Schedule H, Part I, Line 6a NAME OF THE RELATED ORG THAT PREPARED COMMUNITY BENEFIT REPORT
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THE HOSPITAL IS A WHOLLY-OWNED (WHOLLY-SPONSORED) SUBSIDIARY OF ST. JOHN HEALTH SYSTEM, INC. - EIN 73-1215174 ("SJHS"). SJHS PREPARED A CONSOLIDATED COMMUNITY BENEFIT REPORT FOR THE CONSOLIDATED ORGANIZATION FOR THIS TAX YEAR. THE REPORT IS MADE AVAILABLE ON DEMAND AND IS REFERENCED BY THE ORGANIZATION IN A NUMBER OF PUBLIC MEETINGS AND COMMUNITY OUTREACH ACTIVITIES.
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Schedule H, Part II DESCRIBE HOW BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY - PART 2
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Health Care that is Safe: St. John is striving to become a "high reliability" organization. High reliability means that we will be exceptionally consistent in accomplishing goals and avoiding catastrophic errors in everything we do in providing health care services. This means reducing medical errors by providing our clinicians and our patients with decision support tools to ensure the care provided is consistently based on sound scientific evidence of effectiveness. Physicians and nurses are leading our quality efforts. Among our clinical areas of focus for improvement are goals to reduce hospital acquired conditions and hospital readmissions. Some specific areas of clinical focus include reducing: - Adverse Drug Events (ADE), - Catheter Urinary Tract Infections (CAUTI), - Central Line Blood Stream Infections (CLABSI), - Surgical Site Infections (SSI), - Ventilator Associated Pneumonia (VAP), - Injuries from Falls and Immobility, - Obstetrical Adverse Events, - Pressure Ulcers, and - Venous Thromboembolism (VTE). Healthcare that Leaves No One Behind: We will continue to advocate for state and federal public policy that recognizes the inherent value of all members of society and provides support systems and adequate funding sources to ensure all of those among us have access to the health care they need. This includes providing affordable access to health care for everyone in the United States in a financially sustainable way. Our Enabling Strengths: We will use our enabling strengths to achieve our mission and vision. Those strengths include: a model community of inspired people working to provide our services and achieve our mission; empowering knowledge - clinical and business information systems that provide our associates actionable, timely data and information upon which they can make informed decisions; the creation of trusted partnerships with external partners to expand our capabilities, COMPLEMENT our service offerings and fulfill our mission; and achieve vital presence in the communities we serve. This vital presence contemplates creation and continuation of important safety net services, world-class centers of clinical excellence and creation of medical homes that promote each individual's participation in their own health and well-being and which create and sustain the infrastructure for promoting healthy communities. Our Point of View: Health care delivery and financing in the United States must change. The cost of the current system relative to the value that communities and individuals are receiving is not sustainable. In order to meet the health care needs and contribute to economic vitality of communities, with special attention to the poor and vulnerable, health care providers must fundamentally reconfigure delivery systems, care processes and cost structures. Delivering safe, high-quality care that is low cost with an exceptional patient experience will increasingly require providers to have a strong regional presence, integrated physician relationships and capabilities across the care continuum. Sustaining the St. John mission into the future will require a more continuous, dynamic relationship with those we serve and the ability to share risk with healthcare purchasers, as opportunities for inpatient growth or commercial rate increases will be limited. The movement to manage health of defined populations demands massive transformational change. This requires rapid assessment, assembly and deployment of the necessary capabilities. We believe the St. John System is well positioned to lead this transformation.
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Schedule H, Part II DESCRIBE HOW BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY - PART 3
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Community Needs Assessment: The St. John System and each St. John Hospital have completed a Community Health Needs Assessment to help us identify the priorities for the limited resources we have to address community need. We partnered with the Tulsa County Health Department and other public and private health care, and educational and community service organizations throughout the service area to complete the assessments, and we are now working to enhance our response to the identified needs. Additional information will be forthcoming about our specific future responses to our assessment of community need. Community Benefit: The community benefit provided by the St. John System includes: uncompensated care for the poor, support for the education of medical professionals, provision of subsidized health services, support for other community organizations, initiatives to improve community health, and medical research to be some of the key areas of focus for providing community benefit. The St. John System does not include amounts recorded as bad debt; shortfalls in the difference between payment for and cost of service to Medicare beneficiaries; payment of property, sales, use, income, payroll, and other taxes; OR considerable economic value provided to the local communities in which we operate as components of community benefit. Care for the Poor: "Care for the Poor" (which includes the estimated cost of services provided to patients who qualify for financial assistance (charity) and the uncompensated cost of care provided to Medicaid beneficiaries) is the largest financial category of community benefit. Support for graduate and allied health medical education is the second largest. St. John provides discounts of at least 30% to all uninsured patients and additional discounts of at least 15% to uninsured patients who make the agreed upon timely payments for services they receive. All uninsured individuals living in households with incomes at or below 300% of the federal poverty limit qualify for free care for medically necessary services. Insured patients and others who are faced with financially catastrophic medical bills are also eligible for and encouraged to seek financial assistance. Consistent with our mission and values, St. John has created programs to seek out better ways to serve the uninsured and the vulnerable members of our society. With generous financial support from donors, including the Chapman trusts, and with guidance and counsel from many partners in our community, St. John has created the Medical Access Program ("MAP") to try to increase and improve access to medical care for segments of the uninsured population. Beginning more than five years ago, MAP continues to grow and expand each year. MAP has brought together a network of primary care providers that provides free clinics and other services to uninsured and low income individuals throughout Tulsa. Key elements of MAP include: - Expansion of free primary care by providing direct financial support to other organizations in the community providing access to free primary care, - Operation of Rockford Medical Clinic. The Rockford Clinic is a free primary care medical home for a segment of the uninsured population that meet certain criteria for participation, - Provision of free diagnostic imaging, including CT, MRI, ultrasound, mammography and basic x-ray for patients who meet criteria, - Access to free specialty services through a network of participating clinics and physician partners and through the facilities and physicians of the St. John System, and - Access to free or reduced cost prescription medications. MAP has limited resources but continues to expand the scope of its services each year, routinely spending at least $5 million per year in donated and St. John funds.
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Schedule H, Part II DESCRIBE HOW BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY - PART 4
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Support for Medical Education: St. John Medical Center, Inc. is a primary teaching hospital for The University of Oklahoma's Tulsa College of Community Medicine residency programs for internal medicine and general surgery and is the primary teaching hospital for the "In His Image" ("IHI") family medicine residency program. St. John works as a founding member of the Tulsa Medical Education Foundation providing financial support for The University of Oklahoma ("OU") residency programs. St. John also provides additional direct support to both OU and IHI residency programs and also provides direct support for a number of nursing education and allied health professional education programs. Other Community Benefit: St. John provides subsidized health services focused on certain emergency services and on post-acute senior services. Each St. John Hospital provides vital emergency medical services in its community. St. John Medical Center, Inc. services as one of only three trauma centers in Oklahoma, Oklahoma's first and only certified comprehensive stroke center, and a tertiary referral center for the entire state of Oklahoma and portions of Missouri, Arkansas, Kansas and Texas. The associates, physicians and facilities of the St. John System provide services to thousands of patients every day. Among the services provided annually are: - More than 54,000 annual inpatient and observation admissions, - More than 160,000 emergency department patient visits, - More than 3,000 births, - More than 28,000 inpatient and outpatient surgeries, - Thousands of other outpatient visits, - More than 510,000 physician office and urgent care clinic visits, - More than 8.1 million laboratory tests. Summary: The thousands of associates, physicians and volunteers that make up St. John Health System, Inc. touch the lives of thousands of patients every day and millions of patients every year. As we seek to transform health care in Oklahoma and the United States, St. John is challenged by many factors including: lack of public resources in Oklahoma that are devoted to care for the poor, health care infrastructure and medical education; competition from investor-owned health care facilities that do not share St. John's mission of service and emphasis on service to the poor and powerless but which seek to gain market share in commercially insured patients; poor economic and health care demographic factors contributing to generally poor health status and high rates of poverty and uninsurance in Oklahoma; and payment for values.
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Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance
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Costs were determined using a cost to charge ratio derived from Worksheet 2, Patient Care Cost to Charges.
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Schedule H, Part II Community Building Activities
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Community Benefit Report: St. John Health System, Inc.'s (the "St. John System" or "St. John") mission is to improve the health status of the individuals who live in the communities we serve with a special emphasis on the poor and vulnerable among us; faithful to the teaching of Jesus Christ and the values of our Sponsors and the Catholic Church. Our promise to our patients and to our communities is to provide medical excellence and compassionate care. We strive to provide healthcare that works, healthcare that is safe and healthcare that leaves no one behind. To meet this mission, the St. John System has operated since the 1920's; growing from a fledgling community hospital, in what was then the southern edge of Tulsa, Oklahoma, to an integrated health care delivery system serving Northeastern Oklahoma and surrounding states. The St. John System includes: thousands of associates, employed physicians and advanced practice providers, hundreds more independent physicians and dozens of volunteers. They serve patients in six owned hospitals operating nearly 800 beds; several senior nursing and housing facilities; dozens of physician offices, clinics and urgent care centers; a reference laboratory; and partnerships and ventures that include a health insurance company, several ambulatory surgery centers and other health care activities. Together, our associates, physicians and volunteers touch the lives of thousands of patients every day, including the poor and the vulnerable. The St. John System is committed to continue the legacy of health care excellence and service started by our original founders and sponsors, the Sisters of the Sorrowful Mother, by continuing to provide vital services to the communities with continued emphasis on service to the poor and powerless. Our Mission and Values: Our mission of service and our Catholic values compel us to fulfill our promise of medical excellence and compassionate care to all who need our services, with a special emphasis on service to the poor and the powerless. We will do this by providing: health care that works; health care that is safe; and health care that leaves no one behind. We will endeavor to establish trusted relationships with our patients over their entire lives: seeking to improve their health and working to heal their minds and bodies when afflicted by injury or illness. Health Care that Works: Our vision calls us to ensure that service is committed to the health and well-being of our communities and that it responds to the needs of individuals throughout their lives. Healthcare that Works includes establishing a trusted relationship between each patient and their health care professionals so that they receive the care they need, including preventative care, when they need it and in a manner that meets their service expectations. We expect our patients to be actively involved in their own health care - participating in informed decisions that will strive to make them healthier. Health care that works assumes that the care provided is person-centered and based on the best available medical evidence, reliably delivered. Becoming truly person-centered requires shifts in focus from traditional models of health care to build an effective and trusted relationship with each patient over their lifetime across the continuum of care - emphasizing prevention and wellness, disease management, and a medical home that promotes a spiritually-centered, holistic approach to supporting a person's health and well-being. Health care that works strives to make sure the value of the care received is exceptional but at an acceptable economic cost - both to the individual and to society.
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Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount
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Accounts are written off to bad debt after all internal collection efforts have been exhausted. Attempts to resolve these outstanding balances can include, but are not limited to statements being sent, phone calls, and letters being sent. Account follow up protocol is based on personal pay balance size owed.
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Schedule H, Part III, Line 3 Bad Debt Expense Methodology
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Jane Phillips Memorial Medical Center has a very robust financial assistance program; therefore, no estimate is made for bad debt attributed to financial assistance eligible patients.
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Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote
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From the consolidated audited financial statements of Ascension Health Alliance, which include the activity of Jane Phillips Memorial Medical Center: The provision for doubtful accounts is based upon management's assessment of expected net collections considering historical experience, economic conditions, trends in healthcare coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payor category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for doubtful accounts. After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted, the System follows established guidelines for placing certain past-due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by the System. Accounts receivable are written off after collection efforts have been followed in accordance with the System's policies. The methodology for determining the allowance for doubtful accounts and related write-offs on uninsured patient accounts has remained consistent with the prior year.
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Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs
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Jane Phillips Memorial Medical Center follows the Catholic Health Association ("CHA") guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit.
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Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance
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The Organization has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance, certain collection practices do not apply.
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Schedule H, Part V, Section B, Line 16b FAP Application website
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- Jane Phillips Memorial Medical Center: Line 16b URL: http://www.stjohnhealthsystem.com/media/file/1826/Financial_Assistance_Form.pdf;
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Schedule H, Part VI, Line 2 Needs assessment
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The Hospital conducted a Community Health Needs Assessment jointly with its parent entity - SJHS. SJHS participates in ongoing community-based needs assessments. Some of the most significant recent activity includes commissioning of a Community Health Needs Assessment and plan for improving community health care conducted by the Tulsa County Health Department and released in 2013. The 2013 assessment has been posted to the Hospital and Health System website: http://www.stjohnhealthsystem.com/jane-phillips/patients/payment-for-services. Many major community health care service organizations participated in these studies. In addition to the above, SJHS through its subsidiary, St. John Medical Center, Inc., has established a Medical Access Program ("MAP") that is attempting to improve and expand access to health care services to the most vulnerable members of the Tulsa community. All SJHS Tulsa Hospitals including: St. John Medical Center, Inc. (Tulsa), Owasso Medical Facility, Inc., St. John Sapulpa, Inc. and St. John Broken Arrow, Inc. participate in this initiative. This program is overseen by representatives of St. John, the George Kaiser Family Foundation, trustees of the Chapman trusts and The University of Oklahoma Tulsa School of Community Medicine. The MAP program includes participation of other health care providers including Good Samaritan clinics, Day Center for the Homeless, Community Health Connections FQHC, Morton Health FQHC, and a network of volunteer physician providers and other organizations. The MAP program regularly receives input from all these organizations on needed services in the community which helps to prioritize the limited resources available to address community needs.
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Schedule H, Part VI, Line 3 Patient education of eligibility for assistance
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The Hospital has a team of financial counselors who, prior to discharge, attempt to visit in person with all uninsured inpatients and all inpatients likely to qualify for medical indigency to explain our financial assistance policies and help guide them through the process of applying for financial assistance. We also attempt to meet with the families of all Medicaid beneficiaries or individuals who we believe could potentially qualify for Medicaid to help them apply for coverage. The Hospital mentions the existence of the Financial Assistance Policy and provides a phone number to call: on its website, in admitting materials, on all invoices for services sent to patients, and in other ways.
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Schedule H, Part VI, Line 4 Community information
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As described above, the Hospital is part of St. John Health System, Inc. ("SJHS"). Although SJHS provides a full spectrum of health related services throughout Northeastern Oklahoma, its tertiary operations and a large part of its other services are concentrated in the Tulsa Metropolitan Statistical Area (the "Tulsa MSA"). According to the 2010 Census, the State of Oklahoma had a resident population of 3,751,351 persons compared to 3,450,654 persons in 2000. This is an 8.7% increase. The U.S. Census Bureau estimated that in 2009, 13.5% of the Oklahoma resident population was eligible for Medicare, compared to 14.7% in 2000. Tulsa County, Oklahoma and the counties that make up the Tulsa MSA, according to the 2010 Census, had populations of 603,403 and 1,008,460, respectively. This compares to populations of 563,299 and 803,235 persons, respectively in 2000, and represents population growth of 7.1% and 25.5%, respectively. The data shows that the counties in the Tulsa MSA that surround Tulsa County grew much faster from 2000 to 2010. At the same time, the population within Tulsa County shifted away from the city of Tulsa and to suburbs such as Owasso and Broken Arrow. The cities of Broken Arrow and Owasso were two of the fastest growing communities in Oklahoma between 2000 and 2010. The population of the city of Owasso grew 56% to 28,915 from 2000 to 2010 and the population of the city of Broken Arrow grew 32% to 98,850 from 2000 to 2010. Wagoner County (southeast of Tulsa) and Rogers County (northeast of Tulsa) showed the two highest population growth rates from 2000 to 2010. Every county in the 8 county Tulsa MSA except Pawnee County grew in population from 2000 to 2010. Washington County, directly north of Tulsa County, which includes the City of Bartlesville (and Jane Phillips Memorial Medical Center), also grew in population from 2000 to 2010. When the population of Washington County is added to the population of the Tulsa County, the 2010 combined population was 1,059,436. There is significant disparity in the general health of populations within the service area depending upon where an individual lives and to what socioeconomic and ethnic group they belong. Citizens who reside in "North" Tulsa and in some areas of "East" and "West" Tulsa generally have poorer health and shorter life spans than individuals who live in "South" Tulsa. Members of minority groups (many of whom reside in the geographic areas described above) share these same health characteristics. It has been demonstrated that these individuals have less access to regular health care services, including specialty care, and many seek even their primary care in hospital emergency rooms, including all of the SJHS Hospitals. Some significant minority groups in the Hospital's and SJHS's principal service area include Native Americans, Hispanics and African Americans. Each of these groups shares common socioeconomic challenges making them more likely to be poor and be uninsured for health care. Each of these groups has unique ethnic health risk factors that contribute to health status that is generally poorer than their White counterparts. However, even among the White population in the Hospital's service area, there is significant adverse health care status. In general, Oklahoma (including the Hospital's service area) ranks near the bottom in many, if not most, measures of health status in the United States. There are high rates of smoking, diabetes, obesity, upper respiratory illness, chronic heart conditions and many other factors. There are high rates of uninsured and underinsured individuals and families in the communities and geographies served by the Hospital, which create many challenges in meeting the demand for basic services and in improving the health status of the population.
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Schedule H, Part VI, Line 5 Promotion of community health
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St. John is a growing integrated delivery system that serves Northeastern Oklahoma and the surrounding area. It has grown significantly in recent years, with increasing revenues from outpatient and physician professional services, as well as other post-acute services. Acute care services are provided on six hospital campuses that are owned by St. John. The owned hospitals are St. John Medical Center, Inc. (the tertiary center in Tulsa, Oklahoma), Jane Phillips Memorial Medical Center in Bartlesville, St. John Owasso in Owasso, Oklahoma, St. John Broken Arrow, Inc., Jane Phillips Nowata Hospital, Inc., a critical access hospital in Nowata, Oklahoma, and St. John Sapulpa, Inc., a critical access hospital in Sapulpa, Oklahoma. Acute care services are also provided at two additional rural critical access hospitals which are managed by Jane Phillips. Diagnostic services and certain acute care services are also provided in a variety of free standing (including hospital-based) settings. The St. John System now includes hundreds of employed physicians and "mid-level providers", and several urgent care clinics, as well as retirement and skilled nursing facilities, including some targeted specifically to serve low-income and physically disabled individuals and other health care providers. St. John is attempting to promote community health in several ways. Most of the affiliated primary care physicians have or are establishing "medical home" models of care that are attempting to improve health status of their patients by better emphasizing preventive care and health screening and by better management of chronic disease. This includes participation in the Medicare Comprehensive Primary Care Initiative. The affiliated primary care physicians utilize a sophisticated electronic medical record that helps provide real time information to make it easier to manage patients' care. The Hospital and the other hospitals in the System have invested heavily in clinical information systems and electronic medical records to better manage patient care during each episode of acute care. St. John is investing in new systems of care to provide better coordination of care between all the different providers responsible for portions of each patient's care, with an emphasis on prevention, screening and coordination of chronic care. The Hospital and St. John Health System, Inc. have invested in tertiary services that are needed by the community. Examples of which include development of Oklahoma's only ACS Level II Trauma Center (the highest accredited center in Tulsa), Northeastern Oklahoma's only JCAHO-accredited stroke center, neonatal intensive care, sophisticated medical technology including all-digital diagnostic radiology, cyberknife and other forms of radiation therapy, DaVinci robotic surgery, an endovascular operating suite, orthopedic and neurosurgical centers of excellence, sophisticated cardiovascular care that emphasizes rapid and effective intervention for heart attack victims and preventive care for those with chronic heart conditions. The Hospital has an open medical staff and has community, religious and physician representatives serving on its board. St. John Health System, Inc. has created and is continuing to create systems and policies to promote better coordination of care and allocation of resources throughout the System. The Hospital participates in many community-wide health screening and health education events, as well as hosting many such events that are open to the public. The Hospital and St. John Health System, Inc. continue to invest in medical education to support the expansion of physicians, nurses and allied health professionals that will serve the current and future generations of patients in the service area. The Hospital participates in St. John Health System, Inc.'s coordinated effort to assess community need collaboratively with other interested parties in the community and to allocate capital and human resources to address the needs of the entire service area. Finally as one of only two major tax-exempt health systems in our service area, St. John reinvests 100% of any profits generated into new or expanded services for the community.
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Schedule H, Part VI, Line 6 Affiliated health care system
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ST. JOHN Health System, Inc., HEADQUARTERED IN TULSA, OKLAHOMA, AND WITH FACILITIES LOCATED THROUGHOUT NORTHEASTERN OKLAHOMA, IS AN OKLAHOMA NONPROFIT HEALTH SYSTEM. IT OWNS AND OPERATES AN INTEGRATED TERTIARY HEALTH CARE DELIVERY SYSTEM THAT PROVIDES SERVICES PRIMARILY IN NORTHEASTERN OKLAHOMA. ST. JOHN HEALTH SYSTEM, INC. AND ITS SUBSIDIARIES, AFFILIATES, AND EMPLOYED AND AFFILIATED PHYSICIANS, PROVIDE HEALTH CARE SERVICES FOR PATIENTS OF ALL AGES ACROSS A BROAD CONTINUUM OF CARE, FROM PHYSICIAN PRIMARY CARE AND SPECIALTY SERVICES TO AMBULATORY AND INPATIENT ACUTE AND POST-ACUTE SERVICES, AND INCLUDING SENIOR NURSING AND SENIOR LIVING SERVICES. THE HEALTH MINISTRY IS RELATED TO ASCENSION HEALTH'S OTHER SPONSORED ORGANIZATIONS THROUGH COMMON CONTROL. SUBSTANTIALLY ALL EXPENSES OF THE HEALTH MINISTRY ARE RELATED TO PROVIDING HEALTH CARE SERVICES. Ascension Health Alliance, d/b/a Ascension (Ascension), is a Missouri nonprofit corporation formed on September 13, 2011. Ascension is the sole corporate member and parent organization of Ascension Health, a Catholic national health system consisting primarily of nonprofit corporations that own and operate local healthcare facilities, or Health Ministries, located in 23 states and the District of Columbia. Ascension is sponsored by Ascension Sponsor, a Public Juridic Person. The Participating Entities of Ascension Sponsor are the Daughters of Charity of St. Vincent de Paul, St. Louise Province; the Congregation of St. Joseph; the Congregation of the Sisters of St. Joseph of Carondelet; the Congregation of Alexian Brothers of the Immaculate Conception Province, Inc. - American Province; and the Sisters of the Sorrowful Mother of the Third Order of St. Francis of Assisi - US/Caribbean Province. Mission: The System directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing, and dedicates its resources to spiritually centered care which sustains and improves the health of the individuals and communities it serves. In accordance with the System's mission of service to those persons living in poverty and other vulnerable persons, each Health Ministry accepts patients regardless of their ability to pay. The System uses four categories to identify the resources utilized for the care of persons living in poverty and community benefit programs: - Traditional charity care includes the cost of services provided to persons who cannot afford healthcare because of inadequate resources and/or who are uninsured or underinsured. - Unpaid cost of public programs, excluding Medicare, represents the unpaid cost of services provided to persons covered by public programs for persons living in poverty and other vulnerable persons. - Cost of other programs for persons living in poverty and other vulnerable persons includes unreimbursed costs of programs intentionally designed to serve the persons living in poverty and other vulnerable persons of the community, including substance abusers, the homeless, victims of child abuse, and persons with acquired immune deficiency syndrome. - Community benefit consists of the unreimbursed costs of community benefit programs and services for the general community, not solely for the persons living in poverty, including health promotion and education, health clinics and screenings, and medical research. Discounts are provided to all uninsured patients, including those with the means to pay. Discounts provided to those patients who did not qualify for assistance under charity care guidelines are not included in the cost of providing care of persons living in poverty and other community benefit programs. The cost of providing care to persons living in poverty and other community benefit programs is estimated by reducing charges forgone by a factor derived from the ratio of each entity's total operating expenses to the entity's billed charges for patient care. Certain costs such as graduate medical education and certain other activities are excluded from total operating expenses for purposes of this computation.
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