2013-08-14T13:29:38-05:00 2012-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2011-10-01 030107300 Brattleboro Memorial Hospital BRAT 8022570341 17 Belmont Avenue Brattleboro VT 05301 Michael Rogers 8022570341 2013-08-14 1 Barbara J McGuan CPA P00219457 2077752387 2013-08-14 2011 2016-03-07 17:11:31Z Michael Rogers 17 Belmont Avenue Brattleboro VT 05301 74358242 0 X http://www.bmhvt.org X 1904 VT To provide health care services on a region-wide basis 11 9 580 109 0 0 298965 459540 58751129 68487383 265171 427213 -202505 -178982 59112760 69195154 0 0 0 0 31969160 36264557 0 0 0 27797062 29030577 59766222 65295134 -653462 3900020 57406774 63371670 23788690 25078736 33618084 38292934 X Brattleboro Memorial Hospital will provide community-based quality health services delivered with compassion and respect. 0 0 51671023 65645783 Provision of Hospital Care, both inpatient and outpatient services, on a region-wide basis. Approximately 90,630 outpatients and 2,054 inpatients were served throughout the year.Brattleboro Memorial Hospital is a modern, well-equipped and professionally staffed community hospital which has been serving greater Brattleboro and the tri-state area since 1904. Throughout our more than a century of caring for our community, BMH has kept up with medical technology which, in turn, has drawn excellent physicians to our facility. The BMH Medical Staff boasts more than 100 board-certified physicians, active in both primary care and many specialties. 1561221 2841600 Charity Care:The Hospital's charity care program is designed to assist those patients who are either uninsured, underinsured or have limited financial resources that impact their ability to fully pay for their hospital care. Before completing an application for charity care, patients are first asked to investigate whether or not they may be eligible for Medicare, Medicaid, Veteran's Benefits or other governmental or public assistance programs. The Hospital's qualifications for charity care are as follows:1) Charity care is limited to medically necessary services. Patients receiving certain elective services, such as those considered cosmetic, investigational or experimental, are expected to make payment arrangements in advance, as these types of services are not covered by the charity care program.2) Patient's family income must be at or below 300% of the current Federal Poverty Income Guidelines for their applicable family size.The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the estimated cost of those services and supplies and equivalent service statistics. The following information measures the levels of the charity care provided during the year ended September 30, 2012:Equivalent percentage of charity care services to all services 2.39%Number of patients receiving charity care 4,760In addition, the Hospital also incurred payment shortfalls in the treatment of Medicare and Medicaid patients. Both of these government programs reimburse for medical services at less than published charges to provide those services. In 2012, the Hospital incurred shortfalls of approximately $5,899,000 and $4,959,000 related to treating Medicare and Medicaid patients, respectively.The Hospital also provided many other community benefits upon which no monetary value can be placed such as:-BMH provides space at no cost to the local non-profit Brattleboro Walk-in Clinic.-Promotes wellness through screening and demonstrations at our annual Health Fair.-Offers free smoking cessation classes.-Collaborates with other community agencies in publishing a community wellnes calenday twice a year. 53232244 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 114 0 1 580 1 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Michael Rogers 8022570341 17 Belmont Avenue Brattleboro VT 05301 Kirsten Beske 1.00 X X 0 0 0 John M Meyer 1.00 X X 0 0 0 Carl Lynde 1.00 X X 0 0 0 Jill Zachary 1.00 X 0 0 0 Rick Fleming 1.00 X 0 0 0 Ben Taggard 1.00 X 0 0 0 Burton Tepfer MD 1.00 X 47442 0 0 Peter Carvell 1.00 X 0 0 0 Deborah Boyle 1.00 X 0 0 0 Richard Carroll 1.00 X 0 0 0 Leslie Morey 1.00 X 0 0 0 Denise Paasche MD 1.00 X 4120 0 0 Steven Gordon 40.00 X 0 226139 13691 Michael Rogers 40.00 X 0 173748 36442 Mary Morgan 40.00 X 0 186266 10227 Clifford Langweiler MD 40.00 X 276580 0 54505 Teresa Fitzharris-Onyon MD 40.00 X 250498 0 51843 Christopher Schmidt MD 40.00 X 246092 0 51817 Joseph Rosen MD 40.00 X 268149 0 35979 Gregory Gadowski MD 40.00 X 266339 0 38417 Barry Beeman 40.00 X 0 101097 3877 1359220 687250 296798 28 1 1 0 Southern VT Health Services Corp 17 Belmont Avenue Brattleboro VT 05301 Management Fees 1613000 Anesthesia Physicians of Brattleboro 17 Belmont Avenue Brattleboro VT 05301 Medical Services 715000 Mayo Medical Laboratories 200 First Street SW Rochester MN 55909 Lab Services 418724 Unibased Systems Arch Inc 14323 South Outer Road Suite 300 So Chesterfield MO 63017 Software & Support 325622 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Temporary Medical Services 287194 18 29655 429885 459540 Patient Service Revenu 621400 118687302 118687302 Meaningful Use Revenue 900099 1538654 1538654 Miscellaneous Revenue 900099 656664 656664 Provision for Bad Debt 621400 -3552356 -3552356 Contractual Allowances 621400 -48842881 -48842881 68487383 229848 229848 226112 405094 -178982 -178982 -178982 4947559 7800 4757543 451 190016 7349 197365 197365 69195154 68487383 0 248231 51563 51563 28381927 23156641 5225286 1013983 827641 186342 5223411 4460045 763366 1593673 1300800 292873 1613000 261000 1352000 42667 42667 69400 69400 40269 40269 186869 98745 88124 2167993 1705451 462542 1609105 1220441 388664 139636 103791 35845 265151 186425 78726 46158 46158 3298535 2319163 979372 956627 956627 Contract Services & Con 4184161 3411857 772304 Drugs 3751556 3751556 0 Provider Taxes 3646926 3646926 0 Medical/Surgical Suppli 3206855 3205769 1086 3805669 2567803 1237866 65295134 53232244 12062890 0 99431 99947 8504708 6238648 4927944 5834564 1532236 1510932 366619 354205 54790502 31952828 22749035 22837674 18630246 25441707 596555 1053993 57406774 63371670 6852333 8351198 10250000 9845000 0 13693 6686357 6868845 23788690 25078736 X 33161976 37834307 178520 179682 277588 278945 33618084 38292934 57406774 63371670 X 3900020 774830 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 18840 18840 0 Explanation of Lobbying Activities: Part II-B, Line 1: BMH is a member of the VT Association of Hospitals and Health Systems and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of BMH and other member organizations in furtherance of their exempt purposes. BMH does not directly perform any lobbying activities. 45499 45499 31527127 15993835 15533292 19508176 14968614 4539562 3709700 990379 2719321 22837674 Due to Medicaid 405471 Due to Medicare 5429820 Interest Rate Swap 1033554 6868845 69195154 65295134 3900020 824950 -50120 774830 4674850 69883557 824950 7466 832416 69051141 40269 103744 144013 69195154 65208707 0 65208707 40269 46158 86427 65295134 Part XI, Line 8 - Other Adjustments: Unrealized Loss on Interest Rate Swap -57,586. Change in Interest in SVHSC 7,466. Total to Schedule D, Part XI, Line 8: -50,120. Part XII, Line 2d - Other Adjustments: Change in Interest in SVHSC 7,466. Part XII, Line 4b - Other Adjustments: Unrealized Loss on Interest Rate Swap 57,586. Transfer to SVHSC 46,158. Part XIII, Line 4b - Other Adjustments: Transfer to SVHSC 46,158. 1 1 X 1 X 300.000000000000 1 X 1 1 1 0 1 1 1244648 1244648 0.01910 13790876 8831526 4959350 0.07600 961837 722818 239019 0.00370 15997361 9554344 6443017 0.09880 12430 12430 0.00020 38602 38602 0.00060 51032 51032 0.00080 16048393 9554344 6494049 0.09960 1 1951721 487930 11980990 17879822 -5898832 X 1 1 1 1 Brattleboro Memorial Hospital Inc

17 Belmont Ave Brattleboro VT 05301

X X X Brattleboro Memorial Hospital 1 1 X X X X X X X X X 11 1 1 1 X X X X X X X X X X 0 1 1 300.000000000000 1 300.000000000000 1 X X 1 1 X X X X X X 0 1 X X X X X 1 X X 0 0 Part I, Line 3c: Brattleboro Memorial Hospital's Free Care program is designed to assist those patients who are either uninsured, underinsured or have limited financial resources that impact their ability to fully pay for their hospital care. When making application for Free Care, patients are first asked to investigate whether or not they may be eligible for Medicare, Medicaid, Veterans' Benefits or other governmental or public assistance programs. Free Care should always be the payor of last resort.A. Qualifications for Free Care:1. Free Care is limited to medically necessary services. Patients receiving certain elective services, such as those considered cosmetic, investigational or experimental, are expected to make payment arrangements in advance, as these types of services are not covered by Free Care;2. Patients' family income must be at or below 300% of the current Federal Poverty Income Guidelines for their family size;3. Patients or their guarantors must complete a Free Care application and provide the hospital with verification of income. Responsible parties may be asked to disclose the identity and amounts of any assets that could be used to pay for medical expenses.NOTE: Income verification may be waived at the discretion of the Director of Patient Financial Services, particularly in those instances in which patients have subsequently qualified for Medicaid, or are deceased, with no estate;4. Free Care applications will be processed within two weeks of the date of their receipt in our Business Office;5. Free Care applies only to those patient accounts still in active Accounts Receivable; no Free Care allowance may be applied against accounts that have been forwarded to a collection agency as Bad Debt.B. Patients will be notified in writing of their approval or denial status within 30 days of the date of receipt of the application and any required supporting documentation. All accounts written off to Free Care must be approved by the Director of Patient Financial Services or the Vice-President of Finance. Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table. The cost accounting system addresses all patient segments. A cost-to-charge ratio was used. Part II: 1.Health Fair 2.Director of the Community Health Team participates in community coalitions such as Fit & Health Kid's Coalition, Healthier Communities Coalition. The HCC coalition, of which the Director of the Community Health Team, is a member, has been instrumental in advocating for healthy nutrition, exercise, food security, Farm to School programming & advocating for improving the built environment & town policies to support health & wellness. Many of the health improvement needs identified by & advocated for by the coalition have been incorporated into the new town plan for Brattleboro. The HCC was recognized for its success & effectiveness. The HCC has conducted Community Healthier Living Index (CHLI) assessments at Green Street School and at BMH. This YMCA tool measures community organization support for physical activity & health eating. Mini grant money will be used to implement strategies for improvements in the areas of health nutrition and exercise. 3.Our Director of Nutrition Services supports local agriculture & has been recognized for BMH's level of support. 550 BMH employees benefit from local foods & healthy choices on our breakfast, lunch & dinner menus daily. Part III, Line 4: A simple RCC was utilized to reduce charges to cost. The estimated bad debt that may be eligible for our charity care policy was based on a 25% eligibility rate. Part III, Line 8: The Medicare shortfall should be considered a community benefit in its entirety. Part III, Line 9b: Patients or their guarantors must complete a Free Care application and provide the hospital with verification of income. Responsible parties may be asked to disclose the identity and amounts of any assets that could be used to pay for medical expenses.NOTE: Income verification may be waived at the discretion of the Director of Patient Financial Services, particularly in those instances in which patients have subsequently qualified for Medicaid, or are deceased, with no estate. Brattleboro Memorial Hospital Part V, Section B, Line 3: A Steering Committee was formed that represented a cross section of diverse community organizations and members that represented various community populations and age groups. Group forums, Steering Communitee meetings and various surveys were conducted during the time period from October 2011 and ending September 2012. The Needs Assessment was approved by the Board in December 2012. Brattleboro Memorial Hospital Part V, Section B, Line 4: Brattleboro Memorial Hospital, Grace Cottage Hospital and The Brattleboro Retreat. Brattleboro Memorial Hospital Part V, Section B, Line 7: Several needs emerged in the research findings that the participating health care organizations cannot fully address at this time. These unmet needs are as follows: Hepatitis C prevention, improved transportation, violence prevention and poverty reduction.The hospital is not addressing Hepatitis C prevention at this time due to other priority health care conditions being selected to focus on for the upcoming three-year period.While the hospital is not currently adressing the needs for improved transportation, violence prevention and poverty reduction they are supporting several community initiatives aimed at addressing these needs. Part VI, Line 2: BMH conducted the December 2012 Community Health Needs Assessment. The needs assessment addressed health and wellness in Windham County, inclusive of lifestyle, access to care, maternal & child health, illness & death, and injury. Methodology included data analysis, on-line surveys, survey questionnaire distribution at public events, various focus groups, provider surveys and 7 formal Steering Committee meetings. Highest priority issues about healthcare & healthcare access were identified.Evaluations were given to all participants of the Community Health Needs Assessment. Participants are asked what health & wellness topics they would like to have presented. Each participant developed an implementation plan. These responses are compiled & prioritized. The committee for the calendar uses these priority requests to plan content of future calendars. Part VI, Line 4: BMH serves a total service area that includes: 22 towns A population of 59,000 Compared to VT/US, residents of the service area tend to be: Older Similarly well off (MI), especially in the secondary service area Less at risk for obesityThe 65+ population will be the fastest growing segment, while the 0-17 and 18-44 age cohorts drop. VT is the second oldest state in the country (after Maine). Median age in the PSA & SSA is higher than Vermont overall & significantly higher than the US median. Brattleboro area employers, like Vermont employers generally, are small in size. The 3 largest employers are: C&S Wholesale, Entergy VT, and BMH. 11,474 people commute to Brattleboro to work.* The unemployment rate for Windham County as of April 2012 was 5.7%. The VT Department of Health publishes a comprehensive Health Status Report every 5 years. The most recent report is dated 2008. County data is compared to goals for VT. The indicators for Windham County for 2008 identified the following areas of concern. Access to health care - residents without a usual doctor; lack of health insurance Breast, Colon and Cervical Cancer screening rates are worse than in Vermont or less than the healthy Vermonter goal. Rates of Injury in Windham County were higher than Vermont in all age groups except 0-9 year olds. X X X X X 0 0 0 0 0 1 1 0 0 Steven Gordon 0 216476 0 0 0 9663 0 0 0 13691 0 239830 0 0 Michael Rogers 0 167983 0 2403 0 3362 0 13397 0 23045 0 210190 0 0 Mary Morgan 0 168922 0 0 0 17344 0 0 0 10227 0 196493 0 0 Clifford Langweiler MD 276580 0 0 0 0 0 12967 0 41538 0 331085 0 0 0 Teresa Fitzharris-Onyon MD 250498 0 0 0 0 0 12250 0 39593 0 302341 0 0 0 Christopher Schmidt MD 246092 0 0 0 0 0 12250 0 39567 0 297909 0 0 0 Joseph Rosen MD 243149 0 25000 0 0 0 12934 0 23045 0 304128 0 0 0 Gregory Gadowski MD 241339 0 25000 0 0 0 12250 0 26167 0 304756 0 0 0 Barry Beeman 0 55849 0 0 0 45248 0 0 0 3877 0 104974 0 0 Part I, Line 6 The bonuses paid in tax year 2011 are mostly contractual however the net earnings are a minor consideration in the senior leadership bonus amounts. Vermont Educational and Health Building Financing Agency 237154467 924166BQ3 2008-02-01 11180000 Advance refund of previously issued bonds 0 0 0 1335000 11180000 145933 11034067 2008 1 0 1 1 0 0 0 0 1 1 1 1 Duetsche Bank 15.000000000000 0 0 0 0 0 X JoAnne Rogers Spouse of Michael Rogers, VP of Finance, Treasurer & CFO 26844 JoAnne Rogers works as the gift shop manager for an average of 20 hours per week. 0 Form 990, Part VI, Section A, line 6 The sole member of the Hospital shall be Southern Vermont Health Services Corporation, a Vermont not-for-profit corporation. Form 990, Part VI, Section A, line 7a The Board of Directors of the Hospital shall consist of eleven persons elected by Southern Vermont Health Service Corporation (sole member) from among membership of the sole member, plus the President and Medical Staff President ex officio but without the power to vote. Directors shall be elected annually by the sole member to hold office for three years and until their successors have been elected and qualified or until thier death or resignation. Elected directors may serve for a maximum of three consective three-year terms. Form 990, Part VI, Section A, line 7b The Board of Directors may not take any of the following actions without the prior approval of Southern Vermont Health Service Corporation (sole member): a) Adopt any annual or long-term capital or operating budget of the Hospital; b) Authorize the Hospital to enter into any contract or engage in any transaction which is not provided for in an annual or long-term capital or operating budget of the Hospital approved by the sole member, where the amount involved exceeds an amount as determined from time to time by the sole member; c) Authorize the Hospital to transfer funds or other assets to any other organization or corporation, where the amount involved exceeds an amount as determined from time to time by the sole member; d) Authorized the Hospital to engage in, or enter into, any transaction involving the borrowing of funds, incurring of debt, and/or guaranteeing, pledging, or collateralizing of any of its assets in connection therewith; e) Adopt any new, or any changes to the existing, long-range or master plans or the Hospital; or f) Organize or acquire, or authorize the organization or acquisition of, any subsidiary or affiliate of the Hospital. Form 990, Part VI, Section B, line 11 The role of the Hospital's Audit Committee includes review of the 990. The Audit Committee engages the auditors and receives the audit and a complete copy of the Form 990, including all schedules. The Audit Committee will report to the Board that the 990 review has occurred. The Board accepts the the Audit Committee reports and the 990. All members of the Board will have access to the 990 prior to filing. Form 990, Part VI, Section B, line 12c Each December, Board Members are required to complete a Conflict of Interest Statement. Beginning FY 2010, these statements were reviewed by outside counsel and reported back to the Board of Directors along with recommendations for action. Form 990, Part VI, Section B, line 15 The Executive Compensation Committe (ECC) of the Board of Directors (BOD) engages an outside compensation consultant to review executive compensation policies, procedures and conduct an independent regional and national market survey for senior leadership positions. The ECC sets the CEO's compensation and reviews the CEO's recommendations for other senior leadership compensation. The actions of the ECC are reviewed and approved by the BOD. Form 990, Part VI, Section C, line 19 Financial statements are published on our website. Our governing documents and conflict of interest policies are not made available to the public. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 824,950. Unrealized Loss on Interest Rate Swap -57,586. Change in Interest in SVHSC 7,466. Total to Form 990, Part XI, Line 5: 774,830. Form 990, part XII, Line 2c The organization did not change its oversight or selection during the tax year. Southern Vermont Health Services Corp 17 Belmont Ave Brattleboro VT 05301 222564588 Provide Health Management Services VT 501(c)(3) Line 7 N/A 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 Southern Vermont Health Services L 1613000 Cash Southern Vermont Health Services C 29655 Cash