Senior Focused Care-59, Rehabilitation-40, Total admissions-6,047. Patient days: ICU/CPCU-7,047, Medical/Surgical-12,025, Oncology-1,749, Obstetrics-1,570, Pediatrics-216, Senior Focused Care-560, Rehabilitation-420, Skilled-960, Newborn ICU-355, Newborn-1,161, Total patient days-26,063. Other statistical information: Surgical procedures-8,483, Cardiac caths-1,369, Emergency room visits-13,680, Outpatient procedures-155,577, Medical oncology service visits-6,679, Clinic visits-145,219. 155126482 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 161 0 1 1718 1 1 1 0 0 0 0 0 0 0 0 0 X 15 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X George Harms CFO 7856235000 2220 Canterbury Drive Hays KS 67601 Nancy Curtis Board Member 0.50 X 0 0 0 Dennis Bieker Board Member 0.50 X 0 0 0 Kenneth Beran Treasurer 0.50 X X 0 0 0 Darrell Werth MD Physician/Board Member 40.00 X 598551 0 33411 Daniel Schippers Chair 0.50 X X 0 0 0 Tom McDonald MD Board Member 0.50 X 0 0 0 Jim Black DO Board Member 0.50 X 0 0 0 Jayne Clarke Board Member 0.50 X 0 0 0 Sharon Dreher Board Member 0.50 X 0 0 0 Alan Moore Secretary 0.50 X X 0 0 0 DG Bickle Board Member 0.50 X 0 0 0 Dr Kurt Rider Physician/Board Member 40.00 X 281739 0 41185 John Jeter MD President & CEO 40.00 X X 495981 0 129311 Lee Hodny Physician/Board Member 40.00 X 742838 0 41185 Mary Martin Board Member 0.50 X 0 0 0 William Overbey Chief Financial Officer (through 1/27/2014) 40.00 X 256963 0 79858 George Harms Chief Financial Officer (beginning 4/21/2014) 40.00 X 0 0 0 Dale Montgomery VP Facilities (through 6/28/2014) 40.00 X 595027 0 56365 Bryce Young Chief Operating Officer 40.00 X 255193 0 79252 D Bruce Whittington VP Human Resources 40.00 X 163681 0 59062 Shae Veach VP Regional Dev 40.00 X 153744 0 56341 Terry Siek Chief Nursing Officer 40.00 X 161975 0 42582 Larry Watts Chief Medical Officer 40.00 X 289255 0 67094 Christine Fisher Physician 40.00 X 910279 0 29265 Alex De Carvalho Physician 40.00 X 1058951 0 29265 Vivek Sharma Physician 40.00 X 1071473 0 31911 Joel Fort Physician 40.00 X 732954 0 38685 Richard Markiewicz Physician 40.00 X 883208 0 20849 8651812 0 835621 120 0 1 0 Quest Diagnostics Inc PO Box 14730 St Louis MO 631504730 Lab Services 4203834 Sovereign Medical Corporation 1582 Charlton Road San Marino CA 91108 Pulmonology Services 1597400 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Physician Coverage 1397308 Anesthesiologist Assoc of Hays PO Box 821 Hays KS 67601 Anesthesia Services 791591 Executive Health Resources PO Box 822688 Philadelphia PA 191822688 EHR Compliance 622395 44 1601785 164308 1766093 Net patient service revenue 621990 175721959 175721959 Services to CAH network and afill 900099 3674151 3674151 Fitness center 900099 1657756 1657756 Retail pharmacy 900099 1240734 1240734 EHR incentive payments 900099 923422 923422 2291013 2291013 185509035 5370424 5370424 89506 111577 -22071 -22071 -22071 Rental income 900099 249850 249850 Nursing mother's resources 446199 2786 2786 252636 192876117 185509035 2786 5598203 X 4822879 1783050 3039829 75666880 64509373 11157507 2763421 2588948 174473 10264386 8632327 1632059 4926680 4083566 843114 229818 229818 436938 436938 228239 228239 20300759 16614752 3686007 418297 14905 403392 497341 346308 151033 2110749 1307103 803646 2090832 1674571 416261 364664 280557 84107 984675 706979 277696 2998912 2998912 11313985 8494540 2819445 1154576 932355 222221 Medical Supplies 18004501 18004501 Pharmaceuticals 12882757 12882757 Repairs and maintenance 4062204 3572528 489676 Taxes and assessments 1573494 1449760 123734 6657639 4248690 2408949 184754626 155126482 29628144 0 5765 193815 4262222 6840012 30002457 28762873 4345938 4265572 3700959 3701097 209666104 125050196 82182907 84615908 80389289 75855620 25696304 27268674 538200 538200 31597421 30497981 262721462 262539752 22682371 22682731 115499 63545 76045689 57750650 696968 1106644 99540527 81603570 X 155618659 172165751 7562276 8770431 163180935 180936182 262721462 262539752 X 8121491 8425601 1208155 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 18069 0 0 0 18069 0 Part II-B, Line 1: Hays Medical Center, Inc., is a member of the Kansas Hospital Association and the American Hospital Association. Both of these organizations engage in lobbying activities for hospital and general health care interests as part of the services provided to members. 9933230 154338 335088 44884 10377772 9480780 106926 388512 42988 9933230 8947679 167515 427208 61622 9480780 8608848 119796 287574 68539 8947679 8099830 332063 234201 57246 8608848 0.59000 0.33000 0.08000 0 1 1 350356 350356 76025820 37152752 38873068 122299316 81521726 40777590 10990612 6375718 4614894 84615908 Hedge funds 17550900 F Private equity funds 4384526 F Real estate limited partnership 5333248 F 27268674 Cash whose use is limited by Board or indenture agreement 6998943 Interest receivable whose use is limited by Board or indenture agreement 75911 Interest in net assets of Hadley Foundation 8770431 Other receivables 1805553 Debt issue costs 608266 Other long-term assets 7046928 Third party payor settlements 2827143 Intercompany receivables 2364806 30497981 Estimated third-party payor settlements 1106644 1106644 X 202531945 8425601 1208155 9633756 192898189 -22072 -22072 192876117 184776698 22072 22072 184754626 0 184754626 Part V, Line 4: The endowed funds held by the Hays Medical Center Foundation are used to help meet both the immediate and long range health care needs of patients of Hays Medical Center, Inc. The Hays Medical Center Foundation provides grants and assistance to Hays Medical Center, Inc., for property and equipment acquisitions, education, and community health issues. Part X, Line 2: Management is not aware of any uncertainties in income tax positions. Part XI, Line 2d - Other Adjustments: Change in beneficial interest in net foundations Part XI, Line 4b - Other Adjustments: Loss on disposal of equipment included as a revenue deduction in Part VIII 1 1 X 1 X 130.000000000000 1 X 1 1 0 1 1 1400813 1400813 0.00760 9685004 7167368 2517636 0.01360 11085817 7167368 3918449 0.02120 1850878 1669612 181266 0.00100 1059742 79134 980608 0.00530 56201806 43778407 12423399 0.06720 8170 8170 0.00000 59120596 45527153 13593443 0.07350 70206413 52694521 17511892 0.09470 82500 82500 0.00040 82500 82500 0.00040 1 3477655 243436 57523096 63952320 -6429224 X 1 1 2 1 Hays Medical Center Inc 2220 Canterbury Hays KS 67601 X X X 2 Pawnee Valley Community Hospital Inc 923 Carroll Ave Larned KS 67550 X X X X Hays Medical Center Inc 1 1 X X X X X X X X X 12 1 0 1 X http://www.haysmed.com/ X X X X X X X X X 1 0 1 1 130.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X X X X X X 1 0 X X X 1 X 0 0 Pawnee Valley Community Hospital Inc 2 1 X X X X X X X X X 12 1 0 1 X htts://www.pawneevalleyhospital.com/ X http://www.pawneecountykansas.com/ X X X X X X X 1 0 1 1 130.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X X X X X X 1 0 X X X 1 X 0 0 Hays Medical Center, Inc. Part V, Section B, Line 3: The CHNA was conducted in collaboration with the Ellis County Health Department. Two Town Hall meetings were organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meetings, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and scoring processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interests of the community served by the Hospital. Key stakeholders in attendance included representatives from: Ellis County, Turning Point Professional Counseling, First Care Clinic, KaMMCO/KMC, Heartland Community Foundation, Regional Prevention Center, Community Assistance Center, Ellis County Health Department, representatives of USD 489 and representatives of Hays Medical Center. The CHNA was coordinated and produced by VVV Research & Development, Inc., from Olathe, Kansas.Annual description of the actions taken by the Medical Center during the fiscal year to address the significant health needs identified throught the most recently conducted CHNA:HaysMed is dedicated to continually learning, engaging, and fulfilling the health needs of the community we serve. As a result of this commitment the following is the annual description of the actions taken during the most recent fiscal year to address the significant health needs identified through the CHNA.Aging Services - HaysMed continues to work collaboratively on palliative and post-acute care services with local Nursing Homes and other Aging Service Organizations. Regular meetings take place with local Nursing Homes and Post-Acute facilities to talk about the coordination of care and how we can take better care of patients.Low Cost Health Services and Access to Primary Care Services - HaysMed launched the opening of the Convenient Care Walk-In clinic in Hays. This clinic is open Monday-Friday 8 am - 7:30 pm, Saturday 9 am - 4:30 pm, and Sunday 12 noon - 5 pm. This clinic has provided a cost effective solution every day of the week for the community to utilize. Mental Health Services - The HaysMed Psychiatric Associates continues to expand and take new patients in the Ellis Community. An outreach of this clinic was established in Pawnee County and services have been expanded to allow additional services in this community. We continue to work closely with Area Mental Health on ways to deliver Psychiatric services to include TelePsych consultations. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 3: The CHNA was conducted in collaboration with the Pawnee County Health Department. A Town Hall meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meeting, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and scoring processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interests of the community served by the Hospital. Key stakeholders in attendance included representatives from: United Way, Welcome Inn Senior Center, Center for Counseling, Elder Care, Inc., Smith Dental Clinic, Pawnee County Sheriff's Office, Larned Police Department, Pawnee County Health Department, County Commissioners, members of the Chamber of Commerce, members of the USD 495 School Board, school nurses of USD 495, local members of the media, local religious organizations, city council members, and representatives of Pawnee Valley Community Hospital. The CHNA was coordinated and produced by VVV Research & Development, Inc., from Olathe, Kansas. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 7: Annual description of the actions taken by the Hospital during the fiscal year to address the significant health needs identified throught the most recently conducted CHNA:Community Wellness - Community Wellness was #1 on the health needs - areas of future focus survey with 50 votes, 22.7%. Comments from the town hall meeting included, "Community is desperately in need of a wellness facility." and "Community needs nutritional education." Being overweight/obese, smoking, drinking in excess, not exercising etc. can lead to poor health. Pawnee County's ranking in adult obesity is at 34% compared to Kansas' county average of 30%. Physical inactivity ranked 30% compared to Kansas' average of 28%. Heart disease and diabetes rank high in Pawnee County. According to the Town Hall meeting, developing a community wellness program and facility was the highest ranked request. In lieu of this, PVCH leadership and county officials believe that this is not something that the hospital and county should be solely involved in orchestrating. Rather, the development and on-going maintenance of a wellness program and facility should be collaborative with other agencies and entities. We identified a key list of organizations that were considered to be part of the wellness coalition to identify and develop a plan. The following is a list of candidates for the coalition: PRIDE, PVCH, PVCH Foundation, USD 495, USD 495 Foundation, Recreation Commission, Pawnee County Health Department, City of Larned, Chamber of Commerce, CHO, Pawnee County Extension Office and Pawnee County Economic Development Commission. The Wellness Coalition has reached out to several different entities (i.e. YMCA) to come to Larned/Pawnee County to develop a wellness center in the community. Although several entities looked at Larned as a potential site for a wellness facility, no serious proposals from these inquiries. Medical Oncology Services - Medical Oncology Services was #5 on the health needs - areas of future focus survey with 25 votes, 11.4%. Comments included: "We have a lot of people in Pawnee County with cancer. A cancer treatment center would be really helpful." ; "There is a need for more specialized service appropriate for the size of town that Larned is." ; and "Specialty services are lacking including OB, Cancer, and Mental Health." The age adjusted cancer mortality rate per 100,000 population is significantly higher than the NW KS 10 counties and Kansas: Pawnee County 195.9, NW KS 10 169.8 and Kansas 188.In order to implement an effective oncology service line, many factors must come together. The following information outlined the plans for implementation of the PVCH oncology service line. We have had the great fortune of being able to partner with the Dreiling/Schmidt Cancer Institute at HMC. In lieu of this partnership, we were able to establish an outreach clinic with Dr. Abuerreish heading up the program. It is vitally important to maintain the relationship with both primary care medical staff as well as specialists. This will ensure consistent continuity for our patients as they move through the continuum of their cancer treatment course.There are many additional components that need to be implemented at PVCH prior to providing cancer treatment services. PVCH leadership had originally established that the program would start once we were in the new facility - spring of 2013. A task force committee was established with members from both PVCH and Dreiling/Schmidt Cancer Institute. The committee functioned as the backbone for developing all operational plans for the cancer therapy service line. This included, but was not limited to, a financial feasibility analysis, budget preparation, hiring experienced human resources, purchasing equipment, developing policies and procedures, advertising, and patient follow-up. It is important to note that if the financial proforma didn't show favorable profitability than we would not proceed with the program. The overall success of the program will be measured by community and patient feedback as well as volume growth. Additionally, the success is highly dependent on community and physician support. It will be important to advertise the oncology service line to regional primary care and medical oncologists. After further analysis by the committee and the Hospital, it was shown that offering oncology services at PVCH was outside of the scope of services PVCH could offer to the community.Mental Health & Counseling - Mental Health & Counseling was #3 on the health needs - areas of future focus survey with 29 votes, 12.7%. Comments included, "Specialty services are lacking including mental health." ; "Local psycho-social/emotional counseling services - A lot of families that move into Larned seem to struggle with functioning at a productive level. The poor functioning of the adults is trickling down to produce children with low functioning mental capabilities, poor coping skills and increased emotional/behavioral issues. These children are then set up to repeat the cycle." ; "Yes, mental health needs are not met for those in the community. We as community members must travel for services." ; and "Difficult to acquire care for mental health." Research data showed:Alzheimer's disease - Pawnee county 33.6%; Kansas 28%. Inadequate social support - Pawnee county - 20%; Kansas 16%. Uninsured - Pawnee county - 17%; Kansas 15%. Number of mental health persons served increasing over a three year period: 149 to 176 - an 18% increase. Pawnee County has at least 10 Foster Care Homes providing out of home care for children removed from homes. A multitude of organizations provide some type of mental health and counseling services. These services can be divided between primarily role such as the Center for Counseling and Consultation, secondary role such as school counselors, social workers employed in medical setting, and tertiary where clients are assisted with and referred to mental health services. At this time, most entities that provide any type of mental and behavioral services find themselves in a situation where any added services must also come with the funding to support them. Keeping this in mind, a work plan was developed that addressed goals to lay the ground work for improving and enhancing the capacity for mental health services using the current agencies' capabilities and resources. Based on this information, Pawnee County had several opportunities to work towards better mental health care. These included: 1) Enhancing mental health for Pawnee County infants and children birth through school age by increasing the number of infants and children screened using the Ages and Stages Social/Emotional Tool; 2) Enhancing the mental health of Pawnee County women who are pregnant or post-partum by increasing the number of pregnant and post-partum women screened using the Edenburg screening tool; and 3) Improving primary mental service access for Pawnee County residents by decreasing the barriers to mental health services in Pawnee County.The following are several areas to be addressed and why the Hospital was not able to address those needs: OB Services - offering OB Services is outside of the scope of services that we can provide as a critical access hospital. We do, however, how have Dr. Goodwin offering pre-natal care for expecting mothers in the community. Nutrition Education - we were planning on addressing this area with the Wellness Facility. When we were unable to move forward with the Wellness Facility, we were not able to move this initiative forward. Home Health & Hospice - after further analysis it was determined that this initiative was outside of the Hospital's scope and available manpower. Dental Services for the Uninsured - with a limited amount of dentists in the county, we were unable to provide this service to the community in the scope that the community was wanting it to happen. Increase Selection of Healthy Eating Options - we were planning on addressing this area with the Wellness Facility. When we were unable to move forward with the Wellness Facility, we were not able to move this initiative forward. Hays Medical Center, Inc. Part V, Section B, Line 14g: Hays Medical Center will proactively seek out applicants who may be in need of financial assistance. Hays Medical Center will post notice of this policy to all patients/guarantors through its registration, pre-registration, and financial counseling process. This policy will also be posted in prominent areas of the Hospital. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 14g: Pawnee Valley Community Hospital, Inc. (PVCH) will proactively seek out applicants who may be in need of financial assistance. PVCH will post notice of this policy to all patients/guarantors through its registration, pre-registration, and financial counseling process. This policy will also be posted in prominent areas of the Hospital. Hays Medical Center, Inc. Part V, Section B, Line 20d: The Hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the Hospital. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 20d: The Hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the Hospital. 4 Hays Family Medicine 2509 Canterbury Hays KS 67601 Family Medicine Pawnee Valley Medical Associates 713 W 11th St Larned KS 67550 Family Medicine HaysMed Psychiatric Associates 205 E 7th St Hays KS 67601 Psychiatric Services Breast Care Center 2501 E 13th St Hays KS 67601 Breast Care Services Part I, Line 7: Hays Medical Center, Inc.'s, cost accounting system was used to calculate community health improvement services, health professions education, and subsidized health services costs. A cost-to-charge ratio derived from Worksheet 2 was used to calculate financial assistance at cost and the community benefit expense attributable to serving Medicaid beneficiaries. Part I, Line 7g: Subsidized health services community benefit expenses include $51,086,039 of expenses attributable to physician clinics that have net operating losses. Part II, Community Building Activities: Hays Medical Center, Inc., helps to support the First Care Clinic in Hays, Kansas. This clinic was established to help lower income individuals receive health care at a reduced cost. Our support helps to increase the number of individuals in Hays, Kansas, who receive quality primary health care. Part III, Line 4: Text of the footnote that describes bad debt expense:Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the HaysMed Group analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts. For receivables associated with services provided to patients who have third-party coverage, the HaysMed Group analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the HaysMed Group records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for uncollectible accounts.Part III, Line 2:Costing methodology: A cost-to-charge ratio derived from Worksheet 2 was used to calculate bad debt expense at cost.Part III, Line 3:Methodology for bad debt cost for financial assistance eligible: This amount was estimated based on historical information from our collection agency on the percentage of accounts referred to collection whose guarantor was indigent. Part III, Line 8: The Medicare cost report was the costing methodology used to determine Medicare allowable costs. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Hays Medical Center, Inc., Medicare cost report for the fiscal year ended June 30, 2014. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Hays Medical Center, Inc., try to determine the estimated self-pay balance prior to the patient receiving services. FAP eligibility is first considered at this point in time. In addition, if full payment is not received or if payment is not made within 30 days, the CSR contacts the patient. If it is determined that at least a 2-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Part VI, Line 3: Information regarding the Hays Medical Center, Inc., charity care program is located on the Hays Medical Center, Inc., website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. In addition, if a customer service representative of Hays Medical Center, Inc., contacts a patient about a bill and in visiting with them they determine that the patient could possibly qualify for the Hospital's charity care policy, they will send the application to the patient as well. Part VI, Line 4: Hays Medical Center, Inc., is located in Hays, Kansas, which has a population of approximately 20,000 people, as of the 2010 census. One of the State of Kansas Regents universities is also located in Hays, Kansas, so the population includes many college-aged students. The median household income of Hays, Kansas, is $44,227. Approximately 5.7% of families and 15.6% of the population were below the poverty line. Almost 6% of the Hospital's revenue is from services provided to patients eligible for Medicaid. Hays Medical Center, Inc., is the only hospital in the city of Hays. In addition, since this is a rural area and because it is the only hospital providing tertiary level care in the region, Hays Medical Center, Inc., provides certain services to the whole western half of the State of Kansas. Part VI, Line 5: Hays Medical Center, Inc., promotes the health of the community by extending medical privileges to most qualified, local physicians. In addition, the majority of the Board of Directors live and work in the city of Hays, but they are not employed by Hays Medical Center, Inc. Part VI, Line 6: Hays Medical Center, Inc., is not a part of an affiliated health care system. X 1 1 X X X X 0 1 0 0 0 1 0 0 0 Darrell Werth MD Physician/Board Member 598500 0 0 0 51 0 14025 0 19386 0 631962 0 0 0 Dr Kurt Rider Physician/Board Member 265193 0 0 0 16546 0 14025 0 27160 0 322924 0 0 0 John Jeter MD President & CEO 487508 0 0 0 8473 0 104651 0 24660 0 625292 0 0 0 Lee Hodny Physician/Board Member 347500 0 382903 0 12435 0 14025 0 27160 0 784023 0 0 0 William Overbey Chief Financial Officer (through 1/2 256872 0 0 0 91 0 52931 0 26927 0 336821 0 0 0 Dale Montgomery VP Facilities (through 6/28/2014) 148885 0 0 0 446142 0 36733 0 19632 0 651392 0 100115 0 Bryce Young Chief Operating Officer 252835 0 0 0 2358 0 52325 0 26927 0 334445 0 0 0 D Bruce Whittington VP Human Resources 153931 0 0 0 9750 0 32656 0 26406 0 222743 0 0 0 Shae Veach VP Regional Dev 150223 0 0 0 3521 0 31235 0 25106 0 210085 0 0 0 Terry Siek Chief Nursing Officer 161923 0 0 0 52 0 33198 0 9384 0 204557 0 0 0 Larry Watts Chief Medical Officer 284616 0 0 0 4639 0 49440 0 17654 0 356349 0 0 0 Christine Fisher Physician 579231 0 294553 0 36495 0 14025 0 15240 0 939544 0 0 0 Alex De Carvalho Physician 532885 0 525912 0 154 0 14025 0 15240 0 1088216 0 0 0 Vivek Sharma Physician 500000 0 571422 0 51 0 14025 0 17886 0 1103384 0 0 0 Joel Fort Physician 350000 0 382903 0 51 0 14025 0 24660 0 771639 0 0 0 Richard Markiewicz Physician 392308 0 307086 0 183814 0 8925 0 11924 0 904057 0 0 0 Part I, Line 1a Benefits identified include tax indemnification on health claims. This benefit is available to the CEO and is included in taxable income. Part I, Line 4b Contributions to plan: John Jeter, M.D. - $73,126 William Overbey - $38,906 Bryce Young - $38,300 Dale Montgomery - $22,708 D. Bruce Whittington $23,465 Shae Veach $22,713 Terry Siek $24,289 Larry Watts $42,692 Distributions from plan: Dale Montgomery $447,917 Part I, Line 6 A portion of incentive compensation for officers and key employees is determined by net earnings exceeding budget for the fiscal year. A Kansas Development Finance Authority 481066589 48543BJD1 2005-11-22 23635944 Construction 0 0 0 B Kansas Development Finance Authority 481066589 48543BLY2 2010-11-02 46930167 Refinancing of previous bond and equipment 0 0 0 A 8505000 23635944 2037125 316000 23319944 2006 0 1 1 1 B 3560000 46930167 667574 29962593 16300000 2012 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 1 B 0 1 0 0 0 0 0 0 1 A 1 B 1 Date Rebate Computation Performed Issuer Name: Kansas Development Finance Authority Date the Rebate Computation was Performed: 11/01/2010 Ann Jeter Family member of John Jeter, CEO 18820 Payments for consulting services 0 Jeter Law Firm Partnership more than 5% owned by family member of John Jeter, CEO 5799 Payments for legal services 0 Lynette Pfannenstiel Family member of D.G. Bickle, current director 97496 Employment arrangement 0 Arlene Werth Family member of Darrell Werth, MD, current director 66849 Employment arrangement 0 John T Jeter Son to John Jeter, CEO 22446 Employment arrangement 0 Kelsey Overbey Daughter of William Overbey, CFO through January 2014 15653 Employment arrangement 0 Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the officers and Board Finance committee. Form 990, Part VI, Section B, line 12c Officers, directors, and key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The CEO's, officers', and key employees' salaries are reviewed annually by an independent consulting group and the Compensation Committee, which is made up of members of the Board. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Financial statements are released to bond holders on a quarterly basis. Form 990, Part IX, line 11g Contract labor: Program service expenses 330,478. Management and general expenses 32,545. Fundraising expenses 0. Total expenses 363,023. Medical professional fees: Program service expenses 9,415,435. Management and general expenses 263,779. Fundraising expenses 0. Total expenses 9,679,214. Laboratory services: Program service expenses 4,526,047. Management and general expenses 0. Fundraising expenses 0. Total expenses 4,526,047. Consulting services: Program service expenses 93,439. Management and general expenses 122,741. Fundraising expenses 0. Total expenses 216,180. Recruiting fees: Program service expenses 0. Management and general expenses 146,000. Fundraising expenses 0. Total expenses 146,000. Non-medical professional fees: Program service expenses 708,493. Management and general expenses 1,247,051. Fundraising expenses 0. Total expenses 1,955,544. Collection and billing fees: Program service expenses 9,270. Management and general expenses 463,285. Fundraising expenses 0. Total expenses 472,555. Other purchased services: Program service expenses 1,531,590. Management and general expenses 1,410,606. Fundraising expenses 0. Total expenses 2,942,196. Form 990, Part XI, line 9: Change in net assets of foundations 1,208,155. Hays Medical Center Foundation 2220 Canterbury Hays KS 67601 481179684 Provide grants and allocations to Hays Medical Center, Inc. KS 501(c)(3) Line 11a, I Hays Medical Center Inc 1 HaysMed Partners Inc 2220 Canterbury Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) Line 3 Hays Medical Center Inc 1 Pawnee Valley Community Hospital Inc 2220 Canterbury Hays KS 67601 481253246 Hospital operated by Hays Medical Center KS 501(c)(3) Line 3 HaysMed Partners Inc 1 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 0 1 0 0 Hays Medical Center Foundation C 1601785 Actual cash Hays Medical Center Foundation Q 231677 Actual cost Pawnee Valley Community Hospital Inc L 427087 Actual cost Pawnee Valley Community Hospital Inc O 333255 Actual cost Pawnee Valley Community Hospital Inc K 86130 Rent agreement Pawnee Valley Community Hospital Inc Q 2090000 Contractual formula