2015-05-15T10:37:27-05:00 2014-06-30 PRICEWATERHOUSECOOPERS LLP 125 HIGH STREET BOSTON MA 02110 990 2013-07-01 020222140 Mary Hitchcock Memorial Hospital % ROBIN KILFEATHER-MACKEY MARY 6036505000 One Medical Center Drive Suite Lebanon NH 03756 Robin Kilfeather-Mackey CFO 2015-05-12 Gwen Spencer P00641463 2013 2016-04-25 22:37:26Z James Weinstein DO MS One Medical Center Drive Lebanon NH 03756 1061670869 false X www.dartmouth-hitchcock.org X 1889 NH Advancing Health Through Research, Education, Clinical Practice, Community Partnerships, providing each person the best care in the right place, at the right time, every time 17 16 5574 525 3720556 434773 10592896 20984972 866375747 892093711 29410853 17100684 47037304 57253892 953416800 987433259 6002824 5272967 0 0 565819711 576706269 0 0 1922209 344911925 354233094 916734460 936212330 36682340 51220929 1236397775 1331158473 697527563 689440250 538870212 641718223 X We advance health through research, education, clinical practice, and community partnerships, providing each person the best care, in the right place, at the right time, every time. false false 756082577 5362465 921459742 Mary Hitchcock Memorial Hospital (the Hospital), is an acute and tertiary care teaching hospital located in Lebanon, New Hampshire. The Hospital is a not-for-profit organization, as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from Federal income taxes on related income pursuant to Section 501(a) of the Code. The Hospital provides a broad range of patient services and health related community services, consistent with its role as a community hospital, a major teaching hospital and a tertiary care referral hospital. These include a full range of services in both acute and critical medicine, surgery, psychiatry and rehabilitation for infants, children and adults. During FY 2014 the Hospital provided 121,743 acute patient days of inpatient service and had 25,737 total acute care discharges, while the Hospital's emergency room was open to the public 24 hours per day, 7 days per week and had 31,268 discharges. The Hospital operates as an integral component of Dartmouth-Hitchcock Medical Center (DHMC), a New Hampshire nonprofit corporation organized for the exploration and coordination of matters of mutual interest among its members: the Hospital, Dartmouth-Hitchcock Clinic (the Clinic), Geisel School of Medicine (GSM), a component of Dartmouth College, and the Veterans Affairs Medical Center in White River Junction, Vermont. The Clinic provides the physician staff to the Hospital and the sophistication essential for the development of the Hospital as the largest and only teaching hospital in New Hampshire and the designation by the federal government as a Rural Referral Center for northern New England. The shared mission of the Hospital and Clinic is to advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time. Its strategic operating plan lays out a path to creating a "sustainable health system to improve the lives of the people and communities we serve, for generations to come." The focus of this work, across the Dartmouth-Hitchcock organization, i.e. all Hospital and Clinic sites, is in three main areas: Improving Population Health; Delivering Value Based Care; and Developing and Implementing New Payment Models. Consistent with this mission and in partnership with the Clinic, the Hospital provides high quality, cost effective, comprehensive, and integrated health care to individuals, families, and the communities it serves regardless of a patient's ability to pay. The Hospital actively supports community-based health care and promotes the coordination of services among health care providers and social services organizations. The Hospital also seeks to work collaboratively with other area health care providers to improve the health status of the region. As a key element in its work to improve population health and move to new payment models, Dartmouth-Hitchcock (D-H) is participating in a number of shared risk/shared savings programs, including the Pioneer ACO program initiated by the Centers for Medicare and Medicaid (CMS). Unlike the traditional fee for service structure, shared risk/savings programs tie rewards to the achievement of quality and cost goals. In 2014, the D-H Pioneer ACO (now called allwell) added three health systems as participants, bringing the number of covered Medicare patients to 47,000. At the end its first year, allwell was one of only 13 participating ACOs to meet all quality and safety metrics and show significant cost reductions, while providing coordinated, patient-centered care to the assigned Medicare population. Participation also continues to expand for OneCare Vermont, an ACO established by D-HH with Fletcher Allen Health Care, Vermont's academic medical center, that includes all 14 of the state's hospitals, hundreds of primary care physicians and specialists, two federally qualified health centers, and several rural health clinics, to coordinate the health care of approximately 42,000 of Vermont's 118,000 Medicare beneficiaries (40 percent of the Hospital and Clinic patients are from Vermont). D-HH continues to be a member of the Mayo Clinic Care Network, a non-ownership affiliation. This arrangement allows D-H physicians to partner with colleagues from Mayo for second opinions and consultations, thus bringing the expertise of both organizations to individual patient care. Much of the consultation is done via telemedicine, another expanding initiative of D-H. The program is intended to strengthen our ability to serve patients in our region with the highest-quality care, close to home. It also allows the Hospital and Clinic to get care to patients in emergency situations quickly and to partner with local health organizations in the delivery of care, something that is particularly important in our rural area. Regionally, as part of its work to create a sustainable health system, D-HH continues to build collaborations with other providers and to look for ways to make care more affordable and convenient for patients and families, while ensuring highest quality. New London Hospital in New Hampshire and Mt Ascutney Hospital and Health System in Vermont became formally affiliated with D-HH in 2014, and discussions are ongoing with other health systems in the two states. In keeping with its sustainable health strategy and mission to provide "the best care, in the right place, at the right time, every time", D-HH entered into an arrangement with CVS MinuteClinic to provide 24/7 urgent care at sites around New Hampshire. This new, lower cost option will allow individuals and families to easily access tests and treatments for illnesses and injuries that do not require the care of an academic medical center or that occur outside normal business hours. Nationally, Dartmouth-Hitchcock is a founding member, with Mayo Clinic, Intermountain Health Care, Denver Health, and The Dartmouth Institute for Health Policy and Clinical Practice, of the High Value Healthcare Collaborative (HVHC). The Collaborative currently comprises 18 health systems. Together, they have a patient base of more than 70 million. The goal of the Collaborative is to improve the quality of health care while lowering costs. Through data sharing and defining of best practices for 8 high-cost, high-variation conditions, the members are improving outcomes and already seeing cost savings. A $26 million grant from CMS is making it possible to integrate shared decision making - the Hospital was the first in the nation to create a Center for Shared Decision Making and integrate tools into clinical care - into the work of the Collaborative. Beyond that grant, however, the HVHC is self-funded by the member health systems. Effective with fiscal year 2000, the Hospital and the Clinic began filing an annual Community Benefit Report with the State of New Hampshire which outlines the community and charitable benefits they provide. The most recent Community Benefit Reports are available upon request or can be found on Dartmouth-Hitchcock's web site (www.dartmouth-hitchcock.org). Financial assistance, formerly called charity care, represents services provided to patients who cannot afford health care services due to inadequate financial resources which result from being uninsured or underinsured. For the year ended June 30, 2014 the Hospital provided financial assistance to 9,885 patients in the amount of $33,291,163, as measured by gross charges. The estimated cost of providing this care for the year ended June 30, 2014 was $12,979,234. The Hospital also routinely provides services to Medicaid patients at reimbursement levels that are below the cost of the care provided. The Community health activities includes the cost or value of several different types of programs including the cost of community based education, health fairs, health screenings, support groups, and programs and materials that promote wellness and prevent illness. Examples of these types of efforts include partnering with the Healthy Eating Active Living NH initiative, the Women's Health Resource Center, and smoking prevention and cessation. This category also includes financial contributions and the contribution of time and services to community programs, hospitals and agencies. The Hospital also provides a significant amount of uncompensated care to its patients reported as provision for bad debts, which is not included in the amounts reported above. During the years ended June 30, 2014, the Hospital reported a provision for bad debts of approximately $25,157,246. 44135769 21645593 As a component of an integrated academic medical center, the Hospital provides significant support for academic and research programs through its support of The Geisel School of Medicine at Dartmouth (GSM), the Hospital provides support for Physicians' unpaid teaching time as part of its Community Benefit Initiatives, consisting of the time physicians spend providing clinical supervision and education for residents and medical students. In addition, the Hospital provides in-kind support for research and other grants representing costs in excess of awards for numerous grant-funded health research and service initiatives awarded to the Clinic and GSM. Other community benefit initiatives include subsidizing the costs of providing medical and clinical education to professionals across New Hampshire, Vermont and beyond as well as uncompensated costs of academic and medical research activities. 800218346 true true false true false false false false false true true true false true true false false true false true true false false false true false true true true true true true false false false false false true true true true true true false false false true true true true false false true 989 0 true 5574 true true true true BD false false false true true false false false false X 17 16 false false false false true true true true true false false true true true true true true false true true true NH X ROBIN KILFEATHER-MACKEY 6036505634 ONE MEDICAL CENTER DRIVE Lebanon NH 03756 X Jennie L Norman Trustee/Board Secretary 1.5 2.5 X X 0 0 0 Hugh C Smith MD Trustee 0.75 1.25 X 0 0 0 Vincent S Conti Trustee 0.75 1.25 X 0 0 0 Anne-Lee Verville Trustee/BD Treas 1/1-2/5/14 0.75 1.25 X X 0 0 0 Barbara Couch Trustee 0.75 1.25 X 0 0 0 Wiley Souba MD ScD Trustee/Ex-Officio, Dean DMS 0.75 1.26 X 0 0 0 William J Conaty Trustee 0.75 1.25 X 0 0 0 William W Helman IV Trustee 0.75 1.26 X 0 0 0 Robert A Oden Jr PhD Trustee/Board Chair 1.5 2.5 X X 0 0 0 James N Weinstein DO MS Trustee Ex-Officio/CEO 38.0 23.01 X X 0 1010719 23574 Alan C Keiller Trustee/BD Treas End12/31/2013 0.75 1.26 X X 0 0 0 Michael J Goran MD Trustee 0.75 1.25 X 0 0 0 Richard S Shreve Trustee End 12/31/2013 0.75 1.25 X 0 0 0 Denis A Cortese MD Trustee 0.75 1.25 X 0 0 0 Matthew B Dunne Trustee 0.75 1.25 X 0 0 0 Senator Judd A Gregg Trustee 0.75 0.75 X 0 0 0 Laura K Landy Trustee 0.75 1.25 X 0 0 0 Paul P Danos Trustee/Brd Treas Eff 2/5/2014 1.5 2.5 X X 0 0 0 Barbara C Jobst MD Trustee Eff 1/1/2014 0.75 0.75 X 0 0 0 Wayne G Granquist Trustee End 12/31/2013 0.75 1.26 X Robin Kilfeather-Mackey CPA Chief Financial Officer 37.0 24.01 X 0 508546 22575 Linda Von Reyn Chf Nursng Officer End 3/22/14 41.0 19.0 X 437094 0 23460 Daniel Jantzen CPA Chief Operating Officer 41.0 20.0 X 619596 0 23450 Stephen Leblanc Exec VP Strtgy & Ntwrk Rltns 15.0 45.0 X 0 626223 22575 Alan Weston Chief HR Officer End 9/2/2013 41.0 19.0 X 375545 0 42511 Neil Castaldo Sr Advisor to CEO End 7/06/13 41.0 19.0 X 1003334 0 37270 Gregg Meyer MD CCO/EVP Pop Hlth End 1/02/14 41.0 19.0 X 0 896398 42589 Jeanine Arden-Ornt General Counsel End 6/30/2014 37.0 24.0 X 448897 0 33700 Vincent Fusca III Chf Stff/Intrm CHRO 9/3-2/3/14 28.0 12.0 X 253782 0 21785 Edward Merrens MD Chief Medical Officer 28.0 12.0 X 0 386361 38160 George Blike MD Chief Quality & Value Officer 28.0 12.0 X 0 441603 23159 Darlene A Saler Actg Chf Nrsng Ofr Eff 3/23/14 41.0 19.0 X 0 0 0 John S Malanowski Chief HR Officer Eff 2/3/2014 41.0 19.0 X 0 0 0 Clifford J Belden MD Actg Chf Clcl Ofr Ef 2/18/2014 28.0 12.0 X 0 648751 38476 Terrence P Carroll PHD Chf Innvtion Offcr Eff 8/19/13 28.0 12.0 X 185713 0 18644 Christine Schon V.P Comm. Grp. Pract. Ops 28.0 12.01 X 0 226056 39401 William Mroz V.P. Op/Clncl Svcs End 7/27/13 41.0 19.0 X 191835 0 22336 Gail Dahlstrom V.P. Facilities Mgmt 41.0 19.0 X 230444 0 18533 Tina Naimie CPA VP Corporate Finance 28.0 13.5 X 217915 0 20157 Wendy Fielding VP Financial Planning 28.0 12.0 X 217934 0 38511 Thomas Dodds MD Dept. Chair Anesthesiology 28.0 12.0 X 0 544134 48760 Richard Rothstein Dept. Chair Medicine, Dean CME 28.0 12.0 X 0 598160 19452 Wendy Wells MD Dept. Chair Pathology 28.0 12.0 X 0 434575 54446 Jocelyn Chertoff MD MS Dept Chair Diagnost Radiology 28.0 12.5 X 0 504492 55731 Edward Catherwood MD MS Center Direct Heart & Vascular 28.0 12.0 X 0 482747 18814 Douglas Merrill Center Director Periop Svs 28.0 12.0 X 0 546540 46451 Stephen Boyce VP Ambulatory Care 28.0 12.0 X 0 178649 29414 Jeffrey OBrien VP Oncology Services 28.0 12.0 X 278646 0 40192 David Gladstone MD Chief Clinical Phys Rad/Onc 28.0 12.0 X 280516 0 48802 Bruce King Pres & CEO New London Hosp 50.0 X 373960 0 23551 Roderic Young VP Communications & Marketing 28.0 12.0 X 296191 0 41653 Martin Purcell VP IS Operations 28.0 12.0 X 291046 0 24839 Susan Reeves VP Colby Sawyer Nursing 28.0 20.0 X 274274 0 46640 Carl Dematteo MD Fmr Chf Ql Compl Ofr/Physician 28.0 12.0 X 0 100582 1792 John Butterly MD Fmr Offr/Exec VP Med Affairs 10.0 32.0 X 0 556033 56784 Lawrence Dacey MD Former CMO/ Phys 28.0 13.3 X 0 499139 15534 Thomas Colacchio MD Former Officer/Phys 28.0 13.0 X 0 1084720 43691 Mary Oseid Fmr Key Emp/VP Enterprise Svcs 28.0 12.0 X 0 282407 14338 Barbara Walters DO MBA Fmr Key Emp/Med Dir Acct Care 22.0 18.0 X 0 359144 19544 Mary Kay Boudewyns Fmr Key Emp/Adm Dir Rev Mgmt 28.0 12.0 X 217526 0 8199 6194248 10915979 1209493 310 true true false TRUSTEES OF DARTMOUTH COLLEGE 37 DEWEY FIELD HANOVER NH 03755 ADMIN & DIR SUPPORT 24055889 Cross Country Staffing PO Box 404674 ATLANTA GA 303844674 Staffing Services 9829131 Turner Contruction Two Seaport Lane BOSTON MA 02210 Construction SVCS 10838042 PC Construction 193 Tilley Drive SOUTH BURLINGTON VT 05403 Construction SVCS 7591767 Towers Watson Delaware Inc 800 Boylston St BOSTON MA 02199 Employee Benefits 6123111 495 4919584 1836451 14228937 1150545 20984972 NET PATIENT SERVICE REVENUE 621110 883716727 883342813 373914 RESEARCH RELATED ACTIVITIES 621110 8376984 8376984 892093711 3457992 29563 3428429 0 0 1441247 657723 783524 0 783524 783524 85893931 135603 71044538 1342304 14849393 -1206701 13642692 13642692 487468 4919584 1193045 -705577 -705577 0 0 PHARMACY INCOME 621110 34562653 34424880 137773 MEANINGFUL USE 621110 5668760 5668760 ALLOCATED REVENUE 621110 5624080 5624080 11320452 5293904 3179306 2847242 57175945 987433259 942731421 3720556 19996310 X 4082157 4082157 1190810 1190810 0 0 12394350 4440744 7763213 190393 542713 542713 425765440 352264507 73500819 114 47596257 39624091 7972154 12 60919906 50716086 10203804 16 29487603 24548557 4939038 8 0 2189657 93941 2095716 611707 611707 37260 37260 0 0 54640381 45167107 9473274 2445434 27161 2418273 16527969 15010914 1517032 23 7789165 6932357 856808 0 13810323 12241266 1569057 2384531 1406619 977912 0 121377 117475 3902 15043910 13389080 1654830 0 38798310 34526469 4271841 3608735 3608735 MEDICAL SUPPLIES 130344547 130222720 121827 MEDICAID ENHANCEMENT TAX 32636371 32636371 EQUIPMENT RENTAL & MAINT 11462920 10201999 1260921 ACDM, GME, TEACHING,& MISC SUP 3674782 3674782 18105715 13514425 2859647 1731643 936212330 800218346 134071775 1922209 465422 193761 44311533 44744859 0 5000000 139143022 145452357 416185 438160 0 0 1304221 1092351 15029475 14174352 23786320 8055419 891872121 484805496 413522455 407066625 199883362 280390609 343778631 331518264 2884068 4385931 0 0 51873081 88645785 1236397775 1331158473 108309292 123803858 0 0 340309 412543 350027555 343068534 0 0 0 0 150382530 148038569 0 0 88467877 74116746 697527563 689440250 X 464266717 555516650 46465618 57291018 28137877 28910555 538870212 641718223 1236397775 1331158473 X 51220929 47127542 4499540 X X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 115920 false true 71820 187740 false LOBBYING ACTIVITY EXPLANATION FORM 990, SCHEDULE C, PART II B, LINES 1B & 1G MARY HITCHCOCK MEMORIAL HOSPITAL EMPLOYS TWO FULL TIME STAFF WHOSE DUTIES INCLUDE LOBBYING. TYPICAL EXPENSES ASSOCIATED WITH THE LOBBYING ACTIVITIES INCLUDE STAFF SALARY, TRAVEL, MEMBERSHIP FEES AND DUES. FROM TIME TO TIME, MARY HITCHCOCK MEMORIAL HOSPITAL, THROUGH ITS EMPLOYEES AND THE USE OF CONSULTANTS, CONTACTS GOVERNMENT OFFICIALS AND LEGISLATORS. THIS CONTACT IS FOR THE PURPOSE OF PROPOSING LEGISLATION OR EXPRESSING AN OPINION ON CHANGES IN LEGISLATION THAT AFFECT THE HOSPITAL AND ITS ABILITY TO CARRY OUT ITS MISSION. TYPICAL ACTIVITIES INCLUDE EMAILING, CALLING, AND MEETING WITH GOVERNMENT OFFICIALS AND LEGISLATORS. FOR THE FISCAL YEAR ENDED JUNE 30, 2014, MARY HITCHCOCK MEMORIAL HOSPITAL INCURRED $115,920 IN CONJUCTION WITH THESE ACTIVITIES. Form 990 Schedule C, Part II B, Line 1I MHMH pays dues to various organizations related to its exempt mission. The amount reported under other activities on line 1I refers to the amount of lobbying activities identified in dues payments to outside organizations. 54935134 17029356 3029123 16800 1648675 73328138 57050185 188155 -357053 5322 1940831 54935134 54023225 30717 3834255 15000 823012 57050185 54110647 398541 842732 1328695 54023225 49493627 3040219 2769857 1193056 54110647 0.45590 0.38750 0.15660 false false 968811 39723823 40692634 472177707 250567478 221610229 4132183 3536282 595901 348387986 230701736 117686250 26481611 26481611 407066625 FIXED INCOME 112413438 F PUBLIC EQUITIES 118392759 F PRIVATE EQUITIES 28246785 F HEDGE FUNDS 56581763 F OTHER INVESTMENTS 15883519 F 331518264 INVESTMENT IN CAPTIVE 2878669 DUE FROM AFFILIATES 40561639 BOND ISSUANCE COSTS 3480726 OTHER MISC ASSETS 25278567 CAPITAL LEASE RECEIVABLE 16446184 88645785 0 THIRD PARTY SETTLEMENTS 25124465 ACCRUED POST RETMNT PENS & MED 40715737 INTEREST RATE SWAP 8276544 74116746 Intended use of Endowment Funds Form 990 Schedule D Part V Line 4 The intended use of the endowment funds is to promote and advance the following mission-related programs: healthcare services, research, charity care, and health education. ASC 740 (Fin 48) Footnote Form 990 Schedule D Part X No ASC 740 (Fin 48) footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption. East Asia and the Pacific Program Services Educational Travel Exp 8280 Europe (Including Iceland and Greenland) Program Services Collection Services 11281 Europe (Including Iceland and Greenland) Program Services Dues 624 Europe (Including Iceland and Greenland) Program Services Honorarium Payments 432 Europe (Including Iceland and Greenland) Program Services Insurance 246616 Europe (Including Iceland and Greenland) Program Services Publications 3450 North America Program Services Honorarium Payments 3179 North America Program Services License 31174 North America Program Services Marketing Services 26496 North America Program Services Moving and Supplies 17395 North America Program Services Professional Services 3450 North America Program Services Publications 711 North America Program Services Software 17973 North America Program Services Educational Travel Exp 86715 North America Program Services Waste 179 Sub-Saharan Africa 3 Program Services Medical Svcs in Rwanda 93273 3 3 551228 551228 true false true true true false Prouty Wlk/Bike 3347989 3232901 115088 13519 17245 948831 CHAD Hlf Mthn 916172 863048 53124 31252 22 51790 8 1142891 823635 319256 20320 7841 2441 3250 96534 5407052 4919584 487468 65091 7841 19708 3250 1097155 1193045 -705577 true true true X 225. true X true true false true true 12979234 12979234 0.01390 134038504 55854222 78184282 0.08370 147017738 55854222 91163516 0.09760 3452763 1264344 2188419 0.00230 39587243 11392875 28194368 0.03020 2465443 2465443 0.00260 3787499 3740785 0.00400 4927940 3062 4924878 0.00530 54220888 12660281 41513893 0.04440 201238626 68514503 132677409 0.14200 34500 34500 629350 273189 356161 88417 88417 12321 12321 764588 273189 491399 false 25157246 257586897 253656138 3930759 X true true 1 1 Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 www.dartmouth-hitchcock.org 01799 X X X X X X Psych Unit and Transplant Unit Cancer Center Mary Hitchcock Memorial Hospital 1 true X X X X X X X X 12 true true true X Please see Part VI X X X X X X X X X X X false false true true 225. true 300. true X X X X X X X X true true X X X X X true false true X false true Form 990, Schedule H, Part V, Section B Line 1 CHNA Report Descriptions Although the final community needs health assessment did not specifically describe the hospital service area, it is described in the annual community benefits report filed with the state of NH. Form 990, Schedule H, Part V, Section B Line 3 Input From Representatives of Community Served by the Hospital Facility D-H is actively engaged in the development of an active Upper Valley Regional Public Health Advisory Council (35+ community representatives) and broader ReThink Health Initiatives (100+ community representatives). Members of these two community health advisory groups have had the opportunity to review and comment on drafts of Dartmouth-Hitchock's Community Health Improvement Plan. The plan document has also been circulated to public health officials in Vermont for their comment. In addition, Dartmouth-Hitchcock representatives serve on numerous boards, task forces, municipal health leadership and planning teams, and other community health leadership entities in order to ensure that we both participate in and better understand the needs of our community. Form 990, Schedule H, Part V, Section B Line 4 CHNA Conducted With One Or More Other Hospital Facilities During 2012, MHMH partnered with Alice Peck Day Memorial Hospital and Mount Ascutney Hospital and Health Care Form 990, Schedule H, Part V, Section B Line 5a Community Health Needs Assessment The Community Health Needs Assessment can be found online at http://patients.dartmouth-hitchcock.org/community_health/community_benefit s_program.html. Form 990, Schedule H, Part V, Section B Line 5c & 5d Community Health Needs Assessment The Needs Assessment was distributed to non-profit organizations throughout the region including the United Way. It is also available from the Organization upon request. Form 990, Schedule H Part V, Section B Line 6i Community Benefits Report Based upon the most recent community benefits report, MHMH is increasing community benefits spending to address identified community needs, particularly, oral health, needs of older adults, substance misuse prevention, and obesity/nutrition/physical activity. Form 990, Schedule H Part V, Section B Line 7 Community Health Needs Identified In FY2014, Mary Hitchcock Memorial Hospital's (MHMH) Community Health Improvement strategies were consistent with the intentions identified in our Community Health Improvement Plan to address identified community health needs by: a) increase investment; b) maintain similar levels of investments for services and initiatives already provided by MHMH; or c) limit investment in areas where other community organizations already provide leadership and services to address the need, or where the identified need is significantly outside the mission/services/scope of MHMH. Mary Hitchcock Memorial Hospital's Community Health Improvement Plan is a 3-year document identifying anticipated investments and activities that it will take to address needs identified in the most recent Upper Valley Community Health Needs Assessment (CHNA). In four cases, items idendtified in the CHNA were not adddressed by MHMH: 1) the need for more affordable housing; 2) the need for more livable wage jobs; 3) the need to reduce rural isolation; and 4) the need for improved quality of education. These needs are outside the traditional mission/services/scope of the hospital; the region looks to other entities, such as Granite United Way, Twin Pines Housing Trust, Lebanon Housing Authority; Vital Communities; and others, for leadership to address these needs. In these cases, MHMH's response may include: a) minimal investment of time, leadership, and expertise, such as serving on community committees; b) making cash investments in the lead organization or addressing smaller aspects of the identified need as part of a collaboration with community organizations, such as cash support for the Upper Valley Housing Coalition and investing in an on-site employment training program for young adults with developmental disabilities; or c) investing in the issue, but in a way that may not meet criteria for inclusion as a Community Benefit, such as investing significantly in regional jobs training activities that help individuals move to higher paying, stable jobs at Dartmouth-Hitchcock or developing pediatric clinic-community approaches to improving care for children with asthma. While these efforts address an identified community need, the cost of these efforts cannot be separated from MHMH's business model or standard of clinical care, thus do not qualify as Community Benefits. Additionally, leadership to address two community needs: cancer prevention; and prevention of unintentional injuries, is lead primarily by teams who are employed by the Geisel School of Medicine at Dartmouth College. In many cases, while leadership for these efforts are provided by staff who have dual appointments to both the Geisel School of Medicine and MHMH, the cost accounting for these efforts occurs through the Geisel School, so MHMH does not claim leadership in these areas of community health improvement. In both cases, however, MHMH does provide cash support to the Geisel School of Medicine teams who do this work in our Hospital Service Area and throughout New Hampshire and Vermont. Form 990, Schedule H Part V, Section B Line 12i Uninsured Discount Policy D-H has a separate Uninsured Discount Policy that outlines how the discount is calculated annually and that it is applied prior to billing any uninsured patient. This assures a patient is not billed at an amount greater than the amount generally billed to patients with insurance. This is referenced as a link in the Financial Assistance Policy. Form 990, Schedule H Part V, Section B Line 14 Financial Assistance Policy availability within the Community MHMH financial assistance policy is posted on MHMH's website, including the verbatim policy and a shorter, more patient-friendly version. In 2014, MHMH changed practice to provide the patient friendly brochure version of the policy to all uninsured patients who enter the health system. MHMH continues to notify patients on the back of the billing statement about financial assistance being available to them. Additionally, MHMH posts information about the policy in public areas throughout the facilities including admission offices. MHMH has also made additional changes internally to increase awareness of the policy, including adding information to the back of the patient's statement about financial assistance available to them, posting information about the policy in public areas throughout the facilities, and ensuring financial assistance policy brochures are available in patient areas. MHMH Screens 100% of uninsured inpatient and same-day patients prior to admission. As part of this process, MHMH checks all state and federal programs to see if individuals are eligible for assistance. Patients are also screend to determine qualification for financial assistance and the application is provided and/or completed at this time. Form 990, Schedule H Part V, Section B Line 20D Maximum charges to financial assistance policy-eligible individuals for emergency or medically-necessary care MHMH uses the average of the three highest commerical payer discounts and applies this as a discount for all uninsured patients. The discount rate is 42%. Form 990, Schedule H Part V, Section B Line 22 Gross Charges to financial assistance policy-eligible individuals Occasionally MHMH may charge an amount equal to the gross charges for any service provided to patients in the event the patient's insurance does not cover a particular service or elective procedure. In certain situations, state law may still prohibit MHMH from charging gross charges. Form 990, Schedule H Part I Line 6a Community Benefits Report Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic (Collectively referred to as Dartmouth-Hitchcock (D-H)) share common board members and operate under an affiliation agreement. D-H performs a joint Community Health Needs Assessment (CHNA) and files a consolidated Community Benefits report. For purposes of IRS Form Schedule H, only Hospital numbers were used. All amounts relating to DHC were excluded. The New Hampshire Community Benefits Report filed for fiscal year 2014, DHC and MHMH combined, totaled $168,364,452. Form 990, Schedule H Part I Line 7 Costing Methodology The costing methodology used to calculate the amounts reported was a cost-to-charge ratio derived from worksheet 2, Ratio of Patient Care Cost-to-Charges. Form 990, Schedule H Part I Line 7G Subsidized health services related to physician clinics The Organization did not include any subsidized health service costs attributable to a physician clinic on Part I, line 7G. Form 990, Schedule H Part II Community Building Activities Community Building activities include expenses related to coalitions that address rural emergency/trauma services, prevention of pediatric obesity, prevention of substance abuse, falls reduction for older adults, public health networks, prescription drug misuse, and low-income housing. These also include cash support and/or contributed in-kind support for the development and maintenance of housing for low-income families, regional economic development, and support for regional workforce development services. Form 990, Schedule H Part III Section A Lines 2 and 3 Bad Debt Expense The amounts reported on Part III, Section A, line 2 were derived from MHMH's audited financial statements (provision for bad debt). As part of MHMH's FInancial Assistance Policy, MHMH makes information available to patients for eligibility and how to apply for free or discounted care. If the patient does not respond to the hospital's attempts to complete the financial assistance package, these patients may be written off to bad debt. Prior to moving any balance to bad debt it is assessed for charity through our presumptive charity process. If the balance meets presumptive charity qualification it is adjusted to financial assistance, therefore, never being moved to bad debt. Form 990, Schedule H Part III Section A Line 4 Audited financial Statement Disclosure for Charity Care and Provision for Bad Debt (Please note that MHMH files a combined audited financial statement with Dartmouth-Hitchcock Clinic and other Subsidiaries). MHMH provides care to patients who meet certain criteria under their financial assistance policies without charge or at amounts less than their established rates. Because MHMH does not anticipate collection of amounts determined to qualify as charity care, they are not reported as revenue. MHMH grants credit without collateral to patients, most of whom are local residents and are insured under third-party arrangements. Additions to the allowance for uncollectible accounts are made by means of the provision for bad debts. Accounts written off as uncollectible are deducted from the allowance and subsequent recoveries are added. The amount of the provision for bad debts is based upon management's assessment of historical and expected net collections, business and economic conditions, trends in federal and state governmental healthcare coverage and other collection indicators. Form 990, Schedule H Part III Section A Line 4 Patient Financial Assistance Qualification MHMH's Policy is to exert everything in the Organization's power to obtain sufficient and adequate information to determine eligibility for financial assistance. If the required information is not obtained in order to determine eligibility for financial assistance, then the amount is recognized as bad debt. MHMH's discount for uninsured patients is currently 42% (before financial assistance is applied). Medicare Shortfalls Form 990, Schedule H Part III Section B Line 8 The costing methodology used to calculate the amounts reported as Medicare Surplus was derived from the Internal Revenue Service's Worksheet B as provided for Part III calculations. MHMH had revenues of $23,594,036 and costs of $29,370,150 for services not included on the Medicare Cost Report (Ambulance Services, Laboratory and other fees screens, and Medicare Part C & D services). MHMH incurred a net loss of $5,776,114 on the provision of these services. Form 990, Schedule H Part III, Line 9b Credit and Collection Policy MHMH has a Credit and Collection Policy that addresses the procedures for patients who choose not to make payment or work with MHMH to make payment arrangements for their bill. The Organization has a separate Financial Assistance Policy that addresses those patients who are unable to make payment. MHMH is a charitable health care organization who treats patients that come for medically necessary care, regardless of their financial status. MHMH offers financial assistance in the form of free or discounted care to those patients who have an inability to pay their bills. The Financial Assistance Policy outlines eligibility criteria for financial assistance; the method by which patients may apply for financial assistance; the basis for calculating amounts charged to patients eligible for financial assistance under this policy; D-H's measures to widely publicize the policy within the community served; and the limitation of charges for emergency or other medically necessary care. Patients can qualify for 25%, 50%, 75%, or 100% reduction based on Federal Poverty Levels as well as a catastrophic guideline of 10% of 2 year's income for those that may not qualify based on assets and income, but who have a bill beyond their means to pay. rm 990, Schedule H Part V, Section D Facility information The Hospital has a Cancer Treatment Center located in Saint Johnsbury, Vermont. This location is registered under the same license as the Organization's main Campus located in Lebanon, New Hampshire. Form 990, Schedule H Part VI Line 2 Needs Assessment Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic (Collectively referred to as Dartmouth-Hitchcock (D-H)) share common board members and operate under an affiliation agreement. D-H performs a joint Community Needs Assessment and files a consolidated Community Benefits report. Dartmouth-Hitchcock participates with other health care charitable trusts and community partners in each of our service areas to complete community health needs assessments. During 2012, MHMH partnered with Alice Peck Day Memorial Hospital, Mount Ascutney Hospital and Health Care, and Granite United Way to conduct a Community Needs Assessment. The needs assessment included reviewing health data available throughout NH and VT Health Departments; BRFSS and youth Risk Behavior Surveys; focus groups with community members from lower-income neighborhoods; and electronic surveys of professional health and social service providers as well as community residents. This information was reviewed by a Steering Committee comprised of community leaders from the health care system, education, public health, and other social service organizations to develop a community needs assessment. The Steering Committee's work was reviewed at larger community gatherings in fall 2012 for further comments and feedback. In addition, MHMH reviewed related health data generated through www.CHNA.org as a comparative tool. MHMH monitors emerging health data on an ongoing basis as it is released by each state, schools, and other community entities. As part of the needs assessment, the Steering Committee reviewed: 1. Health, economic, and education data from sources including Youth Risk Behavior Surveys, the Behavioral Risk Factor Surveillance System, public health and hospital discharge data available in NH Health WRQS, census data, and reports from the New England Common Assessment Program. Additionally, it reviewed the 2011 NH State Health Profile and Upper Valley Regional Health Profile, quantitative and qualitative data from local souces (newspapers, regional planning offices, community forums) to identify concerns that emerged, intensified, or were the source of local attention since the last secondary data was collected. Emergent issues that are not well-reflected in secondary data but were reflected elsewhere include oral health needs (data from UV Smiles school-based oral health clinics), prescription drug misuse (data from the NH Governor's Commission on Alcohol and other Drug Abuse Prevention, Intervention, and Treatment), housing assessments (data from Upper Valley Lake Sunapee Regional Planning Commission), and reductions in availability of appropriate mental health services (news outlets and professional stakeholder interviews). 2. Opinion data from professional stakeholders using an online opinion poll of regional leaders in health, public health, education, municipal governments, public safety, and social service providers. 67 informed stakeholders responded to this survey. 3. Focus group data collected from 6 focus groups largely consisting of lower-income consumers of health/welfare services. 4. Opinion data from residents collected through community list-servs, individual interviews at human service organizations, and focus groups. These surveys were targeted primarily to economically stable households. 196 residents responded to surveys. Dartmouth-Hitchcock regularly monitors newly released health, economic, and education data from our service region to identify emerging regional needs and concerns, including FY 2013 Youth risk Behavior Surveys, the 2013 NH State Health Improvement Plan, NH's emerging state plans to address substance misuse, prescription drug misuse, obesity, and children's behavioral health. Form 990, Schedule H Part VI Line 3 Patient Education of Eligibility for Assistance All uninsured inpatients, same day surgery, observation, and Emergency Department patients are pro-actively screened using an automated tool to identify potential qualification for other federal, state, and local programs. In addition, specific outpatient activities deemed to have a higher rate of need are screened as part of regular protocol. If a patient appears to be eligible, on-site Financial Counselors assist the patient in completing the appropriate paperwork/applications and provide instruction regarding how to complete the qualification process. In some cases a Financial Counselor will act on behalf of the patient, at their signed consent, in order to complete the application process (for example, in New Hampshire a patient must be physically present at the District Office). If a patient doesn't qualify for specific programs, they are also considered for financial assistance as part of their screening. For outpatient services that are not routinely screened, staff interacting with patients are instructed to provide either a financial assistance application or contact information for a Financial Counselor when a patient expresses their inability to make payment. Every application is screened for completed income and asset documentation. Applications are also screened to assure there are no other potential options of federal, state, or local programs. The website, patient statements, and financial brochures all include information about financial assistance and how to apply. Form 990, Schedule H Part VI Line 4 Community Information The Organization defines its service region as New Hampshire and eastern Vermont, with the largest presence in the Lebanon, New Hampshire region, site of Dartmouth-Hitchcock Medical Center which includes Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinics main Northern clinic. MHMH serves the general population with a wide range of services. In addition to general hospital populations, the Organization provides services to patients with highly-specialized needs that are not available elsewhere in New Hampshire. MHMH is the states only tertiary referral center, provides the states only comprehensive cancer center (Norris Cotton Cancer Center - NCCC), operates the only Level I Trauma Center in New Hampshire, operates the only comprehensive childrens hospital and accredited pediatric trauma center in New Hampshire (Childrens Hospital at Dartmouth CHaD), hosts the only Level IV neonatal intensive care nursery and one of two pediatric intensive care units in New Hampshire, and operates the only helicopter transport service in the state. As such, the service population is both the general public seeking primary health care services as well as residents with unique and highly-specialized health care needs. Form 990, Schedule H Part VI Line 5 Promotion of Community Health MHMH supports organizations and initiatives that further health by strengthening and developing key community capacities to address identifed community health needs. This includes hosting or leading community partnerships to address substance misuse, reduce obestiy through community-level strategies; provide funding for children's oral health initiatives, and participation of our staff in other partnerships including the Outpatient Falls Prevention Task Force; the Transportation Management Association, and the Upper Valley Housing Authority. In addition, MHMH operates health education and support services such as a Women's Health Resource Center, the Aging Resource Center; and a Health Education Center. MHMH uses cash contributions, contracted services, and in-kind contribution of staff time and expertise, to support these strategies which improve community health. At MHMH's Lebanon, NH campus, the Hospital extends Professional Staff Privileges to qualified and appropriate physicians who are employees of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and Dartmouth College, who also hold a faculty appointment at Geisel School of Medicine. Mary-Hitchcockss Trustees annually set strategic priorities for the institution and approve operating and capital budgets which allocate surplus funds to improvements in patient care, medical education, research, as well as maintenance of a prudent reserve. Examples of these investments include the development of Mary Hitchcockss Patient Safety and Training Center, ongoing Quality and Patient Safety initiatives; purchases of new and emerging medical technologies, awards made to support translational research, and support for undergraduate medical education at Geisel School of Medicine. Of the 16 voting members of Mary Hitchcock Board of Trustees, 15 are neither contractors nor employees of MHMH. Form 990, Schedule H Part VI Line 6 Affiliated Health Care System Community Benefits are provided by the Dartmouth-Hitchcock health care system, which includes Mary Hitchcock Memorial Hospital, Dartmouth-Hitchcock Clinic, and other related organizations whose primary mission is health care. Mary Hitchcock Memorial Hospital (MHMH) in Lebanon is New Hampshires largest hospital. In Fiscal Year 2014 MHMH had 396 licensed inpatient beds. The Dartmouth-Hitchcock Clinic (DHC) is a multi-specialty physician practice with a network of providers across New Hampshire and Vermont. While DHCs main offices are located in Lebanon, the Clinic also has multi-specialty practices in Manchester, Nashua, Concord, and Keene, NH areas as well as Bennington, VT. In addition, the Clinic provides primary care in rural communities in Vermont and northern New Hampshire. MHMH, DHC sites, and the Geisel School of Medicine (formerly known as the Dartmouth Medical School) faculty and students make up the Dartmouth-Hitchcock (D-H) health care system. The Hospital and Clinic operate jointly through interlocking directorates, strategic planning and management and share identical missions. The Medical School, which works closely with the Hospital and Clinic, is focused on medical education and research. Form 990, Schedule H Part VI Line 7 State filing of Community Benefit Report MHMH files a community Benefit with the State of New Hampshire. true Good Neighbor Health Clinic 70 No Main St White River Jct VT 05001 030346949 501(C)(3) 44850 FMV Programs/Clinic Svcs Grafton Country Senior Citizens Council P O Box 433 Lebanon NH 03766 237248316 501(C)(3) 13810 FMV Elder Services Stagecoach 7 Bayberry Way Mont Vernon NH 03057 030276517 501(c)(3) 25875 FMV Transportn Subsidy Granite State United Way 46 South Main St Concord NH 03301 026006033 501(c)(3) 18621 FMV Program Support David's House 461 Mount Support Rd Lebanon NH 03766 222593431 501(C)(3) 23115 FMV Program Support Lamprey Health 22 Prospect Street Nashua NH 03060 237305106 501(C)(3) 51750 FMV Program Services Mascoma Valley Health Initiative PO Box 2013 Canaan NH 03741 752991608 501(C)(3) 10534 FMV Hlth Adv Cnsl Sppt S The Trustees of Dartmouth College 1 Rope Ferry Road Hanover NH 03755 020222111 501(C)(3) 1804827 FMV Educ and Prog Suppt Alice Peck Day Memorial Hospital 10 APD Memorial Dr Lebanon NH 03766 020222791 501(C)(3) 8970 FMV Dental Prog Svcs Advance Transit PO Box 1027 Wilder VT 05088 222558708 501(C)(3) 69524 FMV Transportn Subsidy Upper Valley Tranporation MGMT Association 195 No Main St White River Jct VT 05001 030355283 501(C)(3) 20700 FMV Transportn Subsidy Great Manchester Chamber of Commerce 54 Hanover Street Manchester NH 03101 020161920 501(c)(3) 5201 FMV Program Support March of Dimes- NH Chapter 25 Lowell St Ste 304 Manchester NH 03101 131846366 501(c)(3) 5175 FMV Program Support NH Fisher Cats Foundation Attn Golf Classic 1 Lane Drive Manchester NH 03101 141973034 501(c)(3) 7418 FMV Program Support Schweitzer Fellows Program 10 Sausville Road Etna NH 03750 131982786 501(c)(3) 6900 FMV Program Support City of Lebanon 51 North Park Street Lebanon NH 03766 436239881 501(c)(3) 8570 FMV Program Support Granite State Fit Kids 2300 Southwood Drive Nashua NH 03063 020519379 501(c)(3) 7935 FMV Program Support Southwestern VT Health Care 100 Hospital Dr BOX 41 Bennington VT 05201 030179435 501(c)(3) 6900 FMV Program Support VNA Hospice of VTNH 66 Benning St Ste 6 West Lebanon NH 03784 036006494 501(c)(3) 6886 FMV Program Support Concord Hospital Trust 250 Pleasant St Concord NH 03301 260378710 501(c)(3) 6038 FMV Program Support City Year NH Pledge 287 Columbus Avenue Boston MA 02116 222882549 501(c)(3) 17250 FMV Program Support Upper Valley Housing Coalition PO Box 17 Lebanon NH 03766 200363702 501(c)(3) 13800 FMV Program Support Town of Enfield PO Box 373 Enfield NH 03748 501(c)(3) 7380 FMV Program Support 23 Patterson Awards 22 5774 FMV Levine Nursing Awards 1 3063 FMV Varnum Nursing Awards 43 27593 FMV Knox Nursing Award 22 42436 FMV Prouty Award 61 33149 FMV E. Hintze Nursing Awards 6 6122 FMV Daniels Nursing Award 26 9773 FMV D-H Tuition Reimbursement Program 516 460046 FMV Waterman Award 1 12515 FMV The Trustees of Dartmouth College 54 590340 FMV Form 990, Schedule I Description of Organization's Procedures for Monitoring the Use of Grants Each award established by Mary Hitchcock Memorial Hospital(Levine Nursing Awards, Knox Nursing Award, Patterson, Varnum, Hintze, and Prouty) has written established guidelines and procedures. Award payments are processed in accordance with the specific terms of each of the awards noted above. The Dartmouth Institute Scholarships (TDI) are paid directly to the College on the behalf of the individuals receiving the award. The coordinators of the program(s) are responsible for assuring that all terms are met, including proper documentation of expenses with receipts. X X true true X X X X true true false false false false false false false Carl Dematteo MD Fmr Chf Ql Compl Ofr/Physician 0 98296 0 0 0 2286 0 346 0 1446 0 102374 0 0 Robin Kilfeather-Mackey CPA Chief Financial Officer 0 474737 0 0 0 33809 0 2250 0 20325 0 531121 0 0 Linda Von Reyn Chf Nursng Officer End 3/22/14 325452 0 0 0 111642 0 3125 0 20335 0 460554 0 0 0 Daniel Jantzen CPA Chief Operating Officer 515734 0 200 0 103662 0 3125 0 20325 0 643046 0 0 0 Stephen Leblanc Exec VP Strtgy & Ntwrk Rltns 0 478986 0 0 0 147237 0 2250 0 20325 0 648798 0 0 John Butterly MD Fmr Offr/Exec VP Med Affairs 0 504542 0 0 0 51491 0 35460 0 21324 0 612817 0 0 Lawrence Dacey MD Former CMO/ Phys 0 444468 0 13622 0 41049 0 2250 0 13284 0 514673 0 0 Alan Weston Chief HR Officer End 9/2/2013 261730 0 200 0 113615 0 26790 0 15721 0 418056 0 0 0 David Gladstone MD Chief Clinical Phys Rad/Onc 265874 0 200 0 14442 0 28451 0 20351 0 329318 0 0 0 Bruce King Pres & CEO New London Hosp 313392 0 0 0 60568 0 3125 0 20426 0 397511 0 0 0 Neil Castaldo Sr Advisor to CEO End 7/06/13 273185 0 0 0 730149 0 24915 0 12355 0 1040604 0 0 0 Mary Oseid Fmr Key Emp/VP Enterprise Svcs 0 274655 0 0 0 7752 0 2250 0 12088 0 296745 0 0 Christine Schon V.P Comm. Grp. Pract. Ops 0 220913 0 300 0 4843 0 23666 0 15735 0 265457 0 0 William Mroz V.P. Op/Clncl Svcs End 7/27/13 189736 0 0 0 2099 0 17287 0 5049 0 214171 0 0 0 Gail Dahlstrom V.P. Facilities Mgmt 221560 0 200 0 8684 0 2799 0 15734 0 248977 0 0 0 James N Weinstein DO MS Trustee Ex-Officio/CEO 0 945851 0 200 0 64668 0 2250 0 21324 0 1034293 0 0 Gregg Meyer MD CCO/EVP Pop Hlth End 1/02/14 0 790556 0 502 0 105340 0 21690 0 20899 0 938987 0 0 Tina Naimie CPA VP Corporate Finance 217604 0 200 0 111 0 17993 0 2164 0 238072 0 0 0 Wendy Fielding VP Financial Planning 217364 0 300 0 270 0 18332 0 20179 0 256445 0 0 0 Barbara Walters DO MBA Fmr Key Emp/Med Dir Acct Care 0 335906 0 0 0 23238 0 2250 0 17294 0 378688 0 0 Jeanine Arden-Ornt General Counsel End 6/30/2014 428678 0 200 0 20019 0 21690 0 12010 0 482597 0 0 0 Vincent Fusca III Chf Stff/Intrm CHRO 9/3-2/3/14 251743 0 0 0 2039 0 20034 0 1751 0 275567 0 0 0 Mary Kay Boudewyns Fmr Key Emp/Adm Dir Rev Mgmt 205225 0 250 0 12051 0 0 8199 0 225725 0 0 0 Edward Merrens MD Chief Medical Officer 0 373068 0 200 0 13093 0 24240 0 13920 0 424521 0 0 George Blike MD Chief Quality & Value Officer 0 428424 0 0 0 13179 0 2250 0 20909 0 464762 0 0 Thomas Colacchio MD Former Officer/Phys 0 669732 0 0 0 414988 0 26790 0 16901 0 1128411 0 0 Clifford J Belden MD Actg Chf Clcl Ofr Ef 2/18/2014 0 621430 0 0 0 27321 0 21690 0 16786 0 687227 0 0 Terrence P Carroll PHD Chf Innvtion Offcr Eff 8/19/13 184817 0 0 0 896 0 13353 0 5291 0 204357 0 0 0 Roderic Young VP Communications & Marketing 295991 0 200 0 0 0 21329 0 20324 0 337844 0 0 0 Martin Purcell VP IS Operations 270097 0 200 0 20749 0 1845 0 22994 0 315885 0 0 0 Thomas Dodds MD Dept. Chair Anesthesiology 0 510210 0 0 0 33924 0 26790 0 21970 0 592894 0 0 Richard Rothstein Dept. Chair Medicine, Dean CME 0 541158 0 8155 0 48847 0 2250 0 17202 0 617612 0 0 Wendy Wells MD Dept. Chair Pathology 0 412232 0 0 0 22343 0 32910 0 21536 0 489021 0 0 Jocelyn Chertoff MD MS Dept Chair Diagnost Radiology 0 446679 0 30558 0 27255 0 34185 0 21546 0 560223 0 0 Edward Catherwood MD MS Center Direct Heart & Vascular 0 447164 0 200 0 35383 0 2250 0 16564 0 501561 0 0 Douglas Merrill Center Director Periop Svs 0 511992 0 0 0 34548 0 24915 0 21536 0 592991 0 0 Stephen Boyce VP Ambulatory Care 0 178063 0 250 0 336 0 9578 0 19836 0 208063 0 0 Jeffrey OBrien VP Oncology Services 271357 0 250 0 7039 0 19841 0 20351 0 318838 0 0 0 Susan Reeves VP Colby Sawyer Nursing 249199 0 200 0 24875 0 26790 0 19850 0 320914 0 0 0 Supplemental Compensation Information Form 990, Schedule J, Part I - Line 1a FROM TIME TO TIME, THE ORGANIZATION PROVIDES CHARTERED TRAVEL SERVICES TO THE CEO. THE COST OF PROVIDING THE CHARTERED SERVICE HAS BEEN DEEMED A COST-EFFICIENT MANNER TO ALLOW THE OFFICER TO WORK WHILE TRAVELLING VERSUS THE TIME LOST DRIVING, ETC. THIS EXPENSE HAS BEEN DEEMEND AN ORDINARY AND NECESSARY BUSINESS EXPENSE AND NON-TAXABLE TO THE RECIPIENT. ALL REQUESTS ARE APPROVED BEFORE PAYMENT TO ENSURE COMPLIANCE WITH INTERNAL POLICIES. The Organization has in place a Management Self Development Plan (MSDP) designed to promote professional and personal development. The MSDP is capped at 2% of gross pay and may be utilized for expenses such as professional dues, meetings and seminars, tuition reimbursement, and other miscellaneous items that promote professional knowledge. The monies may also be used for up to a 50% reimbursement of the cost of a fitness/wellness program designed to maintain the health of management personnel. All expenses are submitted for approval before reimbursement. Form 990, Schedule J, Part I line 4a The following listed individuals received Severance and/or change in control payments during calendar year 2013: During 2012, Thomas Colacchio transitioned from an officer role to a staff physician role. As part of this transition, Thomas Colacchio received a $320,000 change of control payment from Dartmouth-Hitchcock in 2013. The payment is included on Schedule J, Part II, Column (B)iii. During calendar year 2013, Former Chief Human Resource Officer Alan Weston received a $104,614 severance payment from Dartmouth-Hitchcock.The payment is included on Schedule J, Part II, Column (B)iii. During calendar year 2013, Former Senior Advisor to the CEO Neil Castaldo received a $675,000 severance payment from Dartmouth-Hitchcock. The payment is included on Schedule J, Part II, Column (B)iii. Supplemental Nonqualified Retirement Plan: SCHEDULE J, PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (WHICH ARE REFLECTED IN SCHEDULE J, PART II, COLUMN B (III)): James Weinstein $63,480 Robin Kilfeather-Mackey $15,194 Linda Von Reyn $94,589, Daniel Jantzen $90,628, Stephen Leblanc $109,719, John Butterly $44,117, Alan Weston $8,132, Neil Castaldo $43,644, Gregg Meyer $30,800, Jeanine Arden Ornt $18,109, Edward Merrens $12,823, George Blike $12,765, Mary Oseid $7,682, Barbara Walters $22,050, David Gladstone $3,464, Bruce King $45,691, Susan Reeves $4,488, Lawrence Dacey $40,275, Thomas Colacchio $94,988, Clifford Belden $27,195, Richard Rothstein $47,767, Thomas Dodds $33,150, Wendy Wells $21,857, Jocelyn Chertoff $26,481, Edward Catherwood $35,383, Douglass Merrill $31,200, Dartmouth-Hitchcock Supplemental Retirement Plan: Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the Plans for the plan year, but are limited by IRC Section 401 (a)(17) and/or 415. For eligible employees, the Employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC Sections 401(a)(17) and/or 415. MHMH sponsors a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen in 1998 and therefore no further costs of the individual employee insurance premiums have been funded by the organization. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization. A New Hampshire Health and Education Facilities Auth 020279866 644614Y07 2009-08-19 134661088 CURRENT REFUND 2008 (A), (B), (C) false false false B New Hampshire Health and Education Facilities Auth 020279866 644614G29 2010-06-16 73647839 CONSTR. OF FACILITY AND EQUIP. false false false C New Hampshire Health and Education Facilities Auth 020279866 2011-08-31 38119624 CURRENT REFUND 2001 (A) false false false D New Hampshire Health and Education Facilities Auth 020279866 2012-11-28 116170000 CURRENT REFUND 2002 false false false A 19695000 0 134841419 0 0 0 2273111 0 0 0 132387977 0 2010 true false true true B 0 0 73666926 0 3766049 0 1168560 0 0 68713230 0 0 2012 false false true true C 2411468 0 38119624 0 0 0 97500 0 0 0 38022124 0 2011 true false true true D 485000 0 116170000 0 0 0 520000 0 0 0 115650000 0 2013 true false false true A false false false false 0 false false false true B false false false false 0 false false false true C 0 D 0 A false true true false false false 0 false 0 false true B false true false false false false 0 false 0 false true C false true true false true true Morgan Stanley 29.8 true false false 0 false true D false true true false false false 0 false 0 false true A true B true C true D true Additional Information Part I(F) Current Refund 2008 (A), Issued 9/4/2008, Which Advance Refunded 1985 Current Refund 2008 (B), Issued 10/31/2008, Which Advance Refunded 1993 Current Refund 2008 (C), Issued 12/19/2008 Current Refund 2001(A), Issued 10/17/2001, Which Advance Refunded 1997 & 1994 Part II Line 3, Column A & B Difference between part I column E & part II Line 3 is investment earnings DANIEL JANTZEN Officer SPLIT DOLLAR LIFE X 104353 104353 false true true SUSAN REEVES Highly-Comp EE SPLIT DOLLAR LIFE X 138287 138287 false true true BRUCE KING Highly-Comp EE SPLIT DOLLAR LIFE X 126709 126709 false true true MARY KING Disqualified Person SPLIT DOLLAR LIFE X 17740 17740 false true true DEBORAH JANTZEN Disqualified Person SPLIT DOLLAR LIFE X 51071 51071 false true true 438160 Hypertherm Trustee Barbara Couch 350000 See Part V false Nathaniel Arden-Ornt Officer Arden Ornt 61556 Family member employed by MHMH false Vincent Fusca III Officer Fusca II 96325 Family member employed by MHMH false Peter Abdu Trustee Abdu 13319 Family member employed by MHMH false Garth Dunkel Officer Fusca II 18620 Family member employed by MHMH false Christopher Weston Officer Alan Weston 66461 Family member employed by DHC false Business Transactions Name of Interested Person: Barbara Couch Relationship: Trustee Description of Transaction: Barbara Couch is a greater than 35% owner of Hypertherm, an entity that contracts with MHMH for certain medical services for its employees. X 26 681545 Fair Market Value X 1 209000 FMV X Travel and Fuel Cards for Patients 2 45000 FMV X Various items for events, hearing aids,& supplies 241 215000 FMV false true true Schedule M, Part I, Column B The organization reported the number of contributions received in column (b). Use of related organizations to solicit noncash donations Line 32B The organization uses Dartmouth-Hitchcock Medical Center, a supporting Organization, for solicitation of contributions and annual fund activities. From time to time, the Hospital may receive non-cash contributions directly from its donors. Description of classes of members, persons, and the nature of their rights Form 990, Part VI, Line 6 & 7a Dartmouth-Hitchcock Health (D-HH) is the sole corporate Member of Mary Hitchcock Memorial Hospital (MHMH). D-HH has specific authority and reserved powers, including the power to confirm the election of members of the MHMH's Board of Trustees and the power to approve significant governance, financial and operational decisions of MHMH's Trustees. Description of classes of members, persons, and the nature of their rights Form 990, Part VI, Line 7B In addition to reserved powers, Dartmouth-Hitchcock Health (D-HH) shall have the authority to take actions to establish, manage, and govern the System as an integrated health care delivery system in furtherance of the mission of the Hospital and other Organizations. These powers include but are not limited to items such as the ability to approve, disapprove or modify all material governance, programmatic and financial decisions of MHMH's Board of Trustees, to appoint or remove a member of the Hospital's Board of Trustees, assess the Hospital a monetary amount for the payment of the expenses of D-HH, approve the Hospital's budget, approve the borrowings or dispositions of assets by the Hospital, approve key strategic relationships, approve the elimination or addition of any material health care service or program, and other authority to take action on behalf of the Hospital. material health care service or program, and other authority to take action on behalf of the Hospital. Process used by management and/or Governing Body to Review 990 Form 990, Part VI, Line 11b THE FORMS 990 AND 990-T ARE REVIEWED BY THE DIRECTOR OF CORPORATE FINANCE, VICE PRESIDENT OF CORPORATE FINANCE, AND THE CHIEF FINANCIAL OFFICER BEFORE THE FILING OF THE RETURN. ONCE THE RETURN HAS BEEN FULLY PREPARED A FINAL 990 AND 990-T COMPLETE ELECTRONIC VERSION IS SENT OUT TO EACH BOARD MEMBER AND TIME IS ALLOCATED FOR COMMENTS/RESPONSES PRIOR TO OFFICIAL FILING. Conflict of Interest Policy Form 990, Part VI Section B Line 12C Description of Process to Monitor Transactions for Conflicts of Interest The Mary Hitchcock memorial Hospital Board of Trustees approved a policy concerning a voluntary self-disclosure of any potential conflict of interest. The Dartmouth-Hitchcock, Office of Policy Support, Compliance and Audit Services conducts an annual survey of all officers and trustees and performs other procedures as considered necessary to report on compliance with the conflict of interest policy. The Compliance and Audit Services Department then reports to each board any potential conflicts for their review. Per the policy, any conflicts or otherwise perceived conflicts are required to be addressed by the Board of Trusteees on an ongoing basis. In the event a conflict arises, the individual may be removed from participating in any decision making regarding the identified conflict and/or its corresponding transactions. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR UNDERTAKEN Form 990, Part VI, Line 15a Although paid by a related organization, Dartmouth-Hitchcock Clinic, the Compensation for the President is evaluated by an independent third party firm for reasonableness and national data benchmarking. The Compensation Committee along with Independent Trustees approve the final compensation in consideration with the independent third party firm's recommendations and suggestions. This process was last undertaken in 2014. Offices & Positions for Which Process was Used & Year Undertaken Form 990, Part VI, Line 15b Compensation for officers and key employees are evaluated by internal HR staff using national benchmarking data, along with ongoing evaluations by an independent third party firm for reasonableness, with the last formal process in 2012. External benchmarking from an independent third party has been used for any Officer who was hired or received a compensation adjustment since the last process 2012. Compensation rates are determined by following the guidelines of the compensation committee charter and philosophy documents and/or a formal review by compensation committee members. Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Line 19 MHMH's governing documents are available through the New Hampshire Secretary of State. Certain financial information is disclosed through the Community Benefits Annual Report. The audited financial statements, governing documents, and conflict of interest policy are available upon request either in electronic or hardcopy form. Average Hours Per Week Form 990 Part VII Section A, Line 1A, Column B As part of MHMH's and Dartmouth-Hitchcock Clinic's affiliation agreement, the two organizations share officers. As such, the average hours per week are allocated between the two organizations' 990's even though compensation reported in part VII is based on the entity issuing the W-2. In addition, certain officers spend time on Dartmouth-Hitchcock Health, the sole corporate member of both MHMH and DHC, along with two supporting organizations Dartmouth-Hitchcock Medical Center and Hamden Risk Retention Group. Statement of Functional Expenses Form 990 Part IX Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic operate under an affiliation agreement as directed by Dartmouth-Hitchcock Health, the sole Corporate Member of both entities. Due to the integrated operating structure, related mission, and close relationship of the two tax-exempt organizations, expenses are shared between the two entities. All expenses reported within this 990 are the organization's share of expenses as designated by the affiliation agreement. Financial Statements and Reporting Form 990 Part XI, Line 9 Other Changes in Net Assets Include: Pension-related charges: $8,331,475 Unrealized Gain/Loss on Hedge and other ($3,831,935) Total changes in net assets: $4,499,540 Audited Financial Statements Form 990 Part XII, Line 2d The organization's financial information is included in the audited financial statements of Dartmouth-Hitchcock and Subsidiaries, which consists of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and subsidiaries. A-133 Audit Form 990 Part XII, Line 3A DURING FISCAL YEAR 2014, MARY HITCHCOCK MEMORIAL HOSPITAL EXPENDED FUNDS FROM FEDERAL AWARDS IN EXCESS OF THE MINIMUM THRESHHOLD SET FORTH IN THE SINGLE AUDIT ACT AND OMB CIRCULAR A-133, THEREFORE REQUIRING AN AUDIT. DUE TO THE ISSUANCE OF THE COMBINED FINANCIAL STATEMENTS, THE SINGLE AUDIT WAS PERFORMED ON THE COMBINED FINANCIAL INFORMATION OF ALL ORGANIZATIONS. NEW ENGLAND ALLIANCE FOR HEALTH LLC ONE MEDICAL CENTER DRIVE LEBANON NH 03756 264232401 HLTH IMPROVMT NH 52862 381391 MHMH D-H Specialty Services LLC One Medical Center Drive Lebanon NH 03756 460876427 Shd Svgs Prgm NH 0 MHMH DARTMOUTH-HITCHCOCK CLINIC ONE MEDICAL CENTER DRIVE LEBANON NH 03756 222519596 PHYSICIAN SVC NH 501(c)(3) 9 D-HH true DARTMOUTH-HITCHCOCK MEDICAL CENTER ONE MEDICAL CENTER DRIVE LEBANON NH 03756 222715483 SUPPORTNG ORG NH 501(c)(3) 11 TYPE I NA true DARTMOUTH - HITCHCOCK HEALTH One Medical Center Drive Lebanon NH 03756 264812335 SUPPORTNG ORG NH 501(C)(3) 11 Type II NA false HAMDEN RISK RETENTION GROUP INC 30 MAIN STREET STE 330 BURLINGTON VT 05401 208530788 Self Ins VT 501(c)(3) 11 TYPE I DHC true The Hitchcock Foundation One Medical Center Drive Lebanon NH 03756 020222139 HLTHCRE RSRCH NH 501(c)(3) 7 DHC true EverWell Inc One Medical Center Drive Lebanon NH 03756 352506275 Supportng Org NH 501(c)(3) 11 Type I D-HH true The New London Hospital Association Inc 273 County Rd New London NH 03257 020222171 Hospital NH 501(c)(3) 3 D-HH true D-H Mster Invst Prg 1 Med Ctr Dr LEBANON NH 03756 020205863 POOLED INVEST NH MHMH Excluded 24144133 565493670 false 29563 true 0.95916 KEENE HLTH ALLIANCE 580 Court St Keene NH 03431 300179297 Healthcare NH NA Obnet Services LLC 1 Med Ctr Dr Lebanon NH 03756 043746287 Database Serv NH NA One Care VT ACOLLC 111 COLCHESTER AVE Burlington VT 05401 455399218 Shared Saving VT NA The Hitchcock Ptshp 1 Med Ctr Dr Lebanon NH 03756 020514823 Invst in Ptr NH MHMH Investment 4873 0 false false 0.61420 Charit Remndr Unitrusts (5) One Medical Center Drive Lebanon NH 03756 Chart. 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