Management s Discussion and Analysis and Basic Financial Statements June 30, 2013 and 2012 Southern Mono Healthcare District d/b/a Mammoth Hospital

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1 Management s Discussion and Analysis and Basic Financial Statements Southern Mono Healthcare District d/b/a Mammoth Hospital

2 Table of Contents Independent Auditor s Report... 1 Management s Discussion and Analysis... 3 Financial Statements 12 Balance Sheets Balance Sheets Mammoth Hospital Auxiliary, Inc Statements of Revenues, Expenses and Changes in Net Position Statements of Revenues, Expenses and Changes in Net Assets Mammoth Hospital Auxiliary, Inc Statements of Cash Flows Statements of Cash Flows Mammoth Hospital Auxiliary, Inc Notes to Financial Statements Independent Auditor s Report on Internal Control over Financial Reporting and on Compliance and Other Matters Based on an Audit of Financial Statements Performed in Accordance with Government Auditing Standards Summary Schedule of Audit Findings... 37

3 Independent Auditor s Report The Board of Directors Southern Mono Healthcare District d/b/a Mammoth Hospital Mammoth Lakes, California Report on the Financial Statements We have audited the accompanying financial statements of Southern Mono Healthcare District d/b/a Mammoth Hospital (the District), and its discretely presented component unit, which comprise the balance sheets as of, and as of September 30, 2012 and 2011, respectively, and the related statements of revenues, expenses and changes in net position, and cash flows for the years then ended, and the related notes to the financial statements. Management s Responsibility for the Financial Statements Management is responsible for the preparation and fair presentation of these financial statements in accordance with accounting principles generally accepted in the United States of America; this includes the design, implementation, and maintenance of internal control relevant to the preparation and fair presentation of financial statements that are free from material misstatement, whether due to fraud or error. Auditor s Responsibility Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free from material misstatement. An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial statements. The procedures selected depend on the auditor s judgment, including the assessment of the risks of material misstatement of the financial statements, whether due to fraud or error. In making those risk assessments, the auditor considers internal control relevant to the District s preparation and fair presentation of the financial statements in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the District s internal control. Accordingly, we express no such opinion. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluating the overall presentation of the financial statements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion Nicollet Mall, Ste Minneapolis, MN T F EOE 1

4 Opinion In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of Southern Mono Healthcare District d/b/a Mammoth Hospital as of June 30, 2013 and 2012, and its discretely presented component unit as of September 30, 2012 and 2011, and the results of its operations, changes in net position, and cash flows for the years then ended in conformity with accounting principles generally accepted in the United States of America. Other Matters Required Supplementary Information Accounting principles generally accepted in the United States of America require that the management s discussion and analysis on pages 3 through 11 be presented to supplement the basic financial statements. Such information, although not a part of the basic financial statements, is required by the Governmental Accounting Standards Board, who considers it to be an essential part of financial reporting for placing the basic financial statements in an appropriate operational, economic, or historical context. We have applied certain limited procedures to the required supplementary information in accordance with auditing standards generally accepted in the United States of America, which consisted of inquiries of management about the methods of preparing the information and comparing the information for consistency with management s responses to our inquiries, the basic financial statements, and other knowledge we obtained during our audit of the basic financial statements. We do not express an opinion or provide any assurance on the information because the limited procedures do not provide us with sufficient evidence to express an opinion or provide any assurance. Other Reporting Required by Government Auditing Standards In accordance with Government Auditing Standards, we have also issued a report dated October 4, 2013 on our consideration of the District s internal control over financial reporting and on our tests of its compliance with certain provisions of laws, regulations, contracts, grant agreements, and other matters. The purpose of that report is to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on the internal control over financial reporting or on compliance. That report is an integral part of an audit performed in accordance with Government Auditing Standards in considering the District s internal control over financial reporting and compliance. Minneapolis, Minnesota October 4,

5 Management s Discussion and Analysis The management of Southern Mono Healthcare District (SMHD, District or Mammoth Hospital) has prepared this annual discussion and analysis in order to provide an overview of SMHD's financial performance for fiscal year ended June 30, 2013, in accordance with the Governmental Accounting Standards Board Statement No. 34, Basic Financial Statements, and Management's Discussion and Analysis for State and Local Governments. The intent of this discussion and analysis is to provide additional information on SMHD's historical financial performance as a whole in addition to providing a prospective look at revenue growth, operating expenses, capital development plans, economic conditions, and the competitive environment in which SMHD operates. Readers should also review the audited financial statements for fiscal years ( FY ) ended June 30, 2013, 2012 and 2011, and accompanying notes to the financial statements to enhance their understanding of SMHD's financial performance. SMHD Highlights Overall SMHD continued to have favorable financial results in FY The total profit margin (as defined on page 8) was 9.9% in FY 2013, 7.3% in FY 2012 and 10.2% in FY Mammoth Hospital is located in a rural ski resort community and as such, a portion of the business is derived from the visitors to the town. The winter of 2012/2013 yielded better ski conditions, and thus brought more visitors to the town of Mammoth Lakes than the previous year. As a result, Mammoth Hospital experienced an increase in emergency department visits and other related services. In FY 2013, the Board and Leadership Team pursued hospital accreditation as a strategic goal. Mammoth Hospital was surveyed in December 2012 and received national accreditation from DNV Healthcare; a Center for Medicare and Medicaid Services (CMS) approved accrediting agency. As part of the DNV accreditation process, Mammoth Hospital will implement the ISO 9001 Quality Management System over the next 3 years. In November 2012, Mammoth Hospital refinanced most of the General Obligation Series A Bonds. The refinancing reduced the average interest rates from approximately 5% to 3.5%. This refinancing is expected to save taxpayers over $1.3 million over the life of the bonds. In FY 2013, Mammoth Hospital kicked off an Employee Wellness program to incentivize employees to be more accountable for their health. This initial year provided an incentive for employees to obtain basic health screening and complete an on-line survey about their health and wellbeing habits. The goal is to further expand the program in FY 2014 and provide health coaches for employees with on-going health concerns and provide better discounts to employees who actively manage their wellbeing. Mammoth Hospital has completed the HITECH Meaningful Use Stage 1 Inpatient/Hospital attestation process. Mammoth Hospital received incentive payments from both Medicare ($123,000) and from Medi-Cal ($368 thousand) for a total of $491 thousand in FY These monies are reflected in Other Operating Revenue in the FY 2013 Statement of Revenue, Expenses, and Changes in Net Position. Mammoth Hospital expects to receive similar payments through the remaining years of the program. A separate process was required to receive funding for its physician practices. As such the first step was to register its qualifying providers for the adoption/implementation/upgrade. This provided $21,250 per Rural Health Clinic provider up front and prior to the EMR implementation. Mammoth Hospital has registered its providers through the Medi-Cal RHC program for a total of 14 qualifying providers. Mammoth Hospital received $85 thousand in FY 2013 for four of the fourteen providers; the additional $215 thousand was received in early FY

6 Management s Discussion and Analysis As required under the HITECH Act, beginning in November 2012, Mammoth Hospital physician clinics adopted and implemented the Allscripts electronic medical records system. The various clinics were phased in over the last half of the year. The Family Medicine Clinic experienced the largest decline in productivity when they went live in May However, by July 2013 that clinic was at about 90% of its previous volume levels. The Orthopedic Clinic is the last physician specialty clinic to implement and is targeted for late FY In July 2013, a new Family Medicine provider was contracted to provide 8 clinic days per month. In addition, the clinic added a Physician s Assistant, mostly to cover urgent/same-day appointments. Management is anticipating some additional family medicine volumes and is further recruiting a full time family medicine physician and a nurse practitioner the goal is to have those positions filled by the end of FY In January 2013, two permanent full time general surgeons began their practice at Mammoth Hospital. Both physicians have been received well by staff and community members. They have been building the business back up since the sudden loss of our previous general surgeon. In June 2013, Mammoth Hospital joined the National Rural Accountable Care Organization (NRACO). The Mission of the NRACO is to improve population health as well as individual health outcomes, while reducing the cost of care. NRACO will achieve this by forming a national network of rural healthcare providers that benefit collectively from the Medicare Shared Savings Program. Members of the network will achieve savings through care coordination and healthcare technologies. Mammoth Hospital is committed to a $20,000 initial fee and $10,000 a month additional monthly fee. The ACO model is structured to allow facilities, such as Mammoth Hospital s, to work with its community members who have the most severe health care issues to better facilitate their care. The goal is to start slow, analyze the data, and determine what impact it can have to improve the health of Medicare beneficiaries. There is a potential that Mammoth Hospital can recover its cost with the shared savings and grants. After assessing the impact of the ACO model Mammoth Hospital can chose to continue in a more aggressive patient care model, join a new ACO with like participants, or withdraw altogether from the ACO model. In June 2013, Mammoth Hospital closed escrow on 3 acres of adjacent land to the existing hospital property. Approximately $1.4 million was paid to the Town of Mammoth Lakes for this property with two more payments of $457 thousand due over the next two years. The land has been designated to be used for replacement of the inpatient rooms to meet NPC3+ seismic requirements. The FY 2012 Strategic Plan called for the development of a Master Facilities Plan. In addition, in light of the seismic requirements, management had engaged an architect to complete the schematic design, which was completed in FY However, in late June 2013 management received a letter from the Office of Statewide Health Planning and Development granting an extension from the Senate Bill 1953 seismic work until January 1, Thus, at this point the Board of Directors agreed to put the facility replacement project on hold for several years. Over the past year, our Emergency and Obstetrics Departments have been working on The Quest for Zero, an initiative to reduce risk and improve patient safety sponsored by Beta Healthcare Group. All staff including physicians must participate in order to qualify for a reduction in premiums. Mammoth Hospital is proud to announce that its Emergency Department is the first organization under Beta Healthcare that has completed the Level 2 Quest for Zero and consequently will receive a 9% reduction in insurance premium costs for FY Its Obstetrics Department has achieved Level 1 in the Quest for Zero and it also will receive a 5% discount in FY

7 Management s Discussion and Analysis Financial Highlights Financial performance for FY 2013 yielded an increase in net position of approximately $6.1 million. The FY 2012 and 2011 performance resulted in an increase in net position of approximately $4.2 million and $6 million, respectively. Total assets for SMHD at June 30, 2013 increased by approximately $4.6 million to $90.8 million and at June 30, 2012 increased approximately $4.5 million to $86.1 million. Cash and cash equivalents at June 30, 2013 were $27.1 million, and $22.8 million and $22.1 million in the two years prior. Net patient accounts receivable were $9.8 million at June 30, 2013, up $458 thousand from the June 30, 2012 amount of $9.4 million. Fiscal year 2013 continued to be significant year for patient billing and collection activities. Net days in accounts receivable are at 60.9 at June 30, 2013, 62.1 days at June 30, 2012 and 44.5 at June 30, See Patient Accounts Receivable for further details. Current liabilities were $10.0 million at June 30, 2013, which is a slight increase from the prior two years at $9.3 million and $9.2 million, respectively. Current year payments made on long-term debt were $2.4 million in 2013, resulting in $28.9 million remaining in long-term debt at June 30, In addition, approximately $11 million of Series A bonds were refinanced in FY See Current Liabilities for further detail. The operating income was $3.9 million for FY 2013, compared to $1.4 million in FY 2012 and $3.6 million in FY Net patient revenue increased by $3.9 million as compared to a decrease in FY 2012 of $1.8 million and an increase of $2.6 million in FY The current year increase is attributed to an increase in patient days and emergency department visits in both summer and winter. FY 2013 expenses from operations increased by $2 million or 4% mainly due to increased employee health benefit expenses. Total operating expenses were $56.0 million in FY 2013 compared to $53.9 million and $53.5 million in FY 2012 and FY 2011, respectively. The Mammoth Auxiliary, Inc. (Auxiliary) financial statements are as of and for the years ended September 30, 2012 and The Auxiliary reports $225 thousand in cash and cash equivalents, down $4 thousand from On the liability side, the Auxiliary reports $87 thousand in accounts payable, property tax, and accrued expenses and $2.2 million in unrestricted net assets at September 30, In comparison, for fiscal year ended September 30, 2011, the Auxiliary reported $9 thousand in current liabilities and $2.3 million in unrestricted net assets. Operating revenues for the Auxiliary, including in-kind contributions of $263 thousand, were $545 thousand in FY 2012, up $281 thousand from FY This is the first increase of operating revenues over the past four years, which mimics the current economic trends. Expenses, including cost of goods sold of $243 thousand, were $654 thousand, up $404 thousand from prior year for a decrease in unrestricted net assets of $109 thousand. The most significant expenses of the Auxiliary are donations to the Hospital. Overview of Southern Mono Healthcare District and Financial Statements This annual report consists of the financial statements and notes to those statements, which reflect SMHD's financial position and results of its operations, changes in net position and cash flows as of and for the fiscal years ended June 30, 2013, 2012, and The financial statements of SMHD include the balance sheets and statements of revenues, expenses and changes in net position, and statements of cash flows. The balance sheet includes all of SMHD's assets and liabilities, using the accrual basis of accounting, as well as an indication about which assets are designated for specific operating activities and to service debt. 5

8 Management s Discussion and Analysis The statement of revenues, expenses, and changes in net position presents the results of operating activities and the resulting operating income and loss and other activity. Non-operating revenues and expenses consist primarily of property taxes, noncapital contributions and grants, and financing income and expenses. The statement of cash flows reports the net cash used by operating activities, as well as other sources and uses of cash from noncapital financing activities and capital and related financing activities. Balance sheets as of June 30, 2013, 2012, and 2011: Change from Amount Percentage Assets Cash and cash equivalents $ 27,136,776 $ 22,804,174 $ 22,096,076 $ 4,332, % Restricted cash 951, , , , % Receivables Less allowances for uncollectible accounts of $5,499,000, $5,178,000, $4,856,000 9,843,946 9,386,250 6,948, , % Inventories 1,523,327 1,179,247 1,275, , % Prepaid expenses and other 801, , , , % Noncurrent cash 4,909,774 4,595,312 3,708, , % Capital assets - net 45,077,774 46,098,963 45,591,109 (1,021,189) -2.2% Deferred financing costs, net 517, , ,916 (266,036) -33.9% Total assets $ 90,762,399 $ 86,120,202 $ 81,658,757 $ 4,642, % Liabilities and Net Position Liabilities Current liabilities $ 10,042,768 $ 9,343,268 $ 9,347,781 $ 699, % Long-term debt, less current maturities 28,942,817 31,095,306 30,844,822 (2,152,489) -6.9% Total liabilities 38,985,585 40,438,574 40,192,603 (1,452,989) -3.6% Net Position Net investment in capital assets 13,785,877 12,575,685 13,338,147 1,210, % Restricted - expendable for specific operating activities 187, , ,960 (15,055) -7.4% Restricted - expendable for capital acquisitions 9,418 22,822 35,395 (13,404) -58.7% Restricted - expendable for debt service 5,664,168 5,014,176 4,121, , % Unrestricted 32,129,462 27,866,001 23,820,591 4,263, % Total net position 51,776,814 45,681,628 41,466,154 6,095, % Total Liabilities and Net Position $ 90,762,399 $ 86,120,202 $ 81,658,757 $ 4,642, % Cash and Cash Equivalents SMHD's cash and cash equivalents increased by $4.3 million during the fiscal year ended June 30, 2013, as compared to June 30, Days cash on hand, a financial measurement to determine how many days of current operating expenses our cash represents, was 157 days as of June 30, 2011 and increased to 161 and 184 days, respectively, as of June 30, 2012 and June 30, Cash operating expenses per calendar day were $148 thousand for FY 2013, $142 thousand for FY 2012 and $140 thousand in FY

9 Management s Discussion and Analysis Patient Accounts Receivable Net Patient Accounts Receivable (AR) increased during FY 2013 to $9,844 thousand up from $9,386 thousand at June 30, Net AR days were 60.9 at June 30, 2013 which is down from June 30, 2012 at 62.7 (June 30, 2011 was at 44.5). Patient account collections were over $59 million in FY 2013 as compared to $52 million and $58 million in FY 2012 and FY 2011, respectively. The Patient Financial Services (PFS) position was vacant for most of FY 2013, which resulted in the Chief Financial Officer leading the billing/collection efforts and new processes were put in place to improve collection efforts. In April 2013, a new PFS manager was hired and assumed operational efforts. Inventory As of June 30, 2013, inventory was valued at $1.5 million which is up from $1.2 million at June 30, 2012 and $1.3 million at June 30, The increase as of June 30, 2013 is mainly due to increase in the operating room s screws, plates, and instrument plates. Capital Assets Net capital assets decreased $1 million to $45.1 million at June 30, This decrease is primarily due to capital asset depreciation expense of $3.8 million in FY 2013 offset by capital acquisitions of $2.8 million. The decrease is attributed to several large projects including data center and Allscripts implementation in clinics being depreciated as they started their useful life. Net capital assets increased $500 thousand from June 30, 2011 to June 30, 2012, related to the acquisition of land from the Town of Mammoth Lakes. The land is adjacent to the existing hospital. Current Liabilities Current liabilities were $10 million at June 30, 2013, which is a $694 thousand increase from prior year mainly due to third party settlements for Medicare and Medi-Cal cost reports and increase in reserve for self-funded health insurance. Current maturities of long-term debt have decreased by $85 thousand at June 30, 2013 compared to June 30, Estimated third-party payer settlements increased to $1.7 million at June 30, 2013 compared to $865 thousand at June 30, The majority of the current year liability, $1 million, is for the FY 2013 cost report estimated liabilities, and the remaining is owed to Medi-Cal. Long-term Debt Long term debt, less current maturities, decreased by $2.1 million to $28.9 million at June 30, 2013 mainly due to land purchase payments made in June The FY 2012 increase was primarily due to the recording of the debt to the Town of Mammoth Lakes for the land purchase of $2.3 million. Net Position Total net position increased by $6.1 million, $4.2 million and $6 million in FY 2013, FY 2012 and FY 2011, respectively. Unrestricted net position as of June 30, 2013 increased $4.3 million from prior year due to excess of revenues over expenses of approximately $5.4 million offset by an increase in amounts invested in capital assets of $1.2 million. Unrestricted net position at June 30, 2012 increased $4 million due to the excess of revenues over expenses of approximately $3.6 million for FY The FY 2011 increase in unrestricted net position of $5.3 million is due primarily to the excess of revenues over expenses in FY

10 Management s Discussion and Analysis Revenues, Expenses, and Changes in Net Position for the years ended June 30, 2013, 2012 and 2011: Change from Amount Percentage Operating Revenues Net patient service revenue $ 59,043,776 $ 55,178,742 $ 57,004,302 $ 3,865, % Other revenue 794, , , , % Total operating revenues 59,837,856 55,346,779 57,165,579 4,491, % Operating Expenses Salaries, wages, and benefits 25,607,690 23,935,271 23,756,420 1,672, % Professional fees 13,828,190 13,901,708 13,429,910 (73,518) -0.5% Supplies 5,482,344 5,657,509 6,058,957 (175,165) -3.1% Purchased services 4,015,099 3,614,117 3,147, , % Utilities 1,059,708 1,001,084 1,054,560 58, % Rents and leases 752, , ,144 (12,136) -1.6% Insurance 484, , ,641 (56,154) -10.4% Depreciation and amortization 3,742,812 3,785,481 3,970,306 (42,669) -1.1% Other 979, , , , % Total operating expenses 55,951,641 53,942,900 53,546,126 2,008, % Operating Income 3,886,215 1,403,879 3,619,453 2,482, % Nonoperating Revenues (Expenses) Tax revenues 3,087,226 3,637,966 3,153,263 (550,740) -15.1% Interest income 126, , ,927 23, % Grant revenue 748, , % Grant expense (748,125) - - (748,125) 100.0% Interest expense (1,685,456) (1,592,210) (1,670,241) (93,246) 5.9% Noncapital grants and contributions (28,308) 46,125 91,927 (74,433) % Total nonoperating revenues, net 1,500,424 2,195,593 1,693,876 (695,169) -41.0% Revenues in Excess of Expenses 5,386,639 3,599,472 5,313,329 1,787, % Contributions for Capital Assets 223, , ,240 32, % Tax Revenues for Debt Principal Payments 485, , ,000 60, % Increase in Net Position 6,095,186 4,215,474 6,001,569 1,879, % Net Position, Beginning of Year 45,681,628 41,466,154 35,464,585 4,215, % Net Position, End of Year $ 51,776,814 $ 45,681,628 $ 41,466,154 $ 6,095, % Total Profit Margin (Increase in Net Position Divided by Total Operating and Nonoperating Revenue) 9.9% 7.3% 10.2% 8

11 Management s Discussion and Analysis Patient Statistical Data for the years ended June 30, 2013, 2012 and 2011: Change from Amount Percentage Inpatient Statistics Patient Days 1,438 1,404 1, % Adjusted Patient Days 4,948 4,498 4, % Admissions % Discharges % Average Length of Stay % Average Daily Census % Deliveries % In Patient Surgeries (35) -8% Labor Performance Statistics Full Time Equivalents (1) 0% Number of Employees % Outpatient Statistics Emergency Department 9,081 8,732 8, % Observation Hours 6,987 5,694 5,873 1,293 23% Outpatient Surgeries % Clinics Family Medicine Clinic 11,559 12,941 13,239 (1,382) -11% Bridgeport Clinic 1,916 1,743 1, % Neurology Clinic 1,358 1,466 1,376 (108) -7% Urology Clinic 1,800 1,878 1,671 (78) -4% Pediatrics Clinic 3,978 4,397 5,174 (419) -10% Women's Health Clinic 4,690 4,355 4, % Orthopedic Clinic - Mammoth 5,698 5,570 5, % Orthopedic Clinic - Bishop 2,448 2,710 2,255 (262) -10% General Surgery Clinic (153) -22% Dental Clinic 3,470 3,946 4,020 (476) -12% Total Clinic Visits 37,462 39,704 40,130 (2,242) -6% 9

12 Management s Discussion and Analysis Gross Patient Charges The District charges all patients equally based on its established pricing structure for the services rendered. Under antitrust statutes and Medicare regulations, all hospitals are required to charge their patients equally if the same level of service is rendered. The District increased its established prices on select professional and hospital/non physician services effective July 1, 2012 which approximated a minimal 1% overall price increase (the price increase was approximately 1.1% in July 2011 and 2.5% in July 2010). Inpatient days were up 34 days or 2% to 1,438 in FY In addition, emergency department visits were up 450 visits or 10% to 9,081 in FY These increases are attributed to the increase in visitors to Mammoth Lakes due to the higher snow fall. Inpatient surgeries were slightly lower in FY 2013 to 401 from 436 in FY 2012 or 8% decrease. Outpatient surgeries increased by 11 to 804 from 793 in FY Clinic volumes continue to decrease over several years, with a 6% decrease in current year and overall decreases over the past three years from 40,130 to 39,704 to 37,462, for FY 2011, 2012 and 2013, respectively. The major decrease in FY 2013 was in the Family Medicine practice, which is directly correlated to the electronic health record implementation. The first two months after implementation, May and June 2013, resulted in approximately half the normal productivity, however, the first few months of FY 2014 the Family Medicine clinics volume was up to 90% of the normal volume. Deductions from Revenue Contractual allowances are computed deductions based on the difference between gross charges and the contractually agreed-upon rates with third-party government-based programs such as Medicare, Medi-Cal, and other third party insurers. Bad debt allowances are computed based on the age of the account and the determination that collections are not likely. Net Patient Service Revenue Net patient service revenue is the resulting difference between gross patient charges and the deductions from revenue. Compared to FY 2012, net patient service revenues increased by $3.9 million or approximately 7% to $59 million in FY Net revenue as a percentage of gross charges was 63.2%, 62.7% and 64.5% for FY 2013, FY 2012 and FY 2011, respectively. The FY 2013 increase of.5 % can be attributed partially to an increase in collections on aged accounts. Other Operating Revenue Other operating revenue increased significantly by $626 thousand mainly due to Meaningful Use Incentive payments received from Medicare and Medi-Cal for meeting Stage 1 of the HITECH Act requirements. A total of $576 thousand was received and recorded in Other Operating Revenue. 10

13 Management s Discussion and Analysis Operating and Non-Operating Expenses Expenses from operations increased $2 million or 3.7% in FY 2013 from FY 2012 mainly reflected in increased benefits expenses. Salaries, wages and benefits increased by approximately 7% in FY 2013 over FY 2012, or $1.7 million, for a FY 2013 expenditure of $25.6 million. $1.2 million of the FY 2013 increase relates to benefits almost entirely attributed to increased employee health claims. In comparison, this expense category increased by.8% in FY 2012 over FY 2011, or $179 thousand, for a FY 2012 expenditure of $23.9 million. Full time equivalents (FTEs) remained comparable at 265 during FY 2013 as compared to 266 during FY Professional fees remained approximately at the same level as FY 2012, with only a $73 thousand or.5% decrease in FY Professional fees increased $472 thousand or 3.5% in FY 2012 over FY 2011 mainly attributed to contracted services for operational projects. Supplies expense of $5.5 million in FY 2013 decreased from the prior year level by $175 thousand or 3.1%. The reduction is reflective of continuous efforts to negotiate with our suppliers as well as staff and physician alignment in using supplies. Supplies expense posted a decrease of $401 thousand or 6.6% for a total of $5.7 million for FY 2012 as compared to FY 2011 due to one-time $400 thousand inventory adjustment. Purchased services increased in FY 2013 over FY 2012, up $401 thousand to $4 million. The majority of the increase is attributed to the outsourcing of patient account collections on international, workers compensation, and physician office visit services. The collection fees are all based on percentage of collections and most of the international and workers compensation collections were an initial bulk clean up. Insurance expense decreased $56 thousand or 10.4% to $485 thousand in FY 2013 compared to FY 2012 due to a reduction in malpractice insurance as a result of low claims experience. Other costs include such costs as other recruiting, bank service charges and software licensing. In the Non-Operating Revenues/Expenses category, tax revenues were $3.1 million in FY 2013 compared to $3.6 million and $3.2 million in FY 2012 and FY 2011, respectively. Contacting the District s Management This financial report is designed to provide our patients, suppliers, taxpayers, and creditors with a general overview of the District s finances and to show the District s accountability for the money it receives. If you have questions about this report or need additional information, contact Melanie Van Winkle, Chief Financial Officer at at Mammoth Hospital, PO Box 660, 85 Sierra Park Road, Mammoth Lakes, CA

14 Assets Current Assets Cash and cash equivalents $ 27,136,776 $ 22,804,174 Restricted cash 951, ,630 Receivables Patient receivables, net of estimated uncollectibles of approximately $5,499,000 in 2013 and $5,178,000 in ,843,946 9,386,250 Inventories 1,523,327 1,179,247 Prepaid expenses and other 801, ,697 Total current assets 40,256,958 34,641,998 Noncurrent Cash Restricted cash for debt repayment 4,712,468 4,369,546 Restricted cash by contributors 197, ,766 Total noncurrent cash 4,909,774 4,595,312 Capital Assets Capital assets not being depreciated 4,662,159 4,803,395 Capital assets, net of accumulated depreciation 40,415,615 41,295,568 Total capital assets 45,077,774 46,098,963 Deferred Financing Costs, Net of Accumulated Amortization of $154,482 in 2013 and $325,689 in , ,929 Total assets $ 90,762,399 $ 86,120,202 See Notes to Financial Statements

15 Balance Sheets Liabilities and Net Position Current Liabilities Current maturities of long-term debt $ 2,349,080 $ 2,427,972 Accounts payable Trade 3,237,569 3,478,207 Estimated third-party payor settlements 1,700, ,668 Accrued expenses Salaries and benefits 1,899,782 1,824,240 Interest 327, ,487 Reserve for self funded health insurance 528, ,694 Total current liabilities 10,042,768 9,343,268 Long-term Debt, Less Current Maturities 28,942,817 31,095,306 Total liabilities 38,985,585 40,438,574 Net Position Net investment in capital assets 13,785,877 12,575,685 Restricted Expendable for specific operating activities 187, ,944 Expendable for capital acquisitions 9,418 22,822 Expendable for debt service 5,664,168 5,014,176 Unrestricted 32,129,462 27,866,001 Total net position 51,776,814 45,681,628 Total liabilities and net position $ 90,762,399 $ 86,120,202 12

16 Balance Sheets Mammoth Hospital Auxiliary, Inc. September 30, 2012 and Assets Current Assets Cash and cash equivalents $ 225,318 $ 229,387 Inventories 20,000 - Property and Equipment, Net 2,072,419 2,119,860 Total assets $ 2,317,737 $ 2,349,247 Liabilities and Net Assets Current Liabilities Accounts payable $ 77,553 $ - Property taxes payable 6,484 6,246 Other accrued expenses 2,216 2,754 Total current liabilities 86,253 9,000 Net Assets - Unrestricted 2,231,484 2,340,247 Total liabilities and net assets $ 2,317,737 $ 2,349,247 See Notes to Financial Statements 13

17 Statements of Revenues, Expenses and Changes in Net Position Years Ended Operating Revenues Net patient service revenue $ 59,043,776 $ 55,178,742 Other revenue 794, ,037 Total operating revenues 59,837,856 55,346,779 Operating Expenses Salaries, wages, and benefits 25,607,690 23,935,271 Professional fees 13,828,190 13,901,708 Supplies 5,482,344 5,657,509 Purchased services 4,015,099 3,614,117 Utilities 1,059,708 1,001,084 Rents and leases 752, ,183 Insurance 484, ,890 Depreciation and amortization 3,742,812 3,785,481 Other 979, ,657 Total operating expenses 55,951,641 53,942,900 Operating Income 3,886,215 1,403,879 Nonoperating Revenues (Expenses) Tax revenues 3,087,226 3,637,966 Interest income 126, ,712 Grant revenue 748,125 - Grant expense (748,125) - Interest expense (1,685,456) (1,592,210) Noncapital grants and contributions (28,308) 46,125 Total nonoperating revenues, net 1,500,424 2,195,593 Revenues in Excess of Expenses 5,386,639 3,599,472 Contributions for Capital Assets 223, ,002 Tax Revenues for Debt Principal Payments 485, ,000 Increase in Net Position 6,095,186 4,215,474 Net Position, Beginning of Year 45,681,628 41,466,154 Net Position, End of Year $ 51,776,814 $ 45,681,628 See Notes to Financial Statements 14

18 Statements of Revenues, Expenses and Changes in Net Assets Mammoth Hospital Auxiliary, Inc. September 30, 2012 and Operating Revenues Thrift shop income $ 243,223 $ 229,862 Rental income 28,218 23,076 Investment income 16 7 Contributions 4,113 1,540 In-kind contributions 263,223 - Other income 6,451 9,972 Total operating revenues 545, ,457 Operating Expenses Cost of goods sold 243,223 - Donations (Note 10) 283, ,405 Depreciation 47,441 49,939 Property taxes 26,016 24,983 Administrative 10,845 5,194 Utilities 20,955 24,098 Housekeeping and maintenance 22,158 21,015 Total operating expenses 654, ,634 Increase (Decrease) in Unrestricted Net Assets (108,763) 14,823 Net Assets, Beginning of Year 2,340,247 2,325,424 Net Assets, End of Year $ 2,231,484 $ 2,340,247 See Notes to Financial Statements 15

19 Statements of Cash Flows Years Ended Cash Flows from Operating Activities Receipts from and on behalf of patients $ 59,422,043 $ 52,211,368 Payments to suppliers and contractors (27,359,370) (26,297,144) Payments to employees (25,351,487) (24,252,969) Other receipts 794, ,037 Net Cash from Operating Activities 7,505,265 1,829,292 Noncapital Financing Activities Property tax received for operations 1,917,244 2,019,743 Noncapital grants and contributions (28,308) 46,125 Net Cash from Noncapital Financing Activities 1,888,936 2,065,868 Capital and Related Financing Activities Purchase of capital assets, net of construction payables (2,759,218) (2,154,686) Repayment of long-term debt (13,922,436) (1,407,977) Proceeds from issuance of long-term debt 11,476,910 - Payment of deferred financing costs (135,110) - Capital acquisition contributions 223, ,002 Property taxes restricted to debt service 1,654,982 2,043,223 Interest paid on long-term debt, net of accreted interest and bond premium (1,105,705) (1,029,811) Net Cash used for Capital and Related Financing Activities (4,567,030) (2,358,249) Investing Activities Interest received 126, ,712 Net Cash from Investing Activities 126, ,712 Net Increase in Cash and Cash Equivalents 4,954,134 1,640,623 Cash and Cash Equivalents, Beginning of Year 28,044,116 26,403,493 Cash and Cash Equivalents, End of Year $ 32,998,250 $ 28,044,116 Reconciliation of Cash and Cash Equivalents to the Balance Sheets Cash and cash equivalents (including restricted cash) in current assets $ 28,088,476 $ 23,448,804 Cash and cash equivalents (including restricted cash) in noncurrent cash 4,909,774 4,595,312 Total cash and cash equivalents $ 32,998,250 $ 28,044,116 Supplemental Disclosure of Noncash Financing and Operating Activities Acquisition of land through long-term obligation $ - $ 2,182,044 16

20 Statements of Cash Flows Years Ended Reconciliation of Operating Income to Net Cash from Operating Activities Operating income $ 3,886,215 $ 1,403,879 Adjustments to reconcile operating income to net cash from operating activities Depreciation and amortization 3,742,812 3,785,481 Changes in assets and liabilities Receivables (457,696) (3,832,042) Inventories (344,080) 96,150 Prepaid expenses and other (173,511) (7,913) Accounts payable 595, ,435 Accrued liabilities 75,542 (327,743) Estimated liability for health care costs 180,660 10,045 Net Cash from Operating Activities $ 7,505,265 $ 1,829,292 See Notes to Financial Statements 17

21 Statements of Cash Flows Mammoth Hospital Auxiliary, Inc. September 30, 2012 and Cash Flows from Operating Activities Changes in unrestricted net assets $ (108,763) $ 14,823 Adjustments to reconcile change in net assets to net cash used for operating activities Depreciation 47,441 49,939 Changes in assets and liabilities Inventories (20,000) - Accounts payable 77,553 - Accrued expenses and other payables (300) - Net Cash from (used for) Operating Activities (4,069) 64,762 Cash and Cash Equivalents, Beginning of Year 229, ,625 Cash and Cash Equivalents, End of Year $ 225,318 $ 229,387 See Notes to Financial Statements 18

22 Notes to Financial Statements Note 1 - Organization and Significant Accounting Policies Organization Southern Mono Healthcare District (District) is a political subdivision of the State of California, organized under the Local Health Care District Law as set forth in the Health and Safety Code of the State of California. The District owns and operates Mammoth Hospital (Hospital), which is located in Mammoth Lakes, California, a small resort community in the Eastern Sierra Mountains. The Hospital is licensed for 17 beds. The Hospital serves the surrounding community, as well as visitors to the area throughout the year, deriving a significant portion of revenue from third-party payers, including private insurance, Medicare, and Medi-Cal. The District maintains its financial records in conformity with guidelines set forth by the Local Health Care District Law and the Office of Statewide Health Planning and Development of the State of California. Enterprise Fund Accounting The District uses enterprise fund accounting. Revenues and expenses are recognized on the accrual basis using the economic resources measurement focus. GASB Statement No. 61 requires organizations that are "closely related to, or financially integrated with, the primary government be reported as component units by the primary government. Mammoth Hospital Auxiliary, Inc. (Auxiliary) has been included as a discretely presented component unit. The Auxiliary acts primarily as a fund-raising organization to supplement the resources that are available to the District in support of its operations and programs. Use of Estimates The preparation of financial statements in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements. Estimates also affect the reported amounts of revenues and expenses during the reporting period. Actual results could differ from those estimates. Cash and Cash Equivalents Cash and cash equivalents include highly liquid investments with an original maturity of three months or less, and deposits in California Local Agency Investment Fund (LAIF). LAIF is a pooled investment fund which is operated as a money market fund whereby cash transfers are readily obtainable. The District records its deposits at fair value, which approximates cost. The LAIF pool includes structured notes and asset-backed securities, which total 1.88% and 2.75% of the total portfolio as of, respectively. The structured notes and asset-backed securities are subject to market risk as to change in interest rates. The fair value of LAIF is estimated at % and % of the carrying value as of, respectively. The District is considered to be a voluntary participant in LAIF. 19

23 Notes to Financial Statements Restricted Cash Restricted cash consists of a debt service fund into which levied property taxes are deposited to pay principal and interest due on the General Obligation Bonds. This ad valorem tax is irrevocably pledged to the payments of debt service. This fund is held in the County of Mono Treasury (the Treasury). The Treasury maintains amounts in a pooled investment fund and is restricted by California Government Code, Section pursuant to Section to invest in time deposits, U.S. Government securities, state registered warrants, notes, bonds, LAIF, bankers' acceptances, commercial paper, negotiable certificates of deposit, and repurchase or reverse repurchase agreements. The Treasury invests primarily in LAIF. The fair value of the District's position in the pool approximates the carrying value of the pool shares. The Treasury is subject to regulatory oversight by the Treasury Oversight Committee, as required by California Government Code, Section The District is considered to be an involuntary participant in the Treasury. Patient Receivables Patient receivables are uncollateralized customer and third-party payor obligations. Payments of patient receivables are allocated to the specific claims identified on the remittance advice or, if unspecified, are applied to the earliest unpaid claim. Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the District analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third party coverage, the District analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the thirdparty payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the District records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates, if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. The District s process for calculating the allowance for doubtful accounts for self-pay patients has not significantly changed during. The District maintains a material allowance for doubtful accounts from third-party payors. The District has not significantly changed its charity care or uninsured discount policies during fiscal years 2013 and Inventories Inventories are stated at lower of cost (first-in, first-out) or market. 20

24 Notes to Financial Statements Noncurrent Cash Noncurrent cash consists of proceeds from financing leases, which are deposited in escrow accounts; restricted contributions for capital asset acquisitions; and cash in debt service fund designated for the accreted interest related to the capital appreciation bonds. Future debt service payments for the capital appreciation bonds are assessed periodically and deposited into this debt service sinking fund. The escrow accounts are held in government money market funds to be used for equipment purchases. The restricted contributions are included with the cash deposited in a financial institution and in LAIF. Capital Assets Capital asset acquisitions in excess of $5,000 are capitalized and recorded at cost. Contributed capital assets are reported at their estimated fair value at the date of donation. Assets under capital lease obligations are amortized on the straight-line method over the shorter period of the lease term or the estimated useful life. Such amortization is included in depreciation and amortization in the financial statements. All capital assets other than land and construction in progress are depreciated or amortized (in the case of capital leases) using the straight-line method of depreciation using the following asset lives: Land improvements Buildings and improvements Equipment 5-20 years years 3-7 years Deferred Financing Costs and Bond Premium Deferred financing costs and unamortized bond premium relating to the General Obligation Bonds are being amortized over the period the related obligation is outstanding using the straight-line method, which approximates the interest method. The amortization is included in interest expense. Compensated Absences The District employees earn paid-time off (PTO) at varying rates, depending on years of service. PTO accumulates up to a specific amount, as defined in the District s employee manual. Employees are paid for accumulated PTO if employment is terminated. Property Tax Property taxes are levied by the County of Mono on the District's behalf and are intended to support operations and to service debt. The amount of property tax received is dependent upon the assessed real property valuations as determined by the Mono County Assessor. Property taxes are due in two equal installments on November 1 and February 1 each year and are delinquent if not paid by December 10 and April 10, respectively. The District received approximately 5% and 7% of its financial support from property taxes in 2013 and 2012, respectively. Grants and Contributions The District receives grants and contributions from governmental and private entities. Grants and contributions may be restricted for either specific operating purposes or for capital purposes. Amounts that are unrestricted or that are restricted to a specific operating purpose are reported as nonoperating income. Amounts restricted for capital acquisitions are reported after nonoperating revenues and expenses. 21

25 Notes to Financial Statements Restricted Resources When the District has both restricted and unrestricted resources available to finance programs or activities, it is the District's policy to use restricted resources first. Net Position Net position is presented in the following three components: Net investment in capital assets Net investment in capital assets consists of capital assets net of accumulated depreciation and reduced by the balances of any outstanding borrowings used to finance the purchase or construction of those assets. Restricted Expendable Restricted expendable is noncapital net position that must be used for a particular purpose, as specified by creditors, grantors, or contributors external to the District, including amounts on deposit or designated for debt service. Unrestricted Unrestricted is remaining net position that does not meet the definition of Invested in Capital Assets or Restricted. Net Patient Service Revenue The District has agreements with third-party payors that provide for payments to the District at amounts different from its established rates. Payment arrangements include prospectively determined rates, discounted charges, and per diem payments. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payors, and others for services rendered, including estimated retroactive adjustments under reimbursement agreements with third-party payors. Retroactive adjustments are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. Operating Revenues and Expenses The statement of revenues, expenses, and changes in net assets distinguishes between operating and nonoperating revenues and expenses. Operating revenues generally result from exchange transactions associated with providing health care services. Nonexchange revenues, including taxes, grants, and contributions received for purposes other than capital asset acquisitions, are reported as nonoperating revenues. Operating expenses are generally all expenses incurred to provide health care services, other than financing costs. Charity Care The District provides health care services to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Since the District does not pursue collection of these amounts, they are not reported as patient service revenue. The estimated cost of providing these services was $1,116,000 and $1,449,000 for the years ended, respectively, calculated by multiplying the ratio of cost to gross charges for the District by the gross uncompensated charges associated with providing charity care to its patients. Advertising Costs The District expenses advertising costs as they are incurred. 22

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