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Lee Memorial Health System Trauma District & Full Board

of Directors Meetings

Thursday, August 25, 2016 1:00 p.m.

BOARD OF DIRECTORS

OFFICE 239-343-1500

FAX: 239-343-1599

13685 DOCTORS WAY #190 FT MYERS, FLORIDA 33912

CAPE CORAL HOSPITAL

GULF COAST MEDICAL CENTER

HEALTHPARK MEDICAL CENTER

LEE MEMORIAL HOSPITAL

GOLISANO CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA

THE REHABILITATION HOSPITAL

LEE PHYSICIAN GROUP

LEE CONVENIENT CARE

BOARD OF DIRECTORS

DISTRICT ONE

Stephen R. Brown, M.D.

Therese Everly, BS, RRT

DISTRICT TWO

Donna Clarke

Nancy M. McGovern, RN, MSM

DISTRICT THREE

Sanford N. Cohen, M.D.

David Collins

DISTRICT FOUR

Diane Champion

Chris Hansen

DISTRICT FIVE

Jessica Carter Peer

Stephanie Meyer, BSN, RN

AGENDA

TRAUMA DISTRICT & FULL BOARD OF DIRECTORS MEETINGS August 25, 2016 at 1:00 p.m.

Gulf Coast Medical Center – Boardroom (Medical Office Building) 13685 Doctors Way, Ft. Myers, FL 33912

1. CALL TO ORDER (Sanford Cohen, M.D., Board Chairman) Lee Memorial Health System Board of Directors, sitting as the Lee Memorial Health System (LMHS) Board of Directors for Gulf Coast Medical Center & Lee Memorial Hospital/HealthPark Medical Center and the Board of Directors of its subsidiary corporations, including but not limited to Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital; Lee Memorial Home Health, Inc.; and HealthPark Care Center, Inc.

2. INVOCATION & PLEDGE OF ALLEGIANCE (Rev. Mike Warthen, MDiv)

3. PUBLIC INPUT – Agenda Items: Any Public Input is limited to three minutes and a “Request to Address the Board of Directors” card must be completed and submitted to the Board Staff prior to meeting. Individuals wishing to address the Board on a Non Agenda item must notify the Board Staff of the subject matter at least three (3) days prior to the meeting.

4.

RECOGNITIONS Judith C. Maier – 33 years (Richard Helvey, Director, Housekeeping) Kathryn J. Georgeson, RN, BSN, CCM – 33 years (Heidi Shoriak, RN, BS, CCM, Director, Care Management)

5.

LMHS MILITARY SUPPORT – UPDATE (Kim Gaide, Practice Manager, LPG Medical Records)

6. PRESIDENT’S REPORT (Jim Nathan, CEO/President)

RECESS to CALL TO ORDER Lee County Trauma Services District Board of Directors Meeting (Sanford Cohen, M.D., Board Chairman)

RECONVENE LEE MEMORIAL HEALTH SYSTEM BOARD MEETING (Sanford Cohen, M.D., Board Chairman)

LMHS SYSTEM BUSINESS – SANFORD COHEN, M.D., BOARD CHAIRMAN

7.

CONSENT AGENDA (Approve) 1. Full Board Meeting Minutes of April 28, 2016 2. Financial and Statistical Reports of May 31, 2016 3. Financial and Statistical Reports of June 30, 2016 4. Policy 20.02C Conflict of Interest – Reviewed, No Revisions

8.

OBSERVATION VS. INPATIENT (Jon Hart, MD, Lead Physician Advisor, Shelley Koltnow, Interim Chief Compliance Officer, Anne Rose, Vice President, Revenue Cycle)

9.

MEDICAL STAFF RECOMMENDATIONS OF 8/25/2016 (Approve) 1. Lee Memorial Hospital 2. Cape Coral Hospital 3. Gulf Coast Medical Center 4. HealthPark Medical Center 5. Golisano Children’s Hospital of SW Florida

BOARD OF DIRECTORS

OFFICE 239-343-1500

FAX: 239-343-1599

13685 DOCTORS WAY #190 FT MYERS, FLORIDA 33912

CAPE CORAL HOSPITAL

GULF COAST MEDICAL CENTER

HEALTHPARK MEDICAL CENTER

LEE MEMORIAL HOSPITAL GOLISANO CHILDRENS HOSPITAL

OF SOUTHWEST FLORIDA

THE REHABILITATION HOSPITAL

LEE PHYSICIAN GROUP

LEE CONVENIENT CARE

BOARD OF DIRECTORS

DISTRICT ONE

Stephen R. Brown, M.D.

Therese Everly, BS, RRT

DISTRICT TWO

Donna Clarke

Nancy M. McGovern, RN, MSM

DISTRICT THREE

Sanford N. Cohen, M.D.

David Collins

DISTRICT FOUR

Diane Champion

Chris Hansen

DISTRICT FIVE

Jessica Carter Peer

Stephanie Meyer, BSN, RN

AGENDA (Page 2 of 2)

TRAUMA AND FULL BOARD OF DIRECTORS MEETINGS August 25, 2016 at 1:00 p.m.

10. OLD BUSINESS

11. NEW BUSINESS

12. BOARD MEETING CRITIQUE

13. BOARD OF DIRECTORS REPORTS

14. Date of the next Meeting:

September 8, 2016 at 1:00 p.m. Quality & Safety and Full Board of Directors

Gulf Coast Medical Center – Boardroom 13685 Doctors Way, Ft. Myers, FL 33912

ADJOURN (Sanford Cohen, M.D., Board Chairman)

___________________

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS

Invocation &

Pledge of Allegiance

http://www.bing.com/images/search?q=flag+clip+art&view=detailv2&qpvt=flag+clip+art&id=8DF26CC9B65BEFE0F79E30D420AAEAF6A17045C5&selectedIndex=16&ccid=ewVXZQVi&simid=608048506948357551&thid=OIP.M7b0557650562a7c43dbea91b3ae77a93o0

___________________


PUBLIC INPUT

AGENDA ITEMS:

Any public input pertaining to items on the Agenda is limited to three minutes and a “Request to Address the Board of Directors” card must be completed and submitted to the Board Staff prior to meeting.

Refer to Board Policy: 10:15F: Public Addressing the Board

Non-Agenda Item: Individuals wishing to address the Board on an item NOT on the Agenda, the Board office must be notified of subject matter at least three (3) days prior to the meeting to allow staff time to prepare and to insure the matter is within the jurisdiction of the Board.

Proclamation

LEE MEMORIAL HEALTH SYSTEM

would like to recognize with sincere appreciation

in her retirement of 33 dedicated service years to the Lee Memorial Health System.

The entire system wishes you health & happiness, and all the best in your future endeavors.

BOARD OF DIRECTORS

District 1 – Stephen R. Brown, MD Therese Everly, BS, RRT District 2 – Donna Clarke Nancy M. McGovern, RN, MSM

District 3 – Sanford N. Cohen, MD David F. Collins District 4 – Diane Champion Chris Hansen

District 5 – Jessica Carter Peer Stephanie L. Meyer, BSN, RN

Judith C. Maier

Proclamation


would like to recognize with sincere appreciation

in her retirement of 33 dedicated service years to the Lee Memorial Health System.

The entire system wishes you health & happiness, and all the best in your future endeavors.

BOARD OF DIRECTORS

District 1 – Stephen R. Brown, MD Therese Everly, BS, RRT District 2 – Donna Clarke Nancy M. McGovern, RN, MSM

District 3 – Sanford N. Cohen, MD David F. Collins District 4 – Diane Champion Chris Hansen

District 5 – Jessica Carter Peer Stephanie L. Meyer, BSN, RN

Kathryn J. Georgeson, RN, BSN, CCM

___________________ LEE MEMORIAL HEALTH SYSTEM

BOARD OF DIRECTORS

MILITARY SUPPORT UPDATE

Kim Gaide, Practice Manager LPG Medical Records

LMHS Military Support Program

The Lee Memorial Health System Military Support Program is: Dedicated to supporting our military men and women and their families while

deployed. Over 75,000 pounds of care packages sent since May 2003. Supporting our returning troops with resume building, VA benefits, job placement,

readjustment to civilian living. Sustaining our homeless veterans with their needs. Support our local veterans with referrals and assistance.

What does the Military Support Program do?

Connected supporters to adopt 17 families for Christmas packages for veteran/ deployed troops families, December 2015.

Sponsors Military Appreciation Day – first Saturday of November, held at First Christian Church. Event all about the Vets and their families – Free Daycare Provided, Resumes built while you wait, Social Support Agencies, VA Burial Benefits, Mental Health Benefits, Eligibility and coordination of VA benefits, Job Placement – employers hiring, Colleges and Universities, MASH Unit to include Health Screenings, PSAs, Flu Shots, Hot Showers, Hair Cuts, Dental screenings, Chow Hall for free breakfast and lunch, Widows Benefits, Aid and Attendance for Assisted Living Benefits, and Shop at our free PX.

Suite Support for the Military is a program with the Florida Everblades – A veteran or active duty member may sign up for a hockey game and take 9 of his/her best friends, pick one of the catered meals and drinks, and also receive passes for free parking. Call or email the information below for more information.

Assist local returning home veterans and their families in getting community resources to them. We have a network of businesses, community organizations, and military supporters that assist us. We also have supplies of wheelchairs and other DME equipment available. Steering committee member of Lee County Community Blue Print, a MOAA program.

Sponsor local troops and their families while on active duty including deployment.

Fundraise (Easter, 4th of July, Thanksgiving, and Christmas) for our care package mailing fund and any other needs the troops may have that families may not be able to afford. We are not supported financially by LMHS.

Send clipped coupons to over 18 bases stateside and overseas to families who can use the clipped coupons at the PX or on-base store.

We send blank greeting cards about 6 weeks before a holiday (Easter, Mothers Day, Fathers Day, Thanksgiving, and Christmas) so that the troops may forward them on signed to their family. They don’t have a Hallmark store at the corner!

Communicates with over 1,200+ military families and supporters to assist our troops with their immediate need: broken ipod replaced and sent in 24 hours, jeep broken down, a family with no food.

Built relationships with FPL, Lee County Electric, and Sprint United so utilities of our supported families were not turned off while their loved one were deployed.

Kim Gaide – 239-343-2045 or [email protected] Facebook page: LMHS Military Support Program PO Box 2218, Fort Myers FL 33902 6/14/2016

mailto:[email protected]

5th AnnualMilitary Appreciation Day

For All VeteransNovember 5, 20169:00 AM - 1:00 PMFirst Christian Church2061 McGregor BoulevardFort Myers, FL 33901

University and Colleges, Local Hiring EmployersCome enjoy the following activities – plus many more:

� Brunch Provided � Health Screenings � Massages

� Social Support Agencies � Hair Cuts

� VA Burial Benefits � Widow Benefits

� Mental Health Benefits � Aid and Attendance for Assisted Living Benefits

� Eligibility and coordination � Shop at our free PX

� of VA benefits � Dental Exams by appointment

� Day Care Provided – Call for Reservations: 239-343-2045 so that we may be

prepared to care for your child(ren) while you take care of yourself.

Brought to you by: For More Information, call 239-343-2045

WELCOME!• Any discharged veteran

• Medically retired• Active duty

• National Guard andReserves

American Legion Post #38

Hearts and Homes forVeterans, Inc.

Victor Paul Tuchman Post400 Jewish War Veterans

Military Support Program at Lee Memorial Health System

First Christian Church

LeeSar

Prudential Financial

American Red Cross

___________________


PRESIDENT’S REPORT

Jim Nathan, CEO / President

1

President’sReportLMHSBoardofDirectors

August25,2016

NOTE:OpenenrollmentforhealthexchangesbeginsNovember15throughJanuary;healthplanshavehadtodeclarewheretheywillbecompetingthissummerandidentifyrateincreases;henceactivityinthemarketplaces!!!AetnatoDropSomeAffordableCareActMarkets

WithdrawingfromACAMarketplacehealthplansin11of15statesincludingFlorida;remaininginDelaware,Iowa,Nebraska,andVirginia

FollowedannouncementsbyUnitedHealthcarepullingoutofArizona,NorthCarolina,SouthCarolinaandKentucky

Aetnahad1.1millionindividualmarketenrollees(837,000intheexchanges);estimatesexchangelossesat$430‐300million

HealthexchangesareonlywaytogarnerFederalsubsidies Likely“one‐market”statesincludeOklahoma,Alabama,Alaska,Wyoming Increasesconcernsaboutsufficientcompetitivehealthexchangeplans

AetnaWarnedItWouldDropOutofObamacareExchangesifItsMergerWasBlocked

April,2016,AetnaCEOstatedthatsellinginsuranceintheACAhealthexchangemarkets“agoodinvestment”

July5,AetnawarnedUSDepartmentofJustice(DOJ)itwas“verylikely”itwouldexitpublicexchangesifmergerwithHumanawasblocked;offeredto“explore”moreexchangecoverageovernextfewyears,”ifmergerapproved

July21,DOJsuedtoblock$37Bmerger August15,Aetnaannouncespullingfrom11of15states;exitingnearly70%

ofcurrentmarkets Meanwhile,Aetnafinishedlastyearwithprofitsof$2.4B,up17.1%over

previousyear Humanadroppedoutof88%ofcurrentmarkets

WhereInsurers’ExitsAreHurtingObamacareExchanges‐‐‐andWhereTheyAren’t

MostmajormetroareassuchasinCalifornia,NewYork,Texas,plusNorthwest,MidwestandNewEnglandareunaffected

o Texas:EvenafterAetnaandUnitedpullout,Austin,Dallas,Houston,andSanAntoniowillhaveatleastthreedifferentinsurers

o Note:BlueCross/BlueShieldofTexasrequestednearlya60%ratehike!

Mosthurt:Arizona,NorthandSouthCarolina,GeorgiaandpartsofFloridao LeeandCollierCountieswillonlyhaveFloridaBlueforthehealth

exchangesin2017

2

25%ofcountiesnationallymayhaveonlyoneinsurerchoice;couldovertimeresultinmoresmallinsurersenteringmarkets

Whilefewerinsurersmayresultinpremiumsrising,over80%ofmarketplaceenrolleeshavesignificantsubsidies

Possibleconsequence:narrowernetworks;fewerchoicesofphysiciansandhospitals

Of13millionindividualsontheexchanges,2millionarewithAetna,Humana,andUnitedHealthcare>>>estimate>>>1‐1.5millionwillneedtoswitch

HealthCostSpikeComing

CommonwealthFund:Increasedpremiumsordroppingfromunprofitablemarketsinevitablenowthatinsurershavetocompeteonpriceinsteadofattractingthehealthiestcustomers

Aetnahadlowestpriceonly16%oftimewhileBlueCrosshadlowestprices42%oftime

Insurersaveragepriceincreaserequestednationally…24%;averageapprovedsofar…17%;lastyearaverageincrease…10%

PotentialACAchangesunderdiscussioninclude:o Helpinginsurersmanageriskincludingextending“reinsurance”

programsettoexpirethisyearand/orincludingprescriptiondruguseinriskadjustmentformula

o Havingstateshelpinsurers(Alaskainvested$55millioninitsonlystateexchangeinsurerlastyear)

o Increasingsubsidiestoindividualsover250%offederalpovertylevel($50,400forafamilyof3)

o Apublicoptionforareaswithlimitedcompetition/choiceofplanso Makingstudentloanpaymentsdeductibleforyoungerenrolleesto

boosttaxcreditsFedsHopetoWooNewCustomerstoObamacare

Lettersgoingdirectlytoindividualswhopaidpenaltiesontaxreturns Planningadvertisingcampaignusingtestimonialsofnewlyinsured Enrollingyounger,healthierindividualshelpsreducetheriskadjustment

challengesandmayreduceorreverseoutmigrationofparticipatinginsurance

CMSWantstoStopProvidersfromInappropriatelySteeringPatientsintoExchangePlans

August18,CMSbeganacceptingpublicinputtopreventhealthprovidersfromsteeringMedicareandMedicaideligibleindividualsintohealthexchangestogainhigherpayments

Healthinsurershaveraisedconcernsthat“thirdparty”organizationsareencouraginghighcostpatientstoenrollinexchangesbysubsidizingtheirpremiums

3

LivesatStake:HowInsuranceStatusCanAffectCancerSurvivalOdds DanaFarberStudy

o Uninsuredmenhad58%higherriskofall‐causemortalityand88%higherriskoftesticulartumormortalitythaninsured

o “…notrelatedtopoornutrition,ethnicity,orotherfactorspossiblyrelatedtopovertybutprobablyduetodelayedpresentationduetofearoffinancialimplications…”

JohnsHopkinsStudy…braincancero Uninsured14%shortersurvivaltimes;43%lesslikelytoreceive

radiationtreatmentWhoAretheRemainingUninsuredandWhyHaven’tTheySignedUpforCoverage?

CommonwealthFundStudy USuninsuredhavedeclinedby20millionsinceACAin2010;24million

estimatedstilluninsured Keyfindingsevenwithdramaticdeclinesinuninsured

o Latinosrosefrom29%ofalluninsuredin2013to40%in2016o Whitesdeclinedfrom50%ofuninsuredto41%o 39%ofuninsuredadultshaveincomesbelowthefederalpovertylevel

whichistwicetherateofoveralladultpopulation Otherkeyfactors

o ACAexcludesundocumentedimmigrantsfromcoverageexpansiono 19statesincludingtwoofthelargest,TexasandFlorida,havechosen

nottoexpandcoverage(accountsfor51%ofuninsured)o Somedemographicgroupsunawareofmarketplaceopportunitieso Concernsaboutaffordability(realorperceived)o Difficultyinselectingplans

GroupCallsonFloridaOfficialstoReconsiderTheirStandAgainstMedicaidExpansion

August17,FloridaCHAIN,LeagueofWomenVotersofFlorida,TampaBayHealthcareCollaborative,TampaCrossroadsunveiledfundedstudy

InHillsboroughandPinellasCounties,nearly110,000uninsuredadultsbetween18and64couldreceivecoverageunderMedicaidexpansion

CitedUniversityofWisconsinstudy:“Statesthathaveexpandedcoverageeligibilityshowsignificantincreasesinself‐reportedhealthstatus.”

Morethan3000uninsuredveteransunder65couldgaincoverage Withfederalreimbursementcuts,healthproviderswillbeforcedtoincrease

chargestotheinsuredtocoveruninsured;whereasexpansionwouldreducesuchpressureduetofeweruninsured

KentuckyeconomistscitedjobincreasesduetoMedicaidexpansion;usingsameformulaitcouldcreate23,000jobsinTampaBayareaalone

StudyidentifiedmajorroadblocksbeingFloridalawmakers

RECESS

To Call to Order the Lee County Trauma Services District

Board of Directors Meeting

Thursday, August 25, 2016

BOARD CHAIRMAN: Sanford Cohen, M.D.

TRAUMA DISTRICT MEETING TO CHAIRMAN:

RECONVENE

Lee Memorial Health System

FULL BOARD OF DIRECTORS MEETING

Thursday, August 25, 2016

BOARD CHAIRMAN: Sanford Cohen, M.D.


BOARD OF DIRECTORS

CONSENT AGENDA

(Approval)

1. Full Board Meeting Minutes of April 28, 2016

2. Financial & Statistical Reports of May 31, 2016

3. Financial & Statistical Reports of June 30, 2016

4. Policy 20.02C Conflict of Interest – No Revisions


FULL BOARD OF DIRECTORS MEETING MINUTES Thursday, April 28, 2016

LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, 13685 Doctors Way, Fort Myers, FL 33912 MEMBERS PRESENT: Sanford N. Cohen, M.D., Board Chairman; Donna Clarke, Board Vice Chairman; David Collins, Board Treasurer; Therese Everly, Board Secretary; Steven Brown, M.D., Board Member; Diane Champion, Board Member; Chris Hansen, Board Member; Nancy McGovern, RN, MSM, Board Member; Jessica Carter Peer, Board

Member; Stephanie Meyer, BSN, RN, Board Member MEMBERS ABSENT:

NOTE: Documents referred to in these minutes are on file by reference to this meeting date in the Office of the Board of Directors and on the Board of Directors website at www.leememorial.org/boardofdirectors, for public inspection.

SUBJECT DISCUSSION ACTION FOLLOW-UP

MEETING CALLED TO ORDER

The LEE MEMORIAL HEALTH SYSTEM FULL BOARD OF DIRECTORS MEETING

was CALLED TO ORDER at 1:02 p.m. by Sanford Cohen, M.D., Board Chairman.

INVOCATION AND

PLEDGE OF ALLEGIANCE

Rev. Denise Sawyer, MDiv, BCC gave the Invocation, followed by the Pledge of Allegiance.

PUBLIC INPUT None at this time

RECOGNITIONS Mary Kirkwood, RN, MS was recognized for 35 years of service.

Doug Wade was recognized for 36 years of service. Pete Morgan was recognized for 25 years of service.

DEPT. OF ACADEMICS

AND MEDICAL EDUCATION UPDATE

Dr. Eric Goldsmith presented an update on the Department of Academics and Medical Education for LMHS. The Department of Academics and Medical Education website is http://intranet1/academics/default.asp Discussion ensued amongst Board members regarding the need for more psychiatrists and a focus on behavioral health as part of the family medicine residency programs.

David Collins made a motion to make education a core principle to be emphasized through our strategic initiatives and administration to be informed of such. Nancy McGovern seconded the motion. Steve Brown asked that the motion be tabled and a lengthy discussion ensued. Steve Brown withdrew his request to table the education motion. All voted in favor of the motion and it carried with no opposition.

Education update to be presented at September Board meeting.

RECESS MEETING

MEETING RECESSED at 2:23 p.m. to Convene Lee County Trauma Services District Meeting.

RECONVENE

MEETING RECONVENED FULL BOARD MEETING at 2:53 p.m.

by Sanford N. Cohen, M.D., Board Chairman.

CONSENT AGENDA Dr. Cohen asked for approval of the Consent Agenda consisting of:

A. Behavioral Health Board of Directors Workshop minutes of April 7, 2016. B. Policy 20.17R Financial Goal Policy

A motion was made by Nancy McGovern to accept the Consent Agenda consisting of: A. Behavioral Health Board of Directors Workshop minutes of April

7, 2016. B. Policy 20.17R Financial Goal Policy The motion was seconded by Diane Champion and it carried with no opposition.

LEE MEMORIAL HEALTH SYSTEM FULL BOARD OF DIRECTORS MEETING MINUTES

Thursday, April 28, 2016 Page 2 of 3


GOLISANO CHILDREN’S

HOSPITAL SWFL PI INDICATORS

Alex Daneshmand, D.O. presented the 2016 semi-annual GCHSWF performance indicators.

A motion was made by Chris Hansen to accept the Golisano Children’s Hospital of SWFL PI indicators. The motion was seconded by Steve Brown and it carried with no opposition.

EQUIPMENT LOAN Ben Spence recommended approval to adopt the resolution approving the

execution and delivery of a third lease schedule to the master lease agreement with Banc of America Public Capital Corp in the maximum principal amount of $25,000,000; approving the form of documents and conditions to be met in connection with the second lease schedule; authorizing the appropriate officers of the Lee Memorial Health System to take all actions in connection therewith; and providing an effective date. Jim Humphrey stated for the record that he has reviewed and approved the resolution.

A motion was made by David Collins to adopt the resolution approving the execution and delivery of a third lease schedule to the master lease agreement with Banc of America Public Capital Corp in the maximum principal amount of $25,000,000; approving the form of documents and conditions to be met in connection with the second lease schedule; authorizing the appropriate officers of the Lee Memorial Health System to take all actions in connection therewith; and providing an effective date. The motion was seconded by Chris Hansen and it carried with no opposition.

MEDICAL STAFF

RECOMMENDATIONS OF 4/28/16

Dr. Cohen asked for a motion to approve the Medical Staff Recommendations as of 4/28/16: A. Lee Memorial Hospital B. Cape Coral Hospital C. Gulf Coast Medical Center D. HealthPark Medical Center E. Golisano Children’s Hospital of SWFL Stephanie Meyer recused herself from voting.

A motion was made by Therese Everly to approve the Medical Staff Recommendationsas of 4/28/16: A. Lee Memorial Hospital B. Cape Coral Hospital C. Gulf Coast Medical Center D. HealthPark Medical Center E. Golisano Children’s Hospital of SWFL The motion was seconded by Nancy McGovern and it carried with no opposition.

OLD BUSINESS None

NEW BUSINESS Chris Hansen requested periodical updates to the Board on our progress with the

LMHS quality ratings and whether we are showing improvement transitions. David Collins asked for updates every 6 weeks until we get a handle on this issue. Therese Everly requested dashboards on CMS ratings utilizing real time data.

Therese Everly made a motion to receive reports on the advances being made toward quality improvement every six weeks. The motion was seconded by David Collins and it carried with no opposition.

The first report out scheduled for the 6/9/16 Board meeting.

BOARD MEETING

CRITIQUE Great meeting with great discussion.

BOARD OF

DIRECTORS REPORTS

Therese Everly attended a Chamber of Commerce lecture on healthcare with a presentation by Scott Kashman. Steve Brown attended an Alzheimer’s meeting in Naples.

LEGISLATIVE DELEGATION

RECOGNITION OF CENTENNIAL

The meeting was adjourned prior to this Agenda item.

LEE MEMORIAL HEALTH SYSTEM FULL BOARD OF DIRECTORS MEETING MINUTES

Thursday, April 28, 2016 Page 3 of 3


NEXT REGULAR MEETING

The next LEE MEMORIAL HEALTH SYSTEM PLANNING AND FULL BOARD OF DIRECTORS MEETINGS

will be held on May 12, 2016, at 1:00 p.m. in the Gulf Coast Medical Center, Medical Office Building, Boardroom

13685 Doctors Way, Fort Myers, FL 33912

ADJOURNMENT The LEE MEMORIAL HEALTH SYSTEM

FULL BOARD OF DIRECTORS MEETING ADJOURNED at 3:45 p.m.

by Sanford Cohen, M.D., Board Chairman.

Minutes were recorded by Donna Shapiro, Assistant to the Board of Directors

________________________________________ Therese Everly Date approved

Board Secretary


LEE COUNTY, FLORIDA CONSOLIDATED FINANCIAL STATEMENTS AND STATISTICAL REPORTS

MAY 31, 2016

LEE MEMORIAL HEALTH SYSTEM CONSOLIDATED FINANCIAL STATEMENTS & STATISTICAL REPORTS TABLE OF CONTENTS SECTION A PAGE CONSOLIDATED SCHEDULES HIGHLIGHTS A.1 EXECUTIVE SUMMARY A.2 CONSOLIDATED STATISTICAL REPORT A.3 CONSOLIDATED INCOME STATEMENT A.4 SOURCES & APPLICATIONS OF FUNDS A.6 CONSOLIDATED BALANCE SHEET A.7 CONSOLIDATED FINANCIAL RATIOS A.8 CONSOLIDATED PAYOR MIX A.10

Lee Memorial Health System Operating Highlights

For the month ended May 31, 2016

Adjusted admits for the month ended May 31, 2016 are 11,503 which is 1.8% below budget. Actual inpatient admits for the month are 6,192 or 7.7% less than budget and actual patient days are 32,809 or 4.6% less than budget which resulted in an increase in length of stay to 5.30 days. Outpatient volumes are up significantly as seen in Emergency room visits which are 4.5% above budget at 18,165 and outpatient surgeries of 2,089 which are above budget by 13.1%. Net patient revenue for May reflects an $8.8 million or 7.1% favorable variance to budget. This favorable variance in net patient revenue is the result of a favorable rate variance of $11.1 million due to increase Case Mix Index to 1.62 vs. budget of 1.46 and better payer mix, offset by an unfavorable volume variance of $2.3 million. Net Patient Revenue per CMI adjusted admit for the month ended May 31, 2016 is $7,127 vs. budget of $7,237. Total operating expenses before depreciation and interest expense are 7.2% higher than budget. Salaries & Wages are 2.8% higher than budget, largely due to staff not flexing to the reduced volumes. Salaries, Wages & Benefits as a percent of Net Operating Revenue are 53.6% for May 2016 versus a budget of 55.6%. The actual hourly pay rate is $32.41 which is $0.46 lower than budget. Supply expense came in over budget by 9.3%; on a case mix adjusted admission basis the variance is also unfavorable at $1,357 actual vs. $1,351 budget. The majority of this variance was seen in drug expense which was over budget $0.9 million. Purchased services are over budget by $2.6 million, the majority of which was due to locum tenens being brought in to fill in for the shortage in coverage for our Hospitalist Program. Total operating costs per case mix adjusted admit is less than budget at $6,527 actual vs. $6,621, a 1.4% favorable variance. FTEs/AOB are higher than budget by 2.8% (5.53 actual vs. 5.38 budget) during May 2016. Productive FTE’s per adjusted daily admission were 5.7% higher than budget at 26.73 vs. a budget of 25.28, resulting in lower productivity than budgeted. The gain from operations is $5.3 million or 3.9% versus a budgeted gain of $5.1 million or 4.0%. Excess revenue over expenses is a gain of $9.5 million versus a budget of $10.8 million, resulting in $1.4 million negative variance. The majority of this negative variance is due to expenses for salaries, drug costs and contracts for locum tenens being higher than budgeted as mentioned above. For the month, Cash & Investments increased by $11.5 million to $974.9 million. Cash flow from Operations increased $16.8 million while working capital decreased by $5.3 million. Cash was reduced by $10.3 million for routine equipment replacement and $1.4 million for principal payments made during May on net borrowings. Days in Accounts Receivable decreased from 45.6 days in April to 44.6 days in May resulting in a source of cash of $9.7 million. Total Notes & Bonds payable on May 31, 2016 is $685.7 million resulting in the Cash to Debt ratio of 142.2%.

Page A.1

Page A.2

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED EXECUTIVE SUMMARYFor the Period Ending May 31, 2016

Act to Bud Act to PY Act to Bud Act to PYInpatient Volumes: Admits - Adults & Peds 6,707 6,192 6,672 -7.7% -7.2% 58,622 54,692 57,453 -6.7% -4.8% Patient Days - Adults & Peds 34,398 32,809 35,656 -4.6% -8.0% 298,704 278,100 296,898 -6.9% -6.3% Length of Stay 5.13 5.30 5.34 -3.3% 0.9% 5.10 5.08 5.17 0.2% 1.6%

Inpatient Surgeries 1,644 1,718 1,617 4.5% 6.2% 14,459 14,600 14,379 1.0% 1.5%

Outpatient Volumes: Emergency Room Visits 17,387 18,165 17,370 4.5% 4.6% 141,406 146,972 141,433 3.9% 3.9% Outpatient Surgeries 1,847 2,089 1,758 13.1% 18.8% 14,744 16,290 14,951 10.5% 9.0% Hospital Based Physician Visits 36,754 35,011 18,830 -4.7% 85.9% 302,102 301,460 163,271 -0.2% 84.6% Physician Visits 67,305 72,067 60,093 7.1% 19.9% 546,633 560,593 504,134 2.6% 11.2% Home Health Visits 5,911 5,768 5,392 -2.4% 7.0% 46,532 46,353 44,280 -0.4% 4.7%

Adjusted Admits 11,715 11,503 11,444 -1.8% 0.5% 99,313 98,604 96,196 -0.7% 2.5% (overall in/outpat volume indicator)Total Case Mix Index 1.46 1.62 1.43 10.8% 13.4% 1.46 1.55 1.44 5.9% 7.7%

Operating Ratios: Net Revenue/Adj Adm CMI 7,438 7,308 7,478 -1.7% -2.3% 7,224 7,158 7,248 -0.9% -1.3% Operating Exp/Adj Adm CMI 6,621 6,527 6,633 1.4% 1.6% 6,355 6,282 6,189 1.2% -1.5% Supply Exp/Adj Adm CMI 1,351 1,357 1,413 -0.5% 4.0% 1,345 1,358 1,376 -0.9% 1.3%

Wages/Ben - % of Net Oper Rev 55.6% 53.6% 53.8% 3.6% 0.5% 54.7% 53.1% 51.2% 2.9% -3.7% Supplies as a % of Net Oper Rev 18.2% 18.6% 18.9% -2.2% 1.7% 18.6% 19.0% 19.0% -1.9% 0.0%

Charity/Bad Debt - % of Gross Rev 6.4% 7.0% 5.7% -9.6% -22.1% 6.4% 6.3% 6.3% 1.1% -1.0%

FTEs/AOB 5.38 5.53 5.08 -2.8% -8.8% 5.20 5.27 4.88 -1.3% -8.0% Productive Hours/Adjusted Admit 144.5 152.7 140.7 -5.7% -8.6% 138.1 139.4 131.0 -0.9% -6.4% Average Hourly Rate 32.87 32.41 31.75 1.4% -2.1% 32.71 33.01 31.68 -0.9% -4.2%

Financial Ratios: Operating Margin (%) 4.0% 3.9% 4.3% -2.1% -8.9% 5.5% 5.9% 8.0% 6.4% -26.8% Excess Margin (%) 8.1% 6.7% 6.4% -17.1% 5.2% 9.5% 10.1% 12.0% 6.2% -15.7%

Liquidity Ratios: Days Cash on Hand (net of VRDB) 243.7 244.3 264.6 Cash to Debt (%) 140.7% 142.2% 142.1% Days in Acct Receivable 43.8 44.6 43.9

Income Statement Summary (in Thousands)Total Net Operating Revenue 127,461 136,198 122,278 6.9% 11.4% 1,048,396 1,092,562 1,002,401 4.2% 9.0%Total Operating Expenses 122,385 130,885 117,044 -6.9% -11.8% 990,598 1,028,455 922,058 -3.8% -11.5% Consolidated Gain(Loss) from Oper 5,077 5,313 5,234 4.7% 1.5% 57,798 64,107 80,343 10.9% -20.2%

Investment Earnings/Non Op Income 5,759 4,145 2,780 -28.0% 49.1% 46,117 51,205 44,844 11.0% 14.2%

Consolidated Excess Rev over Exp 10,836 9,458 8,014 -12.7% 18.0% 103,915 115,312 125,187 11.0% -7.9%

Balance Sheet Highlights (In Thousands): Cash & Investments 954,570 974,902 945,969 Bonds & Notes Payable 678,459 685,735 665,858

VRDB = variable rate demand bondsCMI = Case Mix Index

Current Month Year-to-DateBudget Actual Prior Year % Variance Budget Actual Prior Year % Variance

Page A.3

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED STATISTICAL SUMMARYFor the Period Ending May 31, 2016

Act to Bud Act to PY Act to Bud Act to PY

Admissions ADULTS 6,085 5,568 6,062 -8.5% -8.1% 53,388 49,381 52,325 -7.5% -5.6% PEDIATRICS 361 340 348 -5.7% -2.3% 3,108 3,021 3,054 -2.8% -1.1% NICU 68 79 78 16.8% 1.3% 530 552 545 4.1% 1.3% POST ACUTE 194 205 184 5.7% 11.4% 1,595 1,738 1,529 9.0% 13.7%Total Adult & Peds 6,707 6,192 6,672 -7.7% -7.2% 58,622 54,692 57,453 -6.7% -4.8% NEWBORNS 460 469 541 2.0% -13.3% 4,092 4,052 4,120 -1.0% -1.7%Total Admissions 7,167 6,661 7,213 -7.1% -7.7% 62,714 58,744 61,573 -6.3% -4.6%

Patient Days ADULTS 27,250 25,450 28,332 -6.6% -10.2% 239,956 219,270 239,450 -8.6% -8.4% PEDIATRICS 1,076 1,047 1,081 -2.7% -3.1% 9,606 9,916 9,545 3.2% 3.9% NICU 1,330 1,437 1,447 8.0% -0.7% 10,964 10,616 10,908 -3.2% -2.7% POST ACUTE 4,742 4,875 4,796 2.8% 1.6% 38,178 38,298 36,995 0.3% 3.5%Total Adult & Peds 34,398 32,809 35,656 -4.6% -8.0% 298,704 278,100 296,898 -6.9% -6.3% NEWBORNS 1,074 1,122 1,219 4.4% -8.0% 9,539 9,291 9,632 -2.6% -3.5%Total Patient Days 35,473 33,931 36,875 -4.3% -8.0% 308,243 287,391 306,530 -6.8% -6.2%

Average Length of Stay ADULTS 4.48 4.57 4.67 -2.1% 2.2% 4.49 4.44 4.58 1.2% 3.0% PEDIATRICS 2.98 3.08 3.11 -3.2% 0.9% 3.09 3.28 3.13 -6.2% -5.0% NICU 19.66 18.19 18.55 7.5% 1.9% 20.67 19.23 20.01 7.0% 3.9% POST ACUTE 24.44 23.78 26.07 2.7% 8.8% 23.94 22.04 24.20 7.9% 8.9%Total Adult & Peds 5.13 5.30 5.34 -3.3% 0.9% 5.10 5.08 5.17 0.2% 1.6% NEWBORNS 2.34 2.39 2.25 -2.4% -6.2% 2.33 2.29 2.34 1.6% 1.9%Total Length of Stay 4.95 5.09 5.11 -2.9% 0.4% 4.92 4.89 4.98 0.5% 1.7%

OP Registrations EMERGENCY ROOM 17,387 18,165 17,370 4.5% 4.6% 141,406 146,972 141,433 3.9% 3.9% OP SURGERY CASES 1,847 2,089 1,758 13.1% 18.8% 14,744 16,290 14,951 10.5% 9.0%SUBTOTAL 19,234 20,254 19,128 5.3% 5.9% 156,150 163,262 156,384 4.6% 4.4%

Visits HOME HEALTH VISITS 5,911 5,768 5,392 -2.4% 7.0% 46,532 46,353 44,280 -0.4% 4.7% HOSP BASED PHY VISITS 36,754 35,011 18,830 -4.7% 85.9% 302,102 301,460 163,271 -0.2% 84.6% PHYSICIAN VISITS 67,305 72,067 60,093 7.1% 19.9% 546,633 560,593 504,134 2.6% 11.2% TRAUMA SERVICES DISTRICT 774 1,131 768 46.1% 47.3% 8,464 8,820 8,266 4.2% 6.7%SUBTOTAL 110,744 113,977 85,083 2.9% 34.0% 903,731 917,226 719,951 1.5% 27.4%

TOTAL OP 129,978 134,231 104,211 3.3% 28.8% 1,059,881 1,080,488 876,335 1.9% 23.3%


Page A.4

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED STATEMENT OF OPERATIONSFor the Period Ending May 31, 2016(in thousands)


INPATIENT REVENUE 311,402 309,572 297,355 -0.6% 4.1% 2,697,021 2,646,813 2,541,549 -1.9% 4.1%OUTPATIENT REVENUE 232,516 265,504 212,662 14.2% 24.8% 1,872,072 2,125,126 1,713,866 13.5% 24.0%TOTAL PATIENT REVENUE 543,918 575,076 510,017 5.7% 12.8% 4,569,093 4,771,939 4,255,415 4.4% 12.1%

DED FROM REV-MEDICARE 216,268 220,000 203,821 -1.7% -7.9% 1,839,089 1,892,182 1,722,361 -2.9% -9.9%DED FROM REV-MEDICAID 60,884 60,887 60,578 0.0% -0.5% 511,242 485,635 483,581 5.0% -0.4%DED FROM REV-CHARITY 18,306 18,550 14,863 -1.3% -24.8% 153,960 155,914 135,601 -1.3% -15.0%DED FROM REV-HMO/PPO 46,378 57,703 46,861 -24.4% -23.1% 392,806 452,471 373,239 -15.2% -21.2%DED FROM REV-OTHER 61,583 63,356 53,475 -2.9% -18.5% 512,602 572,225 445,978 -11.6% -28.3%DED FROM REV-BAD DEBT 16,475 21,755 14,407 -32.0% -51.0% 139,129 146,965 131,809 -5.6% -11.5%TOTAL DED FROM REV 419,895 442,251 394,004 -5.3% -12.2% 3,548,829 3,705,393 3,292,568 -4.4% -12.5%

NET PATIENT REVENUE 124,024 132,825 116,013 7.1% 14.5% 1,020,264 1,066,546 962,847 4.5% 10.8%OTHER OPER REV 3,438 3,373 6,265 -1.9% -46.2% 28,132 26,016 39,554 -7.5% -34.2%

TOTAL OPERATING REV 127,461 136,198 122,278 6.9% 11.4% 1,048,396 1,092,562 1,002,401 4.2% 9.0%

OPERATING EXPENSES PROD SALARIES 53,800 54,822 48,492 -1.9% -13.1% 430,853 425,781 376,206 1.2% -13.2% PROD OVERTIME 1,421 1,876 1,698 -32.0% -10.5% 11,771 16,512 14,912 -40.3% -10.7% CONTRACT LABOR 121 206 173 -70.7% -19.2% 2,390 2,633 1,985 -10.1% -32.6% NON-PROD SALARIES 5,347 5,495 6,005 -2.8% 8.5% 46,471 53,009 45,654 -14.1% -16.1%TOTAL SALARIES & WAGES 60,689 62,399 56,369 -2.8% -10.7% 491,485 497,935 438,757 -1.3% -13.5%

FRINGE BENEFITS 10,177 10,582 9,474 -4.0% -11.7% 81,729 82,159 74,348 -0.5% -10.5%HEALTH CARE ACCESS 1,457 1,475 1,471 -1.2% -0.3% 12,077 11,849 11,560 1.9% -2.5%SUPPLIES 23,144 25,285 23,099 -9.3% -9.5% 195,273 207,286 190,227 -6.2% -9.0%OTHER SERVICES 6,203 7,553 6,863 -21.8% -10.0% 51,373 56,161 53,256 -9.3% -5.5%PURCHASED SERVICES 11,794 14,355 11,192 -21.7% -28.3% 90,428 103,501 87,683 -14.5% -18.0%

TOTAL OPER EXPENSES 113,462 121,648 108,467 -7.2% -12.2% 922,366 958,892 855,831 -4.0% -12.0%

EBITDA 13,999 14,549 13,811 3.9% 5.3% 126,030 133,670 146,570 6.1% -8.8%

DEPRECIATION/AMORT 7,082 7,387 6,377 -4.3% -15.8% 52,886 54,663 49,748 -3.4% -9.9%INTEREST EXPENSE 1,840 1,850 2,200 -0.5% 15.9% 15,346 14,900 16,479 2.9% 9.6%

GAIN(LOSS) FROM OPER 5,077 5,313 5,234 4.7% 1.5% 57,798 64,107 80,343 10.9% -20.2%


Page A.5

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED INCOME STATEMENT BY ENTITYFor the Year-to-Date Period Ending May 31, 2016(in thousands)

ENTITY Budget Actual Prior Year Variance Budget Actual Prior Year Variance

LEE MEMORIAL HOSPITAL 5,823 7,983 5,390 2,161 54,403 64,744 56,430 10,341HEALTHPARK MEDICAL CTR 11,261 10,219 10,277 (1,042) 83,183 87,695 86,568 4,512CAPE CORAL HOSPITAL 4,965 7,274 4,596 2,309 40,800 43,924 40,148 3,124GULF COAST MEDICAL CENTER 5,441 7,590 4,657 2,149 46,348 57,340 49,544 10,992TRAUMA SERVICES DIST (416) (398) (636) 18 (2,862) (2,961) (2,691) (98)OUTPATIENT CENTERS 2,617 3,083 1,904 466 20,964 22,815 17,248 1,851HEALTHPARK CARE CTR 71 (15) 84 (86) 547 (129) 357 (676)HOME HEALTH AGENCIES (243) (348) (191) (105) (2,029) (2,888) (1,466) (858)FOUNDATION 6 9 6 4 93 241 77 148REHAB HOSPITAL 476 546 518 70 3,789 4,032 3,780 243ALL PHYSICIANS (6,183) (8,667) (4,902) (2,484) (46,162) (57,808) (37,689) (11,646)CORPORATE SERVICES (18,654) (21,840) (16,448) (3,186) (140,589) (152,301) (131,713) (11,711)ALL OTHERS (86) (123) (19) (37) (688) (598) (251) 89

TOTAL GAIN FROM OPS 5,077 5,313 5,234 236 57,798 64,107 80,343 6,309

INT EARN & REALIZED GAIN 1,204 6,329 567 5,126 9,674 34,594 19,867 24,920UNREALIZED GAIN (LOSS) 3,071 (4,503) 1,772 (7,574) 24,568 2,368 13,821 (22,200)UNREALIZED GAIN (LOSS) ON SWAP 0 0 0 0 0 0 0 0OTHER NON OPERATING 3,884 195 106 (3,689) 31,069 (126) 18,866 (31,195)RESTRICTED GIFTS (2,399) 2,125 335 4,524 (19,193) 14,369 (7,709) 33,562

TOTAL NON OPERATING 5,759 4,145 2,780 (1,614) 46,117 51,205 44,844 5,088

EXCESS OF REV/EXPS 10,836 9,458 8,014 (1,378) 103,915 115,312 125,187 11,397

Current Month Year-to-Date

CurrentMonth Year-to-Date

Sources of Funds:

Excess Revenue Over Expenses 9,458 115,312 Depreciation/Amortization Expense 7,387 54,663 (Gain)/Loss on Sale of Assets (6) 68 Total Sources 16,839 170,043

Sources/(Uses) of Funds:

Dec(Inc) in Accts Receivable 9,728 (35,008) Net borrowings (1,373) (28,720) Dec(Inc) in Other Assets 2,032 (805) Inc(Dec) in Liabilities (5,435) 21,849 Capital Expenditures, net (10,263) (94,230) Total Sources/(Uses) (5,311) (136,914)

Net Increase(Decrease) In Funds 11,529 33,129

Cash & Investments at beginning of period 963,373 941,773

Cash & Investments at end of period 974,902 974,902

Total Bonds & Notes Payable-end of period 685,735

Cash to Debt Ratio 142.2%

Page A.6

LEE MEMORIAL HEALTH SYSTEMSOURCES & APPLICATIONS OF FUNDS

For the Year-to-Date Period Ending: May 31, 2016(In thousands)

Page A.7

Lee Memorial Health SystemConsolidated Balance Sheet

Fiscal period ending: May 31, 2016 in Thousands (000's)

ASSETS: Current Prior Month Prior Year LIABILITIES: Current Prior Month Prior Year

Current Assets: Current Liabilities:Cash And Cash Equivalents * 66,798 77,476 57,567 Accounts Payable 36,982 43,425 62,909Operating Fund Investments * 877,498 855,845 854,561 Wages and Benefits Payable 46,458 43,087 27,590Accrued Interest Receivable 391 364 453 Notes Payable - Short Term 24,603 25,710 32,777Accounts Receivable (net) 188,446 195,597 156,985 Current Portion Bonds Payable 0 0 1,100Accounts Receivable - Phys (Net) 13,673 16,250 10,125 Due to State of Florida 12,217 11,817 17,070Inventories 30,735 30,785 30,361 Malpractice Liability - Short Term 3,751 3,751 3,751Limited or Restricted Use Assets 334 333 8,042 Accrued Bond Costs 3,245 1,630 8,815Other Current Assets 28,521 30,643 31,328 Other Current Liabilities 88,414 94,006 58,677

Total Current Assets: 1,206,396 1,207,293 1,149,423 Total Current Liabilities 215,670 223,425 212,688

Other Assets Other Liabilities and Fund BalanceLimited or Restricted Use Assets * 30,606 30,052 29,645 Benefits Payable - Long Term 0 0 0Bond Issuance Costs 0 0 (0) Notes Payable - Long Term 347,533 347,773 366,767Trustee Held Funds * 0 0 0 Due to State of Florida - Long Term 13,228 12,181 4,227Directors/Officers Indemnity Fund * 0 0 0 Malpractice Liability - Long Term 11,402 11,402 11,402Long Term Operating Fund Investments * 0 0 0 Bonds Payable 313,599 313,625 313,811Other Assets 121,498 121,385 117,373 Other Long Term Liabilities 75,495 75,101 72,891

UnRestricted Fund Balance 1,113,320 1,105,987 1,012,377Restricted Fund Balance 92,166 90,041 77,798

Total Other Assets 152,104 151,437 147,018 Total Other Liabilities & Fund Balance 1,966,744 1,956,110 1,859,274

Property and Equipment:Plant In Use 1,529,661 1,521,795 1,522,993Construction in Process 193,849 191,480 109,411Accumulated Depreciation (911,354) (904,227) (861,757)

Total Property & Equipment (Net) 812,157 809,049 770,646

Restricted Assets 11,757 11,757 4,874

TOTAL ASSETS 2,182,414 2,179,536 2,071,961 TOTAL LIABILITIES AND EQUITY 2,182,414 2,179,536 2,071,961

* Cash and InvestmentsAbove Balance Sheet has been adjusted to eliminate intercompany receivables, payables and investments in subsidiaries

Page A.8

LEE MEMORIAL HEALTH SYSTEMFINANCIAL RATIOSFor the Year-to-Date Period Ending May 31, 2016

2014 2016Moody's Financial FYE YTDMedian Goals 2015 5/31/2016

PROFITABILITY RATIOS:Operating Margin (%) - Total 3.1% 3.5% 6.9% 5.9% +Excess Margin (%) 6.3% 6.7% 7.1% 10.1% +Operating CashFlow Margin (%) 10.4% 10.7% 13.8% 12.2% +

LIQUIDITY RATIOS:Days Cash on Hand (net of Callable Debt) 225.2 239.9 261.4 244.3 +Cushion Ratio (x) 19.9 16.7 16.0 16.5 +Cash-to-Debt (%) 155.3% 139.0% 131.8% 142.2% +

CAPITALIZATION RATIOS:Debt to Capitalization(%) - (net of Callable Debt) 32.5% 34.2% 41.4% 38.1% (-)Annual Debt Service Coverage (x) 5.4 3.9 5.0 5.4 +Debt to Cashflow (net of Callable Debt) 2.9 3.8 3.2 2.7 (-)

NOTE: + = Ratios that should be above the Moody's median(-) = Ratios that should be lower than the Moody's median

Page A.9

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED OPERATING RATIOSFor the Period Ending: May 31, 2016(in thousands)


AS % NET OPERATING REVENUE

Wages and Benefits 55.6% 53.6% 53.8% 3.6% 0.5% 54.7% 53.1% 51.2% 2.9% -3.7%Supplies 18.2% 18.6% 18.9% -2.2% 1.7% 18.6% 19.0% 19.0% -1.9% 0.0%All Other Operating Expenses 15.3% 17.2% 16.3% -12.5% -5.6% 14.7% 15.7% 15.2% -7.0% -3.2%Capital Costs 7.0% 6.8% 7.0% 3.1% 3.3% 6.5% 6.4% 6.6% 2.2% 3.6%EBDITA Margin 11.0% 10.7% 11.3% -2.7% -5.4% 12.0% 12.2% 14.6% 1.8% -16.3%Operating Margin 4.0% 3.9% 4.3% -2.1% -8.9% 5.5% 5.9% 8.0% 6.4% -26.8%Excess Margin 8.1% 6.7% 6.4% -17.1% 5.2% 9.5% 10.1% 12.0% 6.2% -15.7%

Per CMI ADJ ADMIT / VISIT

Net Operating Revenue 7,438 7,308 7,478 -1.7% -2.3% 7,224 7,158 7,248 -0.9% -1.2%Total Operating Expenses 6,621 6,527 6,633 1.4% 1.6% 6,355 6,282 6,189 1.2% -1.5%Wages and Benefits 4,135 3,916 4,027 5.3% 2.7% 3,950 3,800 3,710 3.8% -2.4%Supplies 1,351 1,357 1,413 -0.5% 4.0% 1,345 1,358 1,376 -0.9% 1.3%All Other Operating Expenses 1,135 1,255 1,194 -10.5% -5.1% 1,060 1,124 1,103 -6.0% -1.9%Capital Costs 521 496 525 4.8% 5.5% 470 456 479 3.1% 4.8%Operating Margin 296 285 320 -3.8% -10.9% 398 420 581 5.5% -27.7%Excess Margin 632 507 490 -19.7% 3.6% 716 755 905 5.5% -16.5%

LABOR

Productive FTEs/Adj Daily Admit 25.28 26.73 24.62 -5.7% -8.6% 24.17 24.39 22.92 -0.9% -6.4%Average Hourly Rate 32.87 32.41 31.75 1.4% -2.1% 32.71 33.01 31.68 -0.9% -4.2%OP REV % of Total Revenue 42.7% 46.2% 41.7% 8.0% 10.7% 41.0% 44.5% 40.3% 8.7% 10.6%

Prior Year % VarianceCurrent Month Year-to-Date

Budget Actual Prior Year % Variance Budget Actual

Page A.10

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED - PAYOR MIX (BASED ON GROSS REVENUE)For the Period Ending May 31, 2016

Budget Actual Prior Year Budget Actual Prior Year

MEDICARE 35.0% 34.0% 34.3% 35.4% 34.9% 35.7%MEDICARE HMO 13.8% 12.7% 14.3% 13.8% 13.6% 14.1%MEDICAID 4.4% 3.0% 4.4% 4.4% 3.3% 4.5%MEDICAID HMO 9.3% 9.6% 9.7% 9.3% 9.1% 9.4%HMO/PPO 17.0% 18.7% 17.8% 16.9% 17.9% 17.1%COMMERCIAL 3.4% 3.8% 3.5% 3.4% 4.1% 3.4%OTHER 17.1% 18.2% 16.0% 16.8% 17.1% 15.8%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Budget Actual % Variance Budget Actual % VarianceMEDICARE CASE MIX INDEX 1.52 1.78 17.1% 1.52 1.67 9.9%SYSTEM CASE MIX INDEX 1.46 1.62 11.0% 1.46 1.55 6.2%

09/30/15 05/31/16 VarianceGross Accounts Receivable 388,105 499,682 111,577 Net Accounts Receivable 167,111 202,119 35,008 Net Days in Accounts Receivable 43.6 44.6 1.0



LEE COUNTY, FLORIDA CONSOLIDATED FINANCIAL STATEMENTS AND STATISTICAL REPORTS

JUNE 30, 2016

LEE MEMORIAL HEALTH SYSTEM CONSOLIDATED FINANCIAL STATEMENTS & STATISTICAL REPORTS TABLE OF CONTENTS SECTION A PAGE CONSOLIDATED SCHEDULES HIGHLIGHTS A.1 EXECUTIVE SUMMARY A.2 CONSOLIDATED STATISTICAL REPORT A.3 CONSOLIDATED INCOME STATEMENT A.4 SOURCES & APPLICATIONS OF FUNDS A.6 CONSOLIDATED BALANCE SHEET A.7 CONSOLIDATED FINANCIAL RATIOS A.8 CONSOLIDATED PAYOR MIX A.10

Lee Memorial Health System Operating Highlights

For the month ended June 30, 2016

Adjusted admits for the month ended June 30, 2016 are 11,339 which is 2.3% above budget. Actual inpatient admits for the month are 6,042 or 4.7% less than budget and actual patient days are 30,823 or 4.7% less than budget which resulted in length of stay of 5.10 days. Outpatient volumes are up significantly as we continue to see significant growth in short stays at 4,513 which are above budget by 91.9% and outpatient surgeries of 2,194 which are above budget by 20.1%. Net patient revenue for June reflects a $15.8 million or 13.5% favorable variance to budget. This favorable variance in net patient revenue is the result of a favorable rate variance of $13.1 million due to increase Case Mix Index to 1.55 vs. budget of 1.46 and better payer mix, coupled with a favorable volume variance of $2.7 million. Net Patient Revenue per CMI adjusted admit for the month ended June 30, 2016 is $7,564 vs. budget of $7,231. Total operating expenses before depreciation and interest expense are 12.7% higher than budget. Salaries & Wages are 4.3% higher than budget, largely due to staff not flexing to the reduced volumes. Salaries, Wages & Benefits as a percent of Net Operating Revenue are 51.3% for June 2016 versus a budget of 55.8%. The actual hourly pay rate is $33.04 which is $0.22 higher than budget. Supply expense came in over budget by 24.5%; on a case mix adjusted admission basis the variance is also unfavorable at $1,564 actual vs. $1,363 budget. The majority of this variance was seen in drug expense which was over budget $2.2 million. Purchased services are over budget by $4.1 million, the majority of which was due to locum tenens being brought in to fill in for the shortage in coverage for our Hospitalist Program. Total operating costs per case mix adjusted admit is greater than budget at $6,924 actual vs. $6,666, a 3.9% unfavorable variance. FTEs/AOB are higher than budget by 1.3% (5.50 actual vs. 5.42 budget) for June 2016. Productive FTE’s per adjusted daily admission were 0.8% higher than budget at 25.34 vs. a budget of 25.16, resulting in lower productivity than budgeted. The gain from operations is $6.6 million or 4.8% versus a budgeted gain of $3.8 million or 3.2%. Excess revenue over expenses is a gain of $11.9 million versus a budget of $9.6 million, resulting in $2.3 million positive variance. For the month, Cash & Investments increased by $29.7 million to $1,004.6 million. Cash flow from Operations and working capital increased $19.3 and $10.4 million, respectively. Cash was reduced by $16.3 million for routine equipment replacement and increased by $23.6 million for net borrowings. Days in Accounts Receivable decreased from 44.6 days in May to 43.8 days in June resulting in a source of cash of $10.4 million. Total Notes & Bonds payable on June 30, 2016 is $709.4 million resulting in the Cash to Debt ratio of 141.6%.

Page A.1

Page A.2

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED EXECUTIVE SUMMARYFor the Period Ending June 30, 2016

Act to Bud Act to PY Act to Bud Act to PYInpatient Volumes: Admits - Adults & Peds 6,337 6,042 6,415 -4.7% -5.8% 64,959 60,734 63,868 -6.5% -4.9% Patient Days - Adults & Peds 32,344 30,823 32,076 -4.7% -3.9% 331,048 308,923 328,974 -6.7% -6.1% Length of Stay 5.10 5.10 5.00 0.1% -2.0% 5.10 5.09 5.15 0.2% 1.2%

Inpatient Surgeries 1,655 1,726 1,746 4.3% -1.1% 16,114 16,326 16,125 1.3% 1.2%

Outpatient Volumes: Emergency Room Visits 16,054 16,442 16,015 2.4% 2.7% 157,461 163,414 157,448 3.8% 3.8% Outpatient Surgeries 1,826 2,194 1,864 20.1% 17.7% 16,570 18,484 16,815 11.6% 9.9% Hospital Based Physician Visits 38,445 31,980 19,440 -16.8% 64.5% 340,547 333,440 182,711 -2.1% 82.5% Physician Visits 65,397 70,404 59,453 7.7% 18.4% 612,030 630,997 563,587 3.1% 12.0% Home Health Visits 5,723 5,483 5,628 -4.2% -2.6% 52,255 51,836 49,908 -0.8% 3.9%

Adjusted Admits 11,082 11,339 11,164 2.3% 1.6% 110,403 109,956 107,361 -0.4% 2.4% (overall in/outpat volume indicator)Total Case Mix Index 1.46 1.55 1.48 6.0% 5.1% 1.46 1.55 1.44 5.9% 7.4%

Operating Ratios: Net Revenue/Adj Adm CMI 7,460 7,822 7,421 4.9% 5.4% 7,247 7,225 7,267 -0.3% -0.6% Operating Exp/Adj Adm CMI 6,666 6,924 6,327 -3.9% -9.4% 6,391 6,347 6,204 0.7% -2.3% Supply Exp/Adj Adm CMI 1,363 1,564 1,378 -14.7% -13.6% 1,347 1,379 1,376 -2.4% -0.2%

Wages/Ben - % of Net Oper Rev 55.8% 51.3% 50.6% 8.0% -1.5% 54.9% 52.9% 51.1% 3.6% -3.5% Supplies as a % of Net Oper Rev 18.3% 20.0% 18.6% -9.4% -7.7% 18.6% 19.1% 18.9% -2.7% -0.8%

Charity/Bad Debt - % of Gross Rev 6.5% 6.9% 5.8% -7.2% -19.7% 6.4% 6.4% 6.2% 0.2% -2.8%

FTEs/AOB 5.42 5.50 5.35 -1.3% -2.7% 5.22 5.29 4.92 -1.3% -7.4% Productive Hours/Adjusted Admit 143.7 144.8 139.1 -0.8% -4.1% 138.7 139.9 131.8 -0.9% -6.1% Average Hourly Rate 32.83 33.04 31.31 -0.7% -5.5% 32.77 33.01 31.64 -0.7% -4.3%

Financial Ratios: Operating Margin (%) 3.2% 4.8% 8.0% 52.5% -39.5% 5.2% 5.8% 8.0% 10.6% -28.2% Excess Margin (%) 7.6% 8.4% 0.2% 10.3% 5285.6% 9.2% 9.9% 10.8% 7.2% -8.5%

Liquidity Ratios: Days Cash on Hand (net of VRDB) 243.7 250.9 267.6 Cash to Debt (%) 140.7% 141.6% 143.8% Days in Acct Receivable 44.1 43.8 42.1

Income Statement Summary (in Thousands)Total Net Operating Revenue 120,871 137,492 122,244 13.8% 12.5% 1,169,268 1,230,053 1,124,645 5.2% 9.4%Total Operating Expenses 117,041 130,845 112,475 -11.8% -16.3% 1,108,452 1,159,300 1,034,533 -4.6% -12.1% Consolidated Gain(Loss) from Oper 3,831 6,646 9,770 73.5% -32.0% 60,815 70,753 90,113 16.3% -21.5%

Investment Earnings/Non Op Income 5,761 5,280 (9,595) -8.4% -155.0% 51,879 56,485 35,249 8.9% 60.2%

Consolidated Excess Rev over Exp 9,592 11,926 175 24.3% 6725.6% 112,694 127,238 125,362 12.9% 1.5%

Balance Sheet Highlights (In Thousands): Cash & Investments 954,570 1,004,627 955,519 Bonds & Notes Payable 678,459 709,381 664,620

VRDB = variable rate demand bondsCMI = Case Mix Index


Page A.3

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED STATISTICAL SUMMARYFor the Period Ending June 30, 2016


Admissions ADULTS 5,784 5,439 5,797 -6.0% -6.2% 59,172 54,820 58,122 -7.4% -5.7% PEDIATRICS 299 316 353 5.6% -10.5% 3,408 3,337 3,407 -2.1% -2.1% NICU 67 71 78 6.5% -9.0% 597 623 623 4.3% 0.0% POST ACUTE 187 216 187 15.5% 15.5% 1,782 1,954 1,716 9.7% 13.9%Total Adult & Peds 6,337 6,042 6,415 -4.7% -5.8% 64,959 60,734 63,868 -6.5% -4.9% NEWBORNS 504 472 484 -6.4% -2.5% 4,596 4,524 4,604 -1.6% -1.7%Total Admissions 6,841 6,514 6,899 -4.8% -5.6% 69,555 65,258 68,472 -6.2% -4.7%

Patient Days ADULTS 25,398 24,254 25,262 -4.5% -4.0% 265,354 243,524 264,712 -8.2% -8.0% PEDIATRICS 959 904 981 -5.8% -7.8% 10,565 10,820 10,526 2.4% 2.8% NICU 1,404 1,194 1,305 -15.0% -8.5% 12,368 11,810 12,213 -4.5% -3.3% POST ACUTE 4,583 4,471 4,528 -2.4% -1.3% 42,761 42,769 41,523 0.0% 3.0%Total Adult & Peds 32,344 30,823 32,076 -4.7% -3.9% 331,048 308,923 328,974 -6.7% -6.1% NEWBORNS 1,177 1,069 1,040 -9.2% 2.8% 10,716 10,360 10,672 -3.3% -2.9%Total Patient Days 33,521 31,892 33,116 -4.9% -3.7% 341,765 319,283 339,646 -6.6% -6.0%

Average Length of Stay ADULTS 4.39 4.46 4.36 -1.6% -2.3% 4.48 4.44 4.55 0.9% 2.5% PEDIATRICS 3.21 2.86 2.78 10.8% -2.9% 3.10 3.24 3.09 -4.6% -4.9% NICU 21.06 16.82 16.73 20.1% -0.5% 20.71 18.96 19.60 8.5% 3.3% POST ACUTE 24.51 20.70 24.21 15.5% 14.5% 24.00 21.89 24.20 8.8% 9.5%Total Adult & Peds 5.10 5.10 5.00 0.1% -2.0% 5.10 5.09 5.15 0.2% 1.2% NEWBORNS 2.33 2.26 2.15 3.0% -5.4% 2.33 2.29 2.32 1.8% 1.2%Total Length of Stay 4.90 4.90 4.80 0.1% -2.0% 4.91 4.89 4.96 0.4% 1.4%

OP Registrations EMERGENCY ROOM 16,054 16,442 16,015 2.4% 2.7% 157,461 163,414 157,448 3.8% 3.8% OP SURGERY CASES 1,826 2,194 1,864 20.1% 17.7% 16,570 18,484 16,815 11.6% 9.9%SUBTOTAL 17,881 18,636 17,879 4.2% 4.2% 174,031 181,898 174,263 4.5% 4.4%

Visits HOME HEALTH VISITS 5,723 5,483 5,628 -4.2% -2.6% 52,255 51,836 49,908 -0.8% 3.9% HOSP BASED PHY VISITS 38,445 31,980 19,440 -16.8% 64.5% 340,547 333,440 182,711 -2.1% 82.5% PHYSICIAN VISITS 65,397 70,404 59,453 7.7% 18.4% 612,030 630,997 563,587 3.1% 12.0% TRAUMA SERVICES DISTRICT 1,003 1,058 923 5.5% 14.6% 9,467 9,878 9,189 4.3% 7.5%SUBTOTAL 110,568 108,925 85,444 -1.5% 27.5% 1,014,299 1,026,151 805,395 1.2% 27.4%

TOTAL OP 128,449 127,561 103,323 -0.7% 23.5% 1,188,329 1,208,049 979,658 1.7% 23.3%


Page A.4

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED STATEMENT OF OPERATIONSFor the Period Ending June 30, 2016(in thousands)


INPATIENT REVENUE 298,437 301,858 284,880 1.1% 6.0% 2,995,458 2,948,671 2,826,429 -1.6% 4.3%OUTPATIENT REVENUE 223,495 264,636 210,882 18.4% 25.5% 2,095,567 2,389,762 1,924,748 14.0% 24.2%TOTAL PATIENT REVENUE 521,932 566,494 495,762 8.5% 14.3% 5,091,025 5,338,433 4,751,176 4.9% 12.4%

DED FROM REV-MEDICARE 207,580 212,949 187,052 -2.6% -13.8% 2,046,669 2,105,131 1,909,413 -2.9% -10.3%DED FROM REV-MEDICAID 58,053 59,225 56,506 -2.0% -4.8% 569,295 544,860 540,087 4.3% -0.9%DED FROM REV-CHARITY 17,471 21,831 13,214 -25.0% -65.2% 171,432 177,745 148,815 -3.7% -19.4%DED FROM REV-HMO/PPO 44,883 62,744 52,336 -39.8% -19.9% 437,689 515,216 425,574 -17.7% -21.1%DED FROM REV-OTHER 60,511 59,357 56,390 1.9% -5.3% 573,113 631,583 502,368 -10.2% -25.7%DED FROM REV-BAD DEBT 16,261 17,428 15,496 -7.2% -12.5% 155,391 164,393 147,305 -5.8% -11.6%TOTAL DED FROM REV 404,760 433,535 380,994 -7.1% -13.8% 3,953,588 4,138,927 3,673,562 -4.7% -12.7%

NET PATIENT REVENUE 117,173 132,959 114,768 13.5% 15.9% 1,137,437 1,199,506 1,077,614 5.5% 11.3%OTHER OPER REV 3,699 4,532 7,477 22.5% -39.4% 31,831 30,548 47,031 -4.0% -35.0%

TOTAL OPERATING REV 120,871 137,492 122,244 13.8% 12.5% 1,169,268 1,230,053 1,124,645 5.2% 9.4%

OPERATING EXPENSES PROD SALARIES 50,824 51,068 46,364 -0.5% -10.1% 481,677 476,850 422,570 1.0% -12.8% PROD OVERTIME 1,337 1,813 1,662 -35.5% -9.0% 13,108 18,325 16,574 -39.8% -10.6% CONTRACT LABOR 71 160 92 -125.1% -75.3% 2,461 2,793 2,077 -13.5% -34.5% NON-PROD SALARIES 5,308 6,977 5,328 -31.4% -30.9% 52,592 59,987 50,982 -14.1% -17.7%TOTAL SALARIES & WAGES 57,541 60,018 53,446 -4.3% -12.3% 549,839 557,954 492,203 -1.5% -13.4%

FRINGE BENEFITS 9,873 10,568 8,375 -7.0% -26.2% 91,602 92,727 82,724 -1.2% -12.1%HEALTH CARE ACCESS 1,359 1,546 1,447 -13.8% -6.8% 13,435 13,395 13,008 0.3% -3.0%SUPPLIES 22,090 27,495 22,692 -24.5% -21.2% 217,363 234,781 212,919 -8.0% -10.3%OTHER SERVICES 6,144 6,990 6,935 -13.8% -0.8% 57,518 63,150 60,191 -9.8% -4.9%PURCHASED SERVICES 10,999 15,084 11,333 -37.1% -33.1% 101,427 118,585 99,016 -16.9% -19.8%

TOTAL OPER EXPENSES 108,006 121,700 104,228 -12.7% -16.8% 1,031,185 1,080,592 960,060 -4.8% -12.6%

EBITDA 12,866 15,791 18,016 22.7% -12.3% 138,083 149,461 164,586 8.2% -9.2%

DEPRECIATION/AMORT 7,041 7,387 6,579 -4.9% -12.3% 59,926 62,050 56,327 -3.5% -10.2%INTEREST EXPENSE 1,995 1,757 1,667 11.9% -5.4% 17,341 16,658 18,147 3.9% 8.2%

GAIN(LOSS) FROM OPER 3,831 6,646 9,770 73.5% -32.0% 60,815 70,753 90,113 16.3% -21.5%


Page A.5

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED INCOME STATEMENT BY ENTITYFor the Year-to-Date Period Ending June 30, 2016(in thousands)

ENTITY Budget Actual Prior Year Variance Budget Actual Prior Year Variance

LEE MEMORIAL HOSPITAL 5,741 7,020 7,239 1,279 60,144 71,764 63,669 11,620HEALTHPARK MEDICAL CTR 8,284 8,820 9,757 535 91,468 96,515 96,325 5,047CAPE CORAL HOSPITAL 4,407 6,753 5,468 2,346 45,207 50,677 45,616 5,470GULF COAST MEDICAL CENTER 5,498 7,499 7,197 2,000 51,847 64,839 56,742 12,992TRAUMA SERVICES DIST (338) (409) (530) (71) (3,200) (3,369) (3,221) (169)OUTPATIENT CENTERS 2,329 3,516 2,003 1,187 23,294 26,332 19,252 3,038HEALTHPARK CARE CTR 53 11 73 (42) 601 (118) 430 (719)HOME HEALTH AGENCIES (236) (865) (183) (629) (2,265) (3,753) (1,649) (1,487)FOUNDATION 29 8 8 (21) 122 249 84 127REHAB HOSPITAL 460 445 465 (15) 4,249 4,477 4,246 228ALL PHYSICIANS (4,902) (5,840) (5,025) (939) (51,877) (63,649) (42,714) (11,771)CORPORATE SERVICES (17,405) (20,266) (16,666) (2,861) (157,995) (172,567) (148,379) (14,572)ALL OTHERS (91) (46) (36) 45 (779) (644) (287) 135

TOTAL GAIN FROM OPS 3,831 6,646 9,772 2,816 60,815 70,753 90,115 9,938

INT EARN & REALIZED GAIN 1,206 320 227 (886) 10,880 34,914 20,094 24,034UNREALIZED GAIN (LOSS) 3,071 5,465 (11,226) 2,394 27,639 7,833 2,595 (19,805)UNREALIZED GAIN (LOSS) ON SWAP 0 0 0 0 0 0 0 0OTHER NON OPERATING 3,884 25,231 457 21,347 34,953 25,105 19,323 (9,848)RESTRICTED GIFTS (2,399) (25,736) 947 (23,337) (21,592) (11,368) (6,762) 10,225

TOTAL NON OPERATING 5,761 5,280 (9,595) (482) 51,879 56,485 35,249 4,606

EXCESS OF REV/EXPS 9,592 11,926 177 2,334 112,694 127,238 125,364 14,544


CurrentMonth Year-to-Date

Sources of Funds:

Excess Revenue Over Expenses 11,926 127,238 Depreciation/Amortization Expense 7,387 62,050 (Gain)/Loss on Sale of Assets 3 98 Total Sources 19,317 189,386

Sources/(Uses) of Funds:

Dec(Inc) in Accts Receivable 10,399 (24,609) Net borrowings 23,646 (5,074) Dec(Inc) in Other Assets 4,717 3,912 Inc(Dec) in Liabilities (12,063) 9,796 Capital Expenditures, net (16,291) (110,558) Total Sources/(Uses) 10,408 (126,533)

Net Increase(Decrease) In Funds 29,725 62,854

Cash & Investments at beginning of period 974,902 941,773

Cash & Investments at end of period 1,004,627 1,004,627

Total Bonds & Notes Payable-end of period 709,381

Cash to Debt Ratio 141.6%

Page A.6

LEE MEMORIAL HEALTH SYSTEMSOURCES & APPLICATIONS OF FUNDS

For the Year-to-Date Period Ending: June 30, 2016(In thousands)

Page A.7

Lee Memorial Health SystemConsolidated Balance Sheet

Fiscal period ending: June 30, 2016 in Thousands (000's)

ASSETS: Current Prior Month Prior Year LIABILITIES: Current Prior Month Prior Year

Current Assets: Current Liabilities:Cash And Cash Equivalents * 40,461 66,798 57,567 Accounts Payable 39,018 36,982 62,909Operating Fund Investments * 933,461 877,498 854,561 Wages and Benefits Payable 30,014 46,458 27,590Accrued Interest Receivable 434 391 453 Notes Payable - Short Term 24,341 24,603 32,777Accounts Receivable (net) 178,509 188,446 156,985 Current Portion Bonds Payable 0 0 1,100Accounts Receivable - Phys (Net) 14,038 14,500 10,953 Due to State of Florida 8,457 12,217 17,070Inventories 30,820 30,735 30,361 Malpractice Liability - Short Term 3,751 3,751 3,751Limited or Restricted Use Assets 334 334 8,042 Accrued Bond Costs 4,815 3,245 8,815Other Current Assets 27,952 28,521 31,328 Other Current Liabilities 92,956 88,414 58,677

Total Current Assets: 1,226,008 1,207,224 1,150,251 Total Current Liabilities 203,353 215,670 212,688

Other Assets Other Liabilities and Fund BalanceLimited or Restricted Use Assets * 30,706 30,606 29,645 Benefits Payable - Long Term 0 0 0Bond Issuance Costs 0 0 (0) Notes Payable - Long Term 371,467 347,533 366,767Trustee Held Funds * 0 0 0 Due to State of Florida - Long Term 14,332 13,228 4,227Directors/Officers Indemnity Fund * 0 0 0 Malpractice Liability - Long Term 11,402 11,402 11,402Long Term Operating Fund Investments * 0 0 0 Bonds Payable 313,572 313,599 313,811Other Assets 120,580 120,670 116,545 Other Long Term Liabilities 74,653 75,495 72,891

UnRestricted Fund Balance 1,150,983 1,113,320 1,012,377Restricted Fund Balance 66,429 92,166 77,798

Total Other Assets 151,286 151,276 146,190 Total Other Liabilities & Fund Balance 2,002,839 1,966,744 1,859,274

Property and Equipment:Plant In Use 1,536,557 1,529,661 1,522,993Construction in Process 203,241 193,849 109,411Accumulated Depreciation (918,470) (911,354) (861,757)

Total Property & Equipment (Net) 821,328 812,157 770,646

Restricted Assets 7,571 11,757 4,874

TOTAL ASSETS 2,206,192 2,182,414 2,071,961 TOTAL LIABILITIES AND EQUITY 2,206,192 2,182,414 2,071,961

Page A.8

LEE MEMORIAL HEALTH SYSTEMFINANCIAL RATIOSFor the Year-to-Date Period Ending June 30, 2016

2014 2016Moody's Financial FYE YTDMedian Goals 2015 6/30/2016

PROFITABILITY RATIOS:Operating Margin (%) - Total 3.1% 3.5% 6.9% 5.8% +Excess Margin (%) 6.3% 6.7% 7.1% 9.9% +Operating CashFlow Margin (%) 10.4% 10.7% 13.8% 12.2% +

LIQUIDITY RATIOS:Days Cash on Hand (net of Callable Debt) 225.2 239.9 261.4 250.9 +Cushion Ratio (x) 19.9 16.7 16.0 16.4 +Cash-to-Debt (%) 155.3% 139.0% 131.8% 141.6% +

CAPITALIZATION RATIOS:Debt to Capitalization(%) - (net of Callable Debt) 32.5% 34.2% 41.4% 38.1% (-)Annual Debt Service Coverage (x) 5.4 3.9 5.0 5.0 +Debt to Cashflow (net of Callable Debt) 2.9 3.8 3.2 2.9 (-)

NOTE: + = Ratios that should be above the Moody's median(-) = Ratios that should be lower than the Moody's median

Page A.9

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED OPERATING RATIOSFor the Period Ending: June 30, 2016(in thousands)


AS % NET OPERATING REVENUE

Wages and Benefits 55.8% 51.3% 50.6% 8.0% -1.5% 54.9% 52.9% 51.1% 3.6% -3.5%Supplies 18.3% 20.0% 18.6% -9.4% -7.7% 18.6% 19.1% 18.9% -2.7% -0.8%All Other Operating Expenses 15.3% 17.2% 16.2% -12.2% -6.3% 14.7% 15.9% 15.3% -7.6% -3.6%Capital Costs 7.5% 6.7% 6.7% 11.0% 1.4% 6.6% 6.4% 6.6% 3.2% 3.4%EBDITA Margin 10.6% 11.5% 14.7% 7.9% -22.1% 11.8% 12.2% 14.6% 2.9% -17.0%Operating Margin 3.2% 4.8% 8.0% 52.5% -39.5% 5.2% 5.8% 8.0% 10.6% -28.2%Excess Margin 7.6% 8.4% 0.2% 10.3% 5218.4% 9.2% 9.9% 10.8% 7.2% -8.5%

Per CMI ADJ ADMIT / VISIT

Net Operating Revenue 7,460 7,822 7,421 4.9% 5.4% 7,247 7,226 7,267 -0.3% -0.6%Total Operating Expenses 6,666 6,924 6,327 -3.9% -9.4% 6,391 6,348 6,204 0.7% -2.3%Wages and Benefits 4,161 4,016 3,753 3.5% -7.0% 3,976 3,822 3,715 3.9% -2.9%Supplies 1,363 1,564 1,377 -14.7% -13.6% 1,347 1,379 1,376 -2.4% -0.2%All Other Operating Expenses 1,142 1,344 1,197 -17.7% -12.3% 1,068 1,146 1,113 -7.3% -3.0%Capital Costs 558 520 501 6.7% -3.9% 479 462 481 3.5% 3.9%Operating Margin 236 378 593 59.9% -36.3% 377 416 582 10.3% -28.6%Excess Margin 592 678 11 14.6% 6217.1% 698 747 810 7.0% -7.7%

LABOR

Productive FTEs/Adj Daily Admit 25.16 25.34 24.34 -0.8% -4.1% 24.27 24.49 23.07 -0.9% -6.1%Average Hourly Rate 32.83 33.04 31.31 -0.7% -5.5% 32.77 33.01 31.64 -0.7% -4.3%OP REV % of Total Revenue 42.8% 46.7% 42.5% 9.1% 9.8% 41.2% 44.8% 40.5% 8.8% 10.5%

Prior Year % VarianceCurrent Month Year-to-Date

Budget Actual Prior Year % Variance Budget Actual

Page A.10

LEE MEMORIAL HEALTH SYSTEMCONSOLIDATED - PAYOR MIX (BASED ON GROSS REVENUE)For the Period Ending June 30, 2016

Budget Actual Prior Year Budget Actual Prior Year

MEDICARE 34.7% 32.3% 32.0% 35.3% 34.6% 35.3%MEDICARE HMO 13.6% 13.5% 13.9% 13.8% 13.6% 14.1%MEDICAID 4.3% 3.0% 4.9% 4.4% 3.2% 4.6%MEDICAID HMO 9.3% 9.6% 9.6% 9.3% 9.2% 9.5%HMO/PPO 17.0% 20.5% 20.5% 16.9% 18.2% 17.5%COMMERCIAL 3.3% 3.0% 3.1% 3.4% 4.0% 3.4%OTHER 17.9% 18.1% 16.1% 16.9% 17.2% 15.6%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Budget Actual % Variance Budget Actual % VarianceMEDICARE CASE MIX INDEX 1.53 1.70 11.4% 1.52 1.67 9.8%SYSTEM CASE MIX INDEX 1.46 1.55 6.0% 1.46 1.55 5.9%

09/30/15 06/30/16 VarianceGross Accounts Receivable 388,105 442,230 54,125 Net Accounts Receivable 167,111 182,612 15,501 Net Days in Accounts Receivable 43.6 43.8 -


1,336 1,299 1,294

1,382 1,347 1,379

426 416 401 395 379 382

0

200

400

600

800

1,000

1,200

1,400

1,600

2012 Act 2013 Act 2014 Act 2015 Act YTD 2016 Bud YTD 2016 Act

Am

ount

Period

LMHS Supply Cost per Case Mix Adjusted Admit

For the 9 months ending June 30, 2016

Total Supplies/Adjusted Admit CMI Implant Costs/Adjusted Admit CMI

YTD

Excess Revenue over Expenses 127,238Add/(Subtract):

Depreciation & Amortization 62,050Net Dec/(Inc) in Accounts Receivable (24,609)Net Inc/(Dec) in Assets & Liabilities 13,708Principal Payments (5,074)(Gain)/Loss on Sale of Assets 98

Total Cashflow 173,411

Total Actual Cashflow available for Capital @ 80.0% 138,729

YTD Capital Dollars Approved 103,627

YTD Capital $'s Spent 110,558

LEE MEMORIAL HEALTH SYSTEMCASHFLOW AVAILABLE FOR CAPITAL

FOR THE NINE MONTHS ENDING JUNE 30, 2016In 000's

Once this policy is printed, it is not considered a controlled document. Please review electronic version of this policy for the most current document.

20.02C – Conflict of Interest Page 1 of 2

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS POLICY MANUAL no. 20.02C

supersedes no.20.02B --------------------------------------------------------------------------------------------------------------------------------------- category: General Operations title: Conflict of Interest ---------------------------------------------------------------------------------------------------------------------------------------

Date Originated: 1/8/91

Reviewed/No Revision: 10/10/13, 8/25/16

Dates Revised: 10/23/92, 7/31/98, 7/26/02

Next Review Date: 8/25/19

--------------------------------------------------------------------------------------------------------------------------------------- PURPOSE: To affirm that Directors of Lee Memorial Health System, its officers, administrative staff, medical staff with administrative responsibility and employees are subject to the Florida Code of Ethics for public officers and employees, and other laws prohibiting financial conflicts of interest and to provide for a resolution of a conflict of interest. --------------------------------------------------------------------------------------------------------------------------------------- POLICY: The laws prohibiting financial conflicts of interest shall be strictly enforced. Directors, officers, administrative staff, medical staff with administrative responsibility and employees shall be periodically informed of this policy. The Board Attorney shall be responsible for advising Directors. The Hospital’s Legal Services Department shall be responsible for disseminating general information, and for advising employees and the others listed regarding specific issues.

Florida law prohibiting conflicts of interest generally provides: 1. No officer or employee of a hospital, nor any other person, may pay or receive anything of value for

referral of a patient to a hospital or for medical services.

2. No public officer or employee shall accept anything of value which might influence him or her in the performance of official duties.

3. No public officer or employee shall derive a financial benefit from any transaction between any third party and the public agency for which the officer or employee works.

4. No public officer or employee shall enter into a financial arrangement (“do business”) with the public agency for which the officer or employee works. This includes the public officer or employee as owner or major shareholder of a firm or company which does business with the public agency. Exceptions exist for competitive bidding and “sole supplier” situations, if full disclosure is made.

5. Designated public officers and employees must file annual Financial Disclosure forms with the Supervisor of Elections.

The law of Public Agency and Hospital Conflicts of Interest is complex, and specific situations which are not clear infractions shall review with legal counsel. In uncertain cases, an opinion of the Florida Commission on Ethics can be obtained to provide direction.

Once this policy is printed, it is not considered a controlled document. Please review electronic version of this policy for the most current document.

20.02C – Conflict of Interest Page 2 of 2

So that the Board of Directors may address any possible conflict of interest, the following procedure will be followed: 1. If a conflict is known by a Director, the Director shall outline his or her conflict on the issue in a

meeting of the Board and will abstain from voting on that issue. The form (CE Form 8B Memorandum of Voting Conflict for County, Municipal, and Other Local Public Officers) required by law shall be filled out, signed and filed with corresponding minutes.

2. If a perceived conflict is brought to light and not disclosed in a meeting of the Board, any Director may request an opinion of legal counsel. An Ethics Commission opinion may be sought by any Director.


BOARD OF DIRECTORS

OBSERVATION VS INPATIENT

Jon Hart, MD, Lead Physician Advisor Shelley Koltnow, Interim Chief Compliance Officer

Anne Rose, Vice President, Revenue Cycle

Jon Hart, MD, MBAPhysician Advocate/AdvisorLead Physician AdvisorLee Memorial Health System

Determining Disposition Status Placement

CMS Manual System, Pub. 100-02 Medicare Benefit Policy says …Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

(up to 48 hours for Medicare FFS beneficiaries)***Note that managed Medicare and private insurance companies’

admission status rules may vary from those of FFS Medicare (often 23 hours or 24 hours).

… Evaluate a patient’s condition in order to determine the need for acute inpatient placement.

Observe the patient when unsure of diagnosis or trajectory of current symptoms

Avoid potentially unnecessary acute care placement and costs

Decreases burden on ED Does not preclude an eventual inpt status

Any time spent in Observation does not count toward the 3 Day qualifying stay needed for Skilled Nursing placement after the hospital stay.

The clock on those three days does not start until an inpatient order is written

Thus, the importance of correct placement from the start

In what condition will the patient most likely be tomorrow?

“Better” = Observation Is it risky to send the patient home today?

“Yes” = Observation

Is it likely I will know whether to make inpt or send the patient home by tomorrow?


Are vital signs stable?“Yes” = Observation

If undiagnosed, will a diagnosis likely be made in 24 hours?


Will treatment, such as IV fluids, require standard monitoring and be complete within 24 hours?


Is the final “Diagnosis” actually an undiagnosed symptom(s)(e.g., chest pain, abdominal pain, dizzy)


Social reasons Physician or patient convenience Routine prep for diagnostic testing Routine recovery from outpatient

procedures Procedures designated as

“inpatient only”

YES!

OBS-to-Inpt: An outpatient observation patient may be progressed to inpatient status when it is determined the patient’s condition requires an inpatient level of care.

YESInpt-to-OBS (CODE 44):

Hospital utilization review committee, with concurrence from patient’s provider, can change the status if done before the patient is discharged and prior to submitting a bill/claim.

NOTE: This is an acknowledgement of an inappropriate initial placement

Observation status MUST be specifically stated in the order

An order simply documented as “admit” will be treated as an inpatientplacement.

A clearly-worded order will ensure appropriate patient care and prevent hospital billing errors.

Avoid the phrase, “admit to observation”Substitute PLACEMENT for

Admission

* “The decision to admit a patient as an inpatient requires complex medical judgment, including consideration of the patient’s medical history and current medical needs, the medical predictability of

something adverse happening to the patient, and the availability of diagnostic services/procedures when and where the patient presents.”

Observation is appropriate.

Inpatient placement is appropriate.

Alternate level of care is appropriate

Additional time is needed to determine if inpatient placement is medically necessary. Observation is appropriate.

Yes

Unsure

No

No

Can condition beevaluated / treated /

improvedwithin 48 hours?

Does condition require hospital

Treatment?*

Medicare Observation or Inpatient?Placement Decision Test

Yes

Observation services can be provided anywhere in the hospital Example: Continuous monitoring (such as oximetry or

telemetry) can be provided in observation or inpatient status; consider overall severity of illness and intensity of services in determining admission status rather than any single or specific intervention.

Level of care based on severity of condition, foreseeable risks and intensity of services provided, not based on physical location of the bed, dictates placement status.

2 Midnight Benchmark

As initially devised by CMS, the 2 Midnight Benchmark is a prospective tool for physicians to use when determining the status in which to place a patient.

It has come to mean some other things, as well…

2 MN Benchmark

Per CMS: “For purposes of meeting

the 2-midnight benchmark, in deciding whether an inpatient admission

is warranted, the physician must assess whether the beneficiary requires hospital services and whether it is expected that such services will be required for 2 or more midnights. The decision to admit the beneficiary as an inpatient is a complex medical decision made by the physician in consideration of various factors, including the beneficiary’s age, disease processes, comorbidities, and the potential impact of sending the beneficiary home.”

Further, “If the beneficiary is expected to require medically necessary hospital services for 2 or more midnights, then the physician should order inpatient admission and Part A payment is generally appropriate per the 2-midnight benchmark. Except in cases involving services identified by CMS as inpatient-only, if the beneficiary is expected to require medically necessary hospital services for less than 2 midnights, then the beneficiary generally should remain an outpatient and Part A payment is generally inappropriate.”

Note: “The Two-Midnight rule does not prevent the physician from providing any service at any hospital, regardless of the expected duration of the service.”

Caveat:CMS and its contractors retain the option to review all cases and conclude whether the documentation is sufficient or not to support the medical necessity of an inpatient admission.

For this reason, we review cases for:• severity of condition• foreseeable risks• intensity of services provided• clinical information available to the attending

physician at the time the decision to place was actually made.

Abdominal Pain – non-specific Chest Pain / Acute Coronary Syndrome / Unstable

Angina Back Pain Gastrointestinal Bleeding with stable Vital Signs and

Hemoglobin >8.5 & Platelets >60K Gastroenteritis / Nausea / Vomiting Dehydration (uncomplicated) Deep Vein Thrombosis – uncomplicated Syncope – unexplained, orthostatic, uncomplicated

Inpatient if documented as likely / suspected as due to:

Known active cardiac disease (Congestive Heart Failure, Ischemic, Valvular)

Cardiovascular drug-induced Systolic Blood Pressure < 90 Pulse < 60, or High-degree AtrioVentricular-block

Observation if either: Unexplained and none of the

above, or Simple “vaso-vagal” or

“orthostatic”

Inpatient placement: consider when a patient has: Elevated Troponin ST elevation on EKG Myocardial Infarction or dynamic ST-T wave changes on

the EKG Hemodynamic instability Chest pain not responding to Nitroglycerin

Observation: consider when the patient has no EKG or enzyme changes, but the patient’s story suggests the possibility of acute cardiac ischemia (what’s your gut say?)

Complex Example:

Pt presents with chest pain while walking, and pain resolves in ER. Enzymes and EKG are normal and pain doesn’t recur.

Stress Test is abnormal, but patient remains pain-free

Taken for Cardiac Cath and stent placed

Obs or Inpt?

Observation or Inpatient?Part 2: Compliant Care for Bedded Hospital PatientsLee Memorial Health System – Board of Directors Meeting August 25, 2016Shelley C. Koltnow, Interim Chief Compliance Officer

Medicare’s Foundation Philosophy

Social Security Act enacted in August 1935 during Franklin D. Roosevelt’s administration to “create a system of transfer payments in which younger working people support older, retired people” (FDR). Paid by income tax

Entitlement began at age 65

In 1935, average life expectancy was 59.9 for males, 63.9 for females

Big Gap in Social Security – no reliable or consistent health insurance coverage for aged Americans. Cost of healthcare highest when in older years

Health of aged population generally poor

Medicare’s Foundation Philosophy Medicare Program in an amendment to the Social Security Act in July 1965

during the administration of Lyndon B. Johnson (LBJ). Purpose: “To provide health insurance for those age 65 or older, those younger

than age 65 who have received social security disability benefits for more than 24 months, and those with End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS - or Lou Gehrig’s Disease).”

According to President Johnson, “Medicare incorporates the best concepts of health economics, health insurance and health care. These are: Financing the health benefit for beneficiaries

Utilizing controls to assure no fraud, abuse or waste is paid for by the benefit

Quality of care

Methods for administration of payment to be fair and driven by best practices

Qualifications and licensure of providers and suppliers

Patient satisfaction / patient experience”

Medicare, like Social Security, is funded through income tax on working people which paid for those receiving Medicare (regressive tax)

How is Medicare Program Structured?

Modeled upon Social Security and the health insurance plans of the day, Medicare was structured with two parts: Part A – [Entitlement portion] Insurance to cover inpatient hospital services (short

and long term acute hospitals, skilled nursing facilities, inpatient rehabilitation hospital, some home health, and hospice benefits)

Part B – [Voluntary portion] covers physician services, outpatient hospital (including observation services) some additional home health, laboratory, and other services not covered by Part A.

Later, Medicare added two more voluntary parts: Part C (Medicare Advantage – managed care plans) Part D (Medicare prescription drug coverage)

Beneficiaries enroll in Part A around their 65th birthday and most pay no premium for their Part A coverage. They also can elect coverage and pay premiums for voluntary coverage under Parts B, C and D.

Enduring Principles of Medicare

LBJ also wanted to assure that Medicare would: Remain non-directive about health care while assuring such care would be of

sufficient quality and appropriateness for each beneficiary Be ‘medical’ and not ‘custodial’ Would safeguard each individual beneficiary’s cost-sharing through deductibles and

co-payments designed not to burden the beneficiary Not create any incentives to providers and suppliers to overuse a particular service or

benefit to gain profits Protect the funds that taxpayers paid for this benefit Solve the growing problem of caring for the health of aged Americans

Average life expectancy in 1965 – Men: 66.8 and Women 73.1. Medicare helped increase life expectancy for men by 12 years and women by 15 years.

Medicare’s basic philosophy has endured through the 51 years of its existence.

Medical Necessity – Lynchpin for Coverage Medicare coverage depends on whether the care is medically necessary for

the beneficiary and for the population for whom it is covered. “Not all hospital care is appropriate for Part A (inpatient) payment. When a Medicare

beneficiary arrives at a hospital in need of medical or surgical care, physicians or other qualified providers must decide if it is appropriate to admit the beneficiary as an inpatient or treat them as an outpatient.”

This Inpatient/Outpatient decision has significance for utilization of hospital resources, reimbursement, quality of care, beneficiary satisfaction and cost sharing (copay/deductible) and as such, is an element of compliance.

Medical Necessity – “Accepted healthcare services and supplies provided to beneficiaries appropriate to the evaluation and treatment of a disease, condition, illness or injury, and consistent with the applicable standard of care as applied to each individual beneficiary.”

Medical care decisions must not consider monetary benefit to the provider or supplier of care. (implications under the Anti-kickback statute, Stark, and False Claims Act and conflicts of interest). As such, this is an element of compliance.

Payment Differs Under Parts A and B Medicare pays differently for inpatient (Part A) and outpatient observation (Part

B) hospital stays. Part A pays for care prospectively based upon the individual’s diagnosis, procedures

and severity of illness.

Part B pays in a hybrid of prospective care (grouping into a primary service) and fee for service for a particular item, service or procedure.

Inpatient or outpatient status directly impacts the patient’s copay, deductible, cost of drugs (Part B does not cover self-administered drugs) and eligibility for Skilled Nursing care. As such this is an element of compliance.

Continued struggle to properly classify bedded patients as inpatients or observation patients - myriads of rules, criteria, guidance and other information.

Although there are no statutory time requirements for observation services, Medicare guidance and recent rules signal Medicare’s philosophy that observation should result in an admission to inpatient or discharge from the hospital in a relatively short time (24 – 36 hours, 48 hours at the outside).

Evolving Compliance Oversight Health Insurance Portability and Accountability Act (HIPAA) of 1996 set forth

standards for submission of claims and privacy/security of electronic claims, as well as standard data sets.

Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) caused Medicare to reorganize its claim adjudication, replacing Fiscal Intermediaries (Part A claims) and Carriers (Part B claims) with a new system administered by regional Medicare A/B Administrative Contractors (A/B MACs).

Data mining was initiated by MACs to catch and eliminate Fraud, Waste and Abuse [along with starting intensified recoupment and correlating payment of related Part A and Part B claims].

After a demonstration project, Recovery Audit Contractors (RACs) were widely introduced in 2007 to identify errors in paid claims. From outset, RACs focused on medical necessity of short inpatient hospital stays. Paid on % of errors identified.

Compliance Programs Expectations that providers participating in Medicare and other

government programs will: Comply with applicable laws, regulations, guidance and sub-regulatory

information to administer care to beneficiaries and enrollees in government health insurance programs.

Monitor their operations to assure that they have identified, corrected, and prevented (where possible) errors, misconduct, and violations.

Report any overpayments or other misconduct and engage in immediate corrective action to prevent further misconduct.

Assure that employees, agents, volunteers, physicians, and contractors do not have past or present evidence of misconduct

Integrate an effective and evidence-based compliance program into their culture to assure that there is an ethical and patient-centered focus for the organization

Conditions of Participation for Hospitals Regulatory provisions applicable to all hospitals participating in Medicare include:

A qualified and credentialed medical staff 42 C.F.R 482.12 “Patients are admitted to the hospital only on recommendation of a licensed physician or

practitioner who is permitted by the State (and the hospital Medical Staff) to admit patients to the hospital.”

Utilization Review – hospitals paid under the prospective payment system must conduct utilization reviews during hospital stays, particularly the medical necessity of the stay. 42 C.F.R. 482.20 Review of services furnished by the hospital and by members of the medical staff to individuals

entitled to benefits under the Medicare and Medicaid Programs.”

Utilization Review Committee – must have two physicians w/o a conflict of interest related to utilization.

Review appropriateness and duration of hospital stay, including admission (reviews can be before, during and after the stay).

Intended to coordinate use of hospital resources with the attending physician's medical judgment and medical decision making, as Dr. Hart explained in his presentation.

Avoiding Fraud, Waste, Abuse Founding principles of Medicare still in place today:

No monetary inducements or benefit to provider beyond payment for appropriate care.

Medically necessary care. Quality care. Best interest of the beneficiary (patient experience/satisfaction).

Appropriate cost sharing for beneficiaries.

Fraud, Waste and Abuse and the False Claims Act Workhorse statute to combat – False Claims Act (FCA) (“Lincoln’s Law”).

Whistleblower provisions of FCA. Implicated by decisions about Inpatient or Observation status in a hospital bed. Misconduct and self-interest can undermine the principles above.

Health Management Associates Case Study

History and Allegations

HMA operated 71 hospitals in 15 states and was based in Naples, FL

In 2012, 8 whistleblower suits under the False Claims Act were filed alleging:

“HMA billed federal health care programs for medically unnecessary inpatient admissions from the emergency departments at HMA hospitals…”

“Former CEO directed HMA’s corporate practice of pressuring emergency department physicians and hospital administrators to raise inpatient admission rates regardless of medical necessity…”

HMA corporate officers at the CEO’s direction, “exerted significant pressure on doctors in the emergency departments to admit patients who could have been placed in observation, treated as outpatients, or discharged, and that this resulted in submission of inflated or false claims to the federal health care programs.”

History and Allegations “HMA rewarded physicians for these admissions with bonuses and other

incentives, paying kickbacks for referrals in violation of the Anti-Kickback statute (which prohibits exchange of benefits for referrals) and the Stark law (which prohibits physician self-referrals with an entity that compensates them or in which they hold ownership interest).”

Specifically involved HMA hospitals in Georgia, Pennsylvania, North Carolina, Illinois, Florida, South Carolina.

HMA hospital in Laredo, TX deliberately admitted beneficiaries as inpatients for outpatient procedures and surgeries in violation of the FCA, AKS and Stark laws.

HMA CEO was alleged to have promoted this misconduct and the complaints included counts against him personally

Other executives were alleged to have obstructed justice during the investigation of the allegations by the whistleblowers.

Settlement HMA was acquired by Community Health Systems, out of Frankfort, KY.

In 2015, the Department of Justice and CMS settled the whistleblower suits by Settled the False Claims Suits of HMA regarding improper inpatient admissions for

$98.15 million

Entered into a 5-year Corporate Integrity Agreement in exchange for not being excluded from Medicare

Independent Review Organization (IRO) required – not allowed cost for cost report

Cost of CIA varies but meeting its requirements could exceed 10 million per year for such a large organization.

Conclusion Compliance with requirements for Inpatient and Outpatient status for

bedded hospital patients involves: Complex medical judgment and medical decision making by qualified

physicians and providers who are authorized to admit patients to the hospital;

Support of the mandatory utilization review function of the hospital;

Support from the revenue cycle team and compliance department;

Education and training as well as continuing communication with patients and their families;

Continued focus on processes and documentation of the elements (per Dr. Hart’s presentation)

Billing correctly.

Document what you do

Code what you

documentBill what

you codeCollect

what you bill

Inpatient or ObservationPart III: Financial Implications

Anne Rose VP Revenue Cycle

August 25, 2016


Board of Directors Meeting

• Date range of data = February 2016 through April 2016

• Includes both Observation Discharges and Inpatient Discharges with 762 Revenue Code

• Excludes accounts without a payment

By the Numbers

By the NumbersTotal Discharges(762 RevenueCode)

Total Discharged as Inpatient

Total Discharged as Observation

Medicare 3,515 1,418 2,097

Medicare Advantage

1,418 471 947

Commercial Insurance

1,652 325 1,327

• Medicare Observation Patients – $166.00 Annual Deductible + 20% of Medicare

Allowed Amount + Non-Covered Charges*– Allowed Amount = Sum of Ambulatory Payment

Classifications (APCs)**– Amounts owed by patients are generally

covered by Medigap policies, except for Non-Covered charges

*Cannot collect Non-Covered Charges without issuing prior notice to patient**20% of each APC is capped at $1,288.00

Financial Obligations

• Medicare Observation Patients

– Average Amount owed by Patient/Medigap Policy: $428

– Percentage of Patients with Medigap Policy: 93%

– Amounts owed by Patient/Medigap Policy range from $140 to $948


• Medicare Inpatients – $1,288.00 Deductible per Benefit Period + Non-

Covered Charges*– Amounts owed by patients are generally

covered by Medigap policies, except for Non-covered charges

*Cannot collect Non-Covered Charges without issuing prior notice to patient


• Medicare Inpatients – Average Amount owed by Patient/Medigap

Policy: $860 – Percentage of Patients with Medigap Policy:

93%– Amounts owed by Patient/Medigap Policy

range from $0 to $1,288


• Medicare Advantage Observation Patients – Varies by payer and by product– Average amount owed by patient: $101– Amounts owed range from $50 to $2,872

• Medicare Advantage Inpatients – Varies by payer and by product– Average amount owed by patient: $627– Amounts owed range from $100 to $1,925


• Commercial Observation Patients – Varies by payer and by product– Average amount owed by patient: $1,033– Amounts owed range from $25 to $7,900

• Commercial Inpatients – Varies by payer and by product– Average amount owed by patient: $1,810– Amounts owed range from $100 to $7,500


• Post Discharge Medicare – Skilled Nursing Facility (SNF) coverage

requires a 3 day hospital inpatient stay AND must meet skilled nursing criteria

• Post Discharge Medicare Advantage and Commercial – No required hospital stay for coverage


• Medicare Discharge to SNF – Number of Medicare Discharges: 3,515– Number of Discharges to SNF: 306– Number of Discharges that did not qualify for

SNF benefits:0


• Medicare Inpatients – Must be given Important Message from

Medicare (IMM) – IMM given twice during stay—once within 2

calendar days of admission and then within 2 calendar days of discharge

– Outlines discharge appeal rights • Medicare Advantage and Commercial

Inpatients – Communication varies by plan

Patient Communication

• Medicare Patients– 4 Page Communication given upon

observation/admission order in the E.D.’s– 4 Page Communication given upon registration

to all scheduled surgery patients – Trifold brochure given by Care Management

Team on floors • Medicare Advantage /Commercial

Observation Patients– Communication varies by plan


• Medicare Observation Patients– Beginning in October, there will be an

additional notice required to be given to Medicare and Medicare Advantage patients (MOON notice)

– MOON notice requires explanation of observation status and financial implications

– Requires signature acknowledging receipt by patient or family member


Summary• Inpatient or Observation status decisions are based

on clinical guidelines• There are financial implications based on insurance

benefits that are different for inpatient versus observation

• Most Medicare patients have secondary coverage that protects them from personal liability

• On average, observation status carries less financial liability for patients

LEE MEMORIAL HEALTH SYSTEMLee County, Florida

IMPORTANT MESSAGE FROM MEDICAREFM# 120134480-1379RS Rev. 07/16 Page 1 of 2

UCO TAB – MISCELLANEOUS

Department of Health & Human Services Centers for Medicare & Medicaid Services

OMB Approval No. 0938-0692

Patient Name: Patient ID Number: Physician:

An Important Message From Medicare About Your Rights

As A Hospital Inpatient, You Have The Right To: • Receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them.

• Be involved in any decisions about your hospital stay, and know who will pay for it.

• Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here:____________________________________________________________________________________________________

Name of QIO____________________________________________________________________________________________________

Telephone Number of QIO____________________________________________________________________________________________________

Your Medicare Discharge Rights Planning For Your Discharge: During your hospital stay, the hospital staff will be working with you to preparefor your safe discharge and arrange for services you may need after you leave the hospital. When you no longer needinpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date. If you think you are being discharged too soon:

• You can talk to the hospital staff, your doctor and your managed care plan (if you belong to one) about your concerns.

• You also have the right to an appeal, that is, a review of your case by a Quality Improvement Organization (QIO). The QIO is an outside reviewer hired by Medicare to look at your case to decide whether you are ready to leave the hospital.

� If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital.

� If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles).

• If you do not appeal, but decide to stay in the hospital past your planned discharge date, you may have to pay for any services you receive after that date.

• Step by step instructions for calling the QIO and filing an appeal are on page 2.

To speak with someone at the hospital about this notice, call ________________________________________________.

Please sign and date here to show you received this notice and understand your rights. Signature of Patient or Representative Date/Time

Form CMS-R-193 (approved 07/10)

KEPRO, 5201 W. Kennedy Boulevard, Suite 900, Tampa, FL 33609

1 (844) 455-8708 TTY/TDD# 1 (855) 843-4776

(239) 424-2329

SAMPLE SAMPLE SAMPLE SAMPLE





















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LEE MEMORIAL HEALTH SYSTEMLee County, Florida

IMPORTANT MESSAGE FROM MEDICAREFM# 120134480-1379RS Rev. 07/16 Page 2 of 2

UCO TAB – MISCELLANEOUS

Patient Initials Prior to Discharge: ______________ Date:_________________ Time: _________________

Steps To Appeal Your Discharge • Step 1: You must contact the QIO no later than your planned discharge date and before you leave the hospital. If youdo this, you will not have to pay for the services you receive during the appeal (except for charges like copays anddeductibles).

• Here is the contact information for the QIO: Name of QIO (in bold)____________________________________________________________________________________Telephone Number of QIO____________________________________________________________________________________

• You can file a request for an appeal any day of the week. Once you speak to someone or leave a message, your appeal has begun.

• Ask the hospital if you need help contacting the QIO.

• The name of this hospital is : � Cape Coral Hospital 100244� Gulf Coast Medical Center 100220� Lee Memorial Hospital/HealthPark Medical Center 100012� Lee Memorial Rehabilitation Hospital 10T012

• Step 2: You will receive a detailed notice from the hospital or your Medicare Advantage or other Medicare managed care plan (if you belong to one) that explains the reasons they think you are ready to be discharged.

• Step 3: The QIO will ask for your opinion. You or your representative need to be available to speak with the QIO, if requested. You or your representative may give the QIO a written statement, but you are not required to do so.

• Step 4: The QIO will review your medical records and other important information about your case.

• Step 5: The QIO will notify you of its decision within 1 day after it receives all necessary information.

� If the QIO finds that you are not ready to be discharged, Medicare will continue to cover your hospital services.

� If the QIO finds you are ready to be discharged, Medicare will continue to cover your services until noon of the day after the QIO notifies you of its decision.

If You Miss The Deadline To Appeal, You Have Other Appeal Rights: • You can still ask the QIO or your plan (if you belong to one) for a review of your case:

� If you have Original Medicare: Call the QIO listed above.

� If you belong to a Medicare Advantage Plan or other Medicare managed care plan: Call your plan.

• If you stay in the hospital, the hospital may charge you for any services you receive after your planned discharge date.For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048.Additional Information:

KEPRO

1 (844) 455-8708 TTY/TDD# 1 (855) 843-4776

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number forthis information collection is 0938- 0692. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, searchexisting data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improvingthis form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.






















Centers for MediCare & MediCaid serviCes

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Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!

Did you know that even if you stay in a hospital overnight, you might still be considered an “outpatient?” Your hospital status (whether the hospital considers you an “inpatient” or “outpatient”) affects how much you pay for hospital services (like X-rays, drugs, and lab tests) and may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay. You’re an inpatient starting when you’re formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day. You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital. Note: Observation services are hospital outpatient services given to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged. Observation services may be given in the emergency department or another area of the hospital. The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care, but your doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient. Read on to understand the differences in Original Medicare coverage for hospital inpatients and outpatients, and how these rules apply to some common situations. If you have a Medicare Advantage Plan (like an HMO or PPO), your costs and coverage may be different. Check with your plan.






















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What do I pay as an inpatient? • MedicarePartA(HospitalInsurance)coversinpatienthospitalservices.

Generally, this means you pay a one-time deductible for all of your hospital services for the first 60 days you’re in a hospital.

• MedicarePartB(MedicalInsurance)coversmostofyourdoctorserviceswhenyou’re an inpatient. You pay 20% of the Medicare-approved amount for doctor servicesafterpayingthePartBdeductible.

What do I pay as an outpatient? • PartBcoversoutpatienthospitalservices.Generally,thismeansyoupaya

copayment for each individual outpatient hospital service. This amount may vary by service.

Note: The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.

• PartBalsocoversmostofyourdoctorserviceswhenyou’reahospitaloutpatient. You pay 20% of the Medicare-approved amount after you pay the PartBdeductible.

• Generally,prescriptionandover-the-counterdrugsyougetinanoutpatientsetting (like an emergency department), sometimes called “self-administered drugs,”aren’tcoveredbyPartB.Also,forsafetyreasons,manyhospitalshavepolicies that don’t allow patients to bring prescription or other drugs from home. If you have Medicare prescription drug coverage (Part D), these drugs may be covered under certain circumstances. You’ll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your drug plan for more information.

For more detailed information on how Medicare covers hospital services, including premiums, deductibles, and copayments, visit Medicare.gov/publications to view the “Medicare & You” handbook. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.






















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Here are some common hospital situations and a description of how Medicare will pay. Remember, you pay deductibles, coinsurance, and copayments.

Situation Inpatient or Outpatient Part A pays Part B pays

You’re in the emergency department (ED) (also known as the emergency room or “ER”) and then you’re formally admitted to the hospital with a doctor’s order.

Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient following such admission.

Your inpatient hospital stay

Your doctor services

You visit the ED and are sent to the intensive care unit (ICU) for close monitoring. Your doctor expects you to be sent home the next morning unless your condition worsens. Your condition resolves and you’re sent home the next day.

Outpatient Nothing Your doctor services

You come to the ED with chest pain and the hospital keeps you for 2 nights. One night is spent in observation and the doctor writes an order for inpatient admission on the second day.

Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient following such admission.

Your inpatient hospital stay

Doctor services and hospital outpatient services (for example, ED visit, observation services, lab tests, or EKGs)

You go to a hospital for outpatient surgery, but they keep you overnight for high blood pressure. Your doctor doesn’t write an order to admit you as an inpatient. You go home the next day.

Outpatient Nothing Doctor services and hospital outpatient services (for example, surgery, lab tests, or intravenous medicines)

Your doctor writes an order for you to be admitted as an inpatient, and the hospital later tells you it’s changing your hospital status to outpatient. Your doctor must agree, and the hospital must tell you in writing – while you’re still a hospital patient before you’re discharged – that your hospital status changed.

Outpatient Nothing Doctor services and hospital outpatient services

Remember: Even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital.






















- 4 -Information courtesy of Centers for Medicare & Medicaid Services

5400.03 7-15

How would my hospital status affect the way Medicare covers my care in a skilled nursing facility (SNF)? Medicare will only cover care you get in a SNF if you first have a “qualifying inpatient hospital stay.” • Aqualifyinginpatienthospitalstaymeansyou’vebeenahospital inpatient (you were

formally admitted to the hospital after your doctor writes an inpatient admission order) for at least 3 days in a row (counting the day you were admitted as an inpatient, but not counting the day of your discharge).

• Ifyoudon’thavea3-dayinpatienthospitalstayandyouneedcareafteryourdischargefrom a hospital, ask if you can get care in other settings (like home health care) or if any other programs (like Medicaid or Veterans’ benefits) can cover your SNF care. Always ask your doctor or hospital staff if Medicare will cover your SNF stay.

How would hospital observation services affect my SNF coverage? Your doctor may order “observation services” to help decide whether you need to be admitted to a hospital as an inpatient or can be discharged. During the time you’re getting observation services in a hospital, you’re considered an outpatient. This means you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. For more information about how Medicare covers care in a SNF, visit Medicare.gov/publications to view the booklet “Medicare Coverage of Skilled Nursing Facility Care.”Here are some common hospital situations that may affect your SNF coverage:

Situation Is your SNF stay covered?You came to the ED and were formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. You were discharged on the 4th day.

Yes. You met the 3-day inpatient hospital stay requirement for a covered SNF stay.

You came to the ED and spent one day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days.

No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Remember: Any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.






















1. What is outpatient observation?

Observation is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time to determine the need for inpatient admission. The patient will receive periodic monitoring by the hospital’s nursing staff while in observation.

2. What is the difference in billing?

Observation stay is billed as an outpatient service (under Medicare, this would be Part B).

3. What kind of problems do people have that would make observation appropriate?

There are many types of clinical problems that would support the need for observation, such as symptoms that can usually be resolved within 24-48 hours or when the

need for admission is unclear. It is the intent of the Medicare program to allow a physician more time to evaluate/treat a patient and make a decision to admit or discharge. Observation generally does not exceed 24 hours and never (practically speaking) exceeds 48 hours.

4. What are some examples of these problems?

Nausea, vomiting, stomach pain, headache, fever, and some types of shortness of breath

and chest pain.

5. What is meant by a “limited amount

of time”?

Observation is only appropriate for short time periods. Medicare allows 24-48 hours.

6. What happens at the end of the “specified

amount of time”? Typically your physician will decide whether to

discharge you to home or admit you as an inpatient.

7. What if my physician decides my

condition requires acute inpatient care?

When that determination is made, your physician must then write an order to convert

your outpatient observation stay to an inpatient admission.

8. What if my physician decides that I do

not require acute inpatient care?

Your physician will “discharge” you and arrange for your care to be followed up on an

outpatient basis.

9. Can I be placed into outpatient observation after undergoing an outpatient surgical procedure?

Procedures have a routine 4 to 6 hours of recovery associated with them. However, should you experience a post-operative or post-procedural complication then your physician may place you into observation to monitor you or admit you as an inpatient.

10. What type of post-surgical condition may warrant further evaluation in” outpatient observation”?

Inability to urinate

Inability to keep liquids down thus

requiring IV hydration

Inability to control pain

Unexpected surgical bleeding

Unstable vital signs

Inability to safely ambulate after spinal

anesthesia

Unusual reaction to the surgical procedure or anesthesia (e.g.

difficulty awakening from anesthesia, drug reaction, or other post-surgical complication).

11. If I desire to spend the night

after my outpatient surgery, will my stay be covered?

You may stay overnight after an outpatient procedure only if your physician determines that it is medically necessary for you to stay. Observation services are not to be used for the convenience of the hospital physician, patient, or their families. For example, the inability to arrange transportation home does not necessitate an overnight stay.

12. Can my physician order observation services before the procedure is performed?

No. the routine preparation before a test or procedure is not considered to be an observation service. Observation services should only be ordered after the procedure and only after a routine recovery period has revealed a complication that would require additional time for monitoring and treatment.

13. If my physician places me in observation, how does this affect my out-of-pocket costs?

Since observation is an outpatient service, any outpatient coinsurance will apply.

Medicare beneficiaries will be responsible for any “self administrable” medications. This means any medications, which you could give yourself if you were at home,

such as pills and creams, are not-covered items on an outpatient bill.

Developed in conjunction with the FHA Observation Task Force

A Patient’s

Guide to

Medicare

Outpatient

Observation


Department of Care Management

Main Office (239) 343-1157

Revised April 2013

Attention:

Medicare Advantage Participants

Please Note the effect of Outpatient

Observation Status may vary for those

with Medicare HMO coverage, based on

the terms and conditions of the

individual plan; for clarification of how

this affects you specifically; please

contact your insurer directly.

___________________


BOARD OF DIRECTORS

MEDICAL STAFF RECOMMENDATIONS

AUGUST 25, 2016

A. Lee Memorial Hospital

B. Cape Coral Hospital

C. Gulf Coast Medical Center

D. HealthPark Medical Center

E. Golisano Children’s Hospital of SWFL

LEE MEMORIAL HEALTH SYSTEM Lee County, Florida

#1 M E M O R A N D U M

To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: August 17, 2016 Subject: Lee Memorial Hospital Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Jessica Abruzzino, D.O. – Family Medicine b. Salwa Ahsan, M.D. – Family Medicine c. Matxalen Amezaga Urruela, M.D. – Rheumatology d. Willis Barrow, M.D. – Pathology e. David R. Butler, D.O. - Pediatrics f. Estrella Carballido, M.D. – Oncology/Hematology g. Justin Casey, M.D. – Otolaryngology h. Luis Cisneros, M.D. – Internal Medicine i. Christopher Conner, M.D. – Diagnostic Radiology j. Monica Dorvil-Bello, M.D. – Internal Medicine k. Konstantin Dzamashvili, M.D. – Neurology l. Sarah Eccles-Brown, M.D. – Ophthalmology m. Raymond Esper, M.D. – Oncology/Hematology n. Sherry Farag, M.D. – Family Medicine o. Micah Gaar, M.D. – Anesthesiology p. Brian Garrity, D.O. – Internal Medicine q. Valerie Gironda, M.D. – Internal Medicine r. Priyanka Handa, M.D. – Diagnostic Radiology s. Mohammed Islam, M.D. – Family Medicine t. Daniela Kloos, M.D. – Internal Medicine u. Kizhake Kurian, M.D. – Cardiology v. Jason Lakatos, D.O. – Internal Medicine w. Cristina Larrazaleta Fajardo, M.D. – Internal Medicine x. Andres Marte-Grau, M.D. – Internal Medicine y. Rose Moussignac, M.D. – Internal Medicine z. Doris Purvis, M.D. – Internal Medicine aa. Zahira Rosario, M.D. – Internal Medicine bb. Jesus Roa, M.D. – Emergency Medicine cc. Jean Rodney, M.D. – Internal Medicine dd. Ana Salas-Vargas, M.D. – Infectious Disease ee. Piper Squire, M.D. – Internal Medicine ff. Jordan Taillon, M.D. – Pulmonary Medicine gg. Darlyn Victor, M.D. – Internal Medicine

Memorandum to Board of Directors - LMH August 17, 2016 Page 2 of 4

2. Telemedicine Appointment – Privileges Only:

a. Bonnie Anderson, M.D. – Teleradiology b. Sanjam Dhillon, M.D. – Teleradiology c. Bhargav Raman, M.D. – Teleradiology

3. Temporary Privileges:

a. William Kirsh, D.O. – Family Medicine, 08-01-16 – 08-30-16; 09-17-16 – 10-16-16 b. Bhumik Shah, M.D. – Internal Medicine, 07-30-16 – 08-28-16

4. Intrasystem Application:

a. Christine Ayarza, M.D. – Infectious Disease b. Sivakumar Raman, M.D. – Infectious Disease c. Noris Reyes-Figueroa, M.D. – Infectious Disease

5. Leave of Absence:

a. William Rincon, D.O. – OB/Gyn, 05-12-16 – 02-28-17 6. Change of Status:

a. Howard Eisenberg, M.D. – Honorary, effective 08-01-16 b. Donald Gerson, M.D. – Honorary, effective 07-01-16 c. Michael Rubin, M.D. – Honorary, effective 07-01-16

7. Resignations:

a. George Blake, M.D. – Cardiology, effective 07-01-16 b. Orlando Castillo, M.D. – Diagnostic Radiology, effective 06-20-16 c. Vasyl Kasiyan, M.D. – Internal Medicine, effective 07-15-16 d. Kiran Mangalpally, M.D. – Cardiology, effective 08-01-16 e. Aboo T. Mannan, D.O. – Family Medicine, effective 07-14-16 f. Biren Shah, D.P.M. – Podiatry, effective 08-05-16

8. First Year Completion – Privilege Only Appointment:

a. Jeremy Tamir, M.D. – Surgical Wound Care 9. First Year Completion - Active Staff Appointment:

a. Anthony Anfuso, M.D. – Otolaryngology b. Ian Backstrom, M.D. – Emergency Medicine c. Leah Boyette, M.D. – Emergency Medicine d. Leopoldo Duluc-Vega, M.D. – Internal Medicine e. Gary Fischer, M.D. – Family Medicine f. Thomas LaPorta, M.D. – Orthopedic Surgery g. Michael Martinez, M.D. – Pain Management h. Jenny Mas Moya, M.D. – Pathology i. Thomas McGuire, M.D. – Internal Medicine j. Christopher Myer, M.D. – Orthopedic Surgery k. Constantine Plakas, M.D. – Neurosurgery l. Tim Replogle, M.D. – Pain Management

Memorandum to Board of Directors - LMH August 17, 2016 Page 3 of 4 10. First Year Completion - Associate Staff Appointment:

a. Richard Daum, M.D. – Cardiology b. Ricardo Escarcega Alarcon, M.D. – Cardiology c. Nosheen Mazhar, M.D. - Rheumatology d. Jose Perez, M.D. – Internal Medicine e. Mary Pilcher, M.D. – Dermatology f. Alexander Pogrebniak, M.D. – Ophthalmology g. Karla Quevedo, M.D. – Cardiology h. Ramses Rojas, M.D. – Family Medicine i. Frances Romero, M.D. – Family Medicine j. Eleonor Rongo, D.O. – Family Medicine k. Maudeen Scott, M.D. – Family Medicine l. Daniel Stanciu, M.D. – Internal Medicine m. Zaheeruddin Syed, M.D. – Family Medicine n. Biju Thomas, M.D. – General Surgery

11. Allied Health Practitioners:

a. Elsie Cajoux, ARNP – LPG Family Practice at Clayton Court b. Carlos Caycedo, CRNA – Medical Anesthesia c. Ivette Del Castillo, CRNA – Medical Anesthesia d. Marion Edwards, CRNA – Medical Anesthesia e. Jacob Nelson, PA – Joint Implant Surgeons f. Keri Mack, PA – Kagan, Jugan & Associates g. Kara Miller, PA – Florida Cancer Specialists h. Monica Nowak, ARNP – Associates in Nephrology i. Marion O’Hagan, ARNP – LPG Palliative Care j. James Ramirez, ARNP – Millennium Hospitalist Group k. Jill Tanner, ARNP – Surgical Healing Arts l. Ricardo Velazquez, CRNA – Medical Anesthesia

12. Allied Health Practitioner – Intrasystem Application:

a. Ryan Ress, ARNP – Dr. Vijay Ganatra 13. Allied Health Practitioners – Sponsor Change:

a. Julie Anne Chapman, ARNP – Dr. Lopez Gutierrez b. Miriam Ellenburg, ARNP – Lee Trauma Surgeons c. Wendy Featherstone, PA – Regional Breast Care d. Sonia Rangeloff, ARNP – IMA Hospitalist Group

14. Allied Health Practitioner – Additional Sponsor:

a. Monette Audath, ARNP – IMA Hospitalist Group

Memorandum to Board of Directors - LMH August 17, 2016 Page 4 of 4 15. Allied Health Practitioners – Privilege Request:

a. Ann Cromika, ARNP – midline insertion and intraosseous infusion insertion b. Jenevieve Perry, ARNP – Central venous catheter

Approved by the Board of Directors – August 25, 2016

________________________________________________ Sanford N. Cohen, M.D., Chairman - Board of Directors


Lee County, Florida


To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Subject: Cape Coral Hospital Medical Staff Recommendations Date: August 17, 2016 The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Jessica Abruzzino, D.O. – Family Medicine b. Scott Allen, M.D. – Interventional Cardiology c. Willis Barrow, M.D. – Pathology d. Keith Burley, M.D. – Emergency Medicine e. David R. Butler, D.O. - Pediatrics f. Estrella Carballido, M.D. – Oncology/Hematology g. Justin Casey, M.D. – Otolaryngology h. Luis Cisneros, M.D. – Internal Medicine i. Christopher Conner, M.D. – Diagnostic Radiology j. Monica Dorvil-Bello, M.D. – Internal Medicine k. Konstantin Dzamashvili, M.D. – Neurology l. Sarah Eccles-Brown, M.D. – Ophthalmology m. Raymond Esper, M.D. – Oncology/Hematology n. Herbert Ezugha, M.D. – Pediatric Neurology o. Micah Gaar, M.D. – Anesthesiology p. Brian Garrity, D.O. – Internal Medicine q. Valerie Gironda, M.D. – Internal Medicine r. Jacfranz Guiteau, M.D. – General & Transplant Surgery s. Priyanka Handa, M.D. – Diagnostic Radiology t. Lucia Huffman, M.D. – Family Medicine u. Daniela Kloos, M.D. – Internal Medicine v. Kizhake Kurian, M.D. – Cardiology w. Jason Lakatos, D.O. – Internal Medicine x. Andres Marte-Grau, M.D. – Internal Medicine y. Usman T. Mian, M.D. – Emergency Medicine z. Rose Moussignac, M.D. – Internal Medicine aa. Doris Purvis, M.D. – Internal Medicine bb. Zahira Rosario, M.D. – Internal Medicine cc. Jean Rodney, M.D. – Internal Medicine dd. Piper Squire, M.D. – Internal Medicine ee. Jordan Taillon, M.D. – Pulmonary Medicine ff. Darlyn Victor, M.D. – Internal Medicine

Memorandum to Board of Directors - CCH August 17, 2016 Page 2 of 3

2. Telemedicine Appointment – Privileges Only: a. Bonnie Anderson, M.D. – Teleradiology b. Sanjam Dhillon, M.D. – Teleradiology c. Bhargav Raman, M.D. – Teleradiology



4. Reinstatement:

a. Christine Ayarza, M.D. – Infectious Disease 5. Change of Status:


6. Resignations:

a. George Blake, M.D. – Cardiology, effective 07-01-16 b. Orlando Castillo, M.D. – Diagnostic Radiology, effective 06-20-16 c. Vasyl Kasiyan, M.D. – Internal Medicine, effective 07-15-16 d. Kiran Mangalpally, M.D. – Cardiology, effective 08-01-16 e. Jasmine Reese, M.D. – Pediatrics, effective 08-25-16 f. Biren Shah, D.P.M. – Podiatry, effective 08-05-16

7. First Year Completion - Active Staff Appointment:

a. William Binder, M.D. - Neonatology b. Richard Daum, M.D. – Cardiology c. Gary Fischer, M.D. – Family Medicine d. Edward Kirsch, D.O. – Internal Medicine e. Thomas LaPorta, M.D. – Orthopedic Surgery f. Jenny Mas Moya, M.D. – Pathology g. Thomas McGuire, M.D. – Internal Medicine h. Rebecca Miknatis, D.O. – Emergency Medicine i. Christopher Myer, M.D. – Orthopedic Surgery j. Shannon O’Hara, M.D. – OB/Gyn k. Jose Perez, M.D. – Internal Medicine l. Sualy Sosa Perez, M.D. – Cardiology m. Kurt Urban, D.O. – Emergency Medicine

8. First Year Completion - Associate Staff Appointment:

a. Anthony Anfuso, M.D. – Otolaryngology b. Leopoldo Duluc-Vega, M.D. – Internal Medicine c. Israel Guerrero Mantilla, M.D. – Cardiology d. Suying Lam Barriga, M.D. – Pediatric Cardiology e. Michael Martinez, M.D. – Pain Management f. Nosheen Mazhar, M.D. - Rheumatology g. Mary Pilcher, M.D. – Dermatology h. Constantine Plakas, M.D. – Neurosurgery

Memorandum to Board of Directors - CCH August 17, 2016 Page 3 of 3

i. Anna Ramirez-Chernikova, M.D. – Family Medicine j. Tim Replogle, M.D. – Pain Management k. Ramses Rojas, M.D. – Family Medicine l. Eleonor Rongo, D.O. – Family Medicine m. Daniel Stanciu, M.D. – Internal Medicine n. Zaheeruddin Syed, M.D. – Family Medicine o. Dean Wieczorek, D.O. – Family Medicine


a. Angela Bowen, ARNP – LPG Associates in Pediatrics b. Carlos Caycedo, CRNA – Medical Anesthesia c. Ivette Del Castillo, CRNA – Medical Anesthesia d. Marion Edwards, CRNA – Medical Anesthesia e. Brian Fritz, ARNP – Gastroenterology Associates of SW FL f. Keri Mack, PA – Kagan, Jugan & Associates g. Adam Medlin, ARNP – Gastroenterology Associates of SW FL h. Kara Miller, PA – Florida Cancer Specialists i. Marion O’Hagan, ARNP – LPG Palliative Care j. Mark Ohlenkamp, PA - Gastroenterology Associates of SW FL k. Monica Nowak, ARNP – Associates in Nephrology l. James Ramirez, ARNP – Millennium Hospitalist Group m. Jill Tanner, ARNP – Surgical Healing Arts n. Ricardo Velazquez, CRNA – Medical Anesthesia

10. Allied Health Practitioner – Intrasystem Application:

a. Ryan Ress, ARNP – Dr. Vijay Ganatra 11. Allied Health Practitioners – Sponsor Change:

a. Sonia Rangeloff, ARNP – IMA Hospitalist Group 12. Allied Health Practitioner – Additional Sponsor:

a. Monette Audath, ARNP – IMA Hospitalist Group 13. Allied Health Practitioners – Privilege Request:

a. Ann Cromika, ARNP – midline insertion and intraosseous infusion insertion b. Jenevieve Perry, ARNP – Central venous catheter





To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Subject: Gulf Coast Medical Center Medical Staff Recommendations Date: August 17, 2016 The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Scott Allen, M.D. – Interventional Cardiology b. Willis Barrow, M.D. – Pathology c. Errol Campbell, M.D. – Internal Medicine d. Estrella Carballido, M.D. – Oncology/Hematology e. Shawn Carter, M.D. - Nuclear Medicine f. Justin Casey, M.D. – Otolaryngology g. Luis Cisneros, M.D. – Internal Medicine h. Ravi Dalal, M.D. – Diagnostic Radiology i. Monica Dorvil-Bello, M.D. – Internal Medicine j. Konstantin Dzamashvili, M.D. – Neurology k. Sarah Eccles-Brown, M.D. – Ophthalmology l. Raymond Esper, M.D. – Oncology/Hematology m. Brian Garrity, D.O. – Internal Medicine n. Jacfranz Guiteau, M.D. – General & Transplant Surgery o. Mohammad Husain, M.D. – Internal Medicine p. Daniela Kloos, M.D. – Internal Medicine q. Yogesh Koradiya, M.D. – Family Medicine r. Kizhake Kurian, M.D. – Cardiology s. Ryan Lundquist, M.D. – Diagnostic Radiology t. Adam Manko, M.D. – Pulmonary Medicine u. Andres Marte-Grau, M.D. – Internal Medicine v. Rose Moussignac, M.D. – Internal Medicine w. Rachel Nambusi, M.D. – Family Medicine x. Doris Purvis, M.D. – Internal Medicine y. Zahira Rosario, M.D. – Internal Medicine z. Ana Salas-Vargas, M.D. – Infectious Disease aa. Piper Squire, M.D. – Internal Medicine bb. Jordan Taillon, M.D. – Pulmonary Medicine cc. Gary Trewick, M.D. – Family Medicine

Memorandum to Board of Directors - GCMC August 17, 2016 Page 2 of 3

2. Telemedicine Appointment – Privileges Only: a. Bonnie Anderson, M.D. – Teleradiology b. Sanjam Dhillon, M.D. – Teleradiology c. Bhargav Raman, M.D. – Teleradiology



4. Reinstatement:

a. Christine Ayarza, M.D. – Infectious Disease 5. Privilege Request:

a. Gordon Burtch, M.D. – Class II Moderate Sedation b. Jihad Khalil, M.D. – Class III Deep Sedation for TEE’s

6. Change of Status:

a. Howard Eisenberg, M.D. – Honorary, effective 08-01-16 b. Michael Rubin, M.D. – Honorary, effective 07-01-16

7. Resignations:

a. George Blake, M.D. – Cardiology, effective 07-01-16 b. Vasyl Kasiyan, M.D. – Internal Medicine, effective 07-15-16 c. Kiran Mangalpally, M.D. – Cardiology, effective 08-01-16


a. Nelson Aldana, M.D. – Pulmonary Medicine b. Rachel Beste, M.D. – Emergency Medicine c. William Binder, M.D. - Neonatology d. Ricardo Escarcega Alarcon, M.D. – Cardiology e. Israel Guerrero Mantilla, M.D. - Cardiology f. Thomas LaPorta, M.D. – Orthopedic Surgery g. Jenny Mas Moya, M.D. – Pathology h. Thomas McGuire, M.D. – Internal Medicine i. Christopher Myer, M.D. – Orthopedic Surgery j. Constantine Plakas, M.D. – Neurosurgery k. Bryan Robbins, M.D. - Anesthesiology l. Eleonor Rongo, D.O. – Family Medicine m. Daniel Stanciu, M.D. – Internal Medicine n. Biju Thomas, M.D. – General Surgery


a. Anthony Anfuso, M.D. – Otolaryngology b. Richard Daum, M.D. – Cardiology c. Leopoldo Duluc-Vega, M.D. – Internal Medicine d. Gary Fischer, M.D. – Family Medicine e. Suying Lam Barriga, M.D. – Pediatric Cardiology f. Michael Martinez, M.D. – Pain Management g. Nosheen Mazhar, M.D. - Rheumatology

Memorandum to Board of Directors - GCMC August 17, 2016 Page 3 of 3

h. Jose Perez, M.D. – Internal Medicine i. Mary Pilcher, M.D. – Dermatology j. Alexander Pogrebniak, M.D. – Ophthalmology k. Tim Replogle, M.D. – Pain Management l. Ramses Rojas, M.D. – Family Medicine m. Sualy Sosa Perez, M.D. - Cardiology n. Zaheeruddin Syed, M.D. – Family Medicine


a. Lijy Babu, CRNA - Anesthesia & Pain Consultants b. Ashley Bolton, ARNP – Southwest Florida Emergency Physicians c. Andrew Conrad, CRNA - Anesthesia & Pain Consultants d. Brian Fritz, ARNP – Gastroenterology Associates of SW FL e. Keri Mack, PA – Kagan, Jugan & Associates f. Adam Medlin, ARNP – Gastroenterology Associates of SW FL g. Kara Miller, PA – Florida Cancer Specialists h. Jacob Nelson, PA – Joint Implant Surgeons i. Monica Nowak, ARNP – Associates in Nephrology j. Marion O’Hagan, ARNP – LPG Palliative Care k. Mark Ohlenkamp, PA - Gastroenterology Associates of SW FL l. James Ramirez, ARNP – Millennium Hospitalist Group m. Meagan Stark, CRNA – Anesthesia & Pain Consultants n. Jill Tanner, ARNP – Surgical Healing Arts

11. Allied Health Practitioners – Intrasystem Application:

a. Julie Anne Chapman, ARNP – Dr. Lopez Gutierrez b. Sonia Rangeloff, ARNP – IMA Hospitalist Group

12. Allied Health Practitioners – Additional Sponsor:

a. Monette Audath, ARNP – IMA Hospitalist Group b. Rebeca Price, PA – Southwest Florida Emergency Physicians c. Ryan Ress, ARNP – Dr. Vijay Ganatra

13. Allied Health Practitioner – Privilege Request:

a. Ann Cromika, ARNP – midline insertion and intraosseous infusion insertion





To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: August 17, 2016 Subject: HealthPark Medical Center Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Salwa Ahsan, M.D. – Family Medicine b. Scott Allen, M.D. – Interventional Cardiology c. Willis Barrow, M.D. – Pathology d. David R. Butler, D.O. - Pediatrics e. Estrella Carballido, M.D. – Oncology/Hematology f. Justin Casey, M.D. – Otolaryngology g. Luis Cisneros, M.D. – Internal Medicine h. Christopher Conner, M.D. – Diagnostic Radiology i. Monica Dorvil-Bello, M.D. – Internal Medicine j. Konstantin Dzamashvili, M.D. – Neurology k. Sarah Eccles-Brown, M.D. – Ophthalmology l. Peter El Masry, M.D. – OB/Gyn m. Raymond Esper, M.D. – Oncology/Hematology n. Herbert Ezugha, M.D. – Pediatric Neurology o. Micah Gaar, M.D. – Anesthesiology p. Brian Garrity, D.O. – Internal Medicine q. Jacfranz Guiteau, M.D. – General & Transplant Surgery r. Priyanka Handa, M.D. – Diagnostic Radiology s. Daniela Kloos, M.D. – Internal Medicine t. Kizhake Kurian, M.D. – Cardiology u. Cristina Larrazaleta Fajardo, M.D. – Internal Medicine v. Andres Marte-Grau, M.D. – Internal Medicine w. Rose Moussignac, M.D. – Internal Medicine x. Doris Purvis, M.D. – Internal Medicine y. Zahira Rosario, M.D. – Internal Medicine z. Jesus Roa, M.D. – Emergency Medicine aa. Ana Salas-Vargas, M.D. – Infectious Disease bb. Kamaldeep Singh, D.O. – Interventional Cardiology cc. Piper Squire, M.D. – Internal Medicine dd. Jordan Taillon, M.D. – Pulmonary Medicine

Memorandum to Board of Directors - HPMC August 17, 2016 Page 2 of 4

2. Telemedicine Appointment – Privileges Only: a. Bonnie Anderson, M.D. – Teleradiology b. Sanjam Dhillon, M.D. – Teleradiology c. Joel Hardin, M.D. – Pediatric Cardiology d. Bhargav Raman, M.D. – Teleradiology



4. Intrasystem Application:

a. Christine Ayarza, M.D. – Infectious Disease b. Sivakumar Raman, M.D. – Infectious Disease c. Noris Reyes-Figueroa, M.D. – Infectious Disease

5. Privilege Request:

a. Brian Hummel, M.D. – Percutaneous mitral intervention and atrial septal closure b. Murali Muppala, M.D. – Percutaneous mitral intervention and atrial septal closure c. Steven Priest, M.D. – Percutaneous mitral intervention and atrial septal closure

6. Leave of Absence:

a. William Rincon, D.O. – OB/Gyn, 05-12-16 – 02-28-17 7. Change of Status:


8. Resignations:

a. Maged Bakr, M.D. – Gastroenterology, effective 07-31-16 b. George Blake, M.D. – Cardiology, effective 07-01-16 c. Orlando Castillo, M.D. – Diagnostic Radiology, effective 06-20-16 d. Vasyl Kasiyan, M.D. – Internal Medicine, effective 07-15-16 e. Kiran Mangalpally, M.D. – Cardiology, effective 08-01-16 f. Aboo T. Mannan, D.O. – Family Medicine, effective 07-14-16 g. Jasmine Reese, M.D. – Pediatrics, effective 08-25-16 h. Biren Shah, D.P.M. – Podiatry, effective 08-05-16


a. Ian Backstrom, M.D. – Emergency Medicine b. William Binder, M.D. - Neonatology c. Leah Boyette, M.D. – Emergency Medicine d. Charles Burlison, M.D. – OB/Gyn e. Ricardo Escarcega Alarcon, M.D. – Cardiology f. Israel Guerrero Mantilla, M.D. - Cardiology g. Suying Lam Barriga, M.D. – Pediatric Cardiology h. Joseph Lang, M.D. – OB/Gyn i. Michael Martinez, M.D. – Pain Management

Memorandum to Board of Directors - HPMC August 17, 2016 Page 3 of 4

j. Jenny Mas Moya, M.D. – Pathology k. Thomas McGuire, M.D. – Internal Medicine l. Alexander Pogrebniak, M.D. – Ophthalmology m. Karla Quevedo, M.D. – Cardiology n. Tim Replogle, M.D. – Pain Management o. Melvin Seid, M.D. – OB/Gyn


a. Anthony Anfuso, M.D. – Otolaryngology b. Richard Daum, M.D. – Cardiology c. Leopoldo Duluc-Vega, M.D. – Internal Medicine d. Gary Fischer, M.D. – Family Medicine e. Thomas LaPorta, M.D. – Orthopedic Surgery f. Nosheen Mazhar, M.D. - Rheumatology g. Christopher Myer, M.D. – Orthopedic Surgery h. Jose Perez, M.D. – Internal Medicine i. Mary Pilcher, M.D. – Dermatology j. Constantine Plakas, M.D. – Neurosurgery k. Ramses Rojas, M.D. – Family Medicine l. Frances Romero, M.D. – Family Medicine m. Eleonor Rongo, D.O. – Family Medicine n. Sualy Sosa Perez, M.D. - Cardiology o. Daniel Stanciu, M.D. – Internal Medicine p. Zaheeruddin Syed, M.D. – Family Medicine


a. Angela Bowen, ARNP – LPG Associates in Pediatrics b. Elsie Cajoux, ARNP – LPG Family Practice at Clayton Court c. Carlos Caycedo, CRNA – Medical Anesthesia d. Ivette Del Castillo, CRNA – Medical Anesthesia e. Marion Edwards, CRNA – Medical Anesthesia f. Heather Ferry, ARNP – LPG Cardiology at Bass Road g. Kara Miller, PA – Florida Cancer Specialists h. Monica Nowak, ARNP – Associates in Nephrology i. Marion O’Hagan, ARNP – LPG Palliative Care j. James Ramirez, ARNP – Millennium Hospitalist Group k. Leah Stewart, ARNP – Pediatric Orthopedics of SW FL l. Jill Tanner, ARNP – Surgical Healing Arts m. Ricardo Velazquez, CRNA – Medical Anesthesia

12. Allied Health Practitioners – Intrasystem Application:

a. Julie Anne Chapman, ARNP – Dr. Lopez Gutierrez b. Sonia Rangeloff, ARNP – IMA Hospitalist Group

13. Allied Health Practitioners – Sponsor Change:

a. Miriam Ellenburg, ARNP – Lee Trauma Surgeons b. Wendy Featherstone, PA – Regional Breast Care

Memorandum to Board of Directors - HPMC August 17, 2016 Page 4 of 4 14. Allied Health Practitioners – Additional Sponsor:

a. Monette Audath, ARNP – IMA Hospitalist Group b. Ryan Ress, ARNP – Dr. Vijay Ganatra





To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: August 17, 2016 Subject: Golisano Children’s Hospital of Southwest Florida

Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Willis Barrow, M.D. – Pathology b. David R. Butler, D.O. - Pediatrics c. Herbert Ezugha, M.D. – Pediatric Neurology

2. Telemedicine Appointment – Privileges Only:

a. Joel Hardin, M.D. – Pediatric Cardiology 3. Intrasystem Application:

a. Natasha Bower, M.D. – Gynecology 4. Leave of Absence:

a. William Rincon, D.O. – OB/Gyn, 05-12-16 – 02-28-17 5. Resignation:

a. Jasmine Reese, M.D. – Pediatrics, effective 08-25-16 6. First Year Completion - Active Staff Appointment:

a. William Binder, M.D. - Neonatology b. Suying Lam Barriga, M.D. – Pediatric Cardiology c. Alexander Pogrebniak, M.D. – Ophthalmology


a. Angela Bowen, ARNP – LPG Associates in Pediatrics b. Leah Stewart, ARNP – Pediatric Orthopedics of SW FL



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OLD BUSINESS

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NEW BUSINESS

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BOARD MEETING CRITIQUE

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BOARD OF DIRECTORS REPORTS

__________________________________ LEE MEMORIAL HEALTH SYSTEM

BOARD OF DIRECTORS

DATE OF THE NEXT REGULARLY SCHEDULED

MEETING:

QUALITY & SAFETY AND FULL BOARD OF DIRECTORS MEETINGS

Thursday, September 8, 2016

1:00 p.m.

Gulf Coast Medical Center Boardroom, Suite 190

13685 Doctors Way Fort Myers, FL 33912