2012-11-05T09:25:04-06:00 2011-12-31 990 2011-01-01 160756336 Mercy Hospital of Buffalo MERC 7168282993 515 Abbott Road No 500 Buffalo NY 142202039 David P Macholz 7168282974 2012-11-05 2011 2016-02-24 21:20:13Z Joseph D McDonald 2121 Main Street Buffalo NY 14214 327904956 0 X www.chsbuffalo.org X 1957 NY The Catholic Health System (CHS) Mission is to provide quality healthcare services in an acute care setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2011 Community Service Plan can be found at www.chsbuffalo.org. 21 8 2555 247 0 0 55513 2124352 294142910 319119395 606766 586941 3400107 6074268 298205296 327904956 0 0 0 0 133819672 150382297 0 0 0 153370778 163211345 287190450 313593642 11014846 14311314 167549524 207945480 184450721 252521119 -16901197 -44575639 X The Catholic Health System (CHS) Mission is to provide quality healthcare services in a (an) (acute care, long term care, home care) setting. Committed to a common mission, CHS providers continue the healing ministry of Jesus, seeking to improve the health of individuals and communities. We provide high quality service that has reverence, compassion, justice, and excellence. The 2011 Community Service Plan can be found at www.chsbuffalo.org. 0 0 160752502 217981641 Inpatient Routine/Surgery Visits: Acute Care Patient Days = 87,979Newborn Patient Days = 7,043Medical Rehab Patient Days = 5,838Skilled Nursing Patient Days = 30,151Inpatient Ambulatory Surgery Visits = 8,055 64663581 87684318 Outpatient Routine/Surgery Services:Emergency Visits = 59,869Referred Ambulatory Visits =236,957Outpatient Ambulatory Surgery Visits = 14,740 9921357 13453436 Clinic/Primary Care Services:Clinic Visits = 4,792Primary Care Visits = 75,728 235337440 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 1 0 1 182 0 2555 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 21 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X David P Macholz VP Finance Corporate Controller 7168282974 515 Abbott Road Suite 500 Buffalo NY 142202039 Joseph McDonald 37.50 X X 0 1071254 41897 Mark Sullivan 37.50 X X 0 499659 32323 Charles Urlaub 37.50 X X 436009 0 32828 David Macholz 37.50 X X 0 220215 31882 Peter Bergmann 37.50 X 0 558757 31684 Christine Kluckhohn 37.50 X X 0 297068 116618 James Millard 37.50 X 0 296692 157819 Dr Michael Edbauer 25.00 X 0 197492 43593 Dr Michael Albert 1.00 X 0 0 0 Dr Joseph Anain 1.00 X 0 117000 0 Brian Beitz 1.00 X 0 0 0 Frances Crosby RN PhD 1.00 X 0 0 0 Richard Curran MD 1.00 X 0 0 0 Dennis Dombek 1.00 X 0 0 0 Mr William Lawley Jr 1.00 X 0 0 0 James Manzella 1.00 X 0 0 0 Dr Paul Mason 1.00 X 0 25000 0 Michael Montante 1.00 X 0 0 0 Dr David Serra 1.00 X 0 0 0 Cynthia Zane EdD 1.00 X 0 0 0 Monsignor Robert E Zapfel 1.00 X 0 0 0 James A Dunlop Jr 37.50 X 0 443085 112103 Dr Brian D'Arcy 37.50 X 0 602143 48686 John Herman 37.50 X 209144 0 56915 Michael Moley 37.50 X 0 394218 39695 John Stavros 37.50 X 0 248323 39012 Maria Foti 37.50 X 0 230710 30394 Bartholomew Rodrigues 37.50 X 0 218184 33095 Dr Michael Galang 37.50 X 0 331760 25686 Dr Thomas Raab 37.50 X 443884 0 158043 Dr Timothy Gabryel 37.50 X 370908 0 30463 Nancy Sheehan 37.50 X 0 269768 27110 Dr Donald Schmidt 37.50 X 295399 0 128748 Nils Gunnerson 37.50 X 300808 0 72939 Dr Thomas Dilamarter Jr 37.50 X 260815 0 30113 Dr Kevin Shiley 37.50 X 258036 0 20816 Dr Diana Pomakova 37.50 X 232858 0 25383 2807861 6021328 1367845 75 0 1 0 Telco Construction Inc 500 Buffalo Road East Aurora NY 14052 Construction Services 3877783 Aramark Services Inc 1000 East Henrietta Road Rochester NY 14623 Dietary Services 1917198 Nursefinders Inc PO Box 910738 Dallas TX 753910738 Temporary Services 1343753 Siemens Medical Solutions 51 Valley Stream Parkway Malverne PA 19355 Maintenance Services 1287684 Sodexho Operations LLC 60 Grider Street Buffalo NY 14215 Laundry Services 1273696 53 2124352 2124352 Patient Care Services 900099 229859929 229859929 Medicaid/Medicare 900099 88305732 88305732 VA Contract Revenue 621400 953734 953734 319119395 586941 586941 255178 0 255178 255178 255178 Meaningful Use Dollars 900099 3342191 3342191 Cafeteria Revenue 900099 799141 799141 Parking Revenue 900099 604196 604196 1073562 369369 704193 5819090 327904956 322830955 0 2949649 111158877 97732473 13426404 11060075 9724176 1335899 20420870 17954321 2466549 7742475 6807295 935180 174789 33 174756 8582804 6920011 1662793 51303 13706 37597 6343954 3418896 2925058 203923 38621 165302 7835677 821157 7014520 99864 56885 42979 103919 74862 29057 2286446 1937517 348929 11070241 9380840 1689401 2512055 2183162 328893 Medical Supplies 60026710 60939039 -912329 Dues & Shared Services 37258301 37258301 Purchase Services & Oth 15474434 6464867 9009567 Bad Debts 8178587 8178587 3008338 2690992 317346 313593642 235337440 78256202 0 31458970 39896098 7311999 5155449 38602396 43388626 4578406 5557171 2693650 2026820 142047177 55592124 76094452 86455053 154792 157770 6654859 25308493 167549524 207945480 36097034 40294280 35249219 34084286 7788300 11583272 105316168 166559281 184450721 252521119 X -18846407 -46346867 1822687 1648705 122523 122523 -16901197 -44575639 167549524 207945480 X 14311314 -41985756 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1409723 1409723 70091597 28851433 41240164 15200603 8461348 6739255 54613321 18189004 36424317 731933 90339 641594 86455053 Accrued Receivables 2921413 Due From Affiliates 69944 Interest in the Net Assets of Mercy Hospital Foundation Inc 2024239 Workers Compensation Funding 359642 Insurance Recoveries 19933255 25308493 Deferred Comp Liability 163913 Due to Affiliates 8276173 Interest Rate Swap 6384753 Asset Retirement Obligation 5396627 Accrued Pension Obligation 114152596 LT Gen Liab/Workers Comp IBNR 32185219 166559281 327904956 313593642 14311314 -1971065 -1971065 12340249 326405959 625355 625355 325780604 2124352 2124352 327904956 314065710 472068 472068 313593642 0 313593642 Part XI, Line 8 - Other Adjustments: Contributions from Foundation - (489,672) -489,672. Contributions from Grants - (1,634,680) -1,634,680. Foundation Bottom Line - 153,287 153,287. Total to Schedule D, Part XI, Line 8: -1,971,065. Part XII, Line 2d - Other Adjustments: Foundation Activity - 625,355 Part XII, Line 4b - Other Adjustments: Contributions from Foundation - 489,672 Contributions from Grants - 1,634,680 Part XIII, Line 2d - Other Adjustments: Foundation Expenses - 472,068 1 1 1 X 110.000000000000 1 X 500.000000000000 1 1 1 0 1 1 3258841 194016 3064825 0.00980 41217652 35195640 6022012 0.01920 44476493 35389656 9086837 0.02900 1200536 1200536 0.00380 3710267 1193565 2516702 0.00800 254501 254501 0.00080 5165304 1193565 3971739 0.01260 49641797 36583221 13058576 0.04160 20421 20421 0.00010 34742 34742 0.00010 24177 24177 0.00010 3885 3885 0.00000 83225 83225 0.00030 1 3435007 1653018 53670068 56444691 -2774623 X 1 0 2 1 Mercy Hospital of Buffalo

565 Abbott Road Buffalo NY 14220

X X X X Ambulance, Ambulatory Surgery - Multi Specialty, 2 Mercy Ambulatory Care Center

3669 Southwestern Blvd Orchard Park NY 14127

X X X X Lab, CT, ED, Medical Surgical, Mercy Hospital of Buffalo 1 1 1 110.000000000000 1 500.000000000000 1 X X X X X X 1 1 X X X X X X X 1 0 1 X 0 1 Mercy Ambulatory Care Center 2 1 1 110.000000000000 1 500.000000000000 1 X X X X X X 1 1 X X X X X X X 1 0 1 X 0 1 9 East Aurora Medical Center

94 Olean St East Aurora NY 14052

Extension Clinic: OT-O/P, PT-O/P, Speech-O/P, Radiology-O/P, Lab-O/P Chestnut Ridge Family Practice

6300 Powers Rd Orchard Park NY 14127

Extension Clinic: Primary Medical Care O/P Mercy Outpatient Clinic ObGyn

515 Abbott Rd Buffalo NY 14220

Extension Clinic: Prenatal O/P, Primary Medical Care O/P Mercy Comprehensive Care Center

397 Louisiana St Buffalo NY 14202

Extension Clinic: Primary Care, Pediatric, Lab, Podiatry, Prenatal,Radiology OLV Family Care Center

227 Ridge Rd Lackawanna NY 14218

Extension Clinic: Prenatal O/P, Primary Medical Care O/P Mercy Nursing Facility

55 Melroy Ave Lackawanna NY 14218

Long Term Care, Lab-O/P, Radiology- Diagnostic O/P Pace Health Center

55 Melroy Ave Lackawanna NY 14218

Extension Clinic: OT-O/P, PT-O/P, Speech-O/P, Primary Care, Psychology O/P Mercy Ambulatory Care Center

550 Orchard Park Rd West Seneca NY 14224

CT, Lab-O/P, Primary Care, Radiology-O/P, OT-O/P, PT-O/P, Speech-O/P Springville Primary Care Center

27 Franklin St Springville NY 14141

Pediatric-O/P, Primary Medical Care-O/P Part I, Line 6a: Mercy Hospital Community Benefit Report is contained in a report prepared by the Catholic Health System. Part I, Line 7: Costing is a full step down methodology of cost from non-revenue producing departments to revenue producing departments', with assignment of cost to individual charge items based on volume and charge amount. All patient accounts are cost with the same methodology regardless of patient type (inpatient, outpatient, emergency room, etc.) or insurance coverage (Medicare, Medicaid, private insurance, uninsured, etc.). Part I, L7 Col(f): Bad debt expenses of $ 8,178,587 are included in Part IX, line 25, column (A) but subtracted when calculating the percentage in column (f). Part II: Mercy Hospital provided Community Building in the form of Community Support and Leadership Development which improved community leadership by promoting understanding of community healthcare needs and services at various events throughout the community. Environmental improvements included Green Initiatives and Pharmaceutical Waste disposals. Additionally Workforce Development was provided by mentoring and education to students regarding healthcare careers throughout the community. Part III, Line 4: The amount in Part III line 2 is the actual bad debt expenses of $8,178,587 written down to cost, utilizing the Uninsured Ratio of Cost to Charges (RCC) obtained from the full step down methodology of cost described in Part 1, line 7. The amount in Part III line 3 is the estimate of bad debt from uninsured balance which is developed as follows: as policy is to write accounts to bad debt 120 days after discharge, the discharge date period of 10/1/2009 to 9/30/2010 was used to determine the population of uninsured accounts. The balance of these accounts was determined and the RCC was applied to develop the estimate in H Part III Line 3. As our determination of eligibility for the Healthcare Assistance Program (HAP) (Charity Care) is based solely on the presentation for care without insurance, which is now for each account, and use of a sophisticated estimator (PARO) of each guarantor's ability to pay an estimate of "the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy if sufficient information had been available to make a determination of their eligibility" is not relevant. The organization's financial statements do not include a footnote that describes bad debt expense, but the financial statements account for bad debt expenses in the statement of operations as actual expenses written off and an estimate of future write-offs less any recoveries. Part III, Line 8: The costing methodology used to determine the Medicare Allowable costs is Cost to Charge. The shortfall is not treated as a community benefit. Part V, Section A: 1. Mercy Hospital of Buffalo Audiology O/P Cardiac Catheterization (Adult Diagnostic) Cardiac Catheterization - Electrophysiology (EP) Cardiac Catheterization - Percutaneous Coronary Intervention (PCI)Cardiac Surgery - Adult Certified Mental Health Services O/P Clinic Part Time Services Clinical Laboratory ServicesCoronary Care CT Scanner Dental O/P Emergency Department Family Planning O/P Health Fairs O/PIntensive Care Magnetic Resonance Imaging Maternity Medical Social Services Medical/Surgical Neonatal Continuing, Intensive & Intermediate Care Nuclear Medicine - Diagnostic Outpatient Surgery Pediatric & Pediatric O/P Pharmaceutical Service Physical Medical Rehabilitation Physical Medicine and Rehabilitation O/P Podiatry O/P Prenatal O/P Primary Medical Care O/P Radiology - Diagnostic Renal Dialysis - Acute Respiratory Care Therapy - Occupational, Physical O/P Therapy - Speech Language Pathology Part V, Section A: 2. Mercy Ambulatory Care CenterPrimary Medical Care, Radiology Diagnostic, Physical Therapy O/P Mercy Hospital of Buffalo Part V, Section B, Line 13g: Includes information in both English and Spanish on all signage and brochures for financial assistance. Mercy Ambulatory Care Center Part V, Section B, Line 13g: Includes information in both English and Spanish on all signage and brochures for financial assistance. Mercy Hospital of Buffalo Part V, Section B, Line 19d: Highest volume commercial payor rate Mercy Ambulatory Care Center Part V, Section B, Line 19d: Highest volume commercial payor rate Mercy Hospital of Buffalo Part V, Section B, Line 21: There are instances where the full charges on the account are equal to or less than the highest volume commercial payor rate. Mercy Ambulatory Care Center Part V, Section B, Line 21: There are instances where the full charges on the account are equal to or less than the highest volume commercial payor rate. Part VI, Line 2: Mercy Hospital, as part of Catholic Health, involves many participants in assessing community health needs including: 1. New York State Department of Health Prevention Agenda for the Healthiest State Erie County Department of Health Catholic Health Kaleida Health Erie County Medical Center Sheehan Memorial Hospital 2. Health Consumers 3. Patients/residents/clients A. Hospital Inpatients and OutpatientsB. Nursing Home Residents and Families C. Rehabilitation Patients D. Primary Care Center Patients E. Home Care Clients 4. Physicians 5. External Organizations, such as Academia, Community-based organizations, elected officials, employers and business, Faith based organizations, governmental organizations, media, philanthropists and schools.6. Statistical Resources1. New York State Department of Health Prevention Agenda for the Healthiest State Catholic Health worked in collaboration with the Erie County Department of Health, Kaleida Health, ECMC and Sheehan Memorial on the Erie Co. DOH Prevention Agenda for the Healthiest State. In February 2009, an Erie County Joint Planning Committee formed to identify prevention priorities and strategies to focus on collaboratively over the next 3 years, which included: Chronic Disease, Healthy Mothers, Healthy Babies, Healthy Children, Physical Activity and Nutrition and Tobacco Use.2. Health Consumers In creating the Catholic Health and Mercy Hospital strategic plan, input was sought from a variety of constituents including consumers. In August 2008, eight (8) consumer focus groups were conducted asking consumers what they wanted from their patient care experience. These focus groups were created by reaching out to 8,000 area residents who were asked to contact friends/families/neighbors to participate. 3. Patients/residents/clients A. Hospital Inpatients and Outpatients Mercy Hospital continues to participate in a regional patient satisfaction survey through a cooperative effort with the Buffalo Niagara Health Quality Coalition and area hospitals. Patient participation is voluntary. This survey takes place twice per year. Through hospital admission and outpatient ancillary sites, surveys were distributed to individuals to gain an understanding about their healthcare needs and how well their needs were being met. 4. Physicians Mercy Hospital surveys its medical staff annually. Physicians are surveyed on issues relating to the quality and efficiency of services offered throughout Catholic Health. 5. External OrganizationsCatholic Health and Mercy Hospital also engaged in the P2 Collaborative (Pursuing Perfection) dedicated to improving the health of people across the region. There are more than 200 participant organizations including the provider community, payers, community based organizations, religious organizations, local business, colleges & universities, and governmental agencies. Areas of focus include working with physicians and organizations to enhance access to care and improve efficiency of care and empowering all of the Western New York community to take responsibility for and act on their own wellness.In an effort to engage health care needs at the grass roots level, Catholic Health and Mercy Hospital work closely with the following organizations to assess community health need:Niagara Health Quality Coalition, Community Cancer CoalitionAmerican Heart Association, Near East & West Side Task ForceBaker Victory Services, Community Health Center of BuffaloWNY Osteoporosis Resource Ctr., WNY Health Equity Work GroupLiving Healthy Task Force of Erie Co., Minority Health CoalitionBuffalo Public Schools Worksite Wellness, Flu CoalitionEvery Parent Influences Children (EPIC), Tobacco CoalitionWNY Coalition for Diabetes, Community Health FoundationErie Co. Coalition for Diabetes, WNED Public TelevisionCatholic Charities, Niagara University6. Statistical ResourcesCatholic Health and Mercy Hospital used PQI (Preventable Quality Indicators) to map specific areas by zip code to better understand needs and target for need. We mapped specifically for Congestive Heart Failure, Hypertension, Angina & Diabetes to identify target areas for community education & screening initiatives. Other statistical resources used to assess the needs of the communities served included: Buffalo Public Schools: Student Body Mass Index, Erie County Health Assessment Indicators, and Erie County Health Indicators Profile. Goals/Objectives for the priorities identified for Catholic Health and Mercy Hospital include: *Increase consumer knowledge and adoption of healthy lifestyle behaviors by encouraging frequent physical activity and healthy nutrition, leading to improved health status and reduced chronic disease prevalence for residents of Buffalo and Erie County. *Increase participants' ability to identify risk factors for cardiovascular disease. *Lower body mass index (BMI) in youth; early identification of adolescents and adults with high blood pressure, high blood cholesterol and high blood glucose through screening and prevention interventions. *Implement a social marketing campaign to positively influence voluntary behavior of target population to take action to maximize health. *Restrict the availability of less healthy foods and beverages in public service venues in Buffalo and Erie County, such as schools, community centers and hospitals.In addition, Catholic Health and Mercy Hospital utilize resources to manage their public relations and social marketing initiatives (public facing website, Facebook and Twitter); exponentially increasing the effectiveness of its outreach and the success of its Community Service Plan. 2012 Community Education targets: 9,000 biometric screenings (5,610 in underserved areas); 240 community programs held; 4,328 people in attendance at community programs.Measures of Effectiveness: Number of educational programs held (240) and number of participants (4,328). Number of visits to website (617,380) Number of program attendees who attended cardiovascular presentations (1,084). Social media metrics: Facebook pages (4), Facebook fans (4,571), Twitter followers (1,325), website visitors (617,380).Local government facilities, hospitals and school districts adopt policies that limit the portion size of any entree by either reducing the standard portion size of entrees or offering smaller portion sizes in addition to standard portion sizes. Part VI, Line 3: Mercy Hospital informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the Catholic Health System Healthcare Assistance Program (HAP) policy. For example, Mercy Hospital has posters and brochures available which include contact information for the Financial Clearance staff in admissions areas, emergency rooms, primary care and outpatient rehabilitation clinics, Revenue Management Center (RMC) and other areas of the organization's facilities where eligible patients are likely to be present; provides information about financial assistance and HAP contact information to patients as part of the intake process; provides financial assistance and HAP contact information to inpatients either during or within 90 days of discharge of their hospital stay; patient bills include the following language: The Catholic Health System has a Healthcare Assistance Program to assist those in need of financial assistance for qualified patients. If you would like to obtain additional information on the Healthcare Assistance Program, please call (716) 601-3600. Thank you. Our Customer Service area is our front end team to assist all patients in this process. Additionally, we discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, where applicable, and there is information about financial aid posted on the Catholic Health System website. Part VI, Line 4: Mercy Hospital's service area is a mix of urban, suburban, and rural areas comprised of 94% white (non-Hispanic) and 1.9% African-American (non-Hispanic) households. The service area is more elderly than most with 17.1% of the population over the age of 65 compared to a national average of 13.3%. The community consists of fewer households than the national average with annual incomes below $15,000/year at 10.9% compared to a national average of 12.9%. Although Mercy Hospital is not located in a designated Health Professional Shortage Area (HPSA), it draws patients from identified HPSA areas. Additionally, the hospital has at least one extension in a designated HPSA. Part VI, Line 5: Catholic Health System's community service activities at the acute facilities include benefits to the broader community, which include non-billed services and provided services paid below costs. Charity care and benefits to the community are provided through long term care facilities, home care programs and Catholic Health system-wide community programs. These programs touch more than 40,000 Western New York residents through community health education programs, health screenings (including: glucose, blood pressure, and cholesterol screenings; and cardiac, stroke, vascular, diabetes, nutrition, stress management, and women's community programming) clinical and support services, clerkships, internships, scholarships, in-kind donations and community support activities. Additionally, thousands of people make unique visits to the Catholic Health website seeking information about an individual or family healthcare issue, and follow Catholic Health on Facebook and Twitter where daily posts talk to education and prevention of the priority areas.The governing Board of Directors of Mercy Hospital is comprised of community representatives from universities, legal communities, & business leaders. Religious orders are represented, as well as active and retired medical staff members.The Mercy Hospital medical staff can be considered an "open" medical staff, as any physician can apply for privileges. Each application is reviewed by a vigorous credentialing verification process. Part VI, Line 6: Mercy Hospital is affiliated with the Catholic Health System, Inc., a New York State licensed corporation. Catholic Health System, located in Buffalo, New York exempt from taxation and a charitable organization described in Section 501(c) (3) of the Internal Revenue Code of 1986. Catholic Health is also the parent company of the following New York State corporations: Kenmore Mercy Hospital, Sisters of Charity Hospital (Main Street Campus) , and Sisters of Charity Hospital (St. Joseph Campus). Its outpatient and post-acute facilities (and services) include Mercy Ambulatory Care Center, Mercy Diagnostic and Treatment Center, Mercy Diagnostic Center, Sheridan Health Care Center, Sisters Central Park Diagnostic Center, Williamsville Diagnostic Center, Kenmore Specialty Center, Ken-Ton Family Care Center, Lovejoy/St. Vincent Health Center, Mercy Comprehensive Care Center, Mercy OB/GYN Center, OLV Family Care Center, Sisters OB/GYN Center, Springville Primary Care Center, Williamsville Primary Care Center, Catholic Health Home Care, St. Elizabeth's Home, St. Vincent's Home, Father Baker Manor, McAuley Residence, Mercy Nursing Facility at OLV, St. Catherine Laboure Health Care Center, and St. Francis of Williamsville. Reports Filed With States Part VI, Line 7 NY 1 X X X X X X 0 1 0 0 0 1 1 0 0 Joseph McDonald 0 583131 0 208063 0 280060 0 26855 0 15042 0 1113151 0 0 Mark Sullivan 0 373986 0 92715 0 32958 0 17728 0 14595 0 531982 0 0 Charles Urlaub 324839 0 72463 0 38707 0 18124 0 14704 0 468837 0 0 0 David Macholz 0 171337 0 23651 0 25227 0 13750 0 18132 0 252097 0 0 Peter Bergmann 0 346695 0 167259 0 44803 0 13217 0 18467 0 590441 0 0 Christine Kluckhohn 0 186796 0 55065 0 55207 0 97902 0 18716 0 413686 0 0 James Millard 0 214698 0 43291 0 38703 0 156544 0 1275 0 454511 0 0 Dr Michael Edbauer 0 96362 0 59284 0 41846 0 16807 0 26786 0 241085 0 0 James A Dunlop Jr 0 327293 0 82819 0 32973 0 94418 0 17685 0 555188 0 0 Dr Brian D'Arcy 0 253307 0 60760 0 288076 0 30581 0 18105 0 650829 0 0 John Herman 176307 0 24116 0 8721 0 41777 0 15138 0 266059 0 0 0 Michael Moley 0 259903 0 58553 0 75762 0 25222 0 14473 0 433913 0 0 John Stavros 0 169269 0 39644 0 39410 0 21022 0 17990 0 287335 0 0 Maria Foti 0 161084 0 36606 0 33020 0 23570 0 6824 0 261104 0 0 Bartholomew Rodrigues 0 145256 0 34317 0 38611 0 15377 0 17718 0 251279 0 0 Dr Michael Galang 0 265381 0 35389 0 30990 0 20485 0 5201 0 357446 0 0 Dr Thomas Raab 415260 0 5850 0 22774 0 137673 0 20370 0 601927 0 0 0 Dr Timothy Gabryel 308807 0 45727 0 16374 0 24161 0 6302 0 401371 0 0 0 Nancy Sheehan 0 187958 0 43103 0 38707 0 21899 0 5211 0 296878 0 0 Dr Donald Schmidt 272215 0 0 0 23184 0 109558 0 19190 0 424147 0 0 0 Nils Gunnerson 219357 0 42744 0 38707 0 72681 0 258 0 373747 0 0 0 Dr Thomas Dilamarter Jr 213334 0 14235 0 33246 0 23684 0 6429 0 290928 0 0 0 Dr Kevin Shiley 145779 0 96542 0 15715 0 2044 0 18772 0 278852 0 0 0 Dr Diana Pomakova 163248 0 52966 0 16644 0 8551 0 16832 0 258241 0 0 0 Part I, Line 4b Certain Officers and Key employees participated in a supplemental nonqualified retirement plan per the terms and conditions of their employment arrangement. MERCY Pension Gap CHE SERP Joseph McDonald 26,000 106,775 Dr. Brian D'Arcy 9,800 142,750 Michael Moley 20,697 Peter Bergmann 7,334 Part I, Line 6 The 2011 Incentive payments were dependent upon achieving the Catholic Health System Operating Income target for Catholic Health System participants or the Ministry Operating Income target for Ministry participants. MERCY Joseph McDonald $208,062.86 Mark Sullivan $92,715.35 James A. Dunlop, Jr. $82,818.71 Dr. Brian D'Arcy $60,760.29 Nancy Sheehan $43,103.46 Michael Moley $58,552.77 John Stavros $39,644.17 Christine Kluckhohn $55,064.95 Maria Foti $36,606.16 Bartholomew Rodrigues $34,317.41 Dr. Michael Galang $35,389.29 Dr. Michael Edbauer $59,283.90 David Macholz $23,650.40 Peter Bergmann $76,257.65 James Millard $43,290.64 Charles Urlaub $72,462.94 John Herman $24,116.17 Nils Gunnerson $42,743.61 Dr. Kevin Shiley $84,048.50 Dr. Diana Pomakova $52,965.50 Dr. Thomas Raab $5,850.00 Dr. Timothy Gabryel $45,726.53 Dormitory Authority of the State of NY 146000293 64983Q5R6 2006-11-29 13360000 0 0 0 Dormitory Authority of the State of NY 146000293 64983Q5D9 2008-11-26 24700000 0 0 0 13360000 537015 79065 12743920 2006 1 0 1 1 24700000 111729 2642689 1150457 220774 58556 20515795 2010 0 0 1 1 0 0 0 0 1 0 0 0 0 1 0 1 1 HSBC Bank NA 18.500000000000 1 0 0 0 0 0 1 1 HSBC Bank NA 25.600000000000 1 0 0 0 0 Part I A (f) Description of Purpose: To refinance outstanding commercial indebtedness, the proceeds of which were applied to finance the cost of Mercy's operating room expansion, other expansions/improvements at the facility. Part I B (f) Description of Purpose: To finance the cost of an approximately 48,300 square foot addition for a new emergency department, new CT/Radiology facilities, construction of a new main entrance and lobby area, a new ambulance entrance, construction of a rooftop helipad, renovation of library space into conference rooms, other mechanical and electrical improvements and associated demolition and equipping costs. Susan Urlaub Wife of Mercy CEO, C.J. Urlaub 76045 Corporate Nurse Educator 0 James Manzella Acute Care Board Member 326330 Key Employee of Manzella Marketing 0 David Zapfel Brother of BOD, Msgr. Robert Zapfel 62906 HR Employee of CHS 0 Kathleen Zapfel Sister-in-law of BOD, Msgr. Robert Zapfel 58749 HR Employee of CHS 0 Susan Gallagher-Stavros Wife of Key Employee, John Stavros 30035 Nurse, McAuley Seton Home Care 0 Marie Packard Daughter of BOD, Dennis Dombek 46301 Mercy Physical Therapist 0 Form 990, Part VI, Section A, line 6 CHS has three members: Ascension Health, Catholic Health East, and the Diocese of Buffalo, NY. Each member is able to participate equally in electing the governing body, approving significant decisions of the governing body, and in receiving a share of net assets upon dissolution, according to the CHS Bylaws. Form 990, Part VI, Section A, line 7a According to the CHS Bylaws,each member is equally allowed to appoint up to three individuals to act as its representatives on the Corporate Member Board, and in undertaking any action in its capacity as a Member. Form 990, Part VI, Section A, line 7b Each member is entitled to one vote on each matter properly submitted at any membership meeting, and the members also have reserve powers which allow approval for certain business events and ratification of certain business transactions. Form 990, Part VI, Section B, line 11 Yes, an electronic copy of the Form 990 was provided to the CHS Boards of Directors before it was filed. The CHS Board of Directors has delegated the responsibility to review the 990 to the Audit Committee. The CHS Audit Committee reviewed in detail selected information for all CHS entities. Reviewed with the Audit Committee: 1. Core Form Part IV: Checklist of required schedules 2. Core Form Part VI: Governance, Management and Disclosure 3. Core Form Part VII: Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees and Independent Contractors 4. Schedule H: Hospitals 5. Schedule K: Supplemental information on Tax Exempt Bonds 6. Schedule J: Compensation Information 7. Schedule L: Transactions with Interested Persons 8. Schedule R: Related Organizations and Unrelated Partnerships 9. Process for which remaining Core Form was completed, utilizing audited financial information Form 990, Part VI, Section B, line 12c All associates on the Merit program; all Physicians and Non Physician Practitioners as well as Physician groups who are independent contractors or employees of CHS; and all board members must complete a Conflict of Interest Disclosure Statement (COIDS) in order to fulfill the annual requirements. COIDS are distributed to all parties, as per applicable policy, and once complete are followed up with as follows: 1. Associate and Physician completed COIDS are reviewed and signed off by the manager. If a disclosure is noted, it is discussed with the manager, and the document is forwarded to the Compliance officer who reviews and follows up as appropriate. Once review/follow up is completed the Compliance Officer will sign the COIDS, maintain a copy in the compliance office and return the original to HR for filing in the Personnel file. 2. All board member COIDS are returned to Compliance Officer for review and follow up as warranted. The compliance officer will sign each COIDS and retain on file in the compliance office in a confidential manner. Form 990, Part VI, Section B, line 15 In 2011, the Catholic Health System utilized a Compensation Committee of the Board of Directors to monitor the Executive Compensation as per the Executive Compensation Philosophy and Strategy for the CHS CEO; COO; CFO; CEO's for each Ministry; and all Senior Vice Presidents. The Compensation Committee provides oversight to management decisions which are based on outlines approved by the committee, and performs a review of data. The outcome of these meetings is documented. Form 990, Part VI B, Line 16: The Catholic Health System has a process to evaluate its participation in joint venture arrangements under applicable federal tax law, and has taken steps to safeguard the organization's exempt status with respect to such arrangements,and has developed a formal policy to formalize the process. Form 990, Part VI, Section C, line 19 We make our form 990 open for public inspection upon request. Our website includes an annual report which includes selected financial information. Our financial statements, governing documents and conflict of interest policy are provided upon request according to applicable federal and state laws. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Mimimum Pension Liability Adjustment (25,770,244) -25,770,244. Equity Transfer to Affiliates (12,410,626) -12,410,626. Change in Interest in Foundation (212,598) -212,598. Interest Rate Swap Adjustment (3,592,288) -3,592,288. Total to Form 990, Part XI, Line 5: -41,985,756. Catholic Health System Inc 515 Abbott Road Buffalo NY 14220 222565278 Health Care Delivery System NY 501 c 3 Schedule A line 9 N/A 0 Sisters of Charity Hospital 2157 Main Street Buffalo NY 14214 160743187 Acute Care Hospital NY 501 c 3 Schedule A line 3 Catholic Health System Inc 0 Kenmore Mercy Hospital 2950 Elmwood Avenue Kenmore NY 14217 160762843 Acute Care Hospital NY 501 c 3 Schedule A line 3 Catholic Health System Inc 0 Nazareth Home of the Franciscan Sisters 291 North Street Buffalo NY 14201 160813142 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Clare Manor 543 Locust Street Lockport NY 14094 160782647 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Elizabeth Home for the Aged 5539 Broadway Lancaster NY 14086 160743154 Adult Home NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Francis Home of Williamsville 147 Reist St Williamsville NY 14221 160743153 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Francis of Buffalo Inc 34 Benwood Ave Buffalo NY 14214 161523535 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Joseph Manor 2211 West State Street Olean NY 14760 160796400 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Luke Manor for the Chronically Ill 17 Wiard St Batavia NY 14020 160794811 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Mary's Manor 515 6th Street Niagara Falls NY 14301 160924139 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 St Vincent Manor 319 Washington Avenue Dunkirk NY 14048 160743167 Adult Home NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 WNY Catholic Long Term Care Inc 6400 Powers Rd Orchard Park NY 14127 161434368 Skilled Nursing Facility NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 Niagara Homemaker Services (Mercy Home Care) Apple Tree Business Park 2875 Union Cheektowaga NY 14227 161317960 Home Care Provider NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 McAuley Seton Home Care Apple Tree Business Park 2875 Union Cheektowaga NY 14227 161310062 Home Care Provider NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 Catholic Health System Infusion Pharmacy Inc 2875 Union Road Suite 14 Cheektowaga NY 142271461 200198518 Home Care Infusion Services NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 OLV Renaissance Corporation 291 North Street Buffalo NY 14201 200167745 Real Estate Holding Company NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 CHS Program of All-Inclusive Care for the Elderly Inc 55 Melroy Avenue Lackawana NY 14218 261252884 All-inclusive Care for the Elderly NY 501 c 3 Schedule A line 3 Catholic Health System Inc 0 Mercy Hospital Foundation 515 Abbott Road Buffalo NY 14220 222209721 Foundation NY 501 c 3 Schedule A line 7 Mercy Hospital 0 Southtowns Catholic MRI Inc 200 International Drive Buffalo NY 14221 161554081 Imaging NY 501 c 3 Schedule A line 9 Catholic Health System Inc 0 Marian Professional Center Associates LP 350 Essjay Road Suite 101 Williamsville NY 14221 161360469 Rental Real Estate NY N/A Related 98858 0 0 OLV-Brierwood Helathcare Co LLC 6455 Lake Avenue Orchard Park NY 14127 161487207 Rental Real Estate NY N/A Related 24901 152637 0 0 Orchard Park Mercy Corporation Marian Professional Bldg Ste 500 51 Buffalo NY 14220 161470350 Real Estate Holding Company NY Mercy Hospital C 168834 1.00000 Aurora Mercy Corporation 565 Abbott Road Buffalo NY 14220 161354302 Real Estate Development NY Mercy Hospital C 47587 1.00000 Alsace Abbott Corporation 515 Abbott Road Suite 408 Buffalo NY 14220 161355092 Partnership Holding Corporation NY Mercy Hospital C 337299 1.00000 0 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 Orchard Park Mercy Corporation Q 130635