2012-12-10T16:07:50-06:00 2011-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIRCLE SUITE 2600 INDIANAPOLIS IN 46204 990 2011-01-01 310537504 Miami Valley Hospital % J MICHAEL SIMS MIAM 9374999942 110 NORTH MAIN STREET Dayton OH 45402 SCOTT A SHELTON 2012-11-29 true 3176817000 2011 2016-02-24 21:20:13Z X X Bobbie Gerhart 110 N MAIN ST SUITE 500 DAYTON OH 45402 898075064 false X WWW.PREMIERHEALTHPARTNERS.ORG X 1890 OH MIAMI VALLEY HOSPITAL WILL BUILD HEALTHIER COMMUNITIES WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-EFFECTIVE HEALTH CARE SERVICES. 19 11 7460 1037 0 1595275 1299919 713089259 811320920 24409451 12174810 16248343 14005077 755342328 838800726 2388827 9198113 0 0 342227641 369823871 0 0 0 337777496 406178191 682393964 785200175 72948364 53600551 1217646199 1359305439 565468380 737842571 652177819 621462868 MIAMI VALLEY HOSPITAL WILL BUILD HEALTHIER COMMUNITIES WITH OTHERS WHO SHARE OUR COMMITMENT TO PROVIDE HIGH-QUALITY, COST-EFFECTIVE HEALTH CARE SERVICES. false false 686736094 9198113 814335266 PLEASE REFER TO SCHEDULE H. 686736094 true true false true false false false false false false true false false false true true false true false false true false false false false false true true true false true true false false false false false false false true false true false false false false true true true true false false true 519 0 true 7460 true false false false false false false false false false false X 19 11 false true false false true true true true true false false true true true true true true true true true true OH X J MICHAEL SIMS 9374999942 110 N MAIN ST SUITE 500 Dayton OH 45402 X ANGELA CLEMENTS CPA 0.5 X 0 0 0 CHRISTOPHER CROOM MD 0.5 X 0 200371 19075 CHRISTOPHER J DANIS MD 0.5 X 0 272363 0 WILLIAM L GILLISPIE 0.5 X 0 0 0 DAVID W KEY MD 0.5 X 0 0 0 ANITA J MOORE 0.5 X 0 0 0 MARY C NUTTER 0.5 X 0 0 0 JAMES M PACENTA MD 0.5 X 0 623589 45290 NORM J SCHNEIDERMAN MD 0.5 X 24325 0 0 SR RABBI DAVID SOFIAN 0.5 X 0 0 0 WILLIAM C WILSON MD 0.5 X 0 0 0 GARY S COLLIER MD 40.0 X 388067 0 69615 EDWARD BLAKE 0.5 X X 0 0 0 BOBBIE L GERHART 40.0 X X 641791 0 103497 REVEREND DR BRODIE R MATHIS 0.5 X 0 0 0 JAMES J MURPHY MD 0.5 X 0 0 0 Barbara A Johnson 40.0 X X 390363 0 20539 Shery B Oakes 0.5 X 0 0 0 JAMES R PANCOAST 0.5 X 0 2259241 35827 SCOTT A SHELTON 40.0 X 308821 0 7409 DALE E CREECH JR 40.0 X 525911 0 155120 GEOFF WALKER 40.0 X 255741 0 30485 THOMAS J ARQUILLA 40.0 X 203967 0 28003 WILLIAM E LINESCH 40.0 X 424338 0 41137 MARK W SHAW 40.0 X 349386 0 84013 MARY M CLANCY 40.0 X 467688 0 55146 J NICHOLAS LAIR 40.0 X 295289 0 34887 RENEE P GEORGE 40.0 X 269407 0 33415 DEBORAH A MALS 40.0 X 321467 0 39513 DIANE L PLEIMAN 40.0 X 271578 0 13637 MOLLY J HALL 40.0 X 429044 0 30577 J MICHAEL SIMS 40.0 X 315345 0 59434 DIANE L EWING 40.0 X 299597 0 19067 Ann Schuerman 40.0 X 296086 0 47319 THOMAS MOSER 40.0 X 284893 0 24368 6763104 3355564 997373 219 false true false Compunet Clinical Labs 2308 Sandridge Drive MORAINE OH 45349 Clinical Lab 21110578 Miami Valley Emergency Specialists 35 Millard Court SPRINGBORO OH 45066 Medical Services 4965386 Anesthesiology Services Network PO Box 349 DAYTON OH 45409 Medical Services 7073371 DELOITTE CONSULTING LLP PO BOX 7247-6447 PHILADELPHIA PA 191706447 CONSULTATION 3690464 DAWSON HEALTHCARE 3650 OLENTANGY RIVER RD 450 COMLUMBUS OH 43214 AGENCY STAFF 2860778 95 1299919 1299919 NET PATIENT REVENUE 900099 408143885 408143885 MEDICARE/MEDICAID 900099 389012140 389012140 JOINT OPERATING AGREEMENT 900099 13223000 13223000 PASTORAL COUNSELING 900099 520078 520078 HEALTH EDUCATION 900099 139158 139158 282659 282659 811320920 9065207 9065207 0 0 4526930 4333379 193551 193551 193551 57637092 53571950 955539 4065142 -955539 3109603 3109603 0 0 3427816 413470 3014346 3014346 CAFETERIA SALES 722210 6002086 6002086 PARKING GARAGE 812930 1775492 1775492 JOINT VENTURE 900099 122076 122076 2897526 2897526 10797180 838800726 814335266 23165541 9198113 9198113 0 0 0 5327746 4614893 712853 0 287909983 249387627 38522356 17371359 15047071 2324288 38265097 33145227 5119870 20949686 18146618 2803068 117379 101674 15705 436016 377677 58339 436429 436429 44522 44522 0 1197242 1197242 35714363 35714363 3119107 3119107 4508714 3905448 603266 12329698 10679984 1649714 0 13688045 11856585 1831460 651922 564695 87227 0 712394 617076 95318 14306813 14306813 0 67417182 58396763 9020419 8378750 7257673 1121077 OPERATING SUPPLIES 130550539 130550539 PURCHASED SERVICES 56532768 48968684 7564084 LOSS ON INTEREST SWAP ADJ 23359735 23359735 BAD DEBT EXPENSE 18165127 18165127 14511446 12569815 1941631 785200175 686736094 98464081 0 21535 28522 14090622 34142664 0 0 108414623 113070876 0 0 0 0 5863694 9003284 5933123 6175831 7156846 8232457 1155680099 517780562 588176863 637899537 208717186 402756902 92795170 63993890 0 0 22224385 25919184 164252152 58082292 1217646199 1359305439 71666781 85784199 355078 1592084 1108478 1218263 315316616 418612767 0 0 0 0 2237426 4208750 0 0 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PART II-B, LINE 1I: WE CONTRACT WITH A LOBBYIST FOR HEALTHCARE RELATED ISSUES. 35200466 35200466 615527053 260062526 355464527 1346416 1268390 78026 399242213 256449646 142792567 104363951 104363951 637899537 0 PENSION OBLIGATION 147265154 SWAP LIABILITY 27174992 MALPRACTICE INSURANCE 26375227 LOAN GUARANTEE & OTHER LTL 13102158 RESIDENT FICA REFUND PAYABLE 4541553 CONTRACTOR RETAINAGE RESERVE 4062989 WORKERS COMP RESERVE 1087357 WRIGHT STATE NEUROSCIENCE 900000 OTHER 1917078 226426508 Schedule D, Part X, Line 2: Miami Valley Hospital (MVH) is a member, under a joint operating agreement, of Premier Health Partners which is tax-exempt under Section 501(c)(3) of the Internal Revenue Code. As such, there is no income tax liability recorded at December 31, 2011 and 2010. In addition, Management annually reviews its tax positions and has determined that there are no material uncertain tax positions that require recognition in the combined financial statements. MVH and its respective subsidiaries are a group of corporations that are tax-exempt corporations under Section 501(c)(3) of the Internal Revenue Code except for the following subsidiaries: MVHE, Inc. and Premier Health Specialists, Inc. (subsidiaries of MedAmerica Health Systems Corp.) Part V, Line 4: Income generated off the endowment funds are used to support various programs of Miami Valley Hospital. Central America and the Caribbean Investments 31528000 East Asia and the Pacific Investments 15380000 Europe (Including Iceland and Greenland) Investments 36911000 North America Investments 2307000 South America Investments 116000 South Asia Investments 5768000 Central America and the Caribbean Program Services INSURANCE 47000 92057000 92057000 false false false false false false true true X true X true X true true true false true true 48365000 12916000 35449000 0.04620 136965000 120770000 16195000 0.02110 6528000 5060000 1468000 0.00190 191858000 138746000 53112000 0.06920 6387000 6387000 0.00830 26026000 20397000 5629000 0.00730 20702000 2835000 17867000 0.02330 1735000 1735000 0.00230 8000 8000 54858000 23232000 31626000 0.04120 246716000 161978000 84738000 0.11040 212000 212000 0.00030 1373000 1373000 0.00180 1585000 1585000 0.00210 true 18165000 0 133755000 149327000 -15572000 X true true 2 1 MIAMI VALLEY HOSPITAL

ONE WYOMING STREET DAYTON OH 45409

X X X X X 2 MIAMI VALLEY HOSPITAL SOUTH

2400 MIAMI VALLEY DRIVE CENTERVILLE OH 45459

X X X MIAMI VALLEY HOSPITAL 1 true true 200. true 400. true X X X X true true X X X X X X true false X X X X true X false false MIAMI VALLEY HOSPITAL SOUTH 2 true true 200. true 400. true X X X X true true X X X X X X true false X X X X true X false false 2 Dialysis Centers of Dayton LLC

136 South Ludlow St Suite 500 Dayton OH 45402

Dialysis Treatment Lincoln Park Manor

694 Isaac Prugh Way Kettering OH 45429

Assisted Living Part I, Line 6a: The community benefit report for Miami Valley Hospital is part of the Premier Health Partners report. Part I, Line 7, column (f): $17,359,000 of bad debt was excluded from the denominator. Part I, Line 7g: Miami Valley Hospital provides the following subsidized services: Miami Valley Hospital Medical Surgical Health Center is the largest provider of health care for the uninsured and underinsured in the Dayton area, with over 18,000 visits a year. The Center offers care for immediate medical needs, long-term care and chronic conditions. The Center also provides pharmacy vouchers in addition to diagnostic testing and wellness care. The Center provides primary care to patients as well as numerous specialty clinics. It has a dedicated social worker whose knowledge and expertise assists numerous patients in obtaining the services and healthcare they need. Miami Valley Dental Center provides dental care including sub-specialist services like periodontal surgery, endodontics, and oral surgery. The Dental Center has the unique ability to treat patients who might need care for conditions other than dental at the same time as their medical conditions are being monitored and controlled for the procedure. The Center services patients such as very young children with multiple dental problems, or mentally handicapped and developmentally disabled and patients who have a medical condition that must be strictly controlled during dental care. Berry Family Health Center is a separate care facility offering a full range of services associated with primary care including family practice, pediatrics, adolescents, Geriatrics, Psychology, Women's Health, Sports Medicine and minor office surgeries. The center uses a practice of evidence-based medicine in decision making. Emergency Services: Miami Valley Hospital operates a 24-hour emergency room 365 days per year. This emergency room is open to all individuals regardless of their ability to pay. The hospital incurs expenses related to call time and physician subsidies due to the large number of indigent patients coming through the emergency room. For 2011, the amount paid for call time and subsidies was $15,420,000. Part I, Line 7 Charity Care at Cost: A cost to charge ratio was used to calculate this figure. This calculation takes total operating expenses less other operating revenues and bad debt expenses divided by total gross revenues. Unreimbursed medicaid and other means-tested governmental programs were calculated using a cost accounting system. This system addresses all patient segments and includes fully loaded costs. For the remaining items the organization used specific numbers for expense paid directly for these services. Part III, Line 4: The organization used the same cost to charge ratio defined in Part I, Line 7 to determine bad debt expense at cost. The organization does not have a footnote in the audited financial statements which discusses this calculation. Bad debt expense is incurred when an account is taken out of Accounts Receivable and turned over to a collection agency. This action may occur if a patient refuses payment arrangements, refuses to apply for financial assistance and there is not an insurance balance being contended. An account is written off to bad debt after 120 days if an attempt to collect from the patient is made within our collection policy and the patient has not returned phone calls, set up a payment plan, applied for financial assistance and there is not an insurance balance being contended. The collection agency attempts to collect the account in accordance with established guidelines. Collection attempts are ceased and the account returned back to the organization if the patient applies for financial assistance. Any amounts collected from these accounts are credited back against bad debt expense. The organization recognizes that there are accounts written off to bad debt that may have qualified for charity care if the patient provided the necessary financial information. In order to resolve this, the organization has engaged a third party vendor to analyze data based on credit scores to reallocate some of this expense to charity care. These accounts are then sent to our third party vendor who gathers external credit data that presents the account as less than 200% Federal Poverty Level or not enough information (typically indicative of indigent). These accounts are reclassed from bad debt expense to charity expense on our income statement. Any credit score that presents the accounts as greater than 200% Federal Poverty Level remains in bad debt expense. Due to this process, the organization does not feel it has reported bad debt expense for patients eligible under the organization's charity care policy. Part III, Section B, Lines 5, 6, and 7 The amounts reported on Lines 5, 6, and 7 do not include certain Medicare program revenues and costs, and thus do not reflect all of the organization's revenues and costs associated with its participation in Medicare programs. In addition to the amounts reported on Line 5, 6, and 7, the organization received revenue of $88,280,000 and incurred cost of $117,663,000, for an additional net shortfall of $29,383,000 associated with these programs. Below is a reconciliation of the amounts associated with Medicare programs. Allowable Medicare revenue per Medicare Cost Report (Part III, Section B) 133,755,000 Medicare revenue not reported in Part III, Section B 88,280,000 Total Medicare associated revenue 222,035,000 Allowable Medicare cost per Medicare Cost Report (Part III, Section B) 149,327,000 Medicare cost not reported in Part III, Section B 117,663,000 Total Medicare associated cost 266,990,000 Medicare shortfall per Part III, Section B 15,572,000 Additional shortfall not included in Part III, Section B 29,383,000 Total Medicare shortfall 44,955,000 Part III, Line 8: The organization's shortfall should be considered charity care because it is providing high-quality care in excess of the cost to our community residents that need care. The Medicare population at the organization is in excess of 35% of net patient revenue. The organization used a cost accounting system to calculate the Medicare allowable costs. Part III, Line 9b: Miami Valley Hospital makes reasonable efforts to determine whether or not an individual is eligible for assistance under the state or hospital financial assistance policy before engaging in extraordinary collections actions against that individual. Patients who are known to qualify for financial assistance are not subjected to extraordinary collections actions. Any third party collecting self pay receivables on our behalf is required to make reasonable efforts to determine if the individual meets the qualifications of the state or of our hospital financial assistance programs. Reasonable efforts include: a. Validating that the patient owes the unpaid bills and that all sources of third party payment have been identified and billed by the hospital. b. Documenting that Miami Valley Hospital has or has attempted to offer the patient the opportunity to apply for charity care under its financial assistance policy. c. Documented that the patient does not qualify for financial assistance. d. Document that the patient has been offered a payment plan, but has not honored the terms of that plan. Miami Valley Hospital's Financial Counselors meet with both inpatient and outpatient self-pay, and other patients upon request, who may need financial assistance. In addition to assisting patients who want to apply for assistance through the Medicaid program, the Financial Counselor will provide the patient with a financial assistance application. Part V, Section B, Line 11: If the patient's family's income falls within 400% of the federal poverty guidelines, the patient qualifies for assistance under the hospital financial assistance policy. All or part of the account will be written off to charity care, based on a Sliding Fee Schedule. The amounts charged to patients who are eligible for financial assistance are not more than the amounts generally billed to individuals who have insurance covering such care. Patients who qualify for financial assistance are not charged gross charges for emergency or medically necessary care. We offer reasonable payment plans to those who have qualified for charity care. Patients may also qualify for charity care discounts due to a medically-based catastrophic event which has occurred in their life. If a patient qualifies for this discount, he/she would only be held responsible for payment of his/her family's medical expenses up to 25% of their annual income. Part V, Section B, Line 13: Miami Valley Hospital widely distributes information about its financial assistance policy within the Montgomery County area and surrounding communities that it serves. This information includes the method of applying for and accessing financial assistance. Notices are publicized in patients' bills true AMERICAN HEART ASSOCIATION 5455 NORTH HIGH ST COLUMBUS OH 43214 135613797 501(C)(3) 19200 DAYTON GALA CITY OF DAYTON 101 WEST THIRD ST DAYTON OH 45401 316000175 Government 212451 GUN VIOLENCE REDUCTION & GOOD NEIGHBOR POLICE PROGRAM. CITYWIDE DEVELOPMENT CORP 8 N MAIN ST DAYTON OH 45402 310821189 501(C)(3) 42245 GENESIS PROJECT Downtown Dayton. DAYBREAK 605 S PATTERSON BLVD DAYTON OH 45402 310864474 501(C)(3) 6200 ANNUAL PLEDGE DAYTON ART INSTITUTE 456 BELMONTE PARK NORTH DAYTON OH 45405 310537480 501(C)(3) 20840 SPONSOR THE DAYTON FOUNDATION 500 KETTERING TOWER DAYTON OH 45423 316027287 501(C)(3) 5118504 Various MARCH OF DIMES - MIAMI VALLEY DIVISION 3131 S DIXIE DR - 313 DAYTON OH 45439 131846366 501(C)(3) 7500 PRESENTING SPONSOR development. MARY SCOTT NURSING CENTER INC 3109 CAMPUS DR DAYTON OH 45406 316010222 501(C)(3) 32000 GRANT REACH OUT MONTGOMERY COUNTY 25 EAST FORAKER DAYTON OH 45409 311434282 501(C)(3) 136605 RX ASSISTANCE for indigent patients. UNITED WAY GREATER DAYTON PO BOX 634625 CINCINNATI OH 45263 310536658 501(C)(3) 85900 CORPORATE PLEDGE WRIGHT STATE UNIVERSITY 3640 COLONEL GLENN HIGHWAY DAYTON OH 45435 310732831 Government 162600 CONTRIBUTION TO NURSING INST GDAHA - BRIGHTER FUTURES 4 RIVERPLACE DR STE 400 DAYTON OH 45405 311221836 501(C)(6) 30000 HOME NURSING VISITS CULTURE WORKS 126 N MAIN ST STE 210 DAYTON OH 45402 237412338 501(C)(3) 10890 ANNUAL CAMPAIGN DAYTON DEVELOPMENT COALITION 40 N MAIN ST STE 900 DAYTON OH 45423 311423890 501(C)(6) 93407 SPONSOR VICTORIA THEATRE ASSOCIATION 138 N MAIN ST DAYTON OH 45402 310897638 501(C)(3) 96000 SPONSOR PREMIER COMMUNITY HEALTH 23 Jasper Street Dayton OH 45409 311122883 501(c)(3) 530021 Community Health Miami Valley Hospital Foundation 110 North Main Street Suite 500 Dayton OH 45402 311040231 501(c)(3) 1767750 Health Promotion AIDS RESOURCE CENTER OHIO 15 W FOURTH ST SUITE 200 DAYTON OH 45402 311256541 501(C)(3) 50000 AFRICAN AMERICAN OUTREACH CITY FOLK 125 NORTH MAIN STREET SUITE 220 DAYTON OH 45402 311030297 501(C)(3) 6400 SPONSORSHIP DAYTON CONTEMPORARY DANCE CO 840 GERMANTOWN STREET DAYTON OH 45402 237220259 501(C)(3) 8700 SPONSOR DAYTON PHILHARMONIC ORCHESTRA 109 N MAIN ST SUITE 200 DAYTON OH 45402 316000101 501(C)(3) 100100 SPONSOR GOODWILL EASTER SEALS 1511 KUNTZ ROAD DAYTON OH 45404 310537112 501(C)(3) 15000 CAR SEAT PROGRAM HUMAN RACE THEATRE CO 126 N MAIN STREET SUITE 300 DAYTON OH 45402 311176135 501(C)(3) 7680 SPONSOR IMPROVED SOLUTIONS FOR URBAN SYSTEMS INC 140 N KEOWEE STREET DAYTON OH 45402 311355468 501(C)(3) 15000 OPERATIONS SUPPORT JEWISH FEDERATION OF GREATER DAYTON 33 WEST FIRST STREET SUITE 100 DAYTON OH 45402 310537488 501(C)(3) 5740 SPONSOR MUSE MACHINE 126 NORTH MAIN STREET SUITE 310 DAYTON OH 45402 311028673 501(C)(3) 14750 SPONSOR SALVATION ARMY OF DAYTON 138 S WILKINSON STREET DAYTON OH 45402 135562351 501(C)(3) 6640 SUPPORT FOUNDATION FOR CBCCTS 349 S MAIN STREET DAYTON OH 45402 205676673 501(C)(3) 12800 GRANT 26 2 SCHEDULE I, SUPPLEMENTAL INFORMATION: 1) Community benefits budgeted allocations are approved by the Miami Valley Hospital Board annually. 2) Invoices are received in Accounts Payable upon appropriate approval for payment. 3)Disbursements occur according to standard Accounts Payable guidelines. X X X X false true false false false true true false false CHRISTOPHER CROOM MD 0 114121 0 86250 0 0 0 0 0 19075 0 219446 0 0 CHRISTOPHER J DANIS MD 0 272363 0 0 0 0 0 0 0 0 0 272363 0 0 JAMES M PACENTA MD 0 618192 0 3093 0 2304 0 16772 0 28518 0 668879 0 3093 GARY S COLLIER MD 268262 0 76025 0 43780 0 50088 0 19527 0 457682 0 114658 0 BOBBIE L GERHART 443952 0 160027 0 37812 0 93292 0 10205 0 745288 0 189037 0 SCOTT A SHELTON 218280 0 88096 0 2445 0 3699 0 3710 0 316230 0 88096 0 DALE E CREECH JR 332896 0 150791 0 42224 0 130039 0 25081 0 681031 0 185978 0 THOMAS J ARQUILLA 126756 0 67633 0 9578 0 6832 0 21171 0 231970 0 75243 0 WILLIAM E LINESCH 300256 0 103880 0 20202 0 33815 0 7322 0 465475 0 118246 0 MARK W SHAW 255244 0 86405 0 7737 0 62595 0 21418 0 433399 0 86405 0 MARY M CLANCY 313530 0 126634 0 27524 0 41787 0 13359 0 522834 0 151055 0 J NICHOLAS LAIR 199671 0 94873 0 745 0 14638 0 20249 0 330176 0 94873 0 RENEE P GEORGE 202151 0 66675 0 581 0 9394 0 24021 0 302822 0 66675 0 MOLLY J HALL 293242 0 129868 0 5934 0 9448 0 21129 0 459621 0 129868 0 J MICHAEL SIMS 219760 0 81119 0 14466 0 37025 0 22409 0 374779 0 93129 0 DEBORAH A MALS 228112 0 87728 0 5627 0 27219 0 12294 0 360980 0 87728 0 DIANE L PLEIMAN 187629 0 82791 0 1158 0 7317 0 6320 0 285215 0 82791 0 DIANE L EWING 218423 0 76927 0 4247 0 9733 0 9334 0 318664 0 76927 0 Barbara A Johnson 305496 0 81209 0 3658 0 11715 0 8824 0 410902 0 81209 0 Ann Schuerman 234233 0 57776 0 4077 0 38454 0 8865 0 343405 0 57848 0 GEOFF WALKER 183882 0 70507 0 1352 0 10054 0 20431 0 286226 0 70507 0 THOMAS MOSER 217356 0 62730 0 4807 0 7214 0 17154 0 309261 0 62730 0 JAMES R PANCOAST 0 832888 0 434253 0 992100 0 8557 0 27270 0 2295068 0 1411844 Part I, Line 4b: Due to restrictions imposed by the Internal Revenue Code, certain persons are limited in the amount of benefit that can be earned under a qualified retirement plan. Like many employers, Miami Valley Hospital (MVH), compensates for this limitation and supplements the affected executives' qualified pension through certain nonqualified plans. MVH supplements through a Pension Restoration Plan and a Supplemental Executive Retirement Plan (SERP). The benefits under these supplemental nonqualified plans are subject to multi-year vesting and a participant can forfeit benefits earned if vesting requirements are not satisfied. Under the terms of the supplemental plans, and because of tax rules pertaining to taxation of the earned benefits upon vesting, certain individuals received a payout of the cumulative vested benefits under their supplemental plan during 2011. The individuals listed below have met the multi-year vesting requirement under the Pension Restoration Plan and received the associated payment in 2011: Gary Collier $38,633; Dale Creech $35,186; Thomas Arquilla $7,610; William Linesch $14,366; Mary Clancy $24,421; J Michael Sims $12,010; Ann Schuerman $72. Jim Pancoast met the multi-year vesting requirement under the SERP and received $977,591; Bobbie Gerhart met the multi-year vesting requirement under the SERP and received $29,010. All or parts of these payments were also properly reported on prior years' filed IRS Form 990 returns disclosing compensation earned by these individuals under the plans for each such year. However, based on the guidance provided in the instructions to the Form 990, any payments to the participants related to these plans that were made within 2-1/2 months after the end of the organization's tax year are not treated as deferred compensation for purposes of Schedule J. Such amounts are properly reported as compensation for Form 990 purposes when included in the participants' Form W-2 wages, which in this situation is 2012. Part I, Line 6a and 6b: Premier Health Partners (PHP), which Miami Valley Hospital is a member, has an incentive component for all executive and director level employees that ties a portion of their total compensation to organizational and individual objectives and outcomes. The organizational criterion is weighted according to balanced scorecard categories: Positive Work Environment (15%), Quality (30%), Patient Satisfaction (15%), Physician Partnership, (15%), Financial (20%) and Major Projects (5%). The financial category of the scorecard is based on net earnings of the individual hospital and the net earnings of the system of a whole. This financial target is set based on the operating and cash flow margins required to maintain the system Aa credit ratings. Directors, Vice Presidents and above incentive objectives are weighted 45% on organizational criteria and 45% on individual criteria, and 10% on Organizational Effectiveness. The 2011 incentive plan amounts were paid to the participants in 2012. These are not reported as deferred compensation on the 2011 Form 990 based on the definition of deferred compensation contained in the Form 990 instructions. Per the instructions, "deferred compensation is generally treated as earned or accrued in the year that services are rendered, except when entitlement to payment is contingent on satisfaction of organizational goals or specified performance criteria (other than mere longevity of service) under the deferred compensation plan." Based on the incentive program's criteria outlined above, we believe the incentive payments meet the exception noted in the instructions. Such amounts are properly reported as compensation for Form 990 purposes when included in the participants' Form W-2 wages, which in this situation is 2012. COUNTY OF MONTGOMERY OH 316000172 613549GP3 2008-11-13 234895988 SEE SCHEDULE O false false false COUNTY OF MONTGOMERY OH 316000172 613549GZ1 2009-02-24 126463824 SEE SCHEDULE O false false false COUNTY OF MONTGOMERY OH 316000172 613549JL9 2011-04-12 106431124 SEE SCHEDULE O false false false COUNTY OF MONTGOMERY OH 316000172 613549JX3 2011-04-26 85000000 SEE SCHEDULE O false false false 134100000 0 234895988 0 2542599 0 2119000 0 0 34304034 0 396842 2010 true false true true 0 0 126463824 0 5730104 0 2293824 0 0 0 0 0 2010 true false true true 0 0 106431124 0 323387 0 1203000 0 0 105228124 0 362753 2010 false false true true 0 0 85000000 0 996 0 727500 0 0 84272500 0 263138 2010 false false true true false true true true true true 0.00668 0.00000 0.00668 true false true true true true true 0.00668 0.00000 0.00668 true false false false false 0.00000 0.00000 0.00000 true false false false false 0.00000 0.00000 0.00000 true true true true MERRILL LYNCH 0. true true false 0 false true false false false 0 false 0 false true false false true BARCLAYSWELLS FARGO 25. true false false 0 false true false true true BARCLAYSWELLS FARGO 34.5 true false false 0 false true X See Schedule O 0 CHRISTOPHER CROOM DIRECTOR 510593 SEE SCHEDULE L PART V false CHRISTOPHER DANIS DIRECTOR 168092 SEE SCHEDULE L PART V false SCOTT SHELTON DIRECTOR 21110578 SEE SCHEDULE L PART V false Diane Pleiman DIRECTOR 21110578 SEE SCHEDULE L PART V false Schedule L - Part IV: Christopher Croom, M.D. is a 30% owner in Perinatal Partners. Premier Health Specialists (PHS), which is wholly owned by MedAmerica Health Systems(MAHS) completed an asset purchase of Perinatal Partners and brought the physicians onto their payroll in October 2011. Prior to the purchase, MVH contracted with Perinatal Partners to provide medical services. After the asset purchase, the Perinatal Partners contract was assigned to PHS. This contract was audited by our compliance department to ensure we were paying fair market value and did not have any Stark violations. The amounts paid under this contract are competitive and the transaction is at arms-length. The total amount paid to Perinatal Partners in 2011 was $510,593. Christopher Danis, M.D. is a 25% owner in Hand & Reconstructive Surgeons. Miami Valley Hospital contracts with Hand & Reconstructive Surgeons to provide medical services. This contract is audited by our compliance department to ensure we are paying at fair market value and do not have any Stark violations. The amounts paid under this contract are competitive and the transaction is at arms-length. The total amount paid in 2011 was $168,092. Miami Valley Hospital contracts with Compunet for the provision of laboratory services. Scott Shelton and Diane Pleiman are board members of Compunet Clinical Lab. In addition, Scott Shelton is the Chief Financial Officer of Miami Valley Hospital, and Diane Pleiman is a key employee of Miami Valley Hospital. Compunet is owned 33% by MVHE, Inc., which is a related organization of Miami Valley Hospital. The amounts paid under this contract are competitive and the transaction is at arms-length. The total amount paid in 2011 was $21,110,578. Form 990 Reason for Amending Immediately upon timely eFiling the tax return, it was determined that some data fields in Schedule J were included as zeros as a result of a software glitch. Those errors have been corrected and the proper amounts have been included. Form 990 - Part I - Question 10: Miami Valley Hospital has designated its Investments as Trading. In accordance with the AICPA, Guide for Healthcare, all unrealized gains and losses are recognized through the Profit and Loss Statement. For 990 reporting, this activity is excluded per the instructions by the Internal Revenue Service. In 2011, Miami Valley Hospital recognized an unrealized loss of $9,292,760. Form 990, Part VI, Section A, Question 3: Premier Health Partners (PHP) develops and oversees the implementation of the strategic plan for Miami Valley Hospital (MVH), which addresses such matters as location of clinical and administrative expenses and the consolidation of such services. MVH shall comply with and implement this plan and shall not take any action that materially departs from this plan without PHP approval. MVH develops and submits an annual capital and operating budget to PHP for approval. MVH shall adopt and implement the capital and operating budget so approved and/or revised for it by PHP. MVH periodically develops and submits a business plan to PHP for approval. MVH shall implement the business plan approved by PHP. PHP is the sole agent to negotiate all relationships with payors on behalf of MVH with all third party payors and alternative delivery systems including, but not limited to insurers. MVH must have approval from PHP to borrow in any fiscal year, guarantee in any year, or incur any lien or other encumbrance on any property in an amount equal to or greater than $500,000. MVH must seek PHP approval for any acquisitions, sale or transfer of any material asset used in PHP activities. Form 990, Part VI, Section A, Question 6: Miami Valley Hospital has two members. One member is MedAmerica Health Systems, the parent company of the hospital. The second member is Premier Health Partners, an Ohio non-profit corporation formed pursuant to the joint operating agreement. MedAmerica Health Systems has the sole authority to elect the Board of Trustees of the corporation. Premier Health Partners has the general authority to operate and manage the operational activities of the corporation. Form 990, Part VI, Section A, Question 7A: MedAmerica Health Systems (MAHS) has the sole authority to elect the Board of Trustees for Miami Valley Hospital (MVH). MAHS has the authority to remove trustees at any regular or special meeting or by written consent. In addition to removal by MAHS, a trustee may be removed from office with approval by MAHS, by the affirmative vote of not less than two-thirds of the entire Board of Trustees. Premier Health Partners (PHP) has the right to request that MAHS remove a trustee of the corporation if PHP has determined that such trustee is frustrating the goals and purposes of Premier Health Partner's network. Such removal shall not be unreasonably refused by MAHS. Form 990, Part VI, Section A, Question 7B: See the response above for Form 990, Part VI, Section A, Question 3. Form 990, Part VI, Section B, Question 11B: This 990 tax return and attached schedules (the return) are prepared by a staff member in the Tax Department of Premier Health Partners (PHP), of which Miami Valley Hospital is a member. The return is reviewed by the Tax Manager and a Director of the Financial Accounting Department of PHP. The return is concurrently sent to Ernst & Young U.S. LLP for their review. After all changes from the above group are made, the return is reviewed by the Vice President/Controller of PHP and the Chief Financial Officer of this entity. A final version of the return is sent to Ernst & Young U.S. LLP for a final review and then provided to the Board of Directors for review. At the meeting, the Vice President / Controller of PHP shares detailed information on compensation and community benefits, as well as address any other questions from the Board of Directors, pending their review. The 990 tax return is also shared with the Audit Committee of PHP. At the meeting, the Vice President / Controller of PHP shares detailed information on compensation and community benefits, as well as addresses any other questions from the committee. Form 990, Part VI, Section B, Question 12C: Premier Health Partners (PHP), of which Miami Valley Hospital is a member, requires all board members, officers, executives and management personnel to annually review the PHP Comprehensive Conflict of Interest Statement, an explanatory memorandum, the Antitrust Compliance Policy and complete an individual questionnaire disclosing any potential conflicts as defined in the Conflicts of Interest Policy. This is accomplished with a memo sent out annually from the Chairman of the Board and Chief Executive Officer of PHP to all board members, executive directors, vice presidents, directors, purchasing department staff and authorized purchasers. It includes an explanatory memorandum of specific activities that might give cause to a conflict and an individual questionnaire to disclose all such activities. This questionnaire must be completed and signed by the individual. Last, this memo includes a copy of the Antitrust Compliance Policy that must be signed by the individual. All of these documents are sent to the Corporate Compliance Officer. The Corporate Compliance Department ensures all forms are returned and retains the documents for five years. In addition, at each meeting of the Board or any Board Committee, following approval of the minutes, the Board Committee Chair shall request any board member who perceives a potential conflict of interest on any of the meeting's agenda items to disclose the potential conflict. Additionally, any Board or Board Committee meeting where the subject of conflicts of interest is discussed, the normally taken minutes shall contain the name of the party discussing a potential conflict of interest, the nature of the potential conflict of interest and whether a conflict of interest was found to exist. If a conflict of interest does exist, the member will be excused from participating in any discussion or voting on the particular agenda item. The Corporate Compliance Officer reports the results of the PHP Conflicts of Interest questionnaires no less than annually to the Board of Trustees by way of the Compliance and Audit Committee. This review is documented in the minutes of the meeting. Periodically, the Internal Audit department will review a sample of completed Conflict of Interest questionnaires and report the results to the Compliance and Audit Committee. The annual conflicts of interest questionnaires are individually summarized in a Word document and sent electronically to the Finance department for any necessary disclosures required on the 990 tax return. Form 990, Part VI, Section B, Question 15A and 15B: Premier Health Partners, of which Miami Valley Hospital is a member, follows a market- based compensation philosophy designed to attract and retain the executive talent required to meet the high performance standards of our board and our community. PHP annually reviews executive compensation survey data for a regional peer group of systems and hospitals that are similar in size and complexity to PHP and its subsidiaries. The data for the survey is provided by a third party consultant group that is independent of PHP. This report includes comparability for key executives, vice presidents and director level positions. The independent comparability data is reviewed by the executive compensation committee on an annual basis. This committee is comprised of three members, all of which are independent. This committee reviews in detail the compensation for the PHP CEO, COO, CFO, Chief Strategy Officer, and the hospital CEOs. Other positions are reviewed at a high level for reasonableness. All the meeting minutes are documented and kept on file along with any comparability data and the consultant report. After the compensation committee reviews and approves the compensation actions, the process is audited by the internal audit department. The executive compensation committee presents the compensation actions to the PHP board annually. Form 990, Part VI, Section C, Question 19: The governing documents, conflicts of interest policy and financial statements are made available to the public when required by law or for accreditation purposes. Form 990, Part VII, Section A, Question 1a, Column B: Officers work an average of 40 hours spread over the entities listed in schedule R. Form 990, Part X, 2011 Beginning Balance: Certain Balance Sheet line items have been reclassified to conform to the current year's presentation. Form 990, Part XI, Question 5: Unrealized Gain / (Loss) (9,292,760) Equity Transfers (20,380,926) Pension Adjustment (54,894,797) Swap Amortization (188,095) Capital Donation 571,524 Inventory Adjustment 670,555 Funding from Foundation (801,007) Other 4 Total (84,315,502) Form 990, Schedule K, Part 1, Line A, Column F: REFUND MIAMI VALLEY HOSPITAL SERIES 1992B, 1998A, 2003A, 2003B, & 2003C, AND TO PROVIDE FUNDS TO CONSTRUCT THE SOUTH EAST TOWER ON THE HOSPITAL'S CAMPUS. Form 990, Schedule K, Part 1, Line B, Column F: REFUND A PORTION OF MIAMI VALLEY HOSPITAL SERIES 2008A AND 2008B BONDS. Form 990, Schedule K, Part 1, Line C & D, Column F: PROVIDE FUNDS TO CONSTRUCT THE SOUTH EAST TOWER ON THE HOSPITAL'S CAMPUS. Statement pertaining to 2011 Form 5471: UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(a) AND (b), THE TAXPAYER IS REQUIRED TO FILE FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, AS A CATEGORY 5 FILER WITH RESPECT TO CERTAIN CONTROLLED FOREIGN CORPORATIONS (CFCs). THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 5471 FOR THESE CFCs BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. Samaritan Health Partners 110 North Main St, Suite 500 Dayton, OH 45402 EIN: 31-1107411 THE FILING ORGANIZATION, MIAMI VALLEY HOSPITAL, IS NOT FILING A SEPARATE FORM 5471 - SCHEDULE I BECAUSE IT HAS NO INCOME FROM THE FOREIGN CORPORATION. DIALYSIS CENTERS OF DAYTON LLC 110 N MAIN ST SUITE 500 DAYTON OH 45402 311607686 DIALYSIS OH 4465457 37915865 MVH PREMIER HEALTH PARTNERS 110 N MAIN ST SUITE 500 DAYTON OH 45402 311446699 SUPPRTG. ORG. 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