SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2016
Open to Public Inspection
Name of the organization
ADVENTIST HEALTH SYSTEM GEORGIA INC
 
Employer identification number

58-1425000
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
%
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
 
No
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
 
No
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . . 		    10,361,729   10,361,729 7.400 %
b Medicaid (from Worksheet 3, column a) . . . . .     21,951,858 14,881,151 7,070,707 5.050 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     32,313,587 14,881,151 17,432,436 12.450 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     1,732,778   1,732,778 1.240 %
f Health professions education (from Worksheet 5) . . .            
g Subsidized health services (from Worksheet 6) . . . .            
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .            
j Total. Other Benefits . .     1,732,778   1,732,778 1.240 %
k Total. Add lines 7d and 7j .     34,046,365 14,881,151 19,165,214 13.690 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2016
Schedule H (Form 990) 2016
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and
training for community members		            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
14,050,719
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
2,176,932
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
29,150,019
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
28,022,425
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
1,127,594
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2016
Schedule H (Form 990) 2016
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?2Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 Gordon Hospital
1035 Red Bud Road
Calhoun,GA30701
www.gordonhospital.com
064-334 		X X         X      
2 Murray Medical Center
707 Old Dalton Ellijay Road
Chatsworth,GA30705
www.murraymedical.org
105-706 		X X         X      
Schedule H (Form 990) 2016
Page 4
Schedule H (Form 990) 2016
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Gordon Hospital
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 16
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 14
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Statement
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2016
Page 5
Schedule H (Form 990) 2016
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Gordon Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Statment
b
See Statement
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2016
Page 6
Schedule H (Form 990) 2016
Page 6
Part VFacility Information (continued)

Billing and Collections
Gordon Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2016
Page 7
Schedule H (Form 990) 2016
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Gordon Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2016
Page 4
Schedule H (Form 990) 2016
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Murray Medical Center
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		2
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2 Yes  
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 16
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8   No
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20  
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10    
a If "Yes" (list url):  
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2016
Page 5
Schedule H (Form 990) 2016
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Murray Medical Center
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Page 8
b
See Part V, Page 8
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2016
Page 6
Schedule H (Form 990) 2016
Page 6
Part VFacility Information (continued)

Billing and Collections
Murray Medical Center
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2016
Page 7
Schedule H (Form 990) 2016
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Murray Medical Center
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2016
Page 8
Schedule H (Form 990) 2016
Page 8
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
Gordon Hospital Part V, Section B, Line 5: Adventist Health System Georgia, Inc., dba Gordon Hospital (GH or the Hospital), serves Gordon County residents in northwest Georgia. GH is a 69-bed community hospital located in Calhoun, Georgia and is the only hospital located within Gordon County. The Hospital's primary service area includes all zip codes within Gordon County. The population of Gordon County is approximately 56,574 with an average per capita income of approximately $30,872. The 2016 Community Health Needs Assessment (CHNA) for the Hospital was built on input from people representing the broad community, as well as low-income, minority and other medically underserved populations. The Hospital conducted a community survey throughout 2016. It solicited community members to complete the survey at multiple locations including drug stores, community events, the Health Department, and health fairs. There were 351 surveys completed representative of a cross section of both ethnic populations and income levels.As a part of its efforts to ensure broad community-based input into the CHNA process, the Hospital established a Community Health Needs Assessment Committee (CHNAC). The CHNAC was intended to represent the needs of the general community, with a particular focus on including representatives of the medically underserved, low-income and minority populations. Committee members included both internal and community stakeholders. Each member brought a unique perspective of the community, available services and expertise in their field. Community members of the CHNAC represented the following organizations: -Family Connection of Gordon County; -Gordon County Boys & Girls Club;-The local Chamber of Commerce; and-The Gordon County Health Department.
Murray Medical Center Part V, Section B, Line 5: Adventist health System Georgia, Inc, DBA Murray Medical Center (MMC or the Hospital), serves Murray County residents in northwest Georgia. MMC is a 42-bed community hospital located in Chatsworth, Georgia and is the only hospital located within Murray County. The Hospital's primary service area included all zip codes within Murray County. The population of Murray County is approximately 39,565 with an average per capita income of approximately $26,057.The 2016 Community Health Needs Assessment (CHNA) for the Hospital was built on input from people representing the broad community, as well as low-income, minority and other medically underserved populations. The Hospital conducted a community survey throughout 2016. It solicited community members to complete the survey at multiple locations including drug stores, community events, the Health Department, and health fairs. There were 207 surveys completed representative of a cross section of both ethnic populations and income levels.As part of its efforts to ensure broad community-based input into the CHNA process, the Hospital established a Community Health Needs Assessment Committee (CHNAC). The CHNAC was intended to represent the needs of the general community, with a particular focus on including representatives of the medically underserved, low-income and minority populations. Committee members included both internal and community stakeholders. Each member brought a unique perspective of the community, available services and expertise in their field. Community members of the CHNAC represented the following organizations:- Murray Health Department;- Murray Senior Center;- Corner Drugs, a local business;- Murray County Chamber of Commerce;- Murray Boys & Girls Club; and- Gladden Middle School.
Gordon Hospital Part V, Section B, Line 7d: The Hospital has adopted a policy that addresses the public posting requirements of the Community Health Needs Assessment. Under this policy, the Community Health Needs Assessment Reports must be posted on the Hospital's website at least until the date the hospital facility has made widely available on its website its two subsequent Community Health Needs Assessment Reports. The Hospital will also make a paper copy of its Community Health Needs Assessment Report available for public inspection upon request and without charge, at least until the date the hospital facility has made available for public inspection its two subsequent Community Health Needs Assessment Reports.
Murray Medical Center Part V, Section B, Line 7d: The Hospital has adopted a policy that addresses the public posting requirements of the Community Health Needs Assessment. Under this policy, the Community Health Needs Assessment Reports must be posted on the Hospital's website at least until the date the hospital facility has made widely available on its website its two subsequent Community Health Needs Assessment Reports. The Hospital will also make a paper copy of its Community Health Needs Assessment Report available for public inspection upon request and without charge, at least until the date the hospital facility has made available for public inspection its two subsequent Community Health Needs Assessment Reports.
Murray Medical Center Part V, Section B, Line 2: Effective May 1, 2015, the filing organization entered into a leasing arrangement whereby the operating assets of murray medical center, a 42-bed acute-care hospital located in Chatsworth, GA, were leased by the filing organization from the Murray County Memorial Hospital Authority. Prior to May 1, 2015, Murray Medical Center was operated as a governmental hospital, and to the best knowledge of the filing organization, was not also recognized as exempt from federal income tax under internal revenue code (IRC) Section 501(c)(3). Accordingly, Murray Medical Center did not conduct a Community Health Needs Assessment pursuant to IRC Section 501(r) while owned and operated by the Murray County Memorial Hospital Authority.Treas. Reg. Section 1.501(r)-3(d) provides an exception for acquired, new and terminated hospital facilities with respect to meeting the requirements of IRC Section 501(r)(3). Acquired facilities must conduct a Community Health Needs Assessment by the last day of the organization's second taxable year beginning after the date on which the hospital facility was acquired. Accordingly, Murray Medical Center has completed its first Community Health Needs Assessment in 2016 and will adopt its first implementation strategy before May 15, 2017.
Gordon Hospital Part V, Section B, Line 11: Gordon Hospital is part of the Southeast Region of Adventist Health Systems. The Region includes four hospital facilities. This is the third-year update for Gordon Hospital's 2013-2016 Community Health Plan/Implementation Strategy. The Hospital developed this Plan and posted it in May 2014 as part of its 2013 Community Health Needs Assessment process. For the development of both the Community Health Needs Assessment and the Community Health Plan/Implementation Strategy, Gordon Hospital made a particular effort to define and address the needs of low-income, minority and underserved populations in our service area. The 2013 Community Health Needs Assessment used primary data interviews and surveys; and hospital prevalence data to help the Hospital determine the health needs of the community we serve. Once the data was gathered, the primary issues identified in the Needs Assessment were prioritized by community and hospital stakeholders, who then selected key issues for the Hospital to address in its 2013-2016 Community Health Plan. The three-year progress on the community Health Plan is noted below. The narrative describes the issues identified in 2013 and gives an update on the strategies addressing those issues. There is also a description of the identified issues that the Hospital is not addressing. Gordon Hospital is located in Calhoun, Georgia. Because the community is very small (16,000 people), special events, seminars and screenings continue to be effective tools to reach the community. In most cases, participation in hospital-sponsored events was at least double the original goal. Priority: Cancer 2013 Description of the Issue: Cancer (including all types) ranked number 1 in our community survey in Gordon County. The State of Georgia's age adjusted cancer deaths/100,000 is 181.8 vs. the U.S. National average at 178.4. The Healthy People 2020 goal is 160.6. Although the latest CDC showed that Gordon County's cancer rates have stabilized, they are not meeting the HP2020 goals. Therefore, the Community Health Needs Assessment Committee (comprised of community members including those representing low-income, minority and other underserved populations) believed Cancer to be a high priority for our community.2016 Update: Because cancer was identified as a top need, Gordon Hospital held free events and screenings related to breast cancer, melanoma, prostate, oral/head/neck cancers, and smoking cessation; 130 people were screened (the goal was 100). The hospital reached 511 people (the goal was 100) at cancer education programs that included underserved populations, many of whom receive free cancer treatment at the hospital's Harris Radiation Therapy Center. 116 low-cost mammograms were offered in cooperation with the Health Department (the goal was 100). Priority: Access to Health Care2013 Description of the Issue: Another priority identified by community feedback is the lack of affordable health care available in zip code 30139, which is the community of Fairmount in Gordon County. A privately-owned clinic shut its doors for financial reasons and the community was left with no medical coverage. This area is composed largely of seniors who have little to no public transportation, and most physicians are located 25-30 minutes away. The Needs Assessment committee saw a need to bring health care access to that area of our county. 2016 Update: Gordon Hospital opened a primary care clinic in Fairmount; it had over 2,000 patient visits in 2016. In addition, the hospital accepts referrals from free and sliding fee scale clinics operated by the Health Department; the clinics are 14-19 miles from Fairmount. Priority: Heart Disease and Stroke 2013 Description of the Issue: The hospital's Needs Assessment committee also chose heart disease and stroke as priority issues. Cardiovascular disease is the number one killer in the state of Georgia. For Georgia, the age-adjusted death rate per 100,000 is 49.7. It is 42.2 nationally, and the Healthy People 2020 goal is 33.8. This ranked very high in our survey data, as well as within our local industry sector (manufacturing, heavy and light industry, and flooring plants). Employee Health nurses at the various plants were more concerned with employees having heart attacks than with getting hurt on the job. By choosing this priority and focusing on healthy eating, we hope to reduce the incidence of obesity and diabetes for our county as well.2016 Update: Gordon Hospital held many community outreach and education efforts, including 1,267 free monthly blood pressure screenings (the goal was 650) throughout the community at locations such as Walmart. Patients were referred to their family physicians or a Health Department clinic. The hospital's two CREATION Health educational programs (based on the tenants of choice, rest, environment, activity, trust, interpersonal relationships, outlook and nutrition) had 24 graduates. Our weekly CREATION Health Farmers Market averaged 25 vendors and 155 attendees per week during the months of June, July and August. Gordon Hospital had planned to educate 200 fifth-graders in Gordon County on healthy eating, the need for physical activity, and the dangers of tobacco. We changed the format to a health-focused Back-to-School-Blast at which we saw 728 elementary school students (plus their parents), including many from low-income families. Priority: Respiratory Disease and Smoking 2013 Description of the issue: The final priority that the Needs Assessment committee chose is respiratory disease and smoking. From our interviews, we have seen an increase in teen smoking, which in turn leads to higher incidences of respiratory diseases. This priority emerged in both our community survey as well as our internal data. According to the Centers for Disease Control and Prevention, Georgia's percentage of smokers is 17.6%. The Healthy People goal is 12%. The committee believed these two items were intertwined and could be addressed together.2016 Update: The focus of the Breathe Free tobacco cessation program (offered at no cost) has moved from one of graduation to participation. This allows attendees to be exposed to options for tobacco cessation and help them determine their readiness to quit. In 2016, Gordon Hospital held 10 Breathe Free classes with 123 attendees. The hospital also held lung disease/COPD seminars targeted at low-income populations in Gordon County; 1,239 people participated (the goal was 100). Priorities Considered but Not Selected The primary and secondary data in the Community Health Needs Assessment identified multiple community issues. Hospital and community stakeholders used the following criteria to narrow the larger list to the priority areas noted above:1. How acute is the need? (based on data and community concern)2. What is the trend? Is the need getting worse?3. Does the Hospital provide services that relate to the priority?4. Is someone else or multiple groups in the community already working on this issue?5. If the Hospital were to address this issue, are there opportunities to work with community partners?Based on this prioritization process, the Hospital did not choose the following community issues:Substance Abuse (drugs) ranked high in our community surveys. The hospital supports existing community programs including the Drugs Don't Work Program, Red Ribbon Week, Family Intervention Specialists, and Drug Take Back Program. We do not offer drug rehabilitation services but can help community partners work upstream to prevent or decrease addictions.Maternal, Infant and Child Health and unprotected sexual activity ranked high in our survey. Community programs are offered through the Boys and Girls Club, the Teen Health Task Force, and Family Intervention Specialists. The hospital works with the Healthy Families program after a child is born. This issue of unprotected sexual activity is not within the hospital's areas of expertise; the Health Department handles this issue.
Murray Medical Center Part V, Section B, Line 11: ADVENTIST HEALTH SYSTEM GEORGIA, INC., DBA MURRAY MEDICAL CENTER (MMC OR THE HOSPITAL), FORMED A COMMUNITY HEALTH NEEDS ASSESSMENT COMMITTEE (CHNAC) TO REVIEW THE PRIMARY AND SECONDARY DATA COLLECTED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROCESS AND TO FORMULATE THE DETERMINATION OF THE HEALTH PRIORITIES OF MMC USING A SYSTEMATIC APPROACH THAT RELIED HEAVILY ON A DECISION TREE PRIORITY SELECTION PROCESS. THE DECISION TREE FORMAT ASSISTED THE CHNAC IN FOCUSING ON THOSE NEEDS THAT THE HOSPITAL WOULD HAVE THE ABILITY TO INFLUENCE THROUGH THE IMPLEMENTATION OR EXPANSION OF PROGRAMS, SERVICES, OR OTHER ACTIONS, AND THAT MAY BE THE FOCUS OF OTHER COMMUNITY RESOURCES/ORGANIZATIONS WHO ARE ALREADY ADDRESSING THE NEED IN SOME WAY. THE CHNAC USED A PRIORITY SELECTION REPORT TOOL TO ASSIST IN THE REVIEW OF DATA COLLECTED AND PRIORITIZATION OF THE TOP AREAS OF SIGNIFICANT COMMUNITY NEED FOR THE HOSPITAL'S COMMUNITY. THE CHNAC CHOSE THE FOLLOWING THREE PRIORITIES:1. CANCER - NUMBER ONE HEALTH PROBLEM/CONDITION IN THE HOSPITAL'S COMMUNITY. THE CHNAC DETERMINED THAT MMC WAS IN A POSITION TO HELP THE COMMUNITY WITH CANCER DUE TO ITS PARTNERSHIP WITH GORDON HOSPITAL AND THE HARRIS RADIATION CENTER. 2. HIGH BLOOD PRESSURE/CHOLESTEROL & HEART DISEASE - ALL THREE OF THESE HEALTH PROBLEMS/CONDITIONS RANKED HIGH IN THE CHNA. THE CHNAC DETERMINED THAT MMC CAN USE ITS CREATION HEALTH PROGRAMS TO OFFER EDUCATIONAL COMMUNITY EVENTS TO HEIGHTEN AWARENESS OF THE LIFE STYLE CHANGES THAT WILL HELP IN ADDRESSING THESE CONDITIONS.3. DIABETES - THE CHNAC NOTED THAT A NUMBER OF THE BEHAVIOR/RISK FACTORS ON THE MMC COMMUNITY SURVEY ARE DIRECTLY RELATED TO DIABETES. MMC WILL DEVELOP IMPLEMENTATION STRATEGIES TO ADDRESS THESE FACTORS.THE FOLLOWING IDENTIFIED HEALTH NEEDS WERE NOT SELECTED FOR TOP PRIORITY:TEEN PREGNANCY - THERE ARE PROGRAMS IN PLACE THrOUGH THE BOYS & GIRLS CLUB AND OTHER AGENCIES FOR TEEN PREGNANCY ISSUES. MENTAL HEALTH - THE HOSPITAL DOES NOT OFFER MENTAL HEALTH SERVICES. HOWEVER, MENTAL HEALTH SERVICES ARE AVAILABLE IN MURRAY COUNTY.IMMUNIZATIONS (ADULTS & CHILDREN) - THE HOSPITAL WILL SUPPORT THE HEALTH DEPARTMENT IN ITS IMMUNIZATION EFFORTS.ASTHMA (CHILDREN) - ALTHOUGH THERE WAS A SMALL PERCENTAGE OF COMMUNITY RESPONDENTS WHO INDICATED THAT ASTHMA IN CHILDREN WAS A COMMUNITY HEALTH CONCERN, THE CHNAC DETERMINED THAT THE LIMITED RESOURCES OF THE HOSPITAL WOULD BE BETTER USED AT THIS TIME TO FOCUS ON PRIORITIES THAT HAD A BROADER IMPACT ON THE COMMUNITY.
Part V, Section B, Line 7A URL for Gordon Hospital's CHNA: www.gordonhospital.com/about-us/community-benefitURL for Murray Medical Center CHNA: http://www.murraymedical.org/about-us/community-benefit
Part V, Section B, Line 10A URL for Gordon hospital's most recently adopted implementation strategy: www.gordonhospital.com/about-us/community-benefit
Part V, Section B, Line 8-10A Gordon Hospital: The filing organization adopted a Community Health Needs Assessment Report by 12/31/16 and was in the process of developing its Community Health Needs Implementation Strategy. The filing organization's 2017 Community Health Needs Implementation Strategy will be documented in a written report called the "Community Health Plan". The Community Health Plan (CHP) will describe how the filing organization plans to meet its identified prioritized health needs or will identify the health need as one the filing organization does not intend to specifically address and provide an explanation as to why the filing organization does not intend to address that health need. In accordance with Final Regulation Section 1.501(r)-3(c)(5), the filing organization's 2017 CHP was adopted no later than May 15, 2017 and is also posted on the hospital facility's website.As the hospital facility's 2017 Community Health Needs Implementation Strategy was not adopted by the end of the hospital organization's taxable year of December 31, 2016, Schedule H, Part V, Section B, line 9 indicates that 2014 was the tax year in which the hospital facility last adopted an implementation strategy. Schedule H, Part V, Section B, Line 10a reflects the website address for the hospital facility's 2014 Implementation Strategy since this is the most recently adopted Implementation Strategy.Murray Medical Center: Effective May 1, 2015, the filing organization entered in to a leasing arrangement whereby the operating assets of Murray Medical Center were leased by the filing organization From the Murray County Memorial Hospital Authority. Prior to May 1, 2015, Murray medical Center was operated as a governmental hospital, and to the best knowledge of the filing organization, was not also recognized as exempt from federal income tax under internal revenue code (IRC) section 501(c)(3). Accordingly, Murray medical Center did not conduct a Community Health Needs Assessment pursuant to IRC Section 501(r) while owned and operated by the Murray County Memorial Hospital authority.Murray Medical Center adopted its first Community Health Needs Assessment Report by 12/31/16 and was in the process of developing its Community Health Needs Implementation Strategy. The filing organization's 2017 Community Health Needs Implementation Strategy will be documented in a written report called the "Community Health Plan". The Community Health Plan (CHP) will describe how the filing organization plans to meet its identified prioritized health needs or will identify the health need as one the filing organization does not intend to specifically address and provide an explanation as to why the filing organization does not intend to address that health need. In accordance with Final Regulation Section 1.501(r)-3(c)(5), the filing organization's first CHP was adopted no later than May 15, 2017 and is posted on the hospital facility's website.As the hospital facility's 2017 Community Health Needs Implementation Strategy was not adopted by the end of the hospital organization's taxable year of December 31, 2016, Schedule H, Part V, Section B, line 8 indicates that an implementation strategy was not adopted to meet the significant health needs identified through its most recently conducted Community Health Needs Assessment.
Part V, Line 16A, 16B, and 16C: Part V, 16A, FAP website:Gordon Hospitalwww.gordonhospital.com/patients-visitors/after-my-stay/financial-assistance/Murray Medical Centerwww.murraymedical.org/patients-visitors/financial-assistance/Part V, 16B, FAP Application Website:Gordon Hospitalwww.gordonhospital.com/patients-visitors/after-my-stay/financial-assistance/Murray Medical Centerwww.murraymedical.org/patients-visitors/financial-assistance/Part V, 16C, FAP Plain Language Summary website:Gordon Hospitalwww.gordonhospital.com/patients-visitors/after-my-stay/financial-assistance/Murray Medical Centerwww.murraymedical.org/patients-visitors/financial-assistance/
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2016
Page 9
Schedule H (Form 990) 2016
Page 9
Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?19
Name and address Type of Facility (describe)
1 1 - Gordon Hospital Owasa Family Medicine
109 Hospital Court
Calhoun,GA30701 		Physician clinic - Family Practice
2 2 - Gordon Home Care
104 Hospital Court
Calhoun,GA30701 		Home Health Services
3 3 - Gordon Hospital Internal & Family Medici
400 Timms Rd
Calhoun,GA30701 		Physician clinic - Family Practice
4 4 - North Georgia Orthopedic & Sports Medici
106 Hospital Court
Calhoun,GA30701 		Physician clinic - Orthopedic
5 5 - Ambulance Service
101 Professional Court
Calhoun,GA30701 		Ambulance Service
6 6 - Gordon Health Depot
824 GI Maddox Parkway
Chatsworth,GA30705 		Physician clinic - Family Practice
7 7 - Gordon Urgent Care - Calhoun
100 Hospital Court
Calhoun,GA30701 		Physician clinic - Family Practice
8 8 - Gordon Adult & Pediatric Medical Assoc
815 Curtis Parkway SE
Calhoun,GA30701 		Physician Clinic - Internal & Pediatric
9 9 - Ambulance Service
104 Hospital Dr
Chatsworth,GA30705 		Ambulance Service
10 10 - Gordon Hospital Adairsville Family Medic
6000 Joe Frank Harris Pkwy NW
Adairsville,GA30103 		Physician clinic - Family Practice
11 11 - Northwest GEORGIA OB GYN
110 Hospital Court
Calhoun,GA30701 		Physician clinic - OB GYN
12 12 - North Georgia Cancer Center
100 Willowbrook Way
Calhoun,GA30701 		Physician Clinic
13 13 - Gordon Primary Care
105 Willowbrook Way
Calhoun,GA30701 		Physician Clinic - Family Practice
14 14 - Gordon Hospital Cook Family Practice
100 Hospital Court
Chatsworth,GA30705 		Physician Clinic - Family Practice
15 15 - Gordon Hospital Fairmount Family Medicin
2712 Hwy 411
Fairmount,GA30139 		Physician clinic - Family Practice
16 16 - Gordon Neurology
400 Timms Rd
Calhoun,GA30701 		Physician Clinic - Neurologist
17 17 - Northwest Georgia Endocrinology
400 Timms Rd
Calhoun,GA30701 		Physician Clinic - Endocrinology
18 18 - Gordon Urgent Care - Adairsville
7427 Highway 140 NW
Adairsville,GA30103 		Physician clinic - Family Practice
19 19 - Murray Primary Care
106 Hospital Court Suite 2
Chatsworth,GA30705 		Physician Clinic - Family Practice
Schedule H (Form 990) 2016
Page 10
Schedule H (Form 990) 2016
Page 10
Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Form and Line Reference Explanation
Part I, Line 6a: The filing organization was a wholly owned subsidiary of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC) during its current tax year. During the current year, AHSSHC served as a parent organization to 22 tax-exempt 501(c)(3) hospital organizations that operated 44 hospitals in ten states within the U.S. The system of organizations under the control and ownership of AHSSHC is known as "Adventist Health System" (AHS).All hospital organizations within AHS collect, calculate, and report the community benefits they provide to the communities they serve. AHS organizations exist solely to improve and enhance the local communities they serve. AHS has a system-wide community benefits accounting policy that provides guidelines for its health care provider organizations to capture and report the costs of services provided to the underprivileged and to the broader community. Each AHS hospital facility reports their community benefits to their Board of Directors and strives to communicate their community benefits to their local communities. Additionally, the filing organizations most recently conducted community health needs assessment and associated implementation strategy are posted on the filing organization's website.
Part I, Line 7: The amounts of costs reported in the table in line 7 of Part I of Schedule H were determined by utilizing a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges, contained in the Schedule H instructions.
Part III, Line 2: The amount of bad debt expense, reported on line 2 of Section A of Part III is recorded in accordance with Healthcare Financial Management Association Statement No. 15. Discounts and payments on patient accounts are recorded as adjustments to revenue, not bad debt expense.
Part III, Line 3: Methodology for Determining the Estimated Amount of Bad Debt Expense that May Represent Patients who Could Have Qualified under the Filing Organization's Financial Assistance Policy:Self-pay patients may apply for financial assistance by completing a Financial Assistance Application Form (FAA Form). If an individual does not submit a complete FAA Form within 240 days after the first post-discharge billing statement is sent to the individual, an individual may be considered for presumptive eligibility based upon a scoring tool that is designed to classify patients into groups of varying economic means. The scoring tool uses algorithms that incorporate data from credit bureaus, demographic databases, and hospital specific data to infer and classify patients into respective economic means categories. Individuals who earn a certain score on the scoring tool are considered to qualify as eligible for the most generous financial assistance under the filing organization's Financial Assistance Policy. As determined by the filing organization, a nominal amount of such a patient's bill is written off as bad debt expense, while the remaining portion of the patient's bill is considered non-state charity. The amount written off as bad debt expense for those patients who potentially qualify as non-state charity using the scoring tool is the amount shown on line 3 of Section A of Part III. Rationale for Including Certain Bad Debts in Community Benefit:The filing organization is dedicated to the view that medically necessary health care for emergency and non-elective patients should be accessible to all, regardless of age, gender, geographic location, cultural background, physician mobility, or ability to pay. The filing organization treats emergency and non-elective patients regardless of their ability to pay or the availability of third-party coverage. By providing health care to all who require emergency or non-elective care in a non-discriminatory manner, the filing organization is providing health care to the broad community it serves. As a 501(c)(3) hospital organization, the filing organization maintains a 24/7 emergency room providing care to all whom present. When a patient's arrival and/or admission to the facility begins within the Emergency Department, triage and medical screening are always completed prior to registration staff proceeding with the determination of a patient's source of payment. If the patient requires admission and continued non-elective care, the filing organization provides the necessary care regardless of the patient's ability to pay. The filing organization's operation of a 24/7 Emergency Department that accepts all individuals in need of care promotes the health of the community through the provision of care to all whom present. Current Internal Revenue Service guidance that tax-exempt hospitals maintain such emergency rooms was established to ensure that emergency care would be provided to all without discrimination. The treatment of all at the filing organization's Emergency Department is a community benefit. Under the filing organization's Financial Assistance Policy, every effort is made to obtain a patient's necessary financial information to determine eligibility for financial assistance. However, not all patients will cooperate with such efforts and a financial assistance eligibility determination cannot be made based upon information supplied by the individual. In this case, a patient's portion of a bill that remains unpaid for a certain stipulated time period is wholly or partially classified as bad debt. Bad debts associated with patients who have received care through the filing organization's Emergency Department should be considered community benefit as charitable hospitals exist to provide such care in pursuit of their purpose of meeting the need for emergency medical care services available to all in the community.
Part III, Line 4: Financial Statement Footnote Related to Accounts Receivable and Allowance for Uncollectible Accounts:The financial information of the filing organization is included in a consolidated audited financial statement for the current year.The applicable footnote from the attached consolidated audited financial statements that addresses accounts receivable, the allowance for uncollectible accounts, and the provision for bad debts can be found on page 8. Please note that dollar amounts on the attached consolidated audited financial statements are in thousands.
Part III, Line 8: Costing Methodology:Medicare allowable costs were calculated using a cost-to-charge ratio.
Part III, Line 9b: The hospital filing organization's collection practices are in conformity with the requirements set forth in the 2014 Final Regulations regarding the requirements of Internal Revenue Code Section 501(r)(4) - (r)(6). No extraordinary collection actions (ECA's) are initiated by the hospital filing organization in the 120-day period following the date after the first post-discharge billing statement is sent to the individual (or, if later, the specified deadline given in a written notice of actions that may be taken, as described below). Individuals are provided with at least one written notice (notice of actions that may be taken) and a copy of the filing organization's Plain Language Summary of the Financial Assistance Policy that informs the individual that the hospital filing organization may take actions to report adverse information to credit reporting agencies/bureaus if the individual does not submit a Financial Assistance Application Form (FAA Form) or pay the amount due by a specified deadline. The specified deadline is not earlier than 120 days after the first post-discharge billing statement is sent to the individual and is at least 30 days after the notice is provided. A reasonable attempt is also made to orally notify an individual about the filing organization's Financial Assistance Policy and how the individual may obtain assistance with the Financial Assistance application process. If an individual submits an incomplete FAA Form during the 240-day period following the date on which the first post-discharge billing statement was sent to the individual, the hospital filing organization suspends any reporting to consumer credit reporting agencies/bureaus (or ceases any other ECA's) and provides a written notice to the individual describing what additional information or documentation is needed to complete the FAA Form. This written notice contains contact information including the telephone number and physical location of the hospital facility's office or department that can provide information about the Financial Assistance Policy, as well as contact information of the hospital facility's office or department that can provide assistance with the financial assistance application process or, alternatively, a nonprofit organization or governmental agency that can provide assistance with the financial assistance application process if the hospital facility is unable to do so. If an individual submits a complete FAA Form within a reasonable time-period as set forth in the notice described above, the hospital filing organization will suspend any adverse reporting to consumer credit reporting agencies/bureaus until a financial assistance policy eligibility determination can be made.
Supplemental Schedule to Schedule H, Part III, Section B Reconciliation of Schedule H Reported Medicare Surplus/(Shortfall) to Unreimbursed Medicare Costs Associated with the Provision of ServicesTo All Medicare Beneficiaries:The Medicare revenue and allowable costs of care reported in Section B of Part III of Schedule H are based upon the amounts reported in the filing organization's Medicare cost report in accordance with the IRS instructions for Schedule H. On an annual basis, the filing organization also determines its total unreimbursed costs associated with providing services to all Medicare patients. Unreimbursed costs are considered a community benefit to the elderly and are combined into an annual Community Benefit Statement prepared by Adventist Health System. The primary reconciling items between the Medicare surplus/(shortfall) shown on line 7 of Section B of Part III of Schedule H and the filing organization's unreimbursed costs of services provided to Medicare patients as reported in the AHS Community Benefit Report are as follows:- Medicare surplus/(shortfall) shown on line 7 of Section B of Schedule H: $ 1,127,594- Difference in costing methodology: (8,016,712)- Unreimbursed costs incurred for services provided to Medicare patients that are not included in the organization's Medicare cost report: (6,646,467) -------------Total surplus/(shortfall) costs of serving all Medicare patients per the filing organization's community benefit reporting: $(13,535,585)As indicated above, the primary differences between the Medicare surplus/(shortfall) reported on Schedule H, Part III, Section B, line 7 and the filing organization's portion of the Company's annual community benefit statement is due to a difference in the costing methodology and differences in the population of Medicare patients within the calculation. The cost methodology utilized in calculating any Medicare surplus/(shortfall) for purposes of the annual community benefit reporting is based upon the cost-to-charge ratio outlined in Worksheet 2 of the Schedule H instructions. The same cost-to-charge ratio is used to determine the costs associated with services provided to charity care patients and Medicaid patients as reported in Schedule H, Part I, line 7. In addition, the Medicare cost report excludes services provided to Medicare patients for physician services, services provided to patients enrolled in Medicare HMOs, and certain services provided by outpatient departments of the filing organization that are reimbursed on a fee schedule. The Company's own community benefit statement captures the unreimbursed cost of providing services to all Medicare beneficiaries throughout the organization.
Part VI, Line 2: As reported in Schedule H, Part V, Section B, the filing organization's hospitals conducted community health needs assessments (CHNA) during 2013 and 2016. The 2016 CHNAs were adopted by its governing board by December 31, 2016, the end of the filing organization's taxable year in which it conducted the CHNAs. The filing organization's 2016 CHNAs complied with the guidance set forth by the IRS in Final Regulation Section 1.501(r)-3. In addition to the CHNAs discussed above, a variety of practices and processes are in place to ensure that the filing organization is responsive to the health needs of its communities.Such practices and processes involve the following:1.A hospital operating/community board composed of individuals broadly representative of the community, community leaders, and those with specialized medical training and expertise;2.Post-discharge patient follow-up related to the on-going care and treatment of patients who suffer from chronic diseases; 3.Sponsorship and participation in community health and wellness activities that reach a broad spectrum of the filing organization's communities; and 4.Collaboration with other local community groups to address the health care needs of the filing organization's communities.
Part VI, Line 3: The Financial Assistance Policy (FAP), Financial Assistance Application Form (FAA Form), and the Plain Language Summary of the Financial Assistance Policy (PLS) of the filing organization's hospital facilities are transparent and available to all individuals served at any point in the care continuum. The FAP, FAA Form, PLS, and contact information for the hospital facilities' financial counselors are prominently and conspicuously posted on the filing organization's hospital facilities' websites. The websites indicate that a copy of the FAP, FAA Form, and PLS is available and how to obtain such copies in the primary languages of any populations with limited proficiency in English that constitute the lesser of 1,000 individuals or 5% of the members of the community served by the hospital facility (referred to below as LEP defined populations). Signage is displayed in public locations of the filing organization's hospital facilities, including at all points of admission and registration and the Emergency Department. The signage contains the hospital facilities' website address where the FAP, FAA Form, and PLS can be accessed and the telephone number and physical location that individuals can call or visit to obtain copies of the FAP, FAA Form and PLS or to obtain more information about the hospital facilities' FAP, FAA Form and PLS. Paper copies of the hospital facilities' FAP, FAA Form and PLS are available upon request and without charge, both in public locations in the hospital facility and by mail. Paper copies are made available in English and in the primary languages of any LEP defined populations. The filing organization's hospital facilities' financial counselors seek to provide personal financial counseling to all individuals admitted to the hospital facility who are classified as self-pay during the course of their hospital stay or at time of discharge to explain the FAP and FAA Form and to provide information concerning other sources of assistance that may be available, such as Medicaid. A paper copy of the hospital facility's PLS will be offered to every patient as a part of the intake or discharge process. A conspicuous written notice is included on all billing statements sent to patients that notifies and informs recipients about the availability of financial assistance under the filing organization's financial assistance policy, including the following: 1) the telephone number of the hospital facility's office or department that can provide information about the FAP and the FAA Form; and 2) the website address where copies of the FAP, FAA Form and PLS may be obtained. Reasonable attempts are made to inform individuals about the hospital facility's FAP in all oral communications regarding the amount due for the individual's care. Copies of the PLS are distributed to members of the community in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance.
Part VI, Line 4: Adventist Health System Georgia, Inc., d/b/a Gordon Hospital (the Hospital), is a 69-bed community hospital that serves the residents of Calhoun, Gordon County and surrounding areas in Georgia. The Hospital's primary market has a population of approxiamtely 56,574. Gordon Hospital provides the following services to its community: a 24-hour Emergency Center, Ambulance Service, Rehabilitation Services, Intensive and Progressive Care Units, Cancer Resource Center, Radiology, Interventional Radiology, Lab, Cardiopulmonary, Sleep Disorders Center, New Beginnings Maternity Center, Urgent Care Centers, Orthopedic Surgery, Opthalmology Surgery, diagnostic cardiac catheterization lab, and Pastoral Care. The Hospital is the only hospital in Northwest Georgia to be an accredited Breast Imaging Center of Excellence. In November 2012, the Hospital opened a Radiation Oncology Center that for the first time provides this service within the community. There are four unrelated hospitals approximately 20 miles away from Gordon Hospital. The per capita income income in the primary market is approximately $30,872. High school graduates account for approximately 74% of Gordon County, with an estimated 11.7% having a bachelor's degree or higher. The unemployment rate is about 5.7%.Approximately 58.3% of the Hospital's patients during 2016 were covered by Medicare and Medicaid. Medicare patients comprise about 43.7% of the Hospital's patients. Approximately 14.6% of the Hospital's patients are covered by the Medicaid program, 9.8% representing self-pay, with the remaining 31.9% in commercial payors. Approximately 65.6% of the Hospital's in-patients are admitted through the Hospital's emergency department.Adventist Health System Georgia, Inc., dba Murray Medical Center (MMC), is a 42-bed community hospital that serves the residents of chatsworth, murray county and surrounding areas in Georgia. The Hospital's services include: 24-hour emergency department, imaging services, laboratory, ambulance services, orthopedics, respiratory therapy, physical therapy, sports medicine, and surgical services. Murray county's population is approximately 39,565. The per capita income, based on population, in murray county is approximately $26,057. High school graduates account for approximately 72.4% of Murray county with 8.6% holding at least a bachelor's degree. The unemploymnet rate is 7.4%. Approximately 57.6% of MMC's patients were covered by medicare and medicaid. Medicare patients comprised about 39.8% of these patients and approximately 17.8% were covered by the medicaid program. 19.2% of MMC's patients were self-pay, with the remaining 23.2% in commercial payors. Approximately 87.8% of MMC's in-patients were admitted through MMC's emergency department.
Part VI, Line 5: The provision of community benefit is central to the filing organization's mission of service and compassion. Restoring and promoting the health and quality of life of those in the communities served by the filing organization is a function of "extending the healing ministry of Christ and embodies the organization's commitment to its values and principles. The filing organization commits substantial resources to provide a broad range of services to both the underprivileged as well as the broader community. In addition to the community benefit and community building information provided in Parts I, II and III of this Schedule H, the filing organization captures and reports the benefits provided to its communities through faith-based care. Examples of such benefits include the cost associated with chaplaincy care programs and mission peer reviews and mission conferences. During the current year, the filing organization provided $113,391 of benefit with respect to the faith-based and spiritual needs of the communities in conjunction with its operation of community hospitals. The filing organization also provides benefits to its communities' infrastructure by investing in capital improvements to ensure that facilities and technology provide the best possible care to the community. During the current year, the filing organization expended $5,921,920 in new capital improvements. As faith-based mission-driven community hospitals, the filing organization is continually involved in monitoring its communities, identifying unmet health care needs and developing solutions and programs to address those needs. In accordance with its conservative approach to fiscal responsibility, surplus funds of the filing organization are continually being invested in resources that improve the availability and quality of delivery of health care services and programs to the communities it serves.
Part VI, Line 6: Adventist Health System Georgia, Inc. is a part of a faith-based healthcare system of organizations whose parent is Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). The system is known as Adventist Health System (AHS). AHSSHC is an organization exempt from federal income tax under IRC Section 501(c)(3). AHSSHC and its subsidiary organizations operate 44 hospitals in 10 states throughout the U.S., primarily in the Southeastern portion of the U.S. AHSSHC and its subsidiaries also operate 16 nursing home facilities and other ancillary health care provider facilities, such as ambulatory surgery centers and diagnostic imaging centers. As the parent organization of the AHS system, AHSSHC provides executive leadership and other professional support services to its subsidiary organizations. Professional support services include among others corporate compliance, legal, human resources, reimbursement, risk management, and tax as well as treasury functions. The provision of these executive and support services on a centralized basis by AHSSHC provides an appropriate balance between providing each AHS subsidiary hospital organization with mission-driven consistent leadership and support while allowing the hospital organization to focus its resources on meeting the specific health care needs of the community it serves. The reader of this Form 990 should keep in mind that this reporting entity may differ in certain areas from that of a stand-alone hospital organization due to its inclusion in a larger system of healthcare organizations. As a part of a system of hospital and other health care organizations, the filing organization benefits from reduced costs due to system efficiencies, such as large group purchasing discounts, and the availability of internal resources such as internal legal counsel. Each AHS subsidiary pays a management fee to AHSSHC for the internal services provided by AHSSHC. As a result, management fee expense reported by a AHS subsidiary organization may appear greater in relation to management fee expense that may be reported by a single stand-alone hospital. The single stand-alone hospital would likely report costs associated with management and other professional services on various expense line items in its statement of revenue and expense as opposed to reporting such costs in one overall management fee expense. As the reporting of the Form 990 is done on an entity by entity basis, there is no single Form 990 that captures the programs and operations of AHS as a whole. The reader is directed to visit the web-site of AHS at www.adventisthealthsystem.com to learn more about the mission and operations of AHS.
Part VI, Line 7: The filing organization does not file an annual community benefit report with any state agencies.
Schedule H (Form 990) 2016
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