2012-11-05T09:07:57-06:00 2011-12-31 381357951 PLANTE & MORAN PLLC 600 E FRONT ST SUITE 300 TRAVERSE CITY MI 49686 990 2011-01-01 381303843 OTSEGO MEMORIAL HOSPITAL ASSOCIATION OTSE 9897312100 825 N CENTER GAYLORD MI 49735 THOMAS LEMON 9897312100 2012-10-29 1 P00053797 2319477800 2011 2016-02-24 21:20:13Z OTSEGO COUNTY MEMORIAL HOSPITAL ASSOCIATION THOMAS LEMON CEO 825 N CENTER GAYLORD MI 49735 74502348 0 X WWW.MYOMH.ORG X 1946 MI TO PROVIDE QUALITY HEALTHCARE THAT MEETS THE NEEDS OF OUR PATIENTS AND THE COMMUNITIES WE SERVE BY: WORKING IN PARTNERSHIP WITH AREA PHYSICIANS TO PROVIDE PATIENT-FOCUSED CARE WITH QUALITY AND SERVICE SECOND TO NONE; DELIVERING A FULL CONTINUUM OF ACCESSIBLE CARE THAT ADDRESSES THE COMMUNITIES NEEDS; WORKING TO INCREASE THE PUBLIC'S AWARENESS OF THE BREADTH AND DEPTH OF OTSEGO MEMORIAL HOSPITAL'S SERVICES; MEETING THE PROFESSIONAL NEEDS OF OUR DEDICATED STAFF BY PROVIDING THEM WITH OPPORTUNITIES FOR PROFESSIONAL GROWTH AND EDUCATIONAL DEVELOPMENT; AND REMAINING FISCALLY SOUND. 10 9 667 145 0 0 469976 329925 66674528 73460197 48430 122202 361054 357588 67553988 74269912 0 0 0 0 36323986 38832855 0 0 575531 30919730 31320215 67243716 70153070 310272 4116842 44457670 48015526 31770936 31089878 12686734 16925648 X TO PROVIDE QUALITY HEALTHCARE THAT MEETS THE NEEDS OF OUR PATIENTS, AND THE COMMUNITIES WE SERVE. 0 0 37134458 0 54813150 ACUTE INPATIENT AND OUTPATIENT CARE FOR DIAGNOSTIC AND MEDICAL CARE: THERE WERE 70,217 ADMISSIONS FOR MEDICAL, SURGICAL, ICU, BIRTHING CENTER, AND OUTPATIENT REGISTRATIONS THIS PAST YEAR. 12870196 0 14764303 PHYSICIAN DIAGNOSTIC OFFICES AND URGENT CARE CLINIC: THERE WERE 110,195 PATIENTS FOR MED GROUP, MEDICARE, LEWISTON/MONTMORENCY, AND ORTHOPEDICS. 2726747 0 3563821 LONG TERM CARE FOR THE ELDERLY: THIS PAST YEAR THERE WERE 11,249 MCREYNOLDS HALL PATIENT DAYS USED. 2478823 0 356919 COMMUNITY BENEFIT - A COMMUNITY BENEFIT INCLUDES ANY ACTIVITY BY A HOSPITAL, PROVIDER OR HEALTH CARE SYSTEM, WHICH PROVIDES SERVICES THAT IMPROVE THE HEALTH AND QUALITY OF LIFE OF INDIVIDUALS WITHIN THE COMMUNITY. COMMUNITY BENEFITS ARE THOSE SERVICES THAT GO BEYOND DIRECT, MISSION-DRIVEN, AND PATIENT CARE ACTIVITIES. COMMUNITY BENEFITS ALSO INCLUDE DIRECT COST OF CARE SUBSIDIZED BY THE HOSPITAL FOR THOSE PEOPLE WHO ARE UNABLE TO PAY FOR THE CARE THEY RECEIVE. THERE ARE SIX BROAD CATEGORIES OF COMMUNITY BENEFIT, WHICH ARE; COMMUNITY SERVICE ACTIVITY, CHARITY CARE FOR PERSONS UNABLE TO PAY, COSTS IN EXCESS OF PUBLIC PROGRAM PAYMENTS (MEDICARE/MEDICAID), RESEARCH AND EDUCATION, CASH AND IN-KIND DONATIONS, LEADERSHIP AND BUILDING COMMUNITY CAPACITY. CURRENT COMMUNITY SERVICE ACTIVITIES FOR OMH ARE AS FOLLOWS: BASIC LIFE SUPPORT (BLS) INSTRUCTION--FULL COURSE AND RENEWAL: INSTRUCTION IN BASIC LIFE SUPPORT OFFERED TO EMPLOYEES AND COMMUNITY HEALTH CARE PROVIDERS. OUTCOME: COMMUNITY HEALTH CARE PROVIDERS KNOW AND UNDERSTAND HOW TO PROPERLY ADMINISTER BASIC CARDIAC LIFE SUPPORT.BLOOD DRIVES/BONE MARROW DONOR DRIVE: HOST AMERICAN RED CROSS BLOOD DRIVE TO INCREASE THE NUMBER OF BLOOD DONORS AND DONATIONS IN NORTHERN MICHIGAN. A BONE MARROW DONOR REGISTRY DRIVE WAS HELD CONCURRENTLY WITH ONE OF THE BLOOD DRIVES TO INCREASE THE NUMBER OF POTENTIAL MATCHES FOR THOSE NEEDING BONE MARROW TRANSPLANTS. OUTCOME: PROVIDE COMMUNITIES WITH NEEDED RESOURCE AND ADDED INDIVIDUALS TO THE BE THE MATCH DONOR REGISTRY. BLOOD PRESSURE SCREENING: BLOOD PRESSURE SCREENING CLINIC IS HELD. EDUCATIONAL MATERIALS REGARDING PREVENTION OF HYPERTENSION AND STROKE ARE DISTRIBUTED. OUTCOME: REDUCE DEATH AND DISABILITY DUE TO HIGH BLOOD PRESSURE. BREASTFEEDING CLASS: TO RE-ESTABLISH SKILLS NECESSARY TO COPE WITH THE STRESSES OF LABOR, TO PREPARE COUPLES PHYSICALLY, EMOTIONALLY AND INTELLECTUALLY FOR BIRTH. OUTCOME: SKILLS LEARNED PROVIDE A MORE COMFORTABLE LABOR AND BIRTH PROCESS.BREASTFEEDING SUPPORT AND CONSULTATION: BREASTFEEDING MOTHER'S GROUP THAT PROVIDES OPPORTUNITIES TO ASK QUESTIONS AND SHARE EXPERIENCES WITH OTHER NURSING MOTHERS. BREASTFEEDING CONSULTATION WITH A LACTATION SPECIALIST IS AVAILABLE. OUTCOME: TO ENCOURAGE AND ESTABLISH THE OPTIMAL INFANT NUTRITION FOR THE FAMILIES WE SERVE AND HELP THEM REACH THEIR GOALS.CANCER SCREENINGS: TO PROVIDE SCREENINGS FOR BREAST AND PROSTATE CANCER FOR LOW- OR UNINSURED MEMBERS OF THE COMMUNITY TO HELP PREVENT, DETECT, AND TREAT CANCER AT AN EARLIER STAGE. OUTCOME: APPROXIMATELY 60 (COMBINED MALE AND FEMALE) COMMUNITY MEMBERS PARTICIPATED IN THE SCREENINGS. COMMUNITY HEALTH FAIRS: OMH PROVIDES HEALTH INFORMATION AND SCREENING OPPORTUNITIES AT HEALTH FAIRS AND BUSINESSES IN THE AREA.COMPREHENSIVE PHYSICALS: PHYSICALS ARE PROVIDED TO AREA STUDENT ATHLETES FOR A NOMINAL FEE. THIS FEE IS THEN RETURNED TO THE STUDENTS RESPECTIVE ATHLETIC DEPARTMENT PROGRAM. CPR/FIRST AID CLASSES: PARTICIPANTS ARE TAUGHT HOW TO IDENTIFY HEART RISK FACTORS, SYMPTOMS OF A HEART ATTACK AND HOW TO PERFORM ADULT CPR AND THE HEIMLICH MANEUVER FOR CHOKING VICTIMS.OUTCOME: REDUCED NUMBER OF LIVES LOST DUE TO CARDIAC AND RESPIRATORY ARREST AND STROKE. CRITICAL INCIDENT STRESS DEBRIEFING: CHRIS RANDALL AND KATHLEEN DONNELLY, BOTH REGISTERED NURSES, ARE SPECIALLY TRAINED IN CRITICAL INCIDENT STRESS DEBRIEFING. THEY ARE TRAINED TO PROVIDE DEBRIEFING (COUNSELING) FOR PRE-HOSPITAL EMERGENCY SERVICE PERSONNEL, EMERGENCY DEPARTMENT STAFF, AND COUNSELING.OUTCOME: COUNSELING IS PROVIDED TO REQUESTING PRE-HOSPITAL EMERGENCY SERVICE PERSONNEL, EMERGENCY DEPARTMENT STAFF AND/OR COMMUNITY MEMBERS IN THE EVENT OF A CRITICAL INCIDENT OCCURRENCE. FAMILY/PARENTING/SIBLING EDUCATION: A VARIETY OF COURSES (SIBLING-REUNION-CAR SEAT SAFETY) TAUGHT BY A CERTIFIED CHILDBIRTH INSTRUCTOR ARE OFFERED TO EXPECTANT PARENTS THROUGHOUT THE YEAR. OUTCOME: EXPECTANT PARENTS ARE EQUIPPED WITH THE KNOWLEDGE AND SKILLS TO COPE WITH THE STRESSES OF LABOR AND INFANT CARE. THEY ARE PREPARED INTELLECTUALLY, PHYSICALLY AND EMOTIONALLY FOR THIS TASK. FLU SHOTS: ASSISTING STUDENTS AT KIRTLAND COMMUNITY COLLEGE WITH INJECTIONS. GRANTS TO COMMUNITY HEALTH INITIATIVES/PROGRAMS: OMH FOUNDATION PUTS TIME AND RESOURCES INTO RESEARCHING GRANT OPPORTUNITIES FOR OUR COMMUNITY.OUTCOME: OVER $2,000 OF COMMUNITY BENEFIT FROM OMH STAFF FOR RESEARCHING GRANTS.HEART DISEASE/HEALTHY HEART EDUCATION: MARY KING, HEALTH EDUCATION COORDINATOR, ATTENDS MEETINGS AND ACTIVELY PARTICIPATES IN THESE TWO COMMUNITY ORGANIZATIONS/EVENTS WHOSE GOALS ARE TO INCREASE PHYSICAL FITNESS IN COMMUNITY MEMBERS AND TO INCREASE AWARENESS OF THE LINK WITH INACTIVITY AND HEART DISEASE. CHOLESTEROL TESTING AND SCREENINGS HELD.OUTCOME: IMPROVED HEALTHY HEART LIFESTYLE WITH DECREASED HEART DISEASE, DECREASED DEATH DUE TO HEART DISEASE, AND REDUCED CARDIOVASCULAR DISEASE THROUGH PREVENTATIVE ACTIVITIES. HOME CARE: HOME VISITS TO NEWBORNS AND THEIR PARENTS NOT BILLED BY THE HOSPITAL. MEDICAL COMMUNITY DOMESTIC ABUSE TASK FORCE: KATHLEEN DONNELLY, R.N., IS A MEMBER OF THE MEDICAL COMMUNITY DOMESTIC ABUSE TASK FORCE. THIS ORGANIZATION IS COMPRISED OF REPRESENTATIVES FROM AREA HOSPITALS AND HEALTH SERVICES PROVIDERS. THE PURPOSE OF THIS GROUP IS TO EDUCATE ALL HEALTH CARE PROVIDORS. OUTCOME: MEDICAL PERSONNEL ARE ABLE TO IDENTIFY AND AID VICTIMS OF DOMESTIC VIOLENCE WHO MAY NOT KNOW HOW TO, OR WHO MAY BE AFRAID TO, ASK FOR HELP.MEDICAL SUPPLIES DONATION: DONATION OF MEDICAL SUPPLIES TO BAKER COLLEGE FOR USE IN CLASSROOM/LABORATORY EXERCISE.MEETING SPACE/ROOM USAGE: DONATION OF MEETING ROOM SPACE TO COMMUNITY SUPPORT GROUPS AND NON-PROFIT ORGANIZATIONS. NUTRITION/WEIGHT MANAGEMENT/WEIGHT LOSS MANAGEMENT: PROVIDE COUNSELING AND RESOURCES FOR THOSE PATIENTS PRESCRIBED A NUTRITION PLAN BY THEIR PROVIDER, OR OTHERS SEEKING HELP. ALSO HOST EVENTS FOR COMMUNITY MEMBERS TO ATTEND FEATURING SPEAKERS AND HEALTHY COOKING DEMONSTRATIONS. PRENATAL/FAMILY PLANNING/PREPARATION: A PHYSICAL THERAPIST'S PRESENTATION TO EXPECTANT MOTHERS ON EXERCISES THAT WILL PROVE BENEFICIAL BEFORE, DURING AND AFTER DELIVERY. CLASSES ARE OFFERED EVERY THREE MONTHS. OUTCOME: EXPECTANT MOTHERS EXPERIENCE AN EASIER DELIVERY WITH A FASTER RECOVERY RATE. SCHOOL BASED PROGRAMS: OTSEGO MEMORIAL HOSPITAL TEAMS UP WITH GAYLORD HIGH SCHOOL'S OCCUPATIONAL MEDICINE CLASS ALLOWING STUDENTS THE OPPORTUNITY TO JOB SHADOW HEALTH CARE PROFESSIONALS IN VARIOUS SPECIALTIES OF INTEREST TO THEM. OBJECTIVE: TO PROVIDE STUDENTS WITH THE OPPORTUNITY TO LEARN AND EXPLORE AREAS OF INTEREST IN THE HEALTH CARE FIELD SPEAKER'S BUREAU: SCHOOLS, CHURCHES AND OTHER COMMUNITY ORGANIZATIONS REQUEST STAFF MEMBERS TO LECTURE AT THEIR FACILITY ON VARIOUS TOPICS OF INTEREST. OBJECTIVE: TO HAVE AVAILABLE TO THE COMMUNITY MEDICAL PROFESSIONALS WHO ARE EAGER TO SHARE THEIR KNOWLEDGE TO GROUPS AND ORGANIZATIONS AS REQUESTED TOBACCO CESSATION/SMOKING: DEVELOPED AND TESTED BY THE AMERICAN LUNG ASSOCIATION, THIS CLINIC IS INTENDED FOR PEOPLE WHO CAN BENEFIT FROM GROUP SUPPORT IN THEIR EFFORT TO QUIT SMOKING. THIS PROGRAM EMPHASIZES UNLEARNING A HABIT AND DOES NOT INVOLVE SCARE TACTICS. OUTCOME: REDUCED NUMBER OF INDIVIDUALS WHO USE TOBACCO, THEREBY REDUCING THE NUMBER OF LIVES AFFECTED BY CHRONIC LUNG DISEASE, CANCER, BRONCHITIS, ETC TRANSPLANT SUPPORT GROUP OF NORTHERN MICHIGAN: SUPPORT GROUP DESIGNED FOR ANYONE WHO IS PRE- OR POST- TRANSPLANT AND THEIR FAMILIES, CAREGIVERS OR DONORS. OUTCOME: INCREASED RESOURCES FOR TRANSPLANT CANDIDATES, I.E., SHARED INFORMATION ON WHERE TO GO, WHAT TO EXPECT, ETC.--THEREBY PROMOTING BETTER RESULTS AND IMPROVED CHANCES FOR OBTAINING ORGAN TRANSPLANT. 2478823 356919 55210224 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 28 0 1 667 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X AMY BILYEA CONTROLLER 9897312100 825 N CENTER AVE GAYLORD MI 49735 X CHRISTOPHER COLLINS 0.20 X X 0 0 0 THOMAS TOMASKI 0.20 X X 0 0 0 MARY SANDERS 0.20 X X 0 0 0 CAROLYN STUDY 0.20 X X 0 0 0 DAVID BRINEY 0.20 X 0 0 0 SCOTT CHESLEY 0.20 X 0 0 0 DR PETER HANDLEY 40.00 X 251102 0 31598 DONALD SKLARCZYK 0.20 X 0 0 0 DR BECKY ASHLEY 0.20 X 0 0 0 MARCUS WEGMEYER 0.20 X 0 0 0 THOMAS LEMON 39.50 X 215284 0 24205 ROBERT COURTOIS 39.50 X 161290 0 16500 CHANGXIN LI 40.00 X 494281 0 39269 JOHN MOFFAT 40.00 X 566528 0 22000 DAVID MINER 40.00 X 437086 0 0 ROBERT HALTER 40.00 X 388170 0 22000 LOUIS HABRYL 40.00 X 595165 0 22000 3108906 0 177572 44 0 1 0 AHSA LLC PO BOX 945 TRAVERSE CITY MI 49685 TEMPORARY LOCUM SERVICES 820370 MAYO COLLABORATIVE SERVICES PO BOX 9146 MINNEAPOLIS MN 55480 DIAGNOSTIC SERVICES 409306 VITERA HEALTHCARE SERVICES PO BOX 203658 DALLAS TX 753203658 SOFTWARE SERVICES 351975 LEASE PORTFOLIO PO BOX 405 NEWTON MA 02456 PROFESSIONAL SERVICES 343810 NORTHERN MICHIGAN HEMATOLOGY 416 CONNABLE PETOSKEY MI 49770 PHYSICIAN ONCOLOGY SERVICES 250500 14 7522 270765 35373 16265 329925 PATIENT SERVICE REVENU 622110 72368596 72368596 OTHER RELATED REVENUE 622110 1091601 1091601 73460197 161162 161162 166255 57776 108479 108479 108479 130000 5700 130303 44357 -303 -38657 -38960 -38960 CAFETERIA REVENUE 722210 211113 211113 REVENUE FROM JOINT VEN 523000 37996 37996 249109 74269912 73498193 0 441794 773183 315687 457496 29454958 25075456 4215896 163606 860444 723597 132179 4668 5808659 2603234 3204695 730 1935611 1627765 297344 10502 93112 93112 198015 198015 12036 12036 3782157 2447593 1167049 167515 90009 14210 75799 663442 254659 375742 33041 1233608 429785 803425 398 59222 25676 33147 399 197175 143315 51456 2404 1444844 1041589 391127 12128 2532062 1825366 685442 21254 674433 201785 472648 MEDICAL SUPPLIES AND DR 12271163 11788092 480326 2745 PROVISION FOR BAD DEBTS 3452717 3452717 EQUIPMENT RENTAL 1468895 951349 506598 10948 REPAIRS AND MAINTENANCE 1444848 821973 599668 23207 1702477 1480586 175704 46187 70153070 55210224 14367315 575531 943050 1577324 929212 976379 4042716 5358931 0 8000 1068353 1192161 1726475 2016581 51866333 24347696 27185338 27518637 3111484 5447514 250428 428411 5200614 3491588 44457670 48015526 7610238 7402106 0 15417 21681510 20736517 696137 570885 1783051 2364953 31770936 31089878 X 11587417 15826331 1099317 1099317 12686734 16925648 44457670 48015526 X 4116842 122072 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 3803 3803 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: SUPPORTED LOBBYING ACTIVITIES THROUGH ANNUAL DUES PAID TO MICHIGAN HEALTH & HOSPITAL ASSOCIATION. 869562 869562 34512514 13270087 21242427 331504 262774 68730 16002409 10814835 5187574 150344 150344 27518637 COST REPORT SETTLEMENT RECEIVABLE 1526375 BOND ISSUE COSTS 304241 LIFE INSURANCE 37211 INVESTMENT IN AFFILIATES 1623761 3491588 COST REPORT SETTLEMENT PAYABLE 2364953 2364953 1 1 X 1 X 1 X 1 1 0 1 1 1 406 426447 426447 0.00640 1 15825 12249967 11431013 818954 0.01230 2 16231 12676414 11431013 1245401 0.01870 712 1727 71046 6400 64646 0.00100 284 19 10258 10258 0.00020 4 110195 12108750 11386567 722183 0.01080 8 245 62665 62665 0.00090 1008 112186 12252719 11392967 859752 0.01290 1010 128417 24929133 22823980 2105153 0.03160 12 1219 1219 0.00000 4 542 542 0.00000 64 200 13899 13899 0.00020 16 2641 2641 0.00000 96 200 18301 18301 0.00020 1 3452717 258054 21107956 20622778 485178 X 1 1 1 1 OTSEGO MEMORIAL HOSPITAL ASSOCIATION

825 N CENTER AVE GAYLORD MI 49735

X X X LONG-TERM CARE FACILITY AND PHYSICIAN CLINICS OTSEGO MEMORIAL HOSPITAL ASSOCIATION 1 1 1 200.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X 1 0 1 X 0 1 PART I, LINE 3C: UNDER ITS ASSISTANCE PROGRAM OTSEGO MEMORIAL HOSPITAL WILL MAKE AVAILABLE A REASONABLE AMOUNT OF UNCOMPENSATED OR REDUCED PRICE SERVICES TO PERSONS ELIGIBLE UNDER APPLICABLE GUIDELINES. OTSEGO MEMORIAL HOSPITAL'S ASSISTANCE PROGRAM SERVICES ARE NOT LIMITED TO ANY SPECIFIC HOSPITAL SERVICE. INDIVIDUAL ELIGIBILITY FOR ASSISTANCE IS DETERMINED BY MEASURING FAMILY INCOME IN RELATION TO FAMILY SIZE AGAINST THE INCOME POVERTY GUIDELINE ESTABLISHED BY THE COMMUNITY SERVICE ADMINISTRATION. IF THE HOSPITAL DETERMINES THAT SERVICES ARE NOT MEDICALLY NECESSARY, THE HOSPITAL CAN DENY SERVICES UNDER THE FINANCIAL ASSISTANCE PROGRAM. PART I, LINE 6A: N/A PART I, LINE 7: A COST TO CHARGE RATIO, DERIVED FROM WORKSHEET 2, IS USED. PART I, LINE 7G: ALL PHYSICIAN CLINICS ARE INCLUDED AS SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24B - BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE SCHEDULE H, PART I, COLUMN F PERCENTAGE EQUALS $3,452,717. PART II: OTSEGO MEMORIAL HOSPITAL IS INVOLVED IN NUMEROUS COMMUNITY BUILDING ACTIVITIES WHICH PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES. OTSEGO MEMORIAL HOSPITAL STAFF REPRESENT OTSEGO MEMORIAL HOSPITAL ON A VARIETY OF COMMITTEES AND COMMUNITY BOARDS IN WHICH OTSEGO MEMORIAL HOSPITAL OFFERS ASSISTANCE THROUGH STAFF, FACILITIES, AND RESOURCES WITH THE END GOAL OF WORKING TO ADDRESS COMMUNITY ISSUES RELATED TO HEALTH IMPROVEMENT, EDUCATION, POVERTY, WORKFORCE DEVELOPMENT AND ACCESS TO CARE. WE ALSO ENCOURAGE OUR EMPLOYEES TO SERVE IN THE COMMUNITY TO PROMOTE THE HEALTH OF THE COMMUNITIES WE SERVE. AND, WE WORK WITH NEIGHBORHOOD PROGRAMS, INCLUDING PUBLIC AND PRIVATE LOCAL SCHOOLS, OTSEGO COUNTY COMMISSION ON AGING, WORK SITES AND SAFETY NET PROVIDERS TO PROMOTE HEALTH AND WELLNESS AND PREVENT DISEASE. ADDITIONALLY, OTSEGO MEMORIAL HOSPITAL STAFF SIT ON THE MOBILIZING THROUGH ACTION FOR PLANNING AND PARTNERSHIPS (A THOROUGH AND NATIONALLY RECOGNIZED PROGRAM FOR CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT). AS WELL, OTSEGO MEMORIAL HOSPITAL STAFF MEMBERS WERE ACTIVELY INVOLVED IN A BLUE CROSS BLUE SHIELD GRANT RECEIVED BY THE GAYLORD COMMUNITY SCHOOLS TO ENHANCE PHYSICAL ACTIVITY AND PROMOTE HEALTHY EATING IN THE SCHOOLS FOR SCHOOL YEAR 2011-2012. THIS COMMITTEE WAS COMPRISED OF COMMUNITY OFFICIALS, PARENTS, TEACHERS, HOSPITAL STAFF AND PHYSICIANS. PART III, LINE 4: OTSEGO MEMORIAL HOSPITAL REPORTS ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS, AND OTHERS. OTSEGO MEMORIAL HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS AND TRENDS. ACCOUNTS RECEIVABLE FINANCIAL STATEMENT FOOTNOTE:ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALULATING THE COLLECTIBILITY OF ACCOUNT RECEIVABLE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALULATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNT AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.THE CALCULATION FOR ESTIMATED AMOUNT OF THE ORGANIZATIONS BAD DEBT EXPENSE ATTIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATIONS FINANCIAL ASSISTANCE POLICY, $258,054, IS BASED ON OTSEGO MEMORIAL HOSPITAL'S ACTUAL FINANCIAL ASSISTANCE WRITE-OFFS AS A PERCENTAGE OF ACTUAL UNCOMPENSATED CARE (FINANCIAL ASSISTANCE PLUS BAD DEBT). AN ADDED ASSUMPTION IS USED BASED ON THE IDEA THAT BAD DEBT WOULD LIKELY INCREASE BY A PARTICULAR PERCENTAGE DUE TO THE ECONOMIC CLIMATE IN THE DEMOGRAPHIC AREA. PART III, LINE 8: OTSEGO MEMORIAL HOSPITAL PROVIDES HEALTHCARE TO NINE COMMUNITIES IN OTSEGO AND MONTMORENCY COUNTIES, AND IS THE ONLY HEALTHCARE SYSTEM IN THE AREA AND INCLUDES SEVERAL SMALL TOWNS. THE POPULATION INCLUDES A SIGNIFICANT NUMBER OF RETIREES. SERVICES ARE NOT LIMITED TO RESIDENTS OF THESE COMMUNITIES AS THE AREA HAS A HIGH VOLUME OF TRANSIENTS THAT COME FOR THE NUMEROUS RECREATIONAL ACTIVITIES. THE OUTLYING AREAS ARE PREDOMINANTLY IN A RURAL, AGRICULTURAL BASED SETTING. THE FOLLOWING COSTING METHOD OF COST TO CHARGE RATE IS USED; MEDICARE COSTS DIVIDED BY MEDICARE CHARGES. PART III, LINE 9B: ALL PATIENTS RECEIVING TREATMENT AT OTSEGO MEMORIAL HOSPITAL (INCLUDING CHARITY CARE PATIENTS) ARE RESPONSIBLE FOR PAYING IN FULL ALL CHARGES FOR SUCH TREATMENT, LESS ANY AMOUNTS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, DISCOUNT CONSIDERATIONS OR INSURANCE COVERAGE, PER POINT OF SERVICE COLLECTION POLICY. OTSEGO MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 21: OTSEGO MEMORIAL HOSPITAL HAS THE SAME GROSS CHARGES FOR ALL PATIENTS. FOR FAP-ELIGIBLE PATIENTS, OTSEGO MEMORIAL HOSPITAL DOES HAVE DISCOUNTS BASED ON FINANCIAL ASSISTANCE RULES THAT ARE APPLIED IN CALCULATING THE PATIENT'S RESPONSIBILITY. PART VI, LINE 2: OTSEGO MEMORIAL HOSPITAL CONDUCTED A BROADLY BASED SURVEY TO ASSESS THE VARIOUS HEALTH CARE NEEDS OF THE COMMUNITIES THAT IT SERVES IN APRIL 2011. IN ADDITION, OTSEGO MEMORIAL HOSPITAL USES INPUT FROM PHYSICIANS, MEDICAL PROVIDERS, AND COMMUNITY MEMBERS TO ASSIST IN ITS ASSESSMENT OF THE COMMUNITIES' HEALTHCARE NEEDS. OMH WORKS IN COLLABORATION WITH VARIOUS COMMUNITY GROUPS INCLUDING BUT NOT LIMITED TO: UNITED WAY, OTSEGO COUNTY COMMISSION ON AGING, OTSEGO AREA CHAMBER OF COMMERCE, AND OTHER LOCAL ASSOCIATIONS IN ORDER TO CONTINUE TO UNDERSTAND THE LOCAL HEALTHCARE NEEDS OF OUR SERVICE AREA. PART VI, LINE 3: THE OTSEGO MEMORIAL HOSPITAL REGISTRATION MANAGER TRIES TO SEE THE PATIENTS IN ER OR IP. REGISTRATION STAFF HAVE ALSO BEEN TRAINED TO HAND OUT ASSISTANCE PACKAGES. WHEN THE PATIENT COMES IN ON THE WORK LIST THEY ARE ALSO INFORMED OF THE ASSISTANCE PACKAGE AND/OR APPLICATION. THE FORM IS ALSO ON THE OTSEGO MEMORIAL HOSPITAL WEBSITE. THERE ARE ALSO WRITTEN NOTICES AT THE BOTTOM OF THE PATIENT STATEMENTS. WHEN THERE IS A SCHEDULED PROCEDURE AND THE PATIENT DOES NOT HAVE INSURANCE, A CALL IS MADE FOR PAYMENT AND/OR CHARITY CARE ARRANGEMENTS. PART VI, LINE 4: OTSEGO MEMORIAL HOSPITAL PROVIDES HEALTHCARE TO NINE COMMUNITIES IN OTSEGO AND MONTMORENCY COUNTIES, AND IS THE ONLY HEALTHCARE SYSTEM IN THE AREA AND INCLUDES SEVERAL SMALL TOWNS. THE POPULATION INCLUDES A SIGNIFICANT NUMBER OF RETIREES. SERVICES ARE NOT LIMITED TO RESIDENTS OF THESE COMMUNITIES AS THE AREA HAS A HIGH VOLUME OF TRANSIENTS THAT COME FOR THE NUMEROUS RECREATIONAL ACTIVITIES. THE OUTLYING AREAS ARE PREDOMINANTLY IN A RURAL, AGRICULTURAL BASED SETTING. BOTH OTSEGO AND MONTMORENCY COUNTIES HAVE EXPERIENCED HIGHER THAN NORMAL UNEMPLOYMENT RATES AS COMPARED TO THE STATE OF MICHIGAN IN GENERAL. PART VI, LINE 5: OTSEGO MEMORIAL HOSPITAL OFFERS A VARIETY OF PROGRAMS AND SERVICES WITH THE END GOAL OF PROMOTING THE GREATER HEALTH OF THE COMMUNITY. ONE IS THE REACH OUT AND READ LITERACY PROGRAM OFFERED THROUGH THE OTSEGO MEMORIAL HOSPITAL PEDIATRICS PRACTICE, WHICH PROVIDES A BOOK TO EVERY CHILD AGES SIX MONTHS TO FIVE YEARS OLD WHO IS SEEN IN OUR FAMILY PRACTICE OR PEDIATRIC OFFICES FOR A WELL CHILD VISIT. OUR PROVIDERS ARE ALL TRAINED IN THE PROGRAM, AND USE THE GIFT OF THE BOOK TO THE CHILD AS AN OPPORTUNITY TO TALK ABOUT READING IN THE HOME AND THE IMPORTANCE OF READING ALOUD TO THE CHILD. THIS PROGRAM HAS BEEN WIDELY SUCCESSFUL, BOTH PARENTS AND CHILDREN ARE LEARNING THE IMPORTANCE OF READING AND BUILDING AN IN HOME LIBRARY. OTSEGO MEMORIAL HOSPITAL ALSO OFFERS THE DIABETES SELF MANAGEMENT PROGRAM OPERATED BY A CERTIFIED DIABETES EDUCATOR, THIS PROGRAM OFFERS SUPPLIES AND EQUIPMENT TO DIABETIC PATIENTS WHO ARE UNABLE TO AFFORD THE LIFE SAVING EQUIPMENT NEEDED TO MANAGE THEIR DIABETES. BOTH THE REACH OUT AND READ PROGRAM AND THE DIABETES SELF MANAGEMENT PROGRAM ARE FUNDED THROUGH INDIVIDUAL COMMUNITY DONATIONS AND GRANTS. OTSEGO MEMORIAL HOSPITAL IS PART OF THE NORTHERN MICHIGAN DIABETES INITIATIVE--A GROUP OF REGIONAL STAKEHOLDERS AND STEERING COMMITTEE MEMBERS WHO WORK WITH A VISION TO IMPROVE THE CHRONIC CARE MANAGEMENT OF DIABETES. OTSEGO MEMORIAL HOSPITAL OFFERS MONTHLY EDUCATIONAL SESSIONS FREE OF CHARGE TO COMMUNITY MEMBERS ON A VARIETY OF TOPICS, INCLUDING DIABETES, HEART HEALTH, SLEEP APNEA AND MANY OTHERS. ALL PRESENTATIONS ARE OPEN TO THE PUBLIC. ADDITIONALLY, OTSEGO MEMORIAL HOSPITAL HOSTED JOHN OTTERBACHER, A NATIONALLY KNOWN AUTHOR AND MOTIVATIONAL SPEAKER WHO SPOKE ABOUT HEART HEALTH AND DEPRESSION. JOHN'S PRESENTATION WAS OPEN AND FREE TO THE PUBLIC. OTSEGO MEMORIAL HOSPITAL HAS NUMEROUS MEDICAL PRACTICES THAT ARE FEDERALLY QUALIFIED RURAL HEALTHCARE CLINICS, AS WELL AS OTSEGO MEMORIAL HOSPITAL IS LOCATED WITHIN A HEALTH PROFESSIONAL SHORTAGE AREA. BOTH OF THESE QUALIFICATIONS DEMONSTRATE OTSEGO MEMORIAL HOSPITAL'S ISOLATED SERVICE AREA WHICH HAS RESULTED IN CHALLENGING PHYSICIAN RECRUITMENT AND RETENTION. OTSEGO MEMORIAL HOSPITAL'S COMMITMENT TO PROVIDING THE HIGHEST LEVEL OF CARE STARTS WITH PHYSICIAN AND OTHER PROVIDERS. EXTENSIVE RECRUITMENT ACTIVITIES MUST TAKE PLACE IN ORDER TO PROVIDE CARE TO THESE HEALTH PROFESSIONAL SHORTAGE AREAS. PART VI, LINE 6: OTSEGO MEMORIAL HOSPITAL HAS AN AFFILIATION AGREEMENT WITH MUNSON MEDICAL CENTER WHERE THEY COOPERATE IN PROVIDING HEALTH CARE SERVICES TO THE COMMUNITY. INCLUDED IN THE AFFILIATION AGREEMENT ARE VARIOUS PURCHASED SERVICES, SUCH AS: INFORMATION TECHNOLOGY, LAUNDRY, PHYSICIAN RECRUITMENT ASSISTANCE, REIMBURSEMENT SUPPORT, MANAGEMENT DEVELOPMENT, MOBILE IMAGING, ETC. ALSO INCLUDED IN THE AFFILIATION AGREEMENT ARE COLLABORATION ON VARIOUS INITIATIVES, SUCH AS: ICD-10 IMPLEMENTATION, STRATEGIC PLANNING, CEO AND OTHER FORUMS, EDUCATION, CONSULTING, ETC. REPORTS FILED WITH STATES PART VI, LINE 7 MI X X X X 0 0 0 0 0 0 0 0 0 DR PETER HANDLEY 250742 0 0 0 360 0 31598 0 0 0 282700 0 0 0 THOMAS LEMON 214732 0 0 0 552 0 22950 0 1255 0 239489 0 0 0 ROBERT COURTOIS 160258 0 0 0 1032 0 16500 0 0 0 177790 0 0 0 CHANGXIN LI 493729 0 0 0 552 0 39269 0 0 0 533550 0 0 0 JOHN MOFFAT 565496 0 0 0 1032 0 22000 0 0 0 588528 0 0 0 DAVID MINER 436534 0 0 0 552 0 0 0 0 0 437086 0 0 0 ROBERT HALTER 386586 0 0 0 1584 0 22000 0 0 0 410170 0 0 0 LOUIS HABRYL 593581 0 0 0 1584 0 22000 0 0 0 617165 0 0 0 GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 368177AB7 2004-11-23 5285000 REFINANCE & CONSTRUCTION 0 0 0 GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 368177AC5 2004-11-23 5110000 REFINANCE & CONSTRUCTION 0 0 0 GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 368177AD3 2004-11-23 7465000 REFINANCE & CONSTRUCTION 0 0 0 GAYLORD HOSPITAL FINANCE AUTHORITY 383635769 2005-02-14 9000000 CONSTRUCTION 0 0 0 2942021 2942021 5285000 457171 256111 102861 1419302 2005 0 1 1 1 2844583 2844583 5110000 442030 247629 99454 1372295 2005 0 1 1 1 4156014 4156014 7465000 645817 361793 145305 2004961 2005 0 1 1 1 9000000 9000000 2005 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS 250 GENERAL MEMBERS. ANNUAL DUES ARE $5 PER INDIVIDUAL OR $8 PER FAMILY. REQUIREMENTS TO BE A MEMBER ARE A MINIMUM OF EIGHTEEN YEARS OF AGE AND HAS A RESIDENCE IN THE AREA THAT THE HOSPITAL SERVES. EACH MEMBER HAS TWO RIGHTS: ELECTION OF THE BOARD OR OF THE CANDIDATES PROPOSED AND TO VOTE APPROVAL FOR REVISIONS TO CORPORATE BYLAWS. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER HAS TWO RIGHTS: ELECTION OF THE BOARD OR OF THE CANDIDATES PROPOSED AND TO VOTE APPROVAL FOR REVISIONS TO CORPORATE BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER HAS TWO RIGHTS: ELECTION OF THE BOARD OR OF THE CANDIDATES PROPOSED AND TO VOTE APPROVAL FOR REVISIONS TO CORPORATE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BEFORE FILING BY THE FOLLOWING INDIVIDUALS: 1. THE HOSPITAL'S CHIEF EXECUTIVE OFFICER, THOMAS LEMON; 2. THE HOSPITAL'S VP OF FINANCE, ROBERT COURTOIS; AND 3. THE HOSPITAL'S CONTROLLER, AMY BILYEA. THE 990 IS ALSO PRESENTED TO THE ENTIRE HOSPITAL BOARD BEFORE FILING. DURING THIS MEETING MEMBERS HAVE A CHANCE TO ASK QUESTIONS REGARDING THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL'S POLICY REGARDING "CONFLICT OF INTEREST" REQUIRES EACH BOARD MEMBER AND OFFICER TO COMPLETE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES TO DEMONSTRATE CORPORATE COMPLIANCE. THESE FORMS ARE REVIEWED AND ANY CONFLICTS ARE INVESTIGATED BY MANAGEMENT. POTENTIAL CONFLICTS AND RESTRICTIONS ARE DETERMINED AND THEN VOTED UPON, PER POLICY GUIDELINES. IN THE EVENT THAT AN OFFICER OR BOARD MEMBER HAS A CONFLICT OF INTEREST, THAT BOARD MEMBER MUST GIVE WRITTEN NOTICE OF SUCH AN INTEREST OR RELATIONSHIP TO THE BOARD OF DIRECTORS, AND SHALL THEREAFTER REFRAIN FROM VOTING OR OTHERWISE ATTEMPTING TO EXERT ANY INFLUENCE ON THE DECISION. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD'S PERSONNEL SUB-COMMITTEE, WHICH CONSISTS OF FOUR MEMBERS, ANNUALLY REVIEWS THE COMPENSATION OF THE CEO ONLY. THEY UTILIZE MHA SALARY SURVEY DATA, AS WELL AS A MARKET ANALYSIS PERFORMED BY THE HOSPITAL'S HUMAN RESOURCES DEPARTMENT. THE HUMAN RESOURCES MARKET ANALYSIS INCLUDES THREE SOURCES FOR DATA: INTEGRATED HEALTHCARE STRATEGIES, MERCER AND SULLIVAN COTTER, WITH REGRESSION POINT USING $70M IN NET REVENUES AND AN AVERAGE BASED ON HOSPITALS WITHIN A SIMILAR RANGE OF NET REVENUES. EACH OF THE THREE SOURCES USE NATIONAL DATA AND ARE BASED ON A FREE-STANDING HOSPITAL CEO POSITION. THE CEO DETERMINES THE STARTING COMPENSATION FOR THE VICE PRESIDENTS BASED ON MARKET DATA AND ANNUAL INCREASES OCCUR BASED ON PAY-FOR-PERFORMANCE SYSTEMS. THESE PROCESSES WERE LAST UNDERTAKEN IN 2011. FORM 990, PART VI, SECTION C, LINE 19 THE OTSEGO MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY , AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC BY CONTACTING THE HOSPITAL AT 825 N. CENTER GAYLORD MI 49735 OR BY PHONE 989-731-2100. FORM 990, PART VII, SECTION A: THESE INDIVIDUALS DEVOTE THE FOLLOWING HOURS PER WEEK TO, RELATED ORGANIZATION, OTSEGO MEMORIAL HOSPITAL FOUNDATION: THOMAS LEMON 0.50 HOURS PETER HANDLEY 0.50 HOURS ROBERT COURTOIS 0.50 HOURS DAVID BRINEY 0.50 HOURS MARY SANDERS 0.50 HOURS CAROLYN STUDY 0.50 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 65,151. CHANGE IN INTEREST OF NET ASSETS OF CHARITABLE FOUNDATION 327,686. NET ASSETS RELEASED FROM RESTRICTION -270,765. TOTAL TO FORM 990, PART XI, LINE 5: 122,072. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. OTSEGO MEMORIAL HOSPITAL FOUNDATION 825 N CENTER STREET GAYLORD MI 49735 382135473 FUNDRAISING MI 501(C)(3) LINE 11A, I OTSEGO MEMORIAL HOSPITAL ASSOCIATION 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 OTSEGO MEMORIAL HOSPITAL FOUNDATION C 267265 CASH OTSEGO MEMORIAL HOSPITAL FOUNDATION N 84686 FMV - ACTUAL AMOUNTS PAID