2024-05-14T15:38:03-05:00 2023-06-30 990 2022-07-01 620476282 Mountain States Health Alliance MOUN 4233023467 311 Princeton Road Suite 1 Johnson City TN 376012080 Shane Hilton BH EVP/CFO 4233023367 2024-05-14 Shane Hilton 999009999 1 P03077501 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z Alan Levine BH PresCEO 303 Med Tech Prkwy Johnson City TN 37604 975386021 0 X balladhealth.org X 1945 TN Honor those we serve by delivering the best possible care. 4 0 6817 206 457352 206855 11065205 18006238 899832195 950636535 18290 233313 8185688 6020461 919101378 974896547 3286642 1064386 0 0 324864142 345719307 0 0 0 548121007 610993352 876271791 957777045 42829587 17119502 541592959 532273583 120528162 104530311 421064797 427743272 X Honor those we serve by delivering the best possible care.Ballad Health is dedicated to improving the health of the 29-county Appalachian Highlands region. 0 0 797210592 1064386 950237440 See Schedule O 797210592 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 X 0 0 1 6817 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 4 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 TN VA X Shane Hilton 4233023467 303 Med Tech Parkway Johnson City TN 37604 Alan Levine BH PresCEO Director, Chair 1.00 64.00 X X 0 3557360 247091 Eric Deaton BH EVPCOO Director 1.00 64.00 X X 0 1268808 106688 Marvin Eichorn BH EVPCAO Director 1.00 64.00 X X 0 3107146 45520 Tim Belisle BH EVPGen Cnsl Director, Secretary End July 2022 1.00 64.00 X X 0 827127 56231 Andrew Wampler BH Gen Cnsl Director, Secretary End April 2023 1.00 49.00 X X 0 207386 40760 Julie Bennett CLOGovnc Offcr Director, Secretary Start April 2023 1.00 64.00 X X 0 0 0 Lynn Krutak BH EVP/CFO 1.00 64.00 X 0 1209478 109728 Frank Canova Regional CFO 44.00 1.00 X 191083 0 9482 Kenneth Shafer VP/CEO - JCMC 45.00 0.00 X 414450 0 36326 Lemmie Taylor VP/CEO - SSH 45.00 0.00 X 317823 0 52415 Lisa Carter Reg'l Pres - Southern Mkt 45.00 0.00 X 645666 0 54706 Melanie Stanton VP/CEO - FWCH 45.00 0.00 X 364120 0 38876 Morgan May VP/Reg'l CNO 45.00 0.00 X 276536 0 21270 Brandy Lawson Lead Resp Therapist FWCH 40.00 0.00 X 225212 0 20606 David Wild MD VP/Reg'l CMO 45.00 0.00 X 238555 0 13883 Corinne Allen MultiFac Dir - Pharm Svcs 40.00 0.00 X 210282 0 33983 Dwight Owens Admin/COO - IPCH 40.00 0.00 X 290043 0 37622 Greta Morrison AVP, Admin/CNO - RCH 40.00 0.00 X 198219 0 36193 Joshua McFall Fmr Key Empl CFO - Acute Services 0.00 40.00 X 0 455393 61297 Linda White Fmr Offcr VP/Pres - NW Mkt 0.00 45.00 X 0 363355 29806 Chase Wilson Fmr Key Empl CFO Greene Co 0.00 40.00 X 0 296185 40312 Eric Carroll Fmr HComp CEO Greene Co 0.00 40.00 X 0 286231 33164 Clay Runnels MD Fmr Offcr BH EVP/Chief Phys Exec 0.00 65.00 X 0 1095491 98857 Mark Wilkinson MD Fmr HComp BH VP/CMIO 0.00 45.00 X 0 548999 44284 Matthew Loos Fmr HComp BH VP/CAO 0.00 45.00 X 0 507157 46822 3371989 13730116 1315922 379 1 1 0 0 15238519 2430720 336999 18006238 Patient Revenue 622110 949242160 949242160 Diabetes Program Revenue 900099 640692 640692 Lab Outreach Revenue 621500 407341 407341 CARES Act Revenue 900099 246657 246657 O/P Rehabilitation Revenue 900099 99685 99685 950636535 261726 261726 868551 417988 450563 450563 50011 400552 43073 71486 -28413 -28413 -28413 Cafeteria/Vending 722514 2711236 2711236 Network Mgt Services 900099 1867860 1867860 Daycare 624410 263976 263976 726826 36659 690167 5569898 974896547 950237440 457352 6195517 X 1064386 1064386 2857840 339808 2518032 278329140 220991030 57338110 7115024 5698739 1416285 40619842 23982182 16637660 16797461 15929063 868398 341663 341663 239770039 186588300 53181739 611382 86908 524474 5301912 4848305 453607 13409501 12001549 1407952 12346661 12303191 43470 1252321 1184613 67708 25478424 25334782 143642 32753925 31623523 1130402 3617310 3512281 105029 Medical Supplies 222440554 222440554 Support Services 23227484 1951466 21276018 Maintenance 22399028 21914135 484893 Lease - Equipment 2432622 2385129 47493 5610526 3030648 2579878 957777045 797210592 160566453 0 13797 0 247772 205869 172025 75845 99587487 115072479 12937884 13938037 20187849 20177149 3573367 4669516 1022970002 663660679 356694008 359309323 13141003 13141003 35037767 5684362 541592959 532273583 78960736 79365380 11689902 7498677 61266 48120 29816258 17618134 120528162 104530311 X 421051078 427549663 13719 193609 421064797 427743272 541592959 532273583 X 17119502 -413733 -10027294 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 119874 0 0 0 119874 0 Part II-B, Line 1: Mountain States Health Alliance had lobbying expenses of $119,874 which represents the portion of dues paid to various organizations attributable to direct lobbying, including Tennessee Hospital Association and Virginia Hospital and Healthcare Association. 22219663 22219663 535787366 276936968 258850398 4841819 3763742 1078077 441607337 376914314 64693023 18513817 6045655 12468162 359309323 Due to 3rd Party Payors -116436 Operating Lease Obligation ST 475883 Operating Lease Obligation LT 583971 Professional Liabilities Reserve 9970556 Due to Payor Stimulus Reserve 2270500 Deferred Income 4433660 17618134 X Part X, Line 2: Mountain States Health Alliance is included in the audited consolidated financial statements of Ballad Health. The footnote explanation relative to income taxes reads: "Ballad is classified as an organization exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. As such, no provision for federal income taxes is included in the accompanying consolidated financial statements. Taxable subsidiaries are discussed in Note K. No significant uncertain tax positions exist at June 30, 2023 and 2022. Tax returns for 2020 through 2022 are subject to examination by the Internal Revenue Service." 1 1 X 1 X 225.000000000000 1 X 450.000000000000 1 1 0 1 1 32407277 32407277 0.03380 262462381 232453189 30009192 0.03130 294869658 232453189 62416469 0.06510 3412985 697290 2715695 0.00280 17746563 4125618 13620945 0.01420 22781237 19016296 3764941 0.00390 1381364 68289 1313075 0.00140 942886 942886 0.00100 46265035 23907493 22357542 0.02330 341134693 256360682 84774011 0.08840 250000 250000 0.00030 29241 29241 0.00000 30000 30000 0.00000 309241 309241 0.00030 1 54136080 2706804 159278530 147351516 11927014 X 1 1 1 Med Spec of JC LLC Medical Services 0.51000 0.49000 8 1 Johnson City Medical Center 400 N State of Franklin Rd Johnson City TN 37604 balladhealth.org 00000121 X X X X X X Mental Health A 2 Indian Path Community Hospital 2000 Brookside Drive Kingsport TN 37660 balladhealth.org 00000134 X X X X A 3 Franklin Woods Community Hospital 300 Med Tech Parkway Johnson City TN 37604 balladhealth.org 00000123 X X X A 4 Sycamore Shoals Hospital 1501 W Elk Avenue Elizabethton TN 37643 balladhealth.org 00000012 X X X Mental Health A 5 Russell County Hospital 58 Carroll Street Lebanon VA 24266 balladhealth.org H 1892 X X X Mental Health A 6 Johnson County Community Hospital 1901 S Shady Street Mountain City TN 37683 balladhealth.org 00000039 X X X X A 7 Unicoi County Hospital 2030 Temple Hill Road Erwin TN 37650 balladhealth.org 00000119 X X X A 8 Lee County Community Hospital 127 Health Care Drive Pennington Gap VA 24277 balladhealth.org H 1940 X X X X A Facility Reporting Group - A 0 0 1 X X X X X X X X X X 21 1 1 0 1 X balladhealth.org/locations X 1 22 0 1 0 1 X 225.000000000000 450.000000000000 X X X X X 1 1 X X X X 1 X balladhealth.org X balladhealth.org X balladhealth.org X X X X X X 1 X 0 X X X X 1 X 0 0 Part V, Section B Facility Reporting Group A Facility Reporting Group A consists of: - Facility 1: Johnson City Medical Center, - Facility 2: Indian Path Community Hospital, - Facility 3: Franklin Woods Community Hospital, - Facility 4: Sycamore Shoals Hospital, - Facility 5: Russell County Hospital, - Facility 6: Johnson County Community Hospital, - Facility 7: Unicoi County Hospital, - Facility 8: Lee County Community Hospital Facility Reporting Group - A Part V, Section B, line 3j: To understand each community's individual needs, Ballad Health conducted a Community Health Needs Assessment (CHNA) for each Ballad hospital to profile the health of the residents within its service area. Throughout the CHNA process, high priority was given to determining the health disparities and available resources within each community. Community members from each county met with Ballad representatives to discuss current health priorities and identify potential solutions. Priorities established for the CHNAs were determined by the most significant health needs of each community. Ballad Health hospitals, including MSHA hospitals, conducted their fifth CHNA with board approval and publication occurring at the end of FY21. For FY21 CHNAs, Ballad Health utilized a mixed-methods approach for primary and secondary data collection to gather regional information to inform the 2021 community health needs assessments. The secondary data collection entailed the compilation of secondary data pertaining to agreed-upon metrics and indicators from an array of verified sources. The primary data collection component involved both a key stakeholder survey and key stakeholder focus groups. Findings from both research methods were used to prioritize the needs of the community served by each Ballad Health facility and determine priority focus areas for future improvement efforts. Analysis of secondary data for Washington County, TN findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Washington County. For Johnson City Medical Center, Franklin Woods Community Hospital, Niswonger Children's Hospital, and Woodridge Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Washington County are substance abuse, mental health, and Adverse Childhood Experiences (ACEs). Analysis of secondary data for Sullivan County, findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Sullivan County. For Indian Path Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Sullivan County, TN are substance abuse, mental health, and transportation. Analysis of secondary data for Carter County, TN findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Carter County. For Sycamore Shoals Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Carter County, TN are substance abuse, mental health, Adverse Childhood Experiences (ACEs), and transportation.Analysis of secondary data for Unicoi County, findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Unicoi County. For Unicoi County Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Unicoi County, TN are education, mental health, and Adverse Childhood Experiences (ACEs). Analysis of secondary data for Russell County, VA findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Russell County. For Russell County Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Russell County, VA are substance abuse, mental health, and poverty.Analysis of secondary data for Johnson County, TN findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Johnson County. For Johnson County Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Johnson County, TN are substance abuse, mental health, and Adverse Childhood Experiences (ACEs). Facility Reporting Group - A Part V, Section B, line 5: The community health needs assessment process was guided by the Mobilizing for Action Through Planning and Partnerships (MAPP) model, with an understanding that aspects of the model may have to be adapted due to the purpose of the assessment for Ballad Health and constraints related to the COVID-19 pandemic. In coordination with the MAPP model, concepts from both Community-Based Participatory Research (CBPR) and the Arkansas Center for Health Improvement (ACHI) Community Health Assessment Toolkit were also utilized for the assessments. Following guidance from the MAPP model, a Key Stakeholder Survey was designed with the primary aim of identifying the most-pressing community issues. In aligning with principles of CBPR, the key stakeholder survey was designed to allow key stakeholders to frame community issues in their own words through the use of open-ended questions. In addition to the identification of community issues, the key stakeholder survey was also designed to discern why survey respondents believed the community issues they selected had the greatest effect on the overall health and wellbeing of their community. Questions related to ideas and suggestions for improvement efforts, gauging the success of efforts after the previous community health needs assessments, and community struggles related to the COVID-19 pandemic were also included in the survey. Independent focus groups were conducted for each Ballad Health facility in order to provide specific and unique information for each community being served. The MAPP model and questions from the key stakeholder survey were used to guide the development and construction of the focus groups. Because the key stakeholder survey primarily dealt with the identification of community issues, the focus groups were primarily designed to prioritize community issues identified through the key stakeholder survey and discuss actionable items around how to best address these community issues. Questions related to root causes of community issues, the current state of resources to address community issues, needed resources to initiate improvement efforts and be successful, and community struggles related to the COVID-19 pandemic were also included in the focus group facilitation guide. The key stakeholder focus groups were conducted virtually via WebEx and were one hour and thirty minutes in length.For Johnson City Medical Center, Niswonger Children's Hospital, Franklin Woods Community Hospital, and Woodridge Hospital there were thirty-five focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Washington County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders. For Indian Path Community Hospital there were eighteen focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Sullivan County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Sycamore Shoals Community Hospital there were ten focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Carter County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Unicoi County Hospital there were six focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Unicoi County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Russell County Community Hospital there were nine focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Russell County, VA which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Johnson County Community Hospital, there were seven focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Johnson County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders. Activities associated with the June 2021 assessments took place from summer of 2020 through the spring of 2021. The assessment activity including focus groups & surveys were used to develop the hospital implementation plans that were completed fall 2021. Facility Reporting Group - A Part V, Section B, line 6a: Each hospital within Ballad Health completed a CHNA. MSHA's CHNAs were conducted with all Ballad Health hospitals at that time to include: Bristol Regional Medical Center, Hancock County Hospital, Hawkins County Memorial Hospital, Greeneville Community Hospital, Holston Valley Medical Center, Johnson City Medical Center (includes Niswonger Children's Hospital and Woodridge Hospital), Franklin Woods Community Hospital, Indian Path Community Hospital, Lonesome Pine Hospital (including Mountain View campus), Johnson County Community Hospital, Johnston Memorial Hospital, Norton Community Hospital, Dickenson Community Hospital, Russell County Hospital, Smyth County Community Hospital, Sycamore Shoals Hospital, and Unicoi County Hospital. Facility Reporting Group - A Part V, Section B, line 11: During the year, MSHA focused on its CHNA priorities as identified in its FY21 CHNA report. MSHA's primary areas of focus included: substance abuse, mental health, and Adverse Childhood Experiences (ACEs). Many additional community needs exist in our region. It is fiscally impossible for a hospital to address every health need in a community, which is why the CHNA process is used to identify and prioritize areas of focus. A thoughtful CHNA evaluates overall community health needs to determine which ones the hospital can best influence in a positive way. Consideration is given to other organizations in the hospital's geographic area that already offer services addressing specific health needs. In some cases, it is best to simply support an identified health need through a financial donation to another nonprofit organization skilled in certain areas: teen pregnancy, dental health, fighting homelessness, etc. Hospitals also lend support to other nonprofit organizations by serving on their boards, committees, and assisting with fundraising efforts. Ballad Health made financial contributions to other nonprofit organizations providing community services that support MSHA hospitals' CHNAs. Facility Reporting Group - A Part V, Section B, line 13h: Ballad Health's financial assistance policy allows for some exceptions to strictly adhering to federal poverty guidelines when awarding financial assistance. Unique circumstances may be weighed and assessed for financial assistance consideration on a case-by-case basis. Also, there are some services where financial assistance may be provided outside of federal poverty guidelines. These are noted in Ballad Health's financial assistance policy. 6 1 - MSHA dba BH Homecare-Johnson City 509 Med Tech Parkway Ste 200 Johnson City TN 37604 Licensed Home Health Agency 2 - MSHA dba BH Homecare-Abingdon 611 Campus Dr Ste 300 Abingdon VA 24210 Licensed Home Health Agency 3 - MSHA dba BH Homecare-Greeneville 1410 Tusculum Blvd Ste 1600 Greeneville TN 37745 Licensed Home Health Agency 4 - MSHA dba BH Homecare-Norton 96 15th St NW Ste 104A Norton VA 24273 Licensed Home Health Agency 5 - MSHA dba BH Hospice-Bristol 280 Steeles Road Bristol TN 37620 Licensed Hospice Agency 6 - MSHA dba BH Hospice-Abingdon 611 Campus Dr Ste 500 Abingdon VA 24210 Licensed Hospice Agency Part I, Line 3c: Financial assistance approval can apply to an assortment of patients such as those who have exhausted their Medicaid/TennCare benefits, those who qualified for Medicaid/TennCare after the date of service, deceased patients with no estate or assets, uninsured patients, and underinsured patients. While Ballad Health's qualifications for financial assistance is based on federal poverty guidelines, asset values may also be used to determine financial assistance eligibility. Unique circumstances may be assessed on a case-by-case basis. Charity approval covers current or active patient balances when they are approved and there is no limitation or cap on the amount of charity that a patient may receive. Ballad Health hospitals do not stop approving financial assistance for patient accounts if a hospital's charity write-offs exceed the hospital's charity budget.All Ballad Health hospitals provide an uninsured discount. The current uninsured discount for Critical Access Hospitals (CAH's) is 77% and for all other hospitals or physician practices it is 85%. In addition to the uninsured discount, many patients will further qualify for additional financial assistance. All patients seeking financial assistance must submit an application for financial assistance and submit documents in support of the information on the application, unless specifically excluded according to policy guidelines. Medicaid eligible patients will qualify for 100% financial assistance and not be required to complete the required documentation when: a) Medicaid eligibility requirements are met after the service is provided, b) non-covered charges occur on a Medicaid eligible encounter, or c) benefits have been exhausted. Deceased patients with no estate also qualify for 100% financial assistance.Financial assistance determinations may be retroactive for all outstanding balances. In addition, Ballad Health offers a number of programs with special discounts such as lactation consultation services, oncology treatment regimens, enrollment in various community programs and prescription drugs filled post-discharge. Part I, Line 7: The cost to charge ratio (worksheet 2 "ratio of patient care cost to charges") was used to calculate line 7a financial assistance at cost, which includes charity and uninsured discounts. MSHA's cost accounting system was used to determine losses from Tenncare and Medicaid reported on line 7b, with the exception of home health and a small physician clinic. A cost to charge ratio was used for their data because these are smaller divisions not available in MSHA's cost accounting software. Line 7e community health improvement includes costs that are taken directly from departmental operating reports or expenses specific to a community health event, with no additional overhead included in the cost. Line 7f health professions education is comprised of internships (primarily internal medicine residents, nursing, pharmacy, and therapy students) with schools and universities, allowing their health profession students to receive hands-on training in a hospital setting. MSHA's Medicare-approved programs include medical residents, pharmacy and pastoral care. For these programs, Medicare-approved costs and Medicare reimbursement comes from filed Medicare cost reports. The Ballad Health Organizational Development Department maintains records for the non-Medicare programs. Only labor costs are included for MSHA team members that provide training (no overhead is applied) and only a percentage of team members' time is attributed to actual training. For line 7g subsidized health care services, MSHA's cost accounting system is used because MSHA has established, standard costing reports for these services. There are exceptions where MSHA does not use the cost accounting system. A small clinic inside Johnson County Community Hospital (JCCH), a federally designated critical access hospital, is subsidized by JCCH and the clinic's departmental operating report is used to compute the clinic's community benefit. The second exception is a palliative care program. For this program, the department's operating report is used. MSHA is careful to ensure no double counting of cost. Although there are other service lines within MSHA hospitals that lose money, MSHA does not report services that hospitals are required by state licensure to provide, routine services or ancillary services. Line 7h research represents MSHA's expense allocation from Ballad Health for research. Line 7i cash and in-kind contributions includes cash disbursements and in-kind donations of medications to local nonprofit rescue squads and fire departments. In-kind donations of medications are based on actual cost for these items. Part II, Community Building Activities: MSHA leaders support and encourage all team members to volunteer time, money and skills to community service projects and charitable organizations. Senior leaders and board members set a positive example for MSHA team members, serving voluntarily on committees and boards of local service and nonprofit organizations. Some also serve as members and consultants on professional committees and task forces that affect regional development in healthcare and education. MSHA does not capture costs associated with team members that serve on other nonprofit boards or provide services to other nonprofits.MSHA, in collaboration with area health agencies and providers, may offer assistance with coordination, advocacy, or contribute supplies to support groups for their program activities that serve to assist special populations within the area. Most of these organizations work to improve the lives of community members that have limited, or no, financial resources.During FY23 MSHA provided $250,000 to the Appalachian Highlands Economic Development Partnership; $23,741 of community support to the local Boys & Girls Club, community school supplies programs and Farm to Table Program that supports local farmers; $25,000 to the Summit Leadership Foundation Youth Leadership Program and $5,000 to local Chamber of Commerce leadership programs; and $5,500 to the Lee County Sheriff's Department Test Alert System. Part III, Line 2: Self-pay balances include accounts after payments and contractual adjustments (discounts) have been applied from all third-party payors such as Medicare, TennCare/Medicaid, commercial insurers, and others - generally leaving the patient responsible for any remaining deductible and/or co-payment. Other self-pay accounts are from patients with no insurance or other third-party coverage. Under Ballad Health's system-wide self-pay policy, any patient who has no insurance and is ineligible for any government assistance program received an 85% discount. Many self-pay patients will further qualify for financial assistance (sometimes referred to as charity care) if they provide the financial information needed to deem them eligible or upon determination of presumptive charity eligibility. After the normal collection process has indicated an account is uncollectible, MSHA writes the account off to bad debt. The overall self-pay accounts receivable balance is evaluated on an ongoing basis to evaluate the age of accounts receivable, historical write-offs and recoveries and any unusual instances (such as local, regional or national economic conditions) which affect the collectability of receivables. Part III, Line 3: Ballad Health estimates that approximately 5% of MSHA's bad debt would have qualified for financial assistance if patients had provided a financial assistance application and required documentation. Pursuant to the merger, MSHA has begun to score accounts using a presumptive eligibility tool. This tool utilizes various data points for a proprietary algorithm operated by an outside vendor to provide an individual's score which is then relied upon to assign presumptive charity eligibility. There are many instances of patients with large account balances and no health insurance coverage that MSHA believes would qualify for financial assistance. Although patients are encouraged to apply for assistance, many will not do so. MSHA would prefer for patients to submit completed financial assistance applications given that historical data clearly indicates that most uninsured patients and many underinsured patients will qualify for financial assistance under our program. Without a completed application, these are recorded as bad debt instead of charity care. Part III, Line 4: Ballad Health's audited financial statements include a footnote on page 14 that describes bad debt. MSHA is included in the June 30, 2023 audited financial statements of Ballad Health (attached). Part III, Line 8: Excluding Medicare losses reported in Part I subsidized health, the Part III Medicare allowable costs are reported using MSHA's filed Medicare cost report (C/R). The C/R uses a cost to charge ratio based on a step-down allocation methodology. MSHA believes Medicare losses should be allowed as a reportable community benefit, similar to governmental programs such as Medicaid. As a participating provider in the Medicare program, hospitals are required to provide the full regimen of care for the Medicare population. There are a number of care regimens that are compensated by the Medicare program at levels below cost. Therefore, it is only logical to allow hospitals to report these uncompensated services as a community benefit. By making this change, nonprofit providers will be encouraged to continue important care delivery models for our aging population in spite of the fact it may be economically injurious. Part III, Line 9b: Requests for financial assistance are evaluated using established guidelines, while allowing for unique financial circumstances - for example, medically indigent patients with catastrophic medical costs that would threaten the patient's household financial viability. When a patient requests financial assistance or when an application has been received, the patient's account is placed in a hold status to prevent further collection activities until financial assistance eligibility is determined. All Ballad Health hospitals comply with IRS 501(r) regulatory guidelines.Ballad Health's collection policy clearly states that all patients are treated equally - with dignity and respect. Ballad Health ensures that outside collection agencies adhere to Ballad Health billing and collection guidelines. The collection program includes communicating expected financial responsibility prior to service. MSHA hospitals provide assistance to help underinsured and uninsured patients determine sources of payment for medical bills and to help patients determine eligibility for programs such as TennCare or Medicaid.After insurance benefit verification, MSHA hospitals bill insurance carriers. If the insurance carrier denies payment of the service/procedure as non-covered or the patient has exceeded their maximum benefits, the service/procedure will qualify for the uninsured discount.Financial counselors are available to discuss financial assistance with patients and their families. MSHA hospitals provide a number of payment options:- a pre-service discount may be offered- a discount in excess of established discounting rates may be granted for catastrophic high dollar accounts- MSHA hospitals accept all non-contracted and out-of-network payors and will make attempts to work with these payors regarding appropriate reimbursement and billing to their members- as part of Ballad Health's commitments to the State of Tennessee and Commonwealth of Virginia to form Ballad Health, not-in-network discounts are applied per policies in place for MSHA hospitals- payment arrangements are available as long as the account is not with a collection agencyReasonable efforts are made to determine if a patient is eligible for financial assistance - see Schedule H, Part VI, line 3 for information on how patients are informed about the Ballad Health financial assistance policy. Part VI, Line 2: Focusing on population health improvement and associated priority metrics allows Ballad Health to further engage the efforts of its hospitals in partnership with communities in our service areas. It has helped Ballad to better identify health disparities that appear across the individual communities and has helped Ballad to prioritize issues that are most important in each hospital's community. Engaging local community organizations expands partnerships so that organizations work together more to address community health needs. Ballad Health uses a comprehensive process to gather input for and continues to evolve its population health plan. Because our hospitals are located in a region with many chronic disease challenges and high levels of health-related social risks, Ballad Health's goal is to target population health issues to make lasting improvements. Ballad conducts ongoing interviews, focus groups and meetings with external groups, including the regional health departments, United Way agencies, chambers of commerce, schools and community organizations, the regional accountable care community leadership council, as well as internal groups such as our population health and community benefit committee of the Ballad Health board of directors, the Ballad Health population health clinical committee, social needs council, grant advisory committees and our hospital community boards in the creation and on-going implementation of its population health plan. Part VI, Line 3: Consistent with the Ballad Health financial assistance policy, MSHA communicates with and provides education to patients through various avenues regarding governmental assistance programs and hospital financial assistance. Various educational and application documents related to obtaining financial assistance are widely available at MSHA and all documents are available on the Ballad Health website. Printed financial assistance educational materials are part of each registration packet and posters are displayed in highly visible areas of the hospitals. Our financial assistance policy and documents are available in emergency departments and admitting areas. MSHA is also happy to mail all documents to patients and offers a plain language summary. All documents are available in English and Spanish. Financial assistance information is available during pre-registration, registration and/or during financial counseling. MSHA offers governmental program eligibility representatives to assist patients in securing eligibility for TennCare or Medicaid, federal disability and other governmental assistance programs. Additionally, if a patient or community resident expresses an interest in the ACA-healthcare exchange, MSHA representatives have the qualifications and experience to assist them through the entire process. Financial counselors offer financial assistance applications to patients who do not qualify for governmental assistance programs and are unable to pay for some or all of their healthcare.All patient billing statements have verbiage discussing financial assistance along with contact information. The last letter to the patient displays the plain language summary. In all oral correspondences with a patient, if it is identified the patient cannot meet payment requirements on their account, financial assistance is discussed as an option.Applicants are notified of financial assistance determination in writing. Part VI, Line 4: MSHA serves the healthcare needs of 29 Appalachian counties in Northeast Tennessee, Southwest Virginia, Southeast Kentucky, and Northwest North Carolina. All of the counties MSHA serves are federally designated as medically underserved areas. MSHA's largest hospital, Johnson City Medical Center, is a tertiary referral center and level one trauma center. Medically underserved areas are designated by the U.S. Department of Health and Human Services. Shortage areas are identified through analysis of physician to population ratios depending on whether an area is considered to have a high need. Criteria used to determine high need are poverty rates, the percent of the population over age 65, infant mortality rates and fertility rates. MSHA operates 2 critical access hospitals: Johnson County Community Hospital in Tennessee and Lee County Community Hospital in Virginia.Additionally, according to the 2021 County Health Rankings, counties where MSHA hospitals are located ranked poorly for both health outcomes and health factors. Part VI, Line 5: MSHA is dedicated to operating efficiently so that waste is minimized. MSHA's leadership remains mindful of managing limited resources so that adequate facilities and equipment are available for the care of patients. Surplus funds are invested into improving treatment options for patients through new technologies, recruiting physicians and trained staff in shortage areas, and improving MSHA facilities. Various checks and balances are established to ensure that expenditures for operating expenses and capital costs are reasonable and necessary. MSHA has several hospitals with Medicare-approved health profession education programs. In addition, MSHA hospitals serve as training sites for many types of health professions: nursing, pharmacy, psychology, lab, respiratory therapy, EMT, public health, etc. Students from numerous colleges, universities, and programs receive training and experience in MSHA hospitals. MSHA resources are devoted to health conferences for local health professionals, two health resources centers conveniently located in a shopping mall and a wellness center; provide for media coverage to educate residents on health issues; offer events to the public that combine fun activities with health education; and many other programs focused on improving the health of area residents. While MSHA operates hospitals in predominantly low-income, rural and isolated areas, MSHA continues to offer services that operate at a loss because residents would otherwise need to leave their hometown or county to receive needed care. Mountain States merged with Wellmont Health System in February 2018 to form Ballad Health healthcare system. Mountain States and Wellmont still exist as legal entities and continue to operate multiple hospitals. MSHA's governing body is comprised of persons who reside in the organization's primary service areas. Physicians that request privileges who are qualified and credentialed are extended privileges by MSHA. Part VI, Line 6: Mountain State's merger with Wellmont opened up many opportunities not previously available to two competing health systems. Collaboration started post-merger and Ballad Health continues to see progress towards improving efficiencies within our health system, activities consistent with Ballad Health's population health initiative, sharing best practice quality improvements, and other benefits related to operating as one rather than operating in a competitive environment. A clinical council was formed immediately following the merger. The council includes physicians nominated from the leadership of all Ballad hospitals. A Community Benefit and Population Health Committee of the board was established, and various other infrastructures have been established since the merger. Across MSHA's hospitals, there were many projects, programs, and collaborative efforts that took place during the year. MSHA provides care to people in 29 counties in Tennessee, Virginia, Kentucky and North Carolina. Each hospital is fully accredited by The Joint Commission, with the exception of Johnson County Community Hospital and Lee County Community Hospital. JCCH and LCCH receive certification through the states of Tennessee and Virginia since they are critical access hospitals. MSHA, based in Johnson City, Tennessee includes 8 wholly owned hospitals which are included in this Form 990. In addition, MSHA owns 2 hospitals located in Southwest Virginia, each of which file separate returns. In addition to acute care hospitals, the system includes such services as:Primary/specialty physician practices, emergency departments, occupational medicine, rehabilitation, outreach laboratory, mental health, neonatal intensive care, a NACHARI-affiliated children's hospital, renal dialysis, St. Jude's Oncology, inpatient/outpatient surgery, skilled nursing, long-term care, home health, and more. With these additional facilities and services, MSHA extends a highly effective health care delivery system. Since our system is both horizontally and vertically integrated, patients can be efficiently moved along an integrated, comprehensive continuum of care as their health status dictates. MSHA's flagship facility, Johnson City Medical Center is at the core of the system offering full-service tertiary care. In addition to MSHA hospitals, MSHA is the sole member of Blue Ridge Medical Management Corporation (BRMMC). MSHA extends an integrated healthcare delivery system through BRMMC to include multiple primary and specialty care patient access centers and numerous outpatient care sites, including urgent care centers, occupational medicine services, a same day surgery center and rehabilitation.MSHA partners with East Tennessee State University to operate Overmountain Recovery, an opioid addiction recovery facility located in Gray, Tennessee.MSHA is the sole member of Integrated Solutions Health Network, LLC. (ISHN). ISHN operates Anewcare Collaborative, the region's first accountable care organization, bringing together community health care providers to provide better outcomes and improved patient satisfaction at a lower cost.Hospitals in the Ballad Health system work closely with one another to share expertise and resources. Part VI, Line 7, Reports Filed With States TN,VA Part VI, Additional Information Ballad Health is required to report community benefit estimates on a quarterly basis with the states of Tennessee and Virginia. The reporting includes all of Ballad's hospital organizations and is reported using IRS Form 990, Schedule H instructions for reporting community benefit. Ballad operates under a Cooperative Agreement (CA) in Virginia and a Certificate of Public Advantage (COPA) in Tennessee as obligated by agreements between Ballad and the two states to allow Mountain States Health Alliance and Wellmont Health System to merge. 1 Appalachian School of Law 1169 Edgewater Drive Grundy VA 24614 541743079 501c3 260000 0 Improve Access to Healthcare Program East Tennessee State University PO Box 70732 Johnson City TN 37614 626021046 501c3 470000 0 College of Pharmacy East Tennessee State University Foundation PO Box 70721 Johnson City TN 37614 237092731 501c3 32775 0 Center for Nursing Excellence East Tennessee State University Foundation PO Box 70721 Johnson City TN 37614 237092731 501c3 134010 0 Research Kingsport Chamber Foundation 400 Clinchfield St Ste 100 Kingsport TN 37660 581453565 501c3 13750 0 Program Sponsorships Southern Appalachian Ronald McDonald House Charities 418 N State of Franklin Rd Johnson City TN 37604 621578123 501c3 8000 0 Program support 6 Part I, Line 2: The Ballad Health Community Benefit and Population Health Committee is a collective group of members from both Tennessee and Virginia. These members bring a variety of insights into community health improvement, striving to cultivate an understanding of population health, philanthropy, community benefit obligations, and the integral role that Ballad Health plays in enhancing health access. Senior leadership of Ballad Health, including the President and CEO and the COO, are present at these meetings. One of the committee's key duties is to ensure that charitable donations are in line with the policies set by the Ballad Health Board. All applications for assistance are submitted digitally, complete with the necessary information to assess eligibility. Following a thorough review of these applications by the committee, approval must be obtained from various levels, including the Ballad Health CEO or the Ballad Health Board, depending on the level of commitment required. For those seeking funding for a specific event or program, the application should include the following details: -Mission statement of organization -Year organization was founded -Tax status and federal taxpayer ID number -Website -Description of the event/program -Event/program budget -Other sources of income -Impact of the event/program on the health of residents in our region -Beneficiaries of contribution -Number of people served annually -Event/program accomplishments -Measure of accomplishments 1 1 0 0 0 0 0 0 0 Alan Levine BH PresCEO Director, Chair 0 1351717 0 2162808 0 42835 0 218859 0 28232 0 3804451 0 0 Marvin Eichorn BH EVPCAO Director 0 752788 0 598921 0 1755437 0 17400 0 28120 0 3152666 0 0 Eric Deaton BH EVPCOO Director 0 720293 0 530155 0 18360 0 84013 0 22675 0 1375496 0 0 Lynn Krutak BH EVP/CFO 0 682629 0 520077 0 6772 0 82332 0 27396 0 1319206 0 0 Clay Runnels MD Fmr Offcr BH EVP/Chief Phys Exec 0 626281 0 450791 0 18419 0 72852 0 26005 0 1194348 0 0 Tim Belisle BH EVPGen Cnsl Director, Secretary End July 2022 0 277977 0 310583 0 238567 0 29779 0 26452 0 883358 0 0 Lisa Carter Reg'l Pres - Southern Mkt 421628 0 211924 0 12114 0 29940 0 24766 0 700372 0 0 0 Mark Wilkinson MD Fmr HComp BH VP/CMIO 0 424870 0 108231 0 15898 0 18150 0 26134 0 593283 0 0 Matthew Loos Fmr HComp BH VP/CAO 0 396819 0 103742 0 6596 0 18246 0 28576 0 553979 0 0 Joshua McFall Fmr Key Empl CFO - Acute Services 0 359547 0 94810 0 1036 0 34586 0 26711 0 516690 0 0 Kenneth Shafer VP/CEO - JCMC 331343 0 80954 0 2153 0 14702 0 21624 0 450776 0 0 0 Melanie Stanton VP/CEO - FWCH 282891 0 72725 0 8504 0 15740 0 23136 0 402996 0 0 0 Linda White Fmr Offcr VP/Pres - NW Mkt 0 220967 0 125400 0 16988 0 16253 0 13553 0 393161 0 0 Lemmie Taylor VP/CEO - SSH 244069 0 64896 0 8858 0 27619 0 24796 0 370238 0 0 0 Chase Wilson Fmr Key Empl CFO Greene Co 0 229756 0 66225 0 204 0 14416 0 25896 0 336497 0 0 Dwight Owens Admin/COO - IPCH 233629 0 49162 0 7252 0 14582 0 23040 0 327665 0 0 0 Eric Carroll Fmr HComp CEO Greene Co 0 225992 0 59099 0 1140 0 13760 0 19404 0 319395 0 0 Morgan May VP/Reg'l CNO 220672 0 54838 0 1026 0 0 0 21270 0 297806 0 0 0 David Wild MD VP/Reg'l CMO 212523 0 500 0 25532 0 0 0 13883 0 252438 0 0 0 Andrew Wampler BH Gen Cnsl Director, Secretary End April 2023 0 202835 0 1250 0 3301 0 30762 0 9998 0 248146 0 0 Brandy Lawson Lead Resp Therapist FWCH 222512 0 1250 0 1450 0 13579 0 7027 0 245818 0 0 0 Corinne Allen MultiFac Dir - Pharm Svcs 194867 0 9538 0 5877 0 12892 0 21091 0 244265 0 0 0 Greta Morrison AVP, Admin/CNO - RCH 161535 0 31519 0 5165 0 10445 0 25748 0 234412 0 0 0 Frank Canova Regional CFO 163711 0 10500 0 16872 0 0 0 9482 0 200565 0 0 0 Part I, Lines 4a-b The following executives listed in Schedule J, Part II participated in a 457(f) retirement plan provided by Ballad Health (BH). The 457(f) plan is a nonqualified tax-deferred compensation plan available to a select group of key executives for the intent of supporting retention and to offer a competitive total retirement program. Account balances have a "substantial risk of forfeiture". In addition to creditor risk, substantial risk of forfeiture is created through default risk if the participant's employment with Ballad Health is terminated prior to age 65. However, the 457(f) plan contains a non-compete provision that provides the account balance to be paid in a lump sum after the executive satisfies the two-year non-compete period. This provision applies to employer contributions if the executive has provided eligible service for six or more years. The executive will receive the entire account balance if he/she becomes disabled, dies or if the executive terminates for "good reason or is involuntarily terminated without "good cause" within a 24-month period after a change-of-control occurs. Distributions from this plan are subject to federal, state, and local taxes on the entire account balance upon distribution. Alan Levine $201,459 Eric Deaton $ 66,613 Lynn Krutak $ 64,932 Clay Runnels $ 55,452 Tim Belisle $ 22,233 Joshua McFall $ 18,615 Andrew Wampler $ 18,111 Lisa Carter $ 16,333 Linda White $ 10,176 Lemmie Taylor $ 12,436 The following executive received a change-of-control payment. The payment was reported as taxable income with appropriate tax withheld and remitted to the IRS. Tim Belise $179,601 Laura Levine Family Member 41096 See Part V 0 Part IV, Supplemental Information Alan Levine, President and CEO of the Ballad Health/Mountain States Health Alliance Board of Directors, is a family member of Laura Levine, an employee of Mountain States Health Alliance. Part III, Program Service Accomplishments Ballad Health (Ballad) is an integrated healthcare delivery system consisting of 21 hospitals in Northeast Tennessee and Southwest Virginia, including a Level 1 Trauma Center, dedicated children's hospital, several community hospitals, three critical access hospitals, a behavioral health hospital, an addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, outpatient services and a comprehensive medical management corporation. Ballad works closely with an active independent medical community and community stakeholders to improve the health and well-being of over one million people in 29 counties of the Appalachian Highlands in Northeast Tennessee, Southwest Virginia, Northwest North Carolina, and Southeast Kentucky. Ballad is a Tennessee non-profit corporation and is the main provider of healthcare services in Northeast Tennessee and Southwest Virginia. Ballad Health is a tax-exempt entity and the parent corporation of both Mountain States Health Alliance (MSHA) and Wellmont Health System (WHS). On February 1, 2018, Ballad was formed through a merger of two legacy systems, Mountain States Health Alliance and Wellmont Health System. Ballad was formed under state-action immunity in compliance with federal antitrust law, to create a healthier region and keep healthcare local. The action approving the merger was officially taken through the agreements made between Ballad and the State of Tennessee in the Certificate of Public Advantage (the "COPA") and the Letter Authorizing the Cooperative Agreement (the "CA") in Virginia. Pursuant to the COPA and CA, Ballad must fulfill certain obligations, commitments, and covenants. Tennessee and Virginia, through their respective health departments, supervise specific aspects of Ballad's operations under certain conditions of the COPA and the CA. The COPA and amendments are publicly available on the website of the Tennessee Department of Health, at https://www.tn.gov/health/health-program -areas/health-planning/certificate-of-public-advantage.html. The Cooperative Agreement is available on the website of the Virginia Department of Health, at https://www.vdh.virginia.gov/licensure- and-certification/cooperative-agreement/. Form 990 for Mountain States Health Alliance (MSHA) includes eight wholly owned hospitals including a tertiary hospital, a children's hospital and a behavioral health hospital; two others, wholly owned by MSHA, each file a separate return. MSHA is sole shareholder of Blue Ridge Medical Management Corporation (BRMMC), a for-profit entity that owns and manages physician practices and real estate and provides other health care services to patients in Tennessee and Virginia. MSHA is the sole member of Integrated Solutions Health Network, LLC (ISHN). ISHN, also included in this Form 990, is a regional health solutions company headquartered in Johnson City, Tennessee. ISHN is an expansive network of providers serving residents of Northeast Tennessee and Southwest Virginia and consists of provider groups, primary care physicians, specialists, and allied health providers. Specific to the hospitals included in this Form 990, services were provided to: 40,689 inpatients 590,225 outpatient visits 177,233 emergency visits 3,373 deliveries 24,120 surgeries 88,765 home health visits WASHINGTON COUNTY, TN: JOHNSON CITY MEDICAL CENTER (JCMC) - Located in Johnson City, Tennessee and serving the community since 1911. The 585-bed regional tertiary referral center has 416 beds dedicated to acute care, 85 beds for children and 84-beds for behavioral. - Provides a wide array of acute care services, including a complete range of cardiovascular, neurology, oncology, surgical and rehabilitation services. JCMC is a comprehensive, acute-care teaching hospital affiliated with James H. & Cecile C. Quillen College of Medicine at East Tennessee State University (ETSU). - Region's only Level I trauma center, one of only five in Tennessee, with 24/7 orthopedic traumatologist specialist coverage. - Region's only safety net hospital. - Regional Cancer Center at JCMC has relationships with Harvard, Duke, and Vanderbilt universities. - Quantros named JCMC in the top 10% of hospitals in the nation for patient safety in overall medical care, trauma care, heart attack and heart failure treatment, stroke care, hip fracture treatment and major neurological surgery in its 2023 CareChex awards. JCMC was also recognized among the top 100 hospitals and top 10% of hospitals in the nation for medical excellence in hip fracture care. - U.S. News recognized JCMC as "high performing" for knee replacement procedures, heart attack care and treatment, heart failure care and treatment, and care of stroke patients. - Niswonger Children's Hospital (NsCH) is a hospital within a hospital located on the campus of JCMC. NsCH is the only children's hospital in northeast Tennessee and serves more than 200,000 children in the four state, 29-county region. NsCH has more than 20 pediatric subspecialties providing specialty care through a pediatric emergency room and 85 inpatient beds, including a 16-bed neonatal abstinence syndrome unit. The Level III designated neonatal intensive care unit is only one of five state-designated tertiary centers for high-risk maternal fetal care in Tennessee and is the regional referral center for neonatal patents. A Ronald McDonald House is located on the campus and provides services to the pediatric patients and family members. In October 1999, a clinical affiliation was entered with St. Jude's Children's Research Hospital to provide pediatric cancer and other catastrophic disease treatment services. The affiliation with St. Jude's in one of only eight in the country. The First Regional Hemophilia Program, a state sponsored program for congenital bleeding disorders, is housed in the St. Jude affiliate clinic and provides programs for both children and adults with hemophilia. - Woodridge Hospital, a free-standing 84-bed behavioral health hospital located across the street from JCMC, provides mental health and chemical dependency services for adults, adolescents, and children in Northeast Tennessee and Southwest Virginia. Woodridge is the only dedicated inpatient behavioral health hospital in the region and provides a 24/7 intervention helpline. In 2023, Woodridge opened a new access point for behavioral healthcare with a 24/7 walk-in behavioral crisis clinic for patients experiencing behavioral health emergencies, such as suicidal or homicidal ideation, acute psychosis, auditory and/or visual hallucinations and other extreme mental or emotional crises. WASHINGTON COUNTY, TN: FRANKLIN WOODS COMMUNITY HOSPITAL (FWCH) - 80-bed acute care hospital located in Johnson City, Tennessee and providing services since 2010. - Provides specialty and subspecialty care, including general acute medical, maternity, comprehensive diagnostic imaging, emergency services and advanced surgical services, including minimally invasive robotic surgery. - FWCH was the first "Leadership Energy and Environmental Design" (LEED) certified hospital in Tennessee. - U.S. News recognized FWCH as "high-performing" for pulmonary disease care. - Healthgrades recognized FWCH as a Five-Star Recipient for Treatment of Sepsis in 2023. SULLIVAN COUNTY, TN: INDIAN PATH COMMUNITY HOSPITAL (IPCH) - 239-bed acute care hospital located in Kingsport, Tennessee serving the community since 1984. - Provides general medical and surgical services, including the Center for Women and Babies, various outpatient services, including advanced services such as the lung nodule clinic, a regional cancer center, and a sleep center. - IPCH opened the third Niswonger Children's Network Pediatric Emergency department in 2023, strengthening the system of care for children by joining Niswonger Children's Hospital in Johnson City and the J.D. Nicewonder Family Pediatric Emergency Department at Bristol Regional Medical Center. - Quantros named IPCH in the top 10% of hospitals in the nation for patient safety in overall surgical care, medical excellence in general surgery, patient safety in gastrointestinal care in its 2023 CareChex awards. IPCH was also named in the top 10% in the State of Tennessee for patient safety in general surgery. - U.S. News recognized IPCH as "high-performing" in pneumonia care in 2023. CARTER COUNTY, TN: SYCAMORE SHOALS HOSPITAL (SSH) - 121-bed acute care facility located in Elizabethton, Tennessee providing services to the community since 1955. - Provides inpatient, geropsychiatric, and outpatient care for medical and surgical patients. - Quantros named SSH in the top 10% in the nation for medical excellence in gallbladder removal in its 2023 CareChex awards and in the top 10% of hospitals in the State of Tennessee for gastrointestinal hemorrhage. JOHNSON COUNTY, TN: JOHNSON COUNTY COMMUNITY HOSPITAL (JCCH) - Federally designated critical access hospital located in Mountain City, Tennessee serving residents of upper Northeast Tennessee, parts of western North Carolina and Southwest Virginia since 1998. - Provides inpatient, emergency and outpatient care along with cardiac rehabilitation, diagnostic, and physical therapy services. RUSSELL COUNTY, VA: RUSSELL COUNTY HOSPITAL (RCH) - 78-bed Medicare dependent hospital located in Lebanon, Virginia. - Included in the 78-bed complement, is a 20-bed inpatient psychiatric unit. RCH offers a full array of primary care services and some specialty services, including a cancer center. UNICOI COUNTY, TN: UNICOI COUNTY HOSPITAL (UCH) - 10-bed acute care hospital, located in Erwin, Tennessee and providing services since 2018. - Provides general acute inpatient, emergency, cardiology, diagnostic imaging, sleep lab, and rehabilitation services. LEE COUNTY, VA: LEE COUNTY COMMUNITY HOSPITAL (LCCH) - 10-bed critical access hospital located in Pennington Gap, Virginia providing services since 2021 to residents of Southwest Virginia and Southeast Kentucky. - LCCH was specially designed to meet the needs of its community, with acute and emergency services, diagnostic radiology and lab services, outpatient cardiology and additional rotating clinics for specialty care and telehealth access. FOCUSING ON QUALITY EMPHASIZING ZERO-HARM THROUGH TIERED SAFETY HUDDLES - As part of Ballad Health's systemwide initiative to improve safety and reduce harm, Ballad Health continued its tiered safety huddle program throughout the pandemic. Each day, frontline team members across the Ballad Health organization begin their morning with huddles focused on clinical quality and safety. These huddles provide an organized manner for team members to express opportunities to improve safety and quality and strive towards becoming a zero-harm institution. Any issues identified during those huddles are elevated to hospital leadership. If hospital leadership needs help to resolve the problem, the issue is further elevated to the market and corporate levels. Using this approach, Ballad Health can improve outcomes and enhance safety by rapidly deploying resources to support and solve safety issues as they arise. LAUNCH OF IBM/WATSON TOP HEALTH SYSTEM JOURNEY - Since the merger in 2018, one of Ballad Health's priorities has been to instill a zero-harm culture and become one of the highest-performing health systems in America for the quality of care it delivers to patients. After a rigorous review of the various systems for measuring that success, Ballad Health leaders chose IBM/Watson because it provided measurable, achievable, and valid guideposts for the health system. To help lead Ballad Health on this journey to become a top health system in the nation, health system leaders formed the IBM/Watson Top 15 Health System Task Force, comprised of stakeholders from multiple departments of Ballad Health. IBM/Watson identifies the 15 top-performing health systems in the nation based on four key performance domains: inpatient outcomes, extended outcomes, operational efficiency, and patient experience. Dr. Amit Vashist, Ballad Health's chief clinical officer, who leads the IBM/Watson top health system journey, stated, "We looked far and wide at various methodologies to identify the most appropriate benchmarks to measure ourselves against, and we ultimately chose IBM/Watson because it included an ideal blend of metrics and measures that are truly meaningful and appealed to our frontline clinicians, such as hospital-acquired conditions, ED throughput, readmissions, mortality, costs of care and length of stay." CLINICAL COUNCIL - A unique feature of Ballad Health is the establishment of a robust and diverse Clinical Council, comprised of about 30 physicians. The physicians were nominated by the leadership of all Ballad Health hospitals, the health system's medical group and independently practicing community physicians. The Council's members also include pharmacists, advanced practice providers and nurses. The Council reports directly to the Quality Committee of the Ballad Health Board of Directors. The council aims to ensure excellence in clinical care through physician engagement and leadership and is charged with guiding Ballad Health's transformation into a community health improvement system. As a result of the council's efforts, several important quality measures are now performing among the top-decile health systems in America. CONTINUED PUBLIC ADVANTAGE Ballad's compliance with each of the COPA and CA is supervised by Tennessee and Virginia respectively. Ballad is in compliance with all terms of the COPA and CA. Each year since the creation of Ballad, the State of Tennessee and Commonwealth of Virginia have independently confirmed the public advantage created by the unification of the hospitals in the rural region. In the latest report dated March 2023, the Tennessee Department of Health highlighted "Over the life of the COPA, improvement was seen in Ballad Health's service area for most of the Access Sub-Index measures. Significant improvements were seen in preventive health measures such as primary care provider and prenatal care in the first trimester. Improvement was also achieved by Ballad Health in all five screening measures, with the most significant improvement occurring in rates of Colorectal Cancer Screenings and Diabetes and Prediabetes Screenings". TDH also recognizes that Ballad Health continued to invest in standing up and implementing many of its Population Health, Behavioral Health, Children's Health, Rural Health, and Health Research and Graduate Medical Education programs proposed under the system's three-year Spending Plans, even as it prioritized its response to COVID-19. In the Tennessee Department of Health report covering the period of July 1, 2021 to June 30, 2022, the department noted that as a combined health system, "Ballad Health's continued handling of the pandemic and the fact that all of Ballad Health's 21 hospitals, including its many vulnerable rural hospitals, remained open through the year are acknowledged by TDH as two of the system's greatest successes during FY22". In each year before the COVID-19 pandemic, Ballad Health also maintained one of the nation's most successful Accountable Care Organizations, which has been highlighted by the Centers for Medicare and Medicaid Services as one of a handful of organizations that have produced savings for taxpayers in each year since the program's creation, while making high-quality scores. ENVIRONMENTAL, SOCIAL, AND GOVERNANCE (ESG) Ballad Health is committed to being a responsible and concerned citizen of the communities of the service area where it operates and is driven by its mission: "honor those we serve by delivering the best possible care." Ballad continues to deploy initiatives intended to improve the overall health and well-being of the over one million people living in its service area. ENVIRONMENTAL - Environmental stewardship and preserving the environment is important to Ballad and is demonstrated in the following practices: - Environmentally responsible supply chain - Encourage the recycling of materials and minimization of waste - Encourage the reduction of energy usage - Incorporate environmentally preferable alternatives when designing new construction SOCIAL - Social commitments are an integral part of Ballad's mission, vision, and values. By working and collaborating with others in the communities in which it serves, Ballad works "to build a legacy of superior health by listening to and caring for those we serve". Ballad provides direct and in-kind support to improve access to care and deliver healthy lifestyle services, education, and activities. The community health programs are designed to improve access and quality of care, strengthen community outreach and partnerships, decrease healthcare costs, and assist in the reduction of health care disparities in the region. Ballad has opened two new rural hospitals in the past five years. Ballad offers extensive education and outreach programs throughout the community at little or no cost to participants. Program areas include: - Community events, such as health fairs, screenings, flu shots, health and safety education, support groups, stroke education, baby and child health, and medical libraries - Children's resources, such as the Morning Mile Program, B.E.A.R. Buddies, car seat safety, and Families Thrive. - Heart and Soul, senior health, and well-being programs. - General health resources, individual health, nutrition, and safety education. - Regular health education speakers covering a wide range of topics. The following are some of the programs designed to improve healthcare equity and availability: Ballad as a Community Health Improvement Organization: Ballad's goal is to ensure the sustainability of rural healthcare services while improving the health and well-being of the region as a whole. In the short-term, Ballad will address health related social needs to improve access to care, reduce inequity, and empower individuals to adopt healthy behaviors and manage health conditions. In the long-term, Ballad will address social drivers of health to provide a community level foundation for permanent regional health improvement through multi-sector collective impact. Ballad is taking an intergenerational approach to focus on children's health initiatives to give kids a strong start in life, as well as assisting adults with overcoming obstacles to health and self-sufficiency. Ballad is on a journey to universalize social needs screening and prioritized navigation resources throughout the system using embedded Epic tools combined with the UniteUs referral management platform. These efforts are informed and supported by a multi-departmental team called the Social Needs Council which has accountability to the system Population Health Council, the Chief Population Health Officer, and ultimately the board Population Health and Social Responsibility Committee. STRONG Accountable Care Community: Driving Community Level Action and Change: The STRONG Accountable Care Community is a regional collective impact model focusing on community level strategies across a life course model that includes a multi-generation approach to parenting support and family self-sufficiency. Established in 2018, the STRONG Accountable Care Community (STRONG ACC), sponsored by Ballad, is a 350 organization, multi-sector model serving the same geographic footprint as Ballad and additional contiguous counties. The STRONG ACC has adopted the "Five Conditions of Collective Impact": a common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support. Ballad is providing backbone support and investing in the STRONG ACC because the health system believes the collective impact model is necessary to accelerate, leverage, and sustain community level change. The STRONG ACC is also using the UniteUs platform for a "no wrong door" approach to social needs across hundreds of networked organizations. The organization is also creating an Early Care and Education Plan for all of Northeast Tennessee and Southwest Virginia. For more information, visit https://www.strongacc.org/. Accountable Health Communities ("AHC"): When Ballad was awarded the Accountable Health Communities grant from the Centers for Medicare and Medicaid Services in 2017, the system acted on its vision to universalize social needs screening and navigation. Health related social needs create major barriers to health for some individuals. Within Ballad Health, Unite Tennessee and Unite Virginia will allow specially trained staff to conduct health-related social needs screenings for gaps in care, such as food and housing insecurity, transportation challenges or other obstacles. It will then connect those families with community organizations committed to resolving those issues. The network, however, is not dependent on Ballad Health. Participating organizations will also be able to refer clients to each other even if the people they're referring aren't Ballad Health patients. Since its inception, the program has screened 319,349 individuals and identified 50,000 distinct needs, working with nearly 2,000 regional organizations to successfully connect individuals to services which provide food, housing, transportation, safety support, and utilities among other needs. AHC has provided 29,681 community referrals and navigation for 7,573 patients. The program has revealed new information about the extent of social needs within Ballad's patient environment and informed the goal to scale social needs screening and navigation services throughout the organization. Appalachian Highlands Care Network: Appalachian Highlands Care Network, started in 2020, is Ballad's program to serve low-income, uninsured people of the region through a realignment of charity care dollars. The goals of the Appalachian Highlands Care Network are to identify low-income uninsured people, enroll them in the program, and serve them to improve quality of care, increase access to care, and reduce avoidable cost of care. Patients in the program receive free needed medical care from Ballad and a network of other providers. This includes ensuring all patients have a source of primary care and are screened and navigated to social need resources, provided with medical care coordination, and assisted through care management services. Ballad partners significantly with Appalachian Mountain Project Access, the region's free and reduced cost clinics and health departments, and hundreds of regional social support agencies to break down barriers to medical care, improve chronic conditions like diabetes, and address social needs. To date, the program has enrolled more than 4,800 individuals. STRONG Starts: Ballad believes safe, stable, nurturing environments for children are essential to optimal early development and later success in life. Started in 2021, STRONG Starts is aimed at improving birth outcomes and reducing the negative impact of chronic stress for mothers, babies and families. The birth of a new baby is a pivotal time for a mother and her family. No one should feel alone or unsupported during this time. Ballad seeks to connect with every expectant mother as early in her pregnancy as possible to ensure access to early prenatal care - all in partnership with the region's obstetric providers. As the life situation and pregnancy experience for every woman is different, Ballad will build supportive relationships aligned with the unique circumstances of every woman and family. With embedded staff in the region's obstetric practices and hospital birthing centers, these relationships begin early. Staff will help families connect with community resources for issues from food/housing insecurity to parenting resources to education/job training. To date, the program has screened more than 7,300 women and served nearly 3,000 through the course of their pregnancies. The program continues into the post-natal and early stage of life. Ballad staff assist those in the program through kindergarten entry with a whole-family approach. This ongoing relationship will help with evolving needs and the transition in healthcare from the obstetric environment to the pediatric environment. Ballad works with regional pediatricians to ensure they can refer children and families into the program. The developmental milestones of children will be assessed so early supports can be provided, and Ballad assist with connections to community resources as children grow, including programs which support resiliency and early learning environments. Ballad seeks to further support the safety, stability, and self-sufficiency of families and to help ensure children enter kindergarten developmentally, socially, and emotionally ready to learn. This first experience with the educational system is foundational, as it sets the tone for later success with grade level reading, math proficiency, and the academic discipline needed to ensure high school graduation and college and career readiness. These benchmarks are predictors of later economic and health outcomes which can reshape the life trajectory, health, and well-being for children and families for generations to come. To date, this section of the program has served more than 2,000 families. In addition to these programs, Ballad invests significant funding annually to support partnering organizations, Community Health Improvement Sites, who provide aligned services and mutually serve the populations mentioned above. These services include free health services, care coordination, housing supports, substance use and recovery, social needs support, maternal/child supports, early learning and literacy improvement initiatives, and women's health services. Ballad also provides a host of other services to vulnerable populations including free cancer screenings, mobile health services, health fairs, children's resources, and health education programs notably through a network of faith community nurses. Governance Governance is overseen by the Ballad Board of Directors and ongoing ESG work through the following committees: - Audit and Compliance - environmental and sustainability performance - Community Benefit & Population Health - social and community goals and performance - Executive Compensation - human capital; diversity, equity, and inclusion; and pay equity goals and performance - Governance - governance goals and performance - Quality - equity of care, patient safety and quality of care goals and performance Ballad has a conflict-of-interest policy and plans to align reporting with the Sustainability Accounting Standards Board's topics for disclosure and other reporting frameworks in the coming years. Ballad has leader diversity with 30% of CEOs being females and 33% of Executive Vice Presidents being females. CHARITABLE CONTRIBUTIONS - From its inception in February of 2018, Ballad Health made significant contributions to the community it serves totaling over $30 million to date in direct contributions and other community health improvement initiatives. A few examples include: Support for Speedway Children's Charities, aid to Feeding Southwest Virginia, provision of new EKG equipment to regional emergency medical services, and investments in regional programs for schoolchildren. IMPROVING ACCESS TO HEALTHCARE SERVICES RE-IMAGINE RURAL HEALTHCARE - Our region has a variety of health, economic and other issues that, when combined, present a unique and challenging environment for healthcare access and outcomes. These unique challenges were reaffirmed in a 2017 report issued by the Appalachian Regional Commission, the Robert Wood Johnson Foundation and the Foundation for a Healthier Kentucky (Health Disparities in Appalachia), which found that the health outcomes in the greater Appalachian region are worse than those experienced in the United States as a whole in 7 of the 10 leading causes of death: heart disease, cancer, chronic obstructive pulmonary disease (COPD), injury, stroke, diabetes and suicide. The region also faces economic challenges, with performance on incomes, poverty rates, unemployment rates and postsecondary education lagging the national level. This is relevant because, as the study notes, socioeconomic and health outcomes are often interrelated, if not interdependent. Since 2010, more than 151 rural hospitals have closed in the United States, according to the North Carolina Rural Health Research Program. Compared to other states, Tennessee ranks amongst the worst in the nation, with 15 rural hospital closures since 2005. In the region served by Ballad Health, however, it is a different story. Every community in the region with a hospital prior to the merger creating Ballad Health continues to be served by a hospital. In fact, in the middle of the pandemic, Ballad Health opened the country's newest rural hospital. In July 2021, Ballad Health followed through on its promise to the residents of Lee County, Virginia, and reopened Lee County Community Hospital in Pennington Gap. CREATED SINGLE COORDINATED REGIONAL TRAUMA SYSTEM - A critical success factor of the COPA and CA is avoidance of duplication of hospital resources. Ballad Health consolidated two Level I trauma centers operating within 25 miles of each other and subsequently created a coordinated regional trauma system. In approving this move in advance of the merger, the State of Tennessee relied upon the evidence published in multiple respected studies which found higher volume trauma centers lead to improved outcomes. The move toward a single coordinated trauma system followed the guidance of the American College of Surgeons (ACS), which verifies trauma centers. The Tennessee Department of Health, after conducting a rigorous review of the trauma program at Johnson City Medical Center, issued its Level I Trauma Center Reverification Site Visit Report. The report found the hospital "has demonstrated an outstanding commitment to care for the injured patient." Further, the survey resulted in zero deficiencies, a first for trauma care in the region. CONSOLIDATED REGIONAL PERINATAL CENTER - Tennessee law requires a regionalized system of care for high-risk newborns. As a result of this law, Tennessee recognizes five regional perinatal centers. Niswonger Children's Hospital at Johnson City Medical Center is the designated center for regional perinatal care for the Appalachian Highlands. Prior to the merger, two neonatal intensive care units (NICUs) existed and were not coordinated. After the merger, Ballad Health immediately took steps to consolidate the NICUs to achieve a more sustainable and coordinated system of care for neonates, while also reducing the costs associated with maintaining two lower-volume units. After this consolidation, Ballad Health partnered with ETSU's Quillen College of Medicine to provide ongoing expert neonatology coverage for the hospital 24 hours per day. As a result of the merger and NICU consolidation, every newborn in the region has access to more than 25 pediatric specialists at the regional Perinatal Center. EXPANDED ACCESS TO PEDIATRIC SPECIALTIES - With financial support from Ballad Health and the State of Tennessee, the ETSU Quillen College of Medicine was able to successfully recruit pediatric surgeons to support Niswonger Children's Hospital. Our partners at ETSU's Quillen College of Medicine also provide 24/7 neonatology coverage for the NICU. Ballad Health now proudly meets the highest standards for regional perinatal care, something that was not thought possible prior to the merger creating Ballad Health. PARTNERSHIP WITH ETSU TO CREATE FELLOWSHIP PROGRAM IN ADDICTION MEDICINE - Ballad Health and East Tennessee State University formed a partnership to create a new fellowship program in addiction medicine. As part of its commitment to expand education and training in the region, Ballad Health will fund any unreimbursed costs of the fellowship program which, over a 10-year period, could cost more than $2.5 million. ESTABLISHMENT OF CENTER FOR RURAL HEALTH RESEARCH - Tennessee Governor Bill Lee announced the creation of a new Center for Rural Health Research that will be housed at the College of Public Health at East Tennessee State University. In addition to state funding, Ballad Health has committed to contributing more than $15 million during the next 10 years to the Center. The goal of the Center will be to work with Ballad Health, local healthcare delivery partners, national experts and the leadership of ETSU Health to identify new mechanisms to improve health in rural and nonurban communities. Specific emphasis will be placed on strategies that disrupt inter-generational cycles of behaviors that contribute to poor health outcomes, which ultimately can affect college and career-readiness. RECRUITMENT OF NEW PHYSICIANS TO THE APPALACHIAN HIGHLANDS - Ballad Health provided the necessary resources to recruit new specialists to serve our region, many of whom were recruited to private practices not owned by Ballad Health. The addition of specialists is helping to improve access to care in rural communities. For instance, Wise County, Virginia now benefits from an orthopedist, a cardiologist and several other physicians and providers. Wythe County, Virginia, a community not served by a Ballad Health hospital, benefits from a cardiologist recruited by Ballad Health. Throughout the region, new physicians and advanced practitioners, recruited and funded by Ballad Health, are serving the region - from trauma care to pediatrics, from Wythe County, Virginia to Hancock County, Tennessee. OTHER NOTABLE EVENTS AND AWARDS - Ballad has invested significantly across the region specifically in academic and community institutions that serve the people in the service area. Examples of this investment are shown through the continuum of service from the offering of observation opportunities to students of all ages within our clinical facilities, to providing experts to lecture to school children on a broad variety of healthcare topics. The commitment to giving back extends to direct investment in regional educational partners. Some key examples of this include the Appalachian Highlands Center for Nursing Advancement, The Center for Rural Health Research, the STRONG BRAIN Institute, and the Gatton College of Pharmacy Center for Pharmacy, Education, Outreach, and Advocacy. The work of these centers at ETSU focuses on some of the leading issues facing the service area, from the development and support of the next evolution of nursing as a profession, to understanding the unique challenges facing our public health, to the scourge of adverse childhood experiences, to access and intervention at the community pharmacy, Ballad is committed to understanding and addressing the significant issues facing the service area. - Ballad is also engaged in funding the development of new and expanded healthcare training programs across the region. Ballad has granted support of programs in Nursing and Allied Health. From a new BSN program in Southwest Virginia at Emory & Henry College, to a new program in Ultrasonography at Southwest Virginia Community College, we are supporting programs large and small. We have expanded the Medical-legal partnership we have in the Appalachian Highlands to include all of the Ballad facilities as well as many of the outpatient clinics. This one-of-a-kind program partners Ballad with Virginia Tech and the Appalachian School of Law together to address the challenges of access to social supports for the poorest members of the service area. Ballad is a sponsor of a residency in Advanced Education Graduate Dentistry in Southwest Virginia. The endemic problem of poor oral hygiene across service area accounts for loss of economic opportunity, loss of self-esteem, and profound impacts on the health of individuals suffering from missing or diseased teeth. - Ballad's research department serves as the central office for multi-specialty research oversight in the System. In addition to providing full spectrum support for studies generated and managed by the research department, the department provides oversight for studies generated by external groups. The research department has participated in several large-scale, multi-center trials with subject retention at nearly 100%. Oversight services include administrative, legal, regulatory support, internal service arrangement and financial management. Ballad is a world leader in cardiovascular clinical trials. - Received its Accreditation/Department of Distinction from the International Association for Healthcare Security & Safety (IAHSS) - Recognized by Harvard University and UnitedHealthcare as one of four healthcare organizations leading the way towards a 3D model for value-based care - Earned the College of Healthcare Information Management Executives (CHIME) Digital Health Most Wired. - After the creation of a regional and coordinated system of trauma care nearly two years prior, in July 2021, a Tennessee Department of Health survey concluded the trauma program serving the Appalachian Highlands provides "outstanding commitment to care for the injured patient and found zero deficiencies at the Level I Trauma Center at Johnson City Medical Center, a first for trauma care in the region. As a result of the regional and coordinated system of trauma care, Ballad decreased mortality by 40% and reduced the cost of care by approximately $3 million. Part IV, Line 24a and Part X, Line 20 - Tax Exempt Bonds The tax exempt bond liability reflects the portion of bonds issued by Ballad Health, MSHA's parent organization, on behalf of MSHA for capital needs. MSHA pays all costs related to this portion of the bond issue. Form 990, Part V, line 1a For CY22 Ballad Health (BH), MSHA's parent organization, filed Form 1096 on a consolidated basis for all subsidiaries that were required to file Forms 1099-MISC/NEC. MSHA reimburses BH for all expenses related to vendor payments and the expenses are recorded on MSHA's books. Form 990, Part VI, Section A, line 6 Line 6 explanation - Mountain States Health Alliance is a Tennessee non-stock, nonprofit organization with Ballad Health as its sole member. Form 990, Part VI, Section A, line 7a Line 7a explanation - Ballad Health has the authority to appoint Mountain States Health Alliance board members. The President and CEO of Ballad Health serves as the President and CEO for Mountain States Health Alliance. Form 990, Part VI, Section A, line 7b Line 7b explanation - Decisions of the Mountain States Health Alliance Board of Directors are subject to approval by the Ballad Health Board of Directors. Form 990, Part VI, Section B, line 11b Line 11b Explanation - The Ballad Health Tax Department prepares and reviews the Form 990. During preparation other functional areas within the organization provide information and support to complete an accurate return. The return is reviewed by the organization's EVP/CFO and is provided in electronic form to all members of the Board of Directors prior to being filed with the IRS. Form 990, Part VI, Section B, line 12c Ballad Health policy requires Board of Directors and Board Committee members, the Executive Chair/President, and Executive Vice Presidents to complete a conflict of interest disclosure statement on an annual basis. Ballad Health policy also requires team members to complete an annual acknowledgement that they have read and understand the conflict of interest policy and they will complete a conflict of interest disclosure statement if they have a conflict of interest. Should a conflict arise, it is the responsibility of the conflicted individual to update his or her disclosure immediately. All meetings of the board or board committees have a standing agenda item first on the agenda titled "Conflicts of Interest". If a member of the board or board committee has a conflict of interest involving any issue on the board agenda, he or she must declare the conflict of interest during the period allotted for disclosure. If any issue arises during a meeting in which the board member has a conflict of interest, he or she must immediately declare the conflict. While each member of the board or board committee is responsible for disclosing conflicts of interest, it is also the responsibility of any board member aware of a conflict which has not been disclosed to ensure the board is made aware. The presiding officer of a board or board committee meeting may ask a conflicted member to excuse themselves from the meeting during the discussion related to the issue with which the conflict of interest applies. Under no circumstances shall a member vote on a matter that gives rise to a potential conflict. This applies to all Ballad Health organizations. Form 990, Part VI, Section B, line 15 Line 15a - Compensation Process for Top Official The executive compensation committee serves as the compensation oversight committee of Ballad Health's Board of Directors. The executive compensation committee is comprised of members who are determined to be independent and whom are not reliant upon any business relationship with Ballad Health for income or compensation. The compensation plan for Alan Levine, Ballad Health's Chairman, President and CEO, was reviewed and approved by the executive compensation committee and then by the Ballad Health Board of Directors in accordance with the Board's compensation policy and practice. The Board of Directors relies upon the advice of an independent and experienced compensation consultant with knowledge about pay practices for comparable positions within the industry, and who has access to broad data, studies and surveys in order to ensure the compensation falls within competitive and appropriate ranges for the position. Line 15b - Compensation Process for Officers On an annual basis, Ballad Health's Human Resources (H/R) Department evaluates compensation for all executives at a position level of Assistant Vice President and above. H/R's evaluation is based on market data obtained from independent third-party consultants for positions with similar responsibilities at similarly situated organizations. Based on this comparable data, Ballad Health's CEO evaluates the data and, if appropriate, makes necessary adjustments. Any adjustments to Senior Vice Presidents or above are reviewed by the Board of Directors Executive Compensation Committee. In addition, Ballad Health offers an incentive plan to executives based on targeted achievement metrics categorized by; Quality, Service and Safety; Access to Care; Financial Stewardship, and any other metrics approved from time to time by the Board of Directors. Form 990, Part VI, Section C, line 19 Governing documents and conflict of interest policy are made available upon request to the appropriate parties requesting them. Financial statements are made available upon request to appropriate parties requesting them, and they are made available to those parties who own indebtedness of the company on a quarterly basis. Form 990, Part IX, line 11g Collection Services: Program service expenses 0. Management and general expenses 37,679,543. Fundraising expenses 0. Total expenses 37,679,543. Consulting Fees: Program service expenses 5,882. Management and general expenses 1,787,980. Fundraising expenses 0. Total expenses 1,793,862. Contract Labor: Program service expenses 44,652,683. Management and general expenses 7,696,241. Fundraising expenses 0. Total expenses 52,348,924. Dietary Services: Program service expenses 12,323,466. Management and general expenses 0. Fundraising expenses 0. Total expenses 12,323,466. Environmental Services: Program service expenses 9,958,887. Management and general expenses 0. Fundraising expenses 0. Total expenses 9,958,887. Hospital Supported Clinics: Program service expenses 62,298,215. Management and general expenses 0. Fundraising expenses 0. Total expenses 62,298,215. Laboratory Services: Program service expenses 5,669,136. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,669,136. Laundry Services: Program service expenses 3,141,895. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,141,895. Other: Program service expenses 10,352,177. Management and general expenses 6,017,975. Fundraising expenses 0. Total expenses 16,370,152. Physician Fees: Program service expenses 38,185,959. Management and general expenses 0. Fundraising expenses 0. Total expenses 38,185,959. Form 990, Part XI, line 9: Temporarily Restricted Grants -47,523. Intercompany Transfers -9,979,771. 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