2012-05-10T13:27:10-05:00 2011-09-30 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2010-10-01 390799566 TOMAH MEMORIAL HOSPITAL TOMA 6083722181 321 BUTTS AVENUE TOMAH WI 54660 JOSEPH ZEPS 6083722181 2012-05-09 1 KIM HUNWARDSEN CPA 6122536500 2012-05-09 2010 2016-02-24 21:20:13Z PHILIP J STUART 321 BUTTS AVENUE TOMAH WI 54660 43443931 0 X WWW.TOMAHHOSPITAL.ORG X 1948 WI TO PROMOTE AND PROVIDE QUALITY HEALTH CARE TO PATIENTS IN A HOSPITAL SETTING 10 8 319 62 0 0 203993 190406 32879769 34307234 614226 950411 -20020 -9787 33677968 35438264 0 0 0 0 16275654 16637378 0 0 24053 14822487 16192821 31098141 32830199 2579827 2608065 39730220 42438239 11619049 12921768 28111171 29516471 X THE MISSION OF TOMAH MEMORIAL HOSPITAL, INC. IS TO PROMOTE AND PROVIDE QUALITY HEALTH CARE BASED ON CUSTOMER NEED AND EXPECTATIONS. IN FULFILLMENT OF ITS MISSION, TOMAH MEMORIAL HOSPITAL IS COMMITTED TO VIEW ITS CUSTOMERS AND EMPLOYEES THROUGH A HOLISTIC APPROACH WITHOUT CONSIDERATION TO ECONOMIC STATUS, GENDER, ETHNIC ORIGIN OR PERSONAL LIMITATIONS. 0 0 25159776 32093805 TOMAH MEMORIAL HOSPITAL HAS PROVIDED FOR THE HEALTH AND WELL BEING OF THE RESIDENTS OF TOMAH AND THE SURROUNDING COMMUNITIES FOR NEARLY SIXTY YEARS. THE HOSPITAL PROVIDES A BROAD SPECTRUM OF HEALTH AND WELLNESS SERVICES TO THE COMMUNITY, INCLUDING GENERAL MEDICAL/SURGICAL AND SWING BED INPATIENT CARE, DIAGNOSTIC LABORATORY AND RADIOLOGY SERVICES, GENERAL AND SPECIALTY SURGICAL SERVICES, 24 HOUR EMERGENCY CARE SERVICES, OBSTETRIC SERVICES, REHABILITATIVE SERVICES, OCCUPATIONAL HEALTH AND WELLNESS PROGRAMS, AND A COMMUNITY OUTREACH PROGRAM. KEY VOLUME INDICATORS FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2011 ARE AS FOLLOWS:* 1,327 INPATIENT DISCHARGES* 3,595 INPATIENT DAYS* 13,935 EMERGENCY ROOM AND URGENT CARE VISITS* 1,276 SURGICAL AND ENDOSCOPIC PROCEDURES* 11,895 RADIOLOGY PROCEDURES (INCLUDING CT AND MRI)* 68,196 LABORATORY TESTS* 32,425 REHABILITATIVE SERVICES PROCEDURESIN FURTHERANCE OF ITS CHARITABLE MISSION, THE HOSPITAL PROVIDED APPROXIMATELY $724,000 OF FREE AND DISCOUNTED CARE TO AREA RESIDENTS (COST OF CARE EQUAL TO $420,000), AND WROTE OFF $1.87 MILLION OF UNCOLLECTIBLE ACCOUNTS (COST EQUAL TO $1.08 MILLION). ADDITIONALLY, BASED ON IT'S MOST RECENTLY COMPLETED COMMUNITY BENEFITS SURVEY, THE HOSPITAL INCURRED APPROXIMATELY $952,000 IN NET LOSSES RELATED TO PROVIDING CARE FOR INDIVIDUALS WITH HEALTH INSURANCE PROVIDED BY EITHER THE MEDICAID PROGRAM OR OTHER GOVERNMENTAL INSURANCE PROGRAMS. THE HOSPITAL SUBSIDIZES SEVERAL PROGRAMS THAT ARE DEEMED VITAL SERVICES FOR THE COMMUNITY, INCLUDING IN-HOME HOSPICE AND PALLIATIVE CARE SERVICES, A HOSPICE RESIDENCE, A WALK-IN CLINIC LOCATED IN THE RURAL COMMUNITY OF WARRENS, WI, AND A DEDICATED COMMUNITY OUTREACH DEPARTMENT THAT PROVIDES HEALTH AND WELLNESS SERVICES TO AREA EMPLOYERS AND THE TOMAH COMMUNITY. SUBSIDIES FOR THESE PROGRAMS FOR FISCAL 2011 APPROXIMATED $1.62 MILLION. ADDITIONAL DETAILS REGARDING THE HOSPICE PROGRAM AND THE WARRENS WALK-IN CLINIC CAN BE FOUND BELOW. THE HOSPITAL ALSO INVESTED $1.4 MILLION IN A NEW HOSPICE RESIDENCE FACILITY DURING 2011 IN ORDER TO EXPAND CAPACITY AND CONTINUE MEETING THE NEEDS OF AREA RESIDENTS REQUIRING END-OF-LIFE CARE. IN ADDITION TO PROVIDING HIGH QUALITY HEALTHCARE SERVICES, THE HOSPITAL ENCOURAGES EMPLOYEES TO BECOME ACTIVELY INVOLVED IN COMMUNITY ORGANIZATIONS AND PROJECTS THAT PROVIDE OTHER BENEFITS TO LOCAL COMMUNITIES. THE HOSPITAL PROVIDES MANY FREE SERVICES TO THE COMMUNITY, INCLUDING HEALTH AND WELLNESS PRESENTATIONS TO AREA SCHOOL CHILDREN, CPR AND AED TRAINING TO VARIOUS ORGANIZATIONS, WELLNESS FAIRS DEVOTED TO WOMEN AND SENIOR CITIZENS, AND MEETING SPACE TO VARIOUS NON-PROFIT AND CIVIC ORGANIZATIONS. 3328463 1941982 THE HOSPITAL PROVIDES IN-HOME, INPATIENT, AND RESIDENTIAL HOSPICE CARE TO RESIDENTS OF TOMAH AND THE SURROUNDING COMMUNITIES. RESIDENTIAL CARE IS PROVIDED VIA THE OPERATION OF A FOUR BED HOSPICE HOUSE LOCATED ADJACENT TO THE MAIN HOSPITAL CAMPUS. DESPITE SUBSIDIZING THE FINANCIAL LOSSES INCURRED BY THE PROGRAM, THE SERVICES ARE DEEMED VITAL TO THE COMMUNITY AND REPRESENT A NECESSARY COMPONENT OF PATIENT CARE. FOR THE YEAR ENDED SEPTEMBER 30, 2011, THE HOSPICE PROGRAM EXPERIENCED 9,782 PROGRAM DAYS AND 1,006 HOSPICE RESIDENCE DAYS. 503969 271447 THE HOSPITAL BEGAN OPERATING AN OFF-SITE WALK-IN CARE CLINIC DURING 2008 TO BETTER SERVE THE NEEDS OF THE RESIDENTS OF WARRENS, WISCONSIN. FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2011, THE CLINIC EXPERIENCED 3,500 PATIENT VISITS. THE CLINIC PROVIDES RESIDENTS WITH A CLOSE-TO-HOME, LOW-COST OPTION FOR HEALTHCARE SERVICES (INCLUDING BASIC LABORATORY TESTS AND X-RAY CAPABILITIES) RELATED TO MINOR INJURIES AND ILLNESSES, AND ALL SERVICES PROVIDED ARE SUPPORTED BY THE HOSPITAL'S EMERGENCY DEPARTMENT. DESPITE INCURRING A NEGATIVE GROSS CONTRIBUTION MARGIN DURING 2011, THE HOSPITAL'S BOARD OF DIRECTORS BELIEVES THE CLINIC IS AN IMPORTANT ASSET TO THE RESIDENTS OF WARRENS AND REMAINS COMMITTED TO SUPPORTING IT UNTIL IT ACHIEVES A SUSTAINABLE LEVEL OF FINANCIAL PERFORMANCE. 28992208 1 1 0 0 0 0 0 0 1 1 0 0 0 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 1 0 0 0 0 1 1 0 0 0 1 16 0 1 319 1 0 0 0 0 0 0 0 0 0 0 X 10 8 1 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JOSEPH ZEPS 6083740307 321 BUTTS AVENUE TOMAH WI 54660 X ROBERT FASBENDER 1.00 X X 0 0 0 OAKLEY MOSER 1.00 X X 0 0 0 STEVE AUSTIN 1.00 X X 0 0 0 PHIL YAHNKE 1.00 X X 0 0 0 JEFF HOLTHAUS 1.00 X X 0 0 0 CYNTHIA ERDMAN 1.00 X 0 0 0 WES REVELS 1.00 X 0 0 0 WILL SCHANHOFER MD 1.00 X 0 0 0 JAMES QUARTEMONT 1.00 X 0 0 0 MICHAEL SAUNDERS MD 1.00 X 0 0 0 NODJI VAN WYCHEN 1.00 X 0 0 0 ROBB KLINE MD 1.00 X 0 0 0 JERRY MOLNAR 1.00 X 0 0 0 RALPH KNUDSON MD 1.00 X 0 0 0 PENNY PRECOUR-BERRY 1.00 X 0 0 0 JOSEPH ZEPS 40.00 X 115898 0 21015 PHILIP J STUART 40.00 X 0 0 0 EVELYN CHAPMAN 40.00 X 116322 0 18236 DARLA WILSON 40.00 X 146670 0 13190 TODD CHAPMAN 40.00 X 125733 0 5029 GERALD FUSHIANES 40.00 X 114248 0 20949 LAURA J MILLER 40.00 X 125571 0 12346 744442 0 90765 7 0 1 0 EMCARE INC 7032 COLLECTIONS CTR DR CHICAGO IL 60693 CONTRACTED ER PHYSICIANS 1258048 TOMAH ORTHOPEDICS 321 BUTTS AVENUE TOMAH WI 54660 CONTRACTED ORTHOPEDIC SURGEONS 1126719 PHILIPS MEDICAL CAPITAL 1111 OLD EAGLE SCHOOL ROAD WAYNE PA 19087 CT/MRI LEASE 603183 MAYO CLINIC HEALTH SYSTEM 325 BUTTS AVENUE TOMAH WI 54660 RADIOLOGY, PATHOLOGY, & CONTRACTED LABOR 557070 HEALTHTECH MANAGEMENT SERVICES INC PO BOX 636426 CINCINNATI OH 452636426 MANAGEMENT SERVICES 467857 13 7419 182987 21500 190406 PATIENT SERVICE REVENU 622110 34098184 34098184 SUPPORTING REVENUE 621990 209050 209050 34307234 706376 706376 41511 51298 -9787 -9787 -9787 8190703 7701 7954369 236334 7701 244035 244035 35438264 34307234 0 940624 149909 149909 77646 77646 12838530 11152640 1662812 23078 314146 275124 39022 2298280 1993245 305035 958867 827031 131836 235032 235032 14528 14528 83668 83668 6055497 5680219 375278 197687 870 196817 3988626 3820195 167456 975 347093 340152 6941 162043 139473 22570 85510 74092 11418 572296 572296 1945154 1945154 128605 128605 PROVISION FOR BAD DEBTS 1867267 1867267 509815 98199 411616 32830199 28992208 3813938 24053 2538784 3124420 4575955 5042146 479604 461584 242991 191902 31864920 16066681 12924562 15798239 18484868 17347561 281786 282026 201670 190361 39730220 42438239 2154879 2391918 8486702 8220258 977468 2309592 11619049 12921768 X 27421030 28973582 157662 3685 532479 539204 28111171 29516471 39730220 42438239 X 2608065 -1202765 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 535663 185 13959 10603 539204 483734 36960 22725 7756 535663 410683 88020 -6375 8594 483734 1.00000 0 0 34500 34500 22210704 10816540 11394164 8824967 5005103 3819864 794749 245038 549711 15798239 CAPITAL LEASE OBLIGATIONS 1494592 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 815000 2309592 35438264 32830199 2608065 -1200716 -2049 -1202765 1405300 35276611 -194654 -194654 35471265 -33001 -33001 35438264 32881497 51298 51298 32830199 0 32830199 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: PERMANENTLY RESTRICTED NET ASSETS ARE RESTRICTED TO THE HOSPICE ENDOWMENT FUND AND THE BENEFICIAL INTEREST IN A PERPETUAL TRUST. THE INTEREST EARNED CAN BE USED FOR HOSPICE EXPENDITURES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND, AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE, IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 8 - OTHER ADJUSTMENTS: DECREASE IN FAIR VALUE OF BENEFICIAL INTEREST IN PERPETUAL TRUST -2,049. PART XII, LINE 2D - OTHER ADJUSTMENTS: RECLASSIFICATION UNREALIZED LOSSES ON INVESTMENTS INCLUDED IN REVENUE -194,654. PART XII, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED INTEREST INCOME INCLUDED IN FUND BALANCE 9,523. RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS -51,298. PERMANENTLY RESTRICTED INTEREST INCOME INCLUDED IN FUND BALANCE 8,589. PERMANENTLY RESTRICTED CONTRIBUTIONS INCLUDED IN FUND BALANCE 185. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS 51,298. 1 1 X 1 X 50.000000000000 1 X 1 1 1 0 1 1 163 420148 420148 0.01360 6726 4569606 4399914 169692 0.00550 2873 2374256 1591849 782407 0.02530 9762 7364010 5991763 1372247 0.04440 94060 94060 0.00300 4499 3832432 2213429 1619003 0.05230 4499 3926492 2213429 1713063 0.05530 14261 11290502 8205192 3085310 0.09970 0 1083626 14087 6761878 6694928 66950 X 1 1 1 1 TOMAH MEMORIAL HOSPITAL

321 BUTTS AVENUE TOMAH WI 54660

X X X NOT REQUIRED 1 2 HOSPICE TOUCH SERENITY HOUSE

330 BUTTS AVENUE TOMAH WI 54660

HOSPICE RESIDENCE WARRENS WALK IN CLINIC

101 UNITY DRIVE WARRENS WI 54666

WALK-IN CARE CLINIC PART I, LINE 6A: THE ORGANIZATION PARTICIPATES IN THE WISCONSIN HOSPITAL ASSOCIATION (WHA) ANNUAL COMMUNITY BENEFIT REPORTING PROCESS, WHICH IS RELEASED TO THE PUBLIC VIA A WRITTEN REPORT DISTRIBUTED TO MEMBER HOSPITALS AS WELL AS THE WHA'S WEBSITE. THIS REPORTING INITIATIVE ATTEMPTS TO QUANTIFY THE AMOUNT OF COMMUNITY BENEFITS PROVIDED BY THE HOSPITAL, AND INCLUDES FIGURES RELATED TO COMMUNITY CARE WRITE-OFFS, BAD DEBT WRITE-OFFS, MEDICARE AND MEDICAID SHORTFALLS, AND PROGRAMS OPERATED AT A LOSS.THE ORGANIZATION ALSO PREPARES A QUARTERLY NEWSLETTER THAT IS DISTRIBUTED TO THE PUBLIC VIA A MASS-MAILING. THE QUARTERLY NEWSLETTER IS INTENDED TO PROVIDE THE COMMUNITIES THE HOSPITAL SERVES INFORMATION REGARDING HOSPITAL OPERATIONS, FINANCIAL RESULTS, AND PROGRAMS/INITIATIVES INTENDED TO FULFILL THE HOSPITAL'S COMMITMENT TO COMMUNITY. THE NEWSLETTER ALSO CONTAINS FINANCIAL HIGHLIGHTS FROM THE WHA COMMUNITY BENEFIT REPORT. CURRENT AND PRIOR EDITIONS OF THE NEWSLETTER ARE AVAILABLE ON THE HOSPITAL'S WEBSITE. PART I, LINE 7: THE METHODOLOGY FOR DETERMINING CHARITY CARE AND MEDICAID/TRICARE SHORTFALLS AT COST WAS AS FOLLOWS: A COST TO CHARGE RATIO WAS COMPUTED USING TOTALS FROM THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS; THIS RATIO WAS APPLIED TO CHARITY CARE CHARGES, AND GROSS MEDICAID/TRICARE REVENUE. ACTUAL REIMBURSEMENT RECEIVED FROM MEDICAID/TRICARE WAS THEN COMPARED TO THE ESTIMATED COST (COMPUTED BY MULTIPLYING THE CCR BY GROSS CHARGES) TO DETERMINE THE SHORTFALL. ALL OTHER ITEMS WERE BASED ON ACTUAL PROGRAM EXPENSES. ALSO WORTH NOTING THAT THE METHODOLOGY USED FOR CHARITY CARE/TRICARE/MEDICAID IS THE SAME AS THE METHODOLOGY USED BY THE WISCONSIN HOSPITAL ASSOCIATION IN COMPILING THEIR ANNUAL COMMUNITY BENEFIT REPORT. PART I, L7 COL(F): BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX, LINE 25, COLUMN (A) OF $1,867,267 WAS REMOVED FROM THE DENOMINATOR PRIOR TO THE CALCULATION. PART III, LINE 4: BAD DEBT EXPENSE AT COST WAS CONVERTED TO COST USING EXPENSES AND REVENUES FROM THE FINANCIAL STATEMENTS AND APPLYING AN OVERALL COST-TO-CHARGE RATIO.ACCOUNTS ARE NOT WRITTEN OFF TO BAD DEBT UNTIL ALL FORMS OF PAYMENT HAVE BEEN APPLIED TO THE ACCOUNT SUCH AS INSURANCE, DISCOUNTS, AND CONTRACTUAL ALLOWANCES, AND THE REMAINING BALANCE IS THE PERSONAL PORTION DUE. A PAYMENT RECEIVED ON AN ACCOUNT PREVIOUSLY WRITTEN OFF TO BAD DEBT REDUCES BAD DEBT EXPENSE.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN ESTIMATE OF CHARGES FOREGONE TO GROSS PATIENT CHARGES.FINANCIAL STATEMENT FOOTNOTE: THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS. TOMAH MEMORIAL HOSPITAL FOLLOWS THE CHA GUIDELINES IN REPORTING COMMUNITY BENEFITS AND THEREFORE ANY MEDICARE SHORTFALL IS EXCLUDED FROM OUR COMMUNITY BENEFIT REPORT. PROVIDING SERVICES TO MEDICARE PATIENTS IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES, WHICH IS A COMMUNITY BENEFIT. PART III, LINE 9B: TOMAH MEMORIAL HOSPITAL ATTEMPTS TO SCREEN ALL ELECTIVE/SCHEDULED PATIENTS PRIOR TO THE RECEIPT OF SERVICE REGARDING COMMUNITY CARE ELIGIBILITY, AND WORKS WITH PATIENT FINANCIAL SERVICES STAFF TO IDENTIFY EMERGENT/UNSCHEDULED PATIENTS WHO MAY BE ELIGIBLE FOR COMMUNITY CARE (GENERALLY AFTER RECEIPT OF SERVICE). PATIENTS WITHOUT INSURANCE ARE OFFERED A 15% DISCOUNT. PATIENTS THAT EXPRESS AN INTEREST IN COMMUNITY CARE ASSISTANCE, ARE IN THE PROCESS OF APPLYING FOR COMMUNITY CARE ASSISTANCE, OR WAITING ON A DETERMINATION OF COMMUNITY CARE ASSISTANCE WILL NOT HAVE COLLECTION EFFORTS IMPOSED ON THEIR ACCOUNTS. AFTER A DETERMINATION OF COMMUNITY CARE ASSISTANCE IS MADE, ANY PERSONAL PORTION DUE BY THE PATIENT WILL FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER PATIENTS. PART VI, LINE 2: TOMAH MEMORIAL HOSPITAL CURRENTLY OPERATES ON A THREE-YEAR STRATEGIC PLANNING CYCLE. AT THE BEGINNING OF EACH CYCLE, A STRATEGIC PLANNING RETREAT IS HELD DURING WHICH AN ANALYSIS IS CONDUCTED OF THE SERVICES THE HOSPITAL CURRENTLY PROVIDES AND AREAS OF NEED THAT SHOULD BE ADDRESSED BY THE HOSPITAL. THE RETREAT IS OPEN TO ALL HOSPITAL STAFF, HOSPITAL BOARD MEMBERS, AND MEMBERS OF THE HOSPITAL'S MEDICAL STAFF. THE HOSPITAL'S MEDICAL STAFF IS COMPRISED PRIMARILY OF PHYSICIANS EMPLOYED BY OTHER AREA HEALTHCARE PROVIDERS (E.G. MAYO, GUNDERSEN LUTHERAN), AND AS SUCH THEIR INPUT INTO THE STRATEGIC PLANNING PROCESS ALLOWS THE HOSPITAL TO WORK COLLABORATIVELY WITH OTHER HOSPITALS AND HEALTH SYSTEMS IN ASSESSING THE NEEDS OF THE COMMUNITY. THE STRATEGIC PLANNING PROCESS IS FACILITATED BY A REPRESENTATIVE OF HEALTHTECH MANAGEMENT SERVICES, INC. (CONTRACTED MANAGEMENT ORGANIZATION), AND THE THREE YEAR PLAN THAT IS ADOPTED BY THE HOSPITAL'S GOVERNANCE SERVES AS A BLUEPRINT FOR ENSURING THE HOSPITAL IS ADDRESSING THE NEEDS OF THE COMMUNITY.IN ADDITION TO THE FORMAL STRATEGIC PLANNING PROCESS, THE HOSPITAL ENGAGES IN ONGOING DISCUSSIONS WITH VARIOUS STAKEHOLDERS (AREA BUSINESSES, PHYSICIANS, PATIENTS, AND COMMUNITY MEMBERS) REGARDING THE SERVICES OFFERED AT THE HOSPITAL, AND HOSPITAL LEADERSHIP EVALUATES ALL SUGGESTIONS OFFERED FOR IMPROVING THE MANY WAYS IN WHICH THE HOSPITAL SERVES ITS COMMUNITY. PART VI, LINE 3: TOMAH MEMORIAL HOSPITAL MAKES AVAILABLE BROCHURES CONTAINING INFORMATION ABOUT FINANCIAL ASSISTANCE TO ALL PATIENTS SEEN IN THE EMERGENCY ROOM/URGENT CARE AREAS, AND ANY PATIENT THAT REGISTERS FOR A NON-EMERGENT SERVICE IS QUESTIONED BY ADMISSIONS OR NURSING STAFF REGARDING ANY CONCERNS THEY MIGHT HAVE ABOUT THE COST OF THEIR HOSPITAL SERVICES. THE HOSPITAL EMPLOYS A FULL-TIME, DEDICATED PATIENT BENEFIT SPECIALIST WHO WORKS WITH UNINSURED AND UNDERINSURED PATIENTS REGARDING COMMUNITY CARE APPLICATIONS AND FINANCIAL ASSISTANCE. ADDITIONALLY, A REVIEW IS CONDUCTED OF ALL ACCOUNTS THAT BECOME DELINQUENT TO ENSURE THAT AN ATTEMPT TO CONTACT THE PATIENT HAS BEEN MADE BY HOSPITAL STAFF. FINALLY, THE HOSPITAL IS IN THE PROCESS OF ADDING A COMMUNITY CARE & FINANCIAL ASSISTANCE SECTION TO ITS WEBSITE. PART VI, LINE 4: TOMAH MEMORIAL HOSPITAL, INC. IS A 25-BED CRITICAL ACCESS HOSPITAL LOCATED IN TOMAH, WISCONSIN. THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF TOMAH, WI, AND THE OUTLYING COMMUNITIES OF CAMP DOUGLAS, WARRENS, OAKDALE, AND WILTON. TOMAH IS LOCATED IN RURAL WESTERN WISCONSIN, AND AS SUCH A SIGNIFICANT PORTION OF THE HOSPITAL'S PATIENT BASE IS COMPRISED OF AGRICULTURAL WORKERS AND MEMBERS OF THE AMISH COMMUNITY. ADDITIONALLY, TOMAH'S PROXIMITY TO TWO MILITARY INSTALLATIONS RESULTS IN A LARGE PORTION OF SERVICES PROVIDED TO MEMBERS OF THE MILITARY AND THEIR FAMILIES. THE HOSPITAL'S PAYER MIX IS COMPRISED OF APPROXIMATELY 15% MEDICAID, 37% MEDICARE, 7% MILITARY, 5% SELF-PAY, AND 36% COMMERCIAL INSURANCE. THE REIMBURSEMENT CHALLENGES ASSOCIATED WITH PROVIDING A HIGH PERCENTAGE OF SERVICES TO MEDICAID/MEDICARE RECIPIENTS AND THE UNINSURED HAS REQUIRED THE HOSPITAL TO OPERATE AT A HIGH LEVEL OF EFFICIENCY, ENSURING THAT ALL SERVICES PROVIDED REPRESENT AN EXCELLENT VALUE TO AREA COMMUNITY MEMBERS. ALTHOUGH THE HOSPITAL HAS BENEFITED FROM THE ADDITIONAL REIMBURSEMENT AFFORDED THROUGH THE CRITICAL ACCESS HOSPITAL PROGRAM, COMPETITION FOR MARKET SHARE WITH OTHER AREA HEALTHCARE PROVIDERS REQUIRES HOSPITAL LEADERSHIP TO CONTINUALLY REEVALUATE SERVICE OFFERINGS AND BUSINESS LINES FOR APPROPRIATENESS GIVEN THE HEALTHCARE NEEDS OF THE COMMUNITY. PART VI, LINE 6: TOMAH MEMORIAL HOSPITAL'S BOARD OF DIRECTORS IS COMPRISED OF COMMUNITY MEMBERS THAT REPRESENT BOTH A CROSS SECTION OF INDUSTRY EXPERTISE (BANKING, MANUFACTURING, ATTORNEYS, PHYSICIANS, SMALL BUSINESS, ETC.) AS WELL AS AN APPRECIATION OF THE HEALTHCARE NEEDS OF THE COMMUNITY. THE HOSPITAL BUDGETS FOR A TARGETED OPERATING MARGIN OF BETWEEN 3% AND 5% EACH YEAR. THIS TARGET WAS ESTABLISHED BY THE HOSPITAL'S BOARD OF DIRECTORS, AND IS BELIEVED TO REPRESENT AN APPROPRIATE BALANCE BETWEEN FULFILLING THE HOSPITAL'S CHARITABLE PURPOSE AND ACHIEVING FINANCIAL RESULTS THAT ALLOW FOR CONTINUED REINVESTMENT IN STAFF AND EQUIPMENT TO REMAIN COMPETITIVE.THE HOSPITAL OPERATES A FULLY STAFFED COMMUNITY HEALTH INITIATIVES DEPARTMENT DEDICATED TO IMPROVING THE HEALTH OF THE COMMUNITY THROUGH WELLNESS EDUCATION AND PREVENTATIVE HEALTHCARE STRATEGIES. THIS DEPARTMENT MAINTAINS AN ACTIVE PRESENCE IN THE COMMUNITY, SPONSORING SUCH EVENTS AS AN ANNUAL WOMEN'S HEALTH NIGHT, AN ANNUAL SENIOR HEALTH AND SAFETY EXPO, AND VARIOUS OTHER EDUCATIONAL PROGRAMS IN AREA SCHOOLS AND BUSINESSES. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X 0 0 0 0 0 0 0 0 0 DARLA WILSON 139835 0 1917 0 4918 0 5867 0 8798 0 161335 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 3: TOMAH MEMORIAL HOSPITAL DOES NOT PAY COMPENSATION TO THE ADMINISTRATOR DIRECTLY. THE ADMINISTRATOR IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, HEALTHTECH MANAGEMENT SERVICES, INC., AND IS CONSIDERED A COMMON LAW EMPLOYEE OF THE MANAGEMENT COMPANY. THE HOSPITAL BOARD OF DIRECTORS USES THE PROCESSES DESCRIBED IN PART I, QUESTION 3 TO HELP DETERMINE APPROPRIATE COMPENSATION FOR THE ADMINISTRATOR. THE BOARD OF DIRECTORS ALSO APPROVES THE ORGANIZATION'S CONTRACT WITH THE MANAGEMENT COMPANY. SUPPLEMENTAL INFORMATION PART III PART II: PHILIP J. STUART, ADMINISTRATOR, IS COMPENSATED BY HEALTHTECH MANAGEMENT SERVICES, INC., AN UNRELATED MANAGEMENT COMPANY, FOR SERVICES RENDERED TO TOMAH MEMORIAL HOSPITAL. THE ADMINISTRATOR IS CONSIDERED A COMMON LAW EMPLOYEE OF HEALTHTECH MANAGEMENT SERVICES AND THEREFORE HIS COMPENSATION IS NOT REPORTED. WI HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VNC8 2003-07-15 10256096 BLDG EXPANSION AND REFUND 1993 CITY OF TOMAH, WI REV BONDS ISSUED 4/22/1993 0 0 0 2105000 10256096 875300 205122 8022515 1153159 2004 1 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 1 0 0 0 0 0 CINDY LAMBERT FAMILY MEMBER OF CHIEF FINANCIAL OFFICER 36311 COMPENSATION AND BENEFITS AS AN EMPLOYEE 0 SHANA STEELE FAMILY MEMBER OF A CURRENT DIRECTOR OF THE BOARD 41335 COMPENSATION AND BENEFITS AS AN EMPLOYEE 0 TOMAH LUMBER ENTITY OWNED BY VICE CHAIRMAN OF BOARD 1175947 TOMAH MEMORIAL HOSPITAL ENTERED INTO AN AGREEMENT WITH TOMAH LUMBER TO CONSTRUCT A NEW HOSPICE RESIDENCE (PAYMENT FOR SERVICES). 0 X 1 21500 FAIR MARKET VALUE 0 1 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE INCLUDES THE CORPORATION'S OFFICERS AND CHAIRMAN OF STANDING COMMITTEES. THE EXECUTIVE COMMITTEE HAS POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE ARTICLES OF INCORPORATION, BYLAWS, OR THE BOARD. ALL MATTERS OF MAJOR IMPORTANCE WILL BE REFERRED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 2 OAKLEY MOSER AND STEVE AUSTIN HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE ADMINISTRATOR OF TOMAH MEMORIAL HOSPITAL IS EMPLOYED BY HEALTHTECH MANAGEMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A THE NOMINATING COMMITTEE HAS THE DUTY OF PROPOSING TO THE PUBLIC MEMBERSHIP AT THE ANNUAL MEETING AND AT OTHER MEETINGS WHERE VACANCIES ARE TO BE FILLED, THE NAMES OF NOMINEES TO THE BOARD OF DIRECTORS. THE NOMINATING COMMITTEE'S RECOMMENDATIONS ARE ADVISORY AND ADDITIONAL NOMINATIONS MAY BE MADE AT THE MEETING BY ANY MEMBER. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD BEFORE IT IS FILED. THE ADMINISTRATOR, CFO, AND EXECUTIVE/FINANCE COMMITTEE REVIEW THE DRAFT IN DETAIL. FORM 990, PART VI, SECTION B, LINE 12C ALL MEMBERS OF THE BOARD AND ADMINISTRATION TEAM ARE COVERED BY THE CONFLICT OF INTEREST POLICY. POTENTIAL CONFLICTS ARE CONTRACTS OR TRANSACTIONS BETWEEN THE HOSPITAL AND A DIRECTOR OR ANOTHER CORPORATION, FIRM, ASSOCIATION, OR ENTITY IN WHICH THERE IS A MATERIAL FINANCIAL INTEREST. THE HOSPITAL ADMINISTRATION REVIEWS ANNUAL STATEMENTS FOR POTENTIAL CONFLICTS. IF THE HOSPITAL ADMINISTRATION DETERMINES THERE IS A CONFLICT, THE PERSON INVOLVED MUST ABSTAIN FROM VOTING ON ANY MATTER RELATED TO THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE ADMINISTRATOR IS EMPLOYED BY HEALTHTECH MANAGEMENT SERVICES, INC. THE BOARD APPROVES THE CONTRACT ON A THREE YEAR PERIOD WITH TWO ONE-YEAR RENEWAL CLAUSES. COMPARABILITY DATA IS USED DURING THIS PROCESS AND THE DECISION IS DOCUMENTED. THE CONTRACT WAS RENEWED IN FISCAL YEAR 2010. THE ADMINISTRATOR MAKES RECOMMENDATIONS TO THE FINANCE/EXECUTIVE COMMITTEE OF THE BOARD FOR OTHER OFFICERS. COMPARABILITY DATA IS USED DURING THIS PROCESS AND THE DECISIONS ARE DOCUMENTED. THIS IS AN ANNUAL PROCESS AND WAS LAST COMPLETED IN FISCAL YEAR 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY HAVE NOT BEEN AVAILABLE TO THE GENERAL PUBLIC IN THE PAST, ALTHOUGH ADMINISTRATION IS CONSIDERING POSTING THEM ON THE ORGANIZATION'S WEBSITE IN THE FUTURE. FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ORGANIZATION'S BOND ISSUER ON THE INTERNET, AND THE ORGANIZATION PRESENTS AN ANNUAL REPORT TO THE COMMUNITY, OPEN TO THE GENERAL PUBLIC, IN WHICH A FINANCIAL REPORT IS PRESENTED. ADDITIONALLY, AN ANNUAL FINANCIAL REPORT IS INCLUDED IN THE QUARTERLY MAILINGS THE ORGANIZATION SENDS TO ALL COMMUNITY MEMBERS. FORM 990, PART VII, SECTION A: THE FOLLOWING INDIVIDUALS DEVOTED TIME PROVIDING SERVICES TO PEDERSON TRUST FUND FOR THE BENEFIT OF TOMAH MEMORIAL HOSPITAL, A RELATED EXEMPT ORGANIZATION. ROBER FASBENDER 1 HOUR PER WEEK PHIL YAHNKE 1 HOUR PER WEEK JEFF HOLTHAUS 1 HOUR PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,200,716. DECREASE IN FAIR VALUE OF BENEFICIAL INTEREST IN PERPETUAL TRUST -2,049. TOTAL TO FORM 990, PART XI, LINE 5: -1,202,765. PEDERSON TRUST FUND FOR THE BENEFIT OF TOMAH MEMORIAL HOSPITAL 321 BUTTS AVENUE TOMAH WI 54660 396173790 SUPPORT TOMAH MEMORIAL HOSPITAL WI 501(C)(3) LINE 11B, II TOMAH MEMORIAL HOSPITAL 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PEDERSON TRUST FUND FOR THE BENEFIT OF TOMAH MEMORIAL HOSPITAL C