2012-08-15T06:00:29-05:00 2011-09-30 Baker Newman & Noyes Box 507 Portland ME 04112 990 2010-10-01 010234189 Northern Maine Medical Center NORT 2078343155 194 East Main Street Fort Kent ME 04743 Peter J Sirois 2078343155 2012-08-14 1 Nicholas E Porto 2078792100 2012-08-14 2010 2016-02-24 21:20:13Z Peter J Sirois 194 East Main Street Fort Kent ME 04743 46293266 0 X www.nmmc.org X 1948 ME Acute care and long term care hospital and mental health services facility 9 5 605 45 37783 -34290 227660 183185 43910006 45886057 -187032 16282 -76212 141455 43874422 46226979 0 0 0 0 20965773 20381884 0 0 0 25855470 25786540 46821243 46168424 -2946821 58555 29391825 29171280 14493190 14216089 14898635 14955191 The mission of Northern Maine Medical Center is to provide, coordinate, or support access to high quality, affordable health care, and to positively impact our communities' quality of life by improving health status. 0 0 36849416 45905238 Medical care & ancillary services; nursing home & skilled services; physician services 36849416 1 1 0 1 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 77 0 1 605 1 1 1 0 0 0 0 0 0 0 0 0 X 9 5 1 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Nancy Marquis 2078343155 194 East Main Street Fort Kent ME 04743 X Norman Fournier 1.00 X 0 0 0 Guy Raymond 52.00 X 375265 0 21890 John Ezzy 1.00 X 0 0 0 Frances LaBrie 1.00 X 0 0 0 Clifford Ouellette 1.00 X 0 0 0 James Thibodeau 1.00 X 0 0 0 Bob Bellefleur 1.00 X 0 0 0 Rita C Cannan 1.00 X 0 0 0 Richard Cost 1.00 X 0 0 0 Fern Desjardins 1.00 X 0 0 0 Wally Desjardin 1.00 X 0 0 0 Roy Gardner 1.00 X 0 0 0 Nelson Jandreau 1.00 X 0 0 0 John Martin 1.00 X 0 0 0 Bill Melvin 1.00 X 0 0 0 Dr David Mitchell 1.00 X 0 0 0 Kim Ouellette 1.00 X 0 0 0 Ronald Paradis 1.00 X 0 0 0 David Parent 1.00 X 0 0 0 James Roy 1.00 X 0 0 0 Kathy Roy 1.00 X 0 0 0 Michael Sullivan MD 47.00 X 385945 0 21890 Joan Sylvain 1.00 X 0 0 0 Fred Wetmore 2.00 X X 0 0 0 Dan Vaillancourt 1.00 X X 0 0 0 Glenn Lamarr 1.00 X X 0 0 0 Ronald Daigle 1.00 X X 0 0 0 Martin B Bernstein 50.00 X 198494 0 9533 Roger L Lagasse 50.00 X 135879 0 11538 Peter J Sirois 50.00 X 164448 0 21725 Scott Richards 50.00 X 152768 0 22570 Joanne Fortin 50.00 X 123380 0 9924 David Jones MD 50.00 X 311519 0 7853 1847698 0 126923 8 0 1 0 Quest Diagnostics 12436 Collection Center Drive Chicago IL 60693 Lab Test Services 314497 Brian Gretta MD 63 Merganser Cove Road Orrs Island ME 04066 ER Physician Services 187311 Cary Medical Center 163 Van Buren Road Suite 1 Caribou ME 04736 Lab Test Analysis Services 185786 Roof Systems of Maine PO Box 1134 Bangor ME 04401 Contractor Services 140310 New England Pharmacy Solutions PO Box 771 Brunswick ME 04011 Remote Pharmacy Coverage 126500 9 76495 106690 183185 Patient Service Revenu 623000 43735198 43735198 Meaningful Use Revenue 623000 1506543 1506543 Miscellaneous Revenue 623000 493749 455966 37783 Cafeteria Revenue 900099 150567 150567 45886057 7527 7527 84491 84491 84491 84491 75042 66287 8755 8755 8755 Insurance Captive 900099 56964 56964 56964 46226979 45905238 37783 100773 1160434 782718 377716 15886911 13216099 2670812 42328 34784 7544 2043733 1689676 354057 1248478 1025963 222515 180023 111153 68870 98456 60790 37666 612484 378170 234314 8869012 5476054 3392958 1472706 909303 563403 480592 296735 183857 2246096 1386822 859274 904483 558461 346022 Valley Medical Associat 8518998 8518998 Provision for Bad Debts 1254803 1254803 Health Care Provider Ta 1148887 1148887 46168424 36849416 9319008 0 2446668 1452018 1336455 2046079 5067316 5574399 29548 25291 725624 701365 555925 484039 37138318 21560119 17353794 15578199 34953 32952 30430 28190 1811112 3248748 29391825 29171280 5213239 4402224 8834343 7892499 445608 1921366 14493190 14216089 X 14506439 14570814 392196 384377 14898635 14955191 29391825 29171280 X 58555 -1999 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 6375 6375 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: The Organization paid $25,164 in dues to MHA, of which 15.5% was used for lobbying; and, $10,135 to AHA, of which 24.42% was used for lobbying. 392196 105945 715 114479 384377 402401 95643 5196 111044 392196 719671 81375 3267 401912 402401 0.00000 0.00000 1.00000 0 0 196477 196477 18915483 7361399 11554084 1769734 1058508 711226 16256624 13140212 3116412 15578199 Deferred Compensation 483483 Cash Surrender Value of Life Insurance 177744 Construction in Progress 151628 Interest in Synernet Reinsurance 929350 Meaningful Use Receivables 1506543 3248748 Deferred Compensation 483483 Estimated Third-Party Payor Settlements 1437883 1921366 46226979 46168424 58555 -1999 -1999 56556 46224980 -1999 -1999 46226979 0 46226979 46168424 0 46168424 0 46168424 Description of Intended Use of Endowment Funds: Part V, Line 4: To help insure the long-term financial health of the Organization. Description of Uncertain Tax Positions Under FIN 48: Part X: Northern Maine Medical Center is a not-for-profit corporation as described in Section 501(c)(3) of the Internal Revenue Code (the Code), and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Medical Center's tax positions and concluded the Medical Center has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment or disclosure in the consolidated financial statements. With few exceptions, the Medical Center is no longer subject to income tax examination by the U.S. federal or state tax authorities for years before 2008. 1 1 X 1 X 1 X 0 1 0 1 0 385435 385435 0.00860 11140823 8875507 2265316 0.05040 11526258 8875507 2650751 0.05900 28967 9211 19756 0.00040 17604986 8601522 9003464 0.20050 17633953 8610733 9023220 0.20090 29160211 17486240 11673971 0.25990 14516 14516 0.00030 14516 14516 0.00030 0 757649 10392790 9607600 785190 X 1 0 2 1 Northern Maine Medical Center

194 East Main Street Fort Kent ME 04743

X X X 2 Forest Hill

20 Bolduc Avenue Fort Kent ME 04743

X Licensed Hospital Related Facility Northern Maine Medical Center 1 1 X X X X X X X X X 10 1 1 1 X X X X X 0 1 1 200.000000000000 1 250.000000000000 1 X 1 1 X X X 1 X X 1 X X X X X X 1 X 0 1 Part I, Line 3c: Northern Maine Medical Center uses the Federal Poverty Guidelines to determine eligibility. Part I, Line 6a: Northern Maine Medical Center prepares a community benefit report through its annual report process. Within the annual report, the Hospital describes community benefit in financial terms and a summary of services provided. Part I, Line 7: In the IRS Form 990, Schedule H instructions a template, Worksheet 2, was provided as a way to determine the overall cost-to-charge ratio that could be applied throughout the IRS Form 990, Schedule H. Where applicable, the Hospital has utilized the Worksheet 2 template calculation. The only areas where we did not utilize this template calculation were as follows:A. IRS Form 990, Schedule H, Worksheet 6, Subsidized Health Services (which is the supporting schedule for Part I, Line 7g), we did not utilize the Worksheet 2 percentage when we were determining the profit/loss of each of our hospital clinical services and hospital-owned physician practices, SNF, RHCs, ER, and Psych. In addition, when we were compiling the subsidized services and practices listed in 1c above, we utilized the actual estimated costs on the modified Medicare cost report we prepared instead of applying the Worksheet 2 cost-to-charge percentage.B. IRS Form 990, Schedule H, Worksheet 3, Unreimbursed Medicaid and Other Means Tested Government Programs (which is the supporting schedule for Part 1, Lines 7b and 7c), and Worksheet 6, Medicaid allowable costs for the subsidized health services listed on line 1c above (which is part of the line 7g costs), we did not use the Worksheet 2 percentage when calculating the Medicaid allowable costs. Instead, we utilized the actual Medicaid filed cost report for the allowable costs. In addition, for any prior year settlements that were received during the current year, we have netted the settlement against what was filed. Part I, Line 7g: Northern Maine Medical Center has several provider-based physician practices, a skilled nursing facility (SNF), rural health centers (RHCs), an emergency room (ER), and an inpatient psychiatric unit (Psych). Per the instructions for IRS Form 990, Schedule H, Worksheet 6, we are allowed to include any applicable physician practice, SNF, RHCs, ER and Psych that the Hospital subsidizes (i.e., operates at a loss). As such, we have included the following provider-based physician practices, SNF, RHCs and Psych units that operate at a loss (i.e., subsidized by the hospital) and the associated costs of these practices: a. Forest Hill Manor - Skilled Nursing Facility b. Northern Maine Medical Center - Inpatient Psych Unit c. Northern Maine Medical Center - Emergency Room d. Valley Medical Associates RHCs i. Fort Kent ii. Acadia Family Health iii. Station Hill iv. Valley Medical Associates e. Endoscopy f. Valley Medical Associates - Orthopedics/Prosthetics g. Diabetes (includes Dietary Consultation) h. Valley Medical Associates - Oncology i. Ophthalmology j. Ear, Nose, and Throat k. Neurology l. Cardiac Rehab m. CPR/EMT Services n. Wellness o. Valley Medical Associates - Several individual physician practices p. Valley Medical Associates - Anesthesiology q. Valley Medical Associates - Clinic at University of Fort Kent r. Valley Medical Associates - UrologyThe above listed hospital clinical services and hospital-owned physician practices have a community benefit (i.e., aggregate loss or subsidy from the Hospital) of approximately $9.0 million. In addition, the community benefit also does not take into account bad debts, charity care, and contractual adjustments. Thus, this community benefit of approximately $9.0 million is a conservative figure that reconciles to the community benefit reported on IRS Form 990, Schedule H, Part I, Line 7g, Column e. Part I, L7 Col(f): As part of the Hospital's total expenses, there is $1,254,803 of bad debts. This amount has been removed from the Part I, Line 7, Column f calculation per the IRS instructions. Part II: N/A Part III, Line 4: Northern Maine Medical Center classifies bad debts as an operating expense. The Hospital follows the Medicare guidelines for allowable bad debts. It uses the following criteria: a. Reasonable collection efforts were made b. The accounts were uncollectible c. There is no likelihood of recovery at any time in the futureThe bad debt expense at cost was the total write-offs reduced by the ratio of patient care cost to charges. Part III, Line 8: The IRS Form 990, Schedule H instructions/guidance provided a template (Worksheet 2) as a way to determine the overall cost-to-charge ratio that could be applied throughout the IRS Form 990, Schedule H in order to convert charges to cost. Where applicable, we have utilized the Worksheet 2 template calculation. We did not utilize this template calculation on IRS Form 990, Schedule H, Worksheet B, Lines 2 & 6, Medicare Allowable Costs and Payments Related to the Subsidized Health Services, where we utilized the Medicare cost report estimated cost and payment for these services.The Hospital believes that the clinics and units listed in 1c above should be, and are considered, a community benefit due to the fact that without the Hospital subsidizing and offering these clinics and units, the community at large would have to travel at least 45 minutes to the nearest like-hospital and that hospital's service offerings. Additionally, in order to receive inpatient psych services, patients would have to travel at least 4 hours to the nearest inpatient psych unit. As such, Northern Maine believes that by offering, and thus subsidizing, these clinics and units within its community - and thus benefiting the community members by having easy access and commute for these services - it benefits the community at large. Part III, Line 9b: When a patient is referred out to collections but then applies for free or discounted care, the account is pulled back from collections when it is determined that they qualify for one of the programs. If the collection agency suspects that someone may need to apply for one of the programs, it refers the patient back to us. If a patient contacts us after being sent to collections, and qualifies for financial assistance, we then notify the agency to stop the collection process. We make every effort to screen as many people as possible before we send them to collections. Northern Maine Medical Center Part V, Section B, Line 1j: 1a Northern Maine Medical Center (NMMC) is located in Fort Kent, Maine (Aroostook County). Aroostook County is considered rural by the State of Maine and the United States Census Bureau. The hospital service area (HSA) as defined by the Maine Health Data Organization (MHDO) uses the statistical method to determine where the greatest proportion of residents received their inpatient care. The following towns make up the NMMC HSA as defined by the MHDO: Allagash, Eagle Lake, Fort Kent, Frenchville, Grand Isle, Madawaska, New Canada, St. Agatha, St. Francis, St. John Plt, Wallagrass, Winterville Plt., Big Twenty Twp and several surrounding unorganized territories. In 2009, the percentage of Fort Kent residents with income below the poverty level was 36.4%. The percentage of children below the poverty level was 36.7% in 2009. The percentage of the population aged 65 and over was 18% in Aroostook County. The unemployment rate in Aroostook County was 9.3% in 2011, which was higher than the State's rate of 7.8%. Of the individuals 25 years or older in Aroostook County, 23% do not have a high school diploma compared to 15% overall in the State. 1b Northern Maine Medical Center utilizes an electronic medical record system and its related physician practices abstract data for inclusion in disease registries, which provide a vast amount of data relative to patients in care. The needs assessment provides a much broader picture of the community as a whole, including the health status of individuals not in care, as well as functional health status and social demographics (such as employment, income and education levels). The local units of the State's public health infrastructure (known as "Healthy Maine Partnerships") are also integrated into the process so that their data relative to health, environmental and social measures are part of the community dissemination process.1c Northern Maine Medical Center engaged multiple health resource leaders in the community forum invitation list (as described in Section 1g). Additional resources and leaders needed were identified in the breakout sessions (see question for breakout participants, Section 1g). In the Fort Kent service area, key collaborators going forward will include: Northern Maine Medical Center and its owned physician practices, Cary Medical Center, The Aroostook Medical Center, Fish River Rural Health Center, local schools, Aroostook Home Health Services/Valley Home Health Services, Aroostook Mental Health Center, UMFK, and Twin Rivers.1d-1e-1f EMHS, the primary tertiary center utilized by Northern Maine Medical Center, routinely conducts a community health needs assessment (hereafter referred to simply as "needs assessment") across the service area of all of its member hospitals. The most recent assessment, published in 2011, was conducted under a contract with the University of New England Center for Health Planning, Policy and Research (CHPPR) and the University of Southern Maine's Muskie School for Public Health. Using a methodology developed by CHPPR over decades of work, the assessment integrates primary data from a telephone survey to heads of households with secondary data retrieved from state databases (ED usage, Mortality, Cancer Registry, etc.). That data is reviewed in the context of multiple health related domains to develop a composite view of health status, behavioral risks, and barriers to access and care. Results are compared to national and state benchmarks to produce priorities and recommendations as prepared by the consultants.1g See question #31h On a statewide basis, the research consultants developed an advisory committee that met two times during the assessment research and drafting of the publication. These individuals represented a broad spectrum of backgrounds, and include: Carol Bell, Healthy Maine Partnership director; Kelly Bentley, Healthy Maine Partnership director; Gail Dana-Sacco, Wabanaki Center (serving tribal populations); Patricia Hart, Maine Development Foundation; Barbara Leonard, MPH, Maine Health Access Foundation (philanthropic foundation focused on access to care in Maine); Becca Matusovich, Maine Center for Disease Control; Lisa Miller, Bingham Foundation (philanthropic foundation); Dora Ann Mills, MD, Maine Center for Disease Control; Elizabeth Mitchell, Maine Health Management Coalition (representing the State's major employers, insurers and providers); Trish Riley, Governor's Office of Health Policy and Finance (GOHPF); Brian Rines, Advisory Committee for Health System Development (overseen by GOHPF); Rachel Talbot-Ross, Maine Chapter, NAACP; and, Ted Trainer, Public Health Coordinating Council Shawn Yardley, City of Bangor, Department of Health and Welfare. In the local area served by the assessment, multiple parties were engaged in dissemination of the assessment findings and establishment of priorities (see Section 5). Northern Maine Medical Center Part V, Section B, Line 3: On a statewide basis, the research consultants developed an advisory committee that met two times during the assessment research and drafting of the publication. These individuals represented a broad spectrum of backgrounds, and include: Carol Bell, Healthy Maine Partnership director; Kelly Bentley, Healthy Maine Partnership director; Gail Dana-Sacco, Wabanaki Center (serving tribal populations); Patricia Hart, Maine Development Foundation; Barbara Leonard, MPH, Maine Health Access Foundation (philanthropic foundation focused on access to care in Maine); Becca Matusovich, Maine Center for Disease Control; Lisa Miller, Bingham Foundation (philanthropic foundation); Dora Ann Mills, MD, Maine Center for Disease Control; Elizabeth Mitchell, Maine Health Management Coalition (representing the state's major employers, insurers and providers); Trish Riley, Governor's Office of Health Policy and Finance (GOHPF); Brian Rines, Advisory Committee for Health System Development (overseen by GOHPF); Rachel Talbot-Ross, Maine Chapter, NAACP; and, Ted Trainer, Public Health Coordinating Council Shawn Yardley, City of Bangor, Department of Health and Welfare. Northern Maine Medical Center Part V, Section B, Line 4: The needs assessment was developed as a statewide collaborative between the state's three largest health systems: EMHS (in central, eastern and northern Maine), MaineGeneral (in central Maine) and MaineHealth (in southern Maine). Multiple collaborators were involved in the dissemination of the assessment findings and establishment of priorities (see Section 5). Northern Maine Medical Center Part V, Section B, Line 5c: In conjunction with EMHS, Northern Maine Medical Center co-hosted a community forum with The Aroostook Medical Center and Cary Medical Center to present an overview of local assessment results and recommendations. Invitees included: other area hospitals, physician leaders, federally qualified health centers, healthy Maine partnerships, district liaisons linked to Maine CDC, home health and long term care leaders, social service agencies, leaders of the tribal communities, business leaders, legislative leaders, and representatives of the State administration.Attendees were provided an executive summary of the assessment as well as a summary table of data reflective of the service area. A presentation was made by EMHS staff who were members of the assessment development steering committee providing selected data results, trends over time and the priorities and recommendations as suggested by the research consultants.In addition to the community forums, the entire statewide assessment (both narrative and data sets) was posted to the EMHS website. After the forums, power point presentations used at the forum, as well as input collected in the breakout sessions, were also posted on the website. Forum participants were encouraged to go to the website to review the assessment in detail, and access the data for local planning. Media releases were also sent to local news outlets in combination with the forums, encouraging new articles on the forum and inviting all members of the public to view the report on the website.Instructions on the website assist viewers to download and/or print sections of the report. Individuals without computer or printer access were provided a phone number where they can request a printed assessment. Northern Maine Medical Center Part V, Section B, Line 6i: 6a Northern Maine Medical Center plans to meet the prioritized needs through the following initiatives and resources:- NMMC will implement a wellness program for its employees. As one of the larger employers in the area, NMMC can then work with other large employers to implement similar programs.- NMMC will rebuild its patient education component. A diabetic educator has been hired and we are seeking certification for our diabetic education program. - NMMC will implement an electronic medical record in its physician practices to better monitor its patients with chronic conditions and help improve management of their conditions.- NMMC will collaborate with other local hospitals and providers to ensure the necessary specialty services are available.- NMMC will increase community awareness of mental health services available.- NMMC will participate with Health Info Net, Maine's Health Information Exchange, to improve quality and effectiveness through better information exchange. 6g Breakout #1 - Access, Quality and Effectiveness - The following needs were identified through the Community Health Needs Assessment and discussed during the breakout sessions:- Physical Health - Continue to increase insurance coverage- Dental Health - Improved Medicaid reimbursement- Dental Health - Co-locate dental offices with hospitals & physicians- Dental Health - Expand dental hygiene education in rural settings- Continue work of pilot projects- Clearinghouse to review and publish findings from the pilot projectsBreakout #2 - Chronic Disease - The following needs were identified through the Community Health Needs Assessment and discussed during the breakout sessions:- Policy and medical practice changes to improve: patient self-management, community care teams, use of evidence based guidelines- Continued implementation of EMR/PHR and disease registries Breakout #3 Mental Health and Substance Abuse The following needs were identified through the Community Health Needs Assessment and discussed during the breakout sessions:- Collaborative, community level prevention programs for specific populations and age groups- Primary care and ED education for use of screening tools, diagnosis and treatment tools- Coordinate local substance abuse services and resources for primary care providersBreakout #4 - Prevention, Obesity - The following needs were identified through the Community Health Needs Assessment and discussed during the breakout sessions:- Incentives/disincentives for smoking & obesity- Link to employment, the provision of medical care, and community programs- County/public health district/hospital service area online resource guide Northern Maine Medical Center Part V, Section B, Line 7: Northern Maine Medical Center was unable to address all needs identified due to limited staff and financial resources. Certain needs, such as increased insurance coverage and improved Medicaid reimbursement for dental services, have not been addressed since NMMC can only be a portion of the solution; other entities will need to be involved to address all of the needs. NMMC is in the process of rebuilding its patient education component, so certain needs, such as community level prevention programs and primary care and ED education tools, will be addressed once the education framework is in place again. Northern Maine Medical Center Part V, Section B, Line 19d: Individuals are billed at gross amounts and charges are adjusted accordingly, if they qualify for assistance. Northern Maine Medical Center Part V, Section B, Line 21: Individuals are billed at gross amounts and charges are adjusted accordingly, if they qualify for assistance. Schedule H, Part V, Line 2: The community needs assessment was last conducted in fiscal year end 2011. However, for purposes of this Schedule H, Part V, Line 2, IRS instructions call for the year to be listed as the beginning of the fiscal year. Part VI, Line 2: Please see Schedule H, Part V, Section B, Line 1 for a description of NMMC's assessment process. Part VI, Line 3: We notify patients and customers about access to assistance in various ways. The simplest way is the signage, pamphlets, and educational material located around the Organization and in various offices. In every patient access/patient financial services area is a sign explaining the availability of free/discounted care and the Federal Poverty Guidelines. There are also pamphlets located in the outpatient areas explaining free/discounted care and providing information on MaineCare. For inpatients, there is a book in each room which provides all the information on all programs available.Through the patient accounting department, we provide information about these statements. We also counsel patients on the phone about all the programs available whether it is Medicaid or a hospital program. Part VI, Line 4: Northern Maine Medical Center is a 94 staffed bed (29 A&P beds, 6 ICU beds, 14 Psych beds, and 45 SNF beds), full-service, acute-care, not-for profit hospital located in Fort Kent, Maine (Aroostook County). The Hospital is accredited by the joint commission and its mission is to serve its communities with excellence in health care. Its services include acute inpatient, psych inpatient, SNF, 24-hour emergency center, diagnostic, and surgical services. Along with these hospital services, the Hospital employs/contracts with the majority of primary and specialty care physicians in the area. Part VI, Line 6: Northern Maine Medical Center is a local, not-for-profit hospital that serves its local communities and people regardless of their ability to pay. Northern Maine provides financial assistance and sliding scale discounts to self-pay and low-income patients. Also the Hospital participates in government-sponsored health care programs including Medicare, Medicaid, CHAMPUS, and Tricare. The volunteer board of trustees sets the strategic direction for the Hospital and is comprised of community members from the Hospital's service area. This group is made up of local business owners, professionals, and retirees. Northern Maine's non-profit status allows the Hospital to reinvest any excess of revenues over expense back into the Hospital to continuously improve the medical care it delivers. The Hospital allows access to healthcare that would otherwise be difficult. The Hospital is the main employer for the local physicians, including specialty physicians that would otherwise have to be accessed out of the area. X X 1 0 0 0 0 0 0 0 0 Guy Raymond 375265 0 0 0 0 0 0 0 21890 0 397155 0 0 0 Michael Sullivan MD 385945 0 0 0 0 0 0 0 21890 0 407835 0 0 0 Martin B Bernstein 198494 0 0 0 0 0 0 0 9533 0 208027 0 0 0 Peter J Sirois 164448 0 0 0 0 0 0 0 21725 0 186173 0 0 0 Scott Richards 152768 0 0 0 0 0 0 0 22570 0 175338 0 0 0 David Jones MD 311519 0 0 0 0 0 0 0 7853 0 319372 0 0 0 Part I, Line 4a Martin Bernstein and Roger Lagasse resigned from their positions as CEO and CFO, respectively, during the year. As part of their retirement, the following severance packages were paid: Martin Bernstein's severance pay and benefit package totaled $51,796 Roger Lagasse's severance pay and benefit package totaled $5,262 Michelle Sirois Related to an officer of NMMC 58395 Compensation for services as an employee of NMMC. 0 Nola Sirois Related to an officer of NMMC 22272 Compensation for services as an employee of NMMC. 0 Robin Werntgen Related to an officer of NMMC 53851 Compensation for services as an employee of NMMC. 0 Daigle Oil Company President of Daigle Oil Company is a Board Member of NMMC 163866 Purchase of heating oil 0 Form 990, Part VI, Section A, line 2 Peter Sirois and Glenn Lamarr have a family relationship. Form 990, Part VI, Section A, line 4 In May of 2011, the Organization revised its bylaws. A summary of the significant changes are as follows: -Composition of the board of directors was reduced to not less than eight and not more than eleven, with the goal of maintaining a complement of nine trustees. -The board of directors shall include only one physician who is a member of the medical staff (down from three). The physician member shall have voting rights and may not be an officer of the medical staff. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by the Organization's independent public accounting firm and thoroughly reviewed by the CFO and controller. Form 990, Part VI, Section B, line 12c The enforcement of the conflict of interest policy is achieved through annual reporting and ongoing monitoring. Form 990, Part VI, Section B, line 15 The executive committee of the board of directors determines the compensation of the CEO using compensation studies and comparability data. The CEO determines the compensation of other officers and key employees in a similar manner. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part VII, Section A: Guy Raymond and Michael Sullivan, M.D. show reportable compensation on Form 990, Part VII, Section A for services performed in their capacity as employees of Northern Maine Medical Center. Their compensation does not reflect payment for their services as board members of the Hospital or any related organization. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -1,999. Oversight of Audit Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. Valley Medical Association 194 East Main Street Fort Kent ME 04743 223245434 Medical Physician Practice ME 501(C)(3) 3 N/A 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 Valley Medical Association Q 8518998 Actual Outlay