AUDITED FINANCIAL STATEMENTS ERIE COUNTY MEDICAL CENTER CORPORATION (A COMPONENT UNIT OF THE COUNTY OF ERIE) DECEMBER 31, 2014

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1 AUDITED FINANCIAL STATEMENTS ERIE COUNTY MEDICAL CENTER CORPORATION DECEMBER 31, 2014

2 TABLE OF CONTENTS Independent Auditor s Report Page Management s Discussion and Analysis Financial Statements: Statements of Net Position... 9 Statements of Revenues, Expenses and Changes in Net Position Statements of Cash Flows Statements of Net Position Component Units Statements of Revenues, Expenses and Changes in Net Position - Component Units Statements of Cash Flows Component Units Notes to the Financial Statements Required Supplementary Information: Schedule of Funding Progress for the Postemployment Retiree Healthcare Plan Independent Auditor s Report on Internal Control Over Financial Reporting and on Compliance and Other Matters Based on an Audit of the Financial Statements Performed in Accordance with Government Auditing Standards Schedule of Findings and Responses... 44

3 To the Board of Directors of Erie County Medical Center Corporation Buffalo, New York Report on the Financial Statements INDEPENDENT AUDITOR S REPORT We have audited the accompanying financial statements of Erie County Medical Center Corporation (a component unit of the County of Erie) (the Corporation ) and the aggregate discretely presented component units, which comprise the statements of net position as of December 31, 2014 and 2013, 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, which collectively comprise the Corporation s basic 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 opinions 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 entity 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 entity 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 opinions. 1

4 Opinions In our opinion, the financial statements referred to above present fairly, in all material respects, the respective net position of the Corporation and the aggregate discretely presented component units as of December 31, 2014 and 2013, and the respective results of its operations and, where applicable, cash flows thereof for the years then ended in accordance 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 8 and the Schedule of Funding Progress for the Postemployment Retiree Healthcare plan on page 41 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 our report dated March 31, 2015 on our consideration of the Corporation s internal control over financial reporting and on our tests of its compliance with certain provisions of laws, regulations, contracts, and 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 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 Corporation s internal control over financial reporting and compliance. Buffalo, New York March 31,

5 MANAGEMENT S DISCUSSION AND ANALYSIS YEAR ENDED DECEMBER 31, 2014 (000 s omitted) The Corporation is considered a component unit of the County of Erie with its core operating mission the delivery of quality health care services to all persons in need of its services in Erie County, the Western Region and New York State, including persons in need who lack the ability to pay. The Corporation fully embraces and is proud to serve in its role as the safety net provider for its region. To assist the reader in understanding the operations of the Corporation, this required annual report has been composed in three parts: Management s discussion and analysis Financial statements and footnotes Supplemental schedule(s) Introduction: Management has prepared this Discussion and Analysis providing an overview of the financial position and results of activities of Erie County Medical Center Corporation ( the Corporation or ECMCC ) at, and for the year ended, December 31, Comparative information for the years ended December 31, 2013 and 2012, has been provided in certain instances. This narrative and the financial statements and footnotes, are the responsibility of the Corporation s management. The financial statements (the statements of net position, statements of revenues, expenses and changes in net position and the statements of cash flows) present financial information in a form similar to that used by other government hospital corporations and have been prepared in accordance with generally accepted accounting principles in the United States of America including the application of the accrual basis of accounting. The accompanying financial statements of the Corporation include financial data of the Corporation s component units (i) ECMC Lifeline Foundation, Inc. (ii) The Grider Initiative, Inc. (iii) Research For Health in Erie County, Inc. and (iv) Millennium Collaborative Care, LLC. OPERATIONS ANALYSIS: During 2014, the Corporation completed such projects as: the Regional Behavioral Health Center of Excellence; our new Ambulatory Center Building and Surgery Center; the Center for Oncology Care Specializing in Head & Neck, Plastic & Reconstructive Surgery, Dental & Medical Oncology, Maxillofacial Prosthetics, and Breast Oncology; the Great Lakes Café; the Remembrance Garden; and The Gift Corner. Bariatric services have recently been added to ECMC service lines and internal and external primary care services including a primary care expansion and operational improvements are in progress. ECMCC ended the year with the creation of Millennium Collaborative Care (as part of the Delivery System Reform Incentive Payment, or DSRIP) through which the Corporation will lead the transformation of the Medicaid delivery system from a fee-for-service payment system to a population health/preventative care system for the eight (8) county WNY region. In 2015, ECMCC will open: the Russell J. Salvatore Orthopaedic Unit; two additional operating rooms in the Surgery Center; the Center for Occupational and Environmental Medicine; an entirely renovated 6 th floor, zone 1; a new CT Scanner; and new medical office space for Nephology, Urology, Endocrinology, and a Behavioral Medicine Clinic on the third floor of the Ambulatory Center. While ECMC Corporation has accomplished much, the ongoing focus of the Corporation continues to be on quality of care and patient satisfaction. During 2014, ECMCC earned several awards and was recognized by numerous agencies for its efforts in providing quality care including; The New York State Department of Health, The NCQA, The Commission on Accreditation of Rehabilitation Facilities (CARF) and others. 3

6 The success of ECMCC is due to the excellence of our workforce. Our teammates, physicians and leadership have led our quality and operational excellence programs, collaborated and effectively responded to the November blizzard, implemented action plans leading to the accreditation of ECMCC as a designated center for the treatment of Ebola patients and made many other contributions to ECMCC s success. During 2014, a new contract was reached with The New York State Nurses Association (NYSNA) which was ratified by 95% of our nurses. The Lifeline Foundation continued its favorable trend with great success in signature events such as the Spring Fest Gala, its annual golf tournament, October Breast Cancer Awareness Month and other events. The results of the efforts of the Lifeline Foundation lead to over 2,000 breast cancer screenings with its mammography bus, and with a leading donation of $500,000 led to the construction of the Russell J. Salvatore orthopedic unit noted above. FINANCIAL METRIC ANALYSIS: The Corporation s total net position increased $3,023 in 2014 and $7,991 in 2013 as a result of key operating activities discussed above leading to favorable results from operations and net investment earnings as further discussed below. Comparative financial ratios for the Corporation as well as median values for 2013 (most recent available) published by Moody s Investor Services are as follows: Moody s ECMCC Median Operating margin 0.2% 0.2% 0.3% 2.0% Operating cash flow margin 7.5% 6.3% 5.5% 9.0% Debt to total capitalization 61.8% 63.2% 65.9% 35.4% Debt service coverage Days cash on hand Days in accounts receivable Average age of plant The financial ratios reflect stable results from operations as measured by the operating margin as well as improved cash flow generation demonstrated by increasing operating cash flow margin, debt service coverage and improvements in revenue cycle performance associated with a reduction in days revenue in accounts receivable. The reduction in days cash on hand is commensurate with the improvements (reduction) in the average age of plant which is reflective of the investments that ECMCC has made in its physical assets to serve our community as well as the reduction in long term debt as demonstrated by the debt to total capitalization ratio. Comparative information has been provided to the 2013 Median values for these ratios as published by Moody s Investor Services. Management notes that the comparisons of actual performance to these median data is consistent with ECMCC s status as the region s safety net provider. SUMMARY FINANCIAL STATEMENT WITH ANALYSIS: Statement of Net Position: Net position is categorized as follows: Net Investment in Capital Assets - Represents the total investment in capital assets, net of outstanding debt obligations related to those capital assets. Restricted - Includes net position in which the Corporation is legally or contractually obligated to spend resources in accordance with restrictions imposed by third parties. 4

7 Unrestricted - Represents the resources derived primarily from services rendered to patients and other operating revenues. These resources are used for transactions related to the general healthcare operations of the Corporation, and may be used at the discretion of the Board of Directors to meet current expenses for any purpose. A condensed Statement of Net Position is as follows: Assets (000 s omitted) $ Change % Change Current assets $ 150,471 $ 149,428 $ 164,944 $ 1, % Assets whose use is limited 106, , ,162 (4,665) (4.2) Capital assets, net 288, , ,113 (227) (0.1) Other assets 31,286 9,109 5,382 22, Total assets $ 576,922 $ 558,594 $ 544,601 $ 18, % Liabilities Current liabilities $ 125,928 $ 108,448 $ 100,002 $ 17, % Noncurrent liabilities 331, , ,582 (2,175) (0.6) Total liabilities 457, , ,584 15, Net Position Net investment in capital assets 122, ,480 92,906 2, Restricted 11,201 11,049 11, Unrestricted (14,662) (15,521) 4, Total net position 119, , ,017 3, Total liabilities and net position $ 576,922 $ 558,594 $ 544,601 $ 18, % Overall, total assets increased $18,328 from 2013 to 2014 and $13,993 from 2012 to Capital assets include the completion and opening of Terrace View, a 390-bed long term care replacement facility in 2013 and the completion of the Regional Behavioral Health Center of Excellence in Other assets in 2014 include an investment in a joint venture with Kaleida Health. Overall, total liabilities increased $15,305 from 2013 to 2014 and $6,002 from 2012 to Net position had a positive increase of $3,023 (2.6%) in 2014 from 2013 and $7,991 (7.4%) in 2013 from

8 Statement of Revenues, Expenses, and Changes in Net Position: A condensed Statement of Revenues, Expenses and Changes in Net Position is as follows: (000 s omitted) $ Change % Change Net patient services revenue $ 431,724 $ 379,955 $ 382,112 $ 51, % Disproportionate share revenue ( DSH ) 65,883 61,786 57,572 4, Other operating revenue 17,082 26,202 17,841 (9,120) (34.8) Total operating revenues 514, , ,525 46, Total operating expenses 505, , ,917 46, Operating income 9,292 9,233 6, Total non-operating (expenses) revenues (5,166) (107) 6,748 (5,059) (4,728) Excess (deficiency) of revenue over expenses 4,126 9,126 13,356 (5,000) (54.8) Other changes in net position (1,103) (1,135) (1,309) (32) (2.8) Change in net position 3,023 7,991 12,047 (4,968) (62.2) Net position, beginning of year 116, ,017 95,970 7, Net position, end of year $ 119,031 $ 116,008 $ 108,017 $ 3, % Overall, operating revenues increased by $46,746 or 10.0% in 2014 and by $10,418 or 2.3% in Net patient service revenue increased $51,769, or 13.6% in 2014 and decreased by $2,157, or (0.6%) from 2012 to In 2014, volumes increased for both inpatient and outpatient lines of business. Total discharges increased 9.7% from 16,216 to 17,796. Corresponding patient days increased 8.9% from 131,821 to 143,503. Outpatient visits were up 8.1% from 347,509 to 375,676. ER visits increased 2.6% from 64,702 to 66,416. A shift in inpatient service mix to behavioral health from acute care lowered net patient service revenue in 2013 as compared to DSH increased by $4,097, or 6.6%, in 2014 and increased $4,214, or 7.3% in 2013, principally due to changes in uncompensated care provided and changes in estimates for UPL funding. Other operating revenue decreased by $9,120, or 34.8%, in 2014 but increased by $8,361, or 46.9%, in 2013 from The increase from 2012 to 2013 is primarily due to a HEAL NY grant received for a behavioral health expansion initiative substantially completed in The decrease from 2013 to 2014 is the net result of the HEAL NY grant award received in 2013 not carrying forward into 2014 and the recognition of grant revenues associated with the Intermediate Access Assurance Fund associated with the New York State Delivery System Reform Incentive Plan (DSRIP). The Corporation recognized $700 and $1,536 of meaningful use grant funding in 2014 and 2013, respectively. 6

9 Operating expenses increased $46,687, or 10.2%, in 2014 and $7,793, or 1.7%, in Expense increases are attributable primarily to payroll and related costs and professional fees. The Corporation continues to offer opportunities for registered nurses and implemented a more robust physician employment model to meet community health needs. In addition, New York State pension and workers compensation payroll benefit expenses remain at a higher rate than in prior periods. Depreciation and amortization expenses are increased due to the Terrace View and Behavioral Health buildings being put into service 2013 and Investment income decreased by $5,388 in 2014 and decreased $2,229 in 2013, due primarily to variation in investment market performance on fixed income obligations and other investments and decreasing invested asset levels associated with the capital investments noted above. Interest expense increased by $3,072 in 2013 related to opening of the 390-bed Terrace View Long-Term Care Facility in February Interest expense was stable in 2014 at 2013 levels. The Corporation continues to fund a component unit for purposes of physician recruitment and support of other health care initiatives totaling $1,103 and $1,135 in 2014 and 2013, respectively. FORWARD LOOKING FACTORS: Construction was completed in December 2012 on a 390-bed long term care replacement facility on the Grider Street campus which opened in February The construction cost certification associated with this project was completed in the first quarter of 2015 and management is currently working to receive the actual capital component of the Medicaid reimbursement rates associated with this certification, compared to the estimate that has been paid to date. While work was substantially completed on the remaining three floors of the new medical office building in 2013 facilitating the addition of two new operating room suites and clinical space supporting the head and neck, oral oncology and maxillofacial prosthetic programs which collectively began operations in January 2014 additional space for clinical services remained. The planning activities associated with the use of this additional space was completed in 2014 and is expected to be put into service in Management has worked with the New York State Department of Health, and has approved the opening of two additional surgical suites to begin operation in 2015 fully occupying the surgery center space in the medical office building. The remaining floor is constructed to support various physician offices and treatment rooms which are expected to go into service in The medical office building is expected to be fully occupied in A new Comprehensive Psychiatric Emergency Program ( CPEP ) emergency treatment facility opened in January 2014 in what was once a parking lot adjacent to the current Emergency Department entrance. During 2013, the Corporation placed into service additional inpatient behavioral health beds transferred from Kaleida Health, Inc. The phase in of both the CPEP program and the beds transferred from Kaleida, which occurred throughout 2014 with the programs running on a fully phased in basis in The Corporation operates under three collective bargaining agreements that cover substantially all employees. In March 2013, Corporation employees of the Civil Service Employee Association ( CSEA ) approved a new 5-year contract. This new agreement includes the creation of a sub-bargaining unit which represents only Corporation employees. The agreement runs through December 31, Registered Nurses ( RNs ) are covered under an agreement with the New York State Nurses Association ( NYSNA ). The current agreement was executed in September 2014 and expires on December 31, The Corporation s agreement with the American Federation of State, County and Municipal Employees ( AFSCME ) is in effect through December 31, TRANSACTIONS WITH THE COUNTY OF ERIE The Corporation is a component unit of the County of Erie. The County has ongoing contractual and legal obligations to the Corporation, and the Corporation has ongoing contractual and legal obligations to the County. 7

10 Health Reform Law The President signed into law the Patient Protection and Affordable Care Act (the Affordable Care Act ) which includes sweeping changes to how health care is provided, and paid for, in the United States. The President subsequently signed the Health Care and Education Reconciliation Bill (the Reconciliation Act ), which modifies the Affordable Care Act in many respects. Together, the Affordable Care Act and the Reconciliation Act will be referred to as the Health Reform Law. The Health Reform Law expands health insurance coverage to millions of individuals. The health care industry will be subjected to significant new statutory and regulatory requirements, and consequently, structural and operational challenges. In 2012, the U.S. Supreme Court altered certain aspects of the law. Certain other aspects of the law have been delayed through Executive Orders issued by the President of the United States. Management of the Corporation is continually analyzing the Health Reform Law to better understand its effect on current and projected operations, financial performance and financial condition. The Health Reform Law is complex and comprehensive, and includes a myriad of programs, initiatives and changes to existing programs, practices and laws. DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) On April 14, 2014 Gov. Andrew M. Cuomo announced that New York finalized terms and conditions of an agreement with the U.S. government that will allow New York State to reinvest $8 billion in federal savings generated by Medicaid Redesign Team reforms. The Delivery System Reform Incentive Payment, or DSRIP, program is designed to stabilize the state s healthcare safety-net system and to re-align the state s delivery system. The overarching goal of the DSRIP program is to help New York and its health care providers achieve the triple aim of improved population health, improved quality care, and controlled costs. Reducing avoidable hospital admissions by 25 percent over the next five years is the DSRIP program s ultimate objective. Secondarily, the DSRIP program is expected to preserve and transform New York s fragile health care safety net, ensuring all Medicaid beneficiaries have access to vital services. Successful execution of DSRIP-funded projects requires community-focused plans where population health and health care costs are addressed by hospital(s) working with other healthcare organizations such as Federal Qualified Health Centers (FQHCs), physician practices, Health Homes (HHs), and Skilled Nursing Facilities (SNFs). The expectation is to achieve savings by reducing avoidable hospitalizations and Emergency Department visits, requiring hospitals to restructure themselves, reducing beds, strengthening outpatient and primary-care, and improving alignment with post-acute care settings. In Western New York, the first step in this process was to form Millennium Collaborative Care, including nearly 400 health care partners led by the Corporation. In December 2014, Millennium Collaborative Care submitted its application for DSRIP program funding to begin the process of reform. CONTACTING THE CORPORATION S FINANCIAL MANAGEMENT: This financial report is designed to provide our community and creditors with a general overview of Erie County Medical Center Corporation s finances and to demonstrate the Corporation s accountability for the resources it receives. If you have any questions about this report or need additional financial information, contact the Chief Financial Officer, Erie County Medical Center Corporation, 462 Grider Street, Buffalo, New York

11 STATEMENTS OF NET POSITION December 31, 2014 and 2013 (000 s omitted) ASSETS Current assets: Cash and cash equivalents $ 6,251 $ 8,235 Investments 3,270 2,394 Assets whose use is limited 12,529 30,387 Patient accounts receivable, net 51,491 50,004 Other receivables 67,183 50,388 Supplies, prepaids and other 9,747 8,020 Total current assets 150, ,428 Assets whose use is limited 106, ,833 Capital assets, net 288, ,224 Other assets, net 31,286 9,109 Total assets $ 576,922 $ 558,594 LIABILITIES AND NET POSITION Current liabilities: Current portion of long-term debt $ 8,137 $ 7,226 Accounts payable 34,076 37,359 Accrued salaries, wages and employee benefits 22,274 19,689 Accrued other liabilities 34,608 22,041 Deferred revenue 6,323 - Estimated third-party payor settlements 20,510 22,133 Total current liabilities 125, ,448 Long-term debt, net 166, ,129 Self-insured obligations 165, ,009 Total liabilities 457, ,586 Net position: Net investment in capital assets 122, ,480 Restricted: For debt service 11,201 11,049 Unrestricted (14,662) (15,521) Total net position 119, ,008 Total liabilities and net position $ 576,922 $ 558,594 See accompanying notes 9

12 STATEMENTS OF REVENUES, EXPENSES AND CHANGES IN NET POSITION For the Years Ended December 31, 2014 and 2013 (000 s omitted) Operating revenues: Net patient service revenue (net of provision for bad debts of $25,397 in 2014 and $23,710 in 2013) $ 431,724 $ 379,955 Disproportionate share revenue 65,883 61,786 Other operating revenue 17,082 26,202 Total operating revenues 514, ,943 Operating expenses: Payroll, employee benefits and contract labor 283, ,515 Professional fees 65,971 54,009 Purchased services 42,104 35,835 Supplies 68,933 64,160 Other operating expenses 15,452 13,972 Depreciation and amortization 29,168 20,219 Total operating expenses 505, ,710 Operating income 9,292 9,233 Non-operating revenues (expenses): Investment income 3,164 8,552 Interest expense (8,350) (8,337) Grant revenue and other 20 (322) Total net non-operating (expenses) revenues (5,166) (107) Excess of revenues over expenses 4,126 9,126 Transfers to related parties, net (1,103) (1,135) Total change in net position 3,023 7,991 Net position beginning of year 116, ,017 Net position end of year $ 119,031 $ 116,008 See accompanying notes 10

13 STATEMENTS OF CASH FLOWS For the Years Ended December 31, 2014 and 2013 (000 s omitted) Cash flows from operating activities: Receipts from patients and third party payors $ 424,561 $ 369,220 Payments to employees for salaries and benefits (281,184) (269,488) Payments to vendors for supplies and other (181,962) (151,269) Other receipts 77,980 77,633 Net cash provided by operating activities 39,395 26,096 Cash flows from non-capital financing activities: Settlements with Erie County (14,378) - Transfers to component unit (1,103) (1,135) Net cash flows used in non-capital financing activities (15,481) (1,135) Cash flows from capital and related financing activities: Purchases of capital assets (29,552) (63,040) Capital contributions - grants Proceeds from sale of capital assets - 61 Principal payments on long term debt (5,639) (6,936) Interest paid on long term debt (8,224) (8,337) Net cash used in capital and related financing activities (43,397) (77,875) Cash flows from investing activities: Sales of assets whose use is limited, net 22,523 38,804 Investment in affiliates (7,312) (3,777) Investment income 3,164 4,593 (Purchases) sales of investments, net (876) 718 Net cash provided by investing activities 17,499 40,338 Net change in cash and cash equivalents (1,984) (12,576) Cash and cash equivalents: Beginning of year 8,235 20,811 End of year $ 6,251 $ 8,235 Supplemental disclosure of non-cash activity: Change in fair value of assets whose use is limited $ (3,489) $ 3,959 Transfer to component unit $ 1,103 $ 1,135 See accompanying notes 11

14 STATEMENTS OF CASH FLOWS (CONTINUED) For the Years Ended December 31, 2014 and 2013 (000 s omitted) Reconciliation of operating income to net cash provided by operating activities: Operating income $ 9,292 $ 9,233 Adjustments to reconcile operating income to net cash provided by operating activities: Depreciation and amortization 29,168 20,219 Provision for bad debt 25,397 23,711 Increase in assets: Patient accounts receivable (26,884) (28,978) Other receivables (16,795) (10,305) Supplies, prepaids and other (1,727) (722) Increase (decrease) in liabilities: Accounts payable (3,283) 7,990 Accrued liabilities 15,152 5,684 Deferred revenue 6,323 - Estimated third-party payor settlements (1,623) (5,518) Self-insured obligations 4,375 4,782 Net cash provided by operating activities $ 39,395 $ 26,096 See accompanying notes 12

15 STATEMENTS OF NET POSITION COMPONENT UNITS December 31, 2014 and 2013 (000 s omitted) ECMC The Research for Millennium ECMC The Research for Lifeline Grider Health in Collaborative Lifeline Grider Health in Foundation, Initiative, Erie County, Care Foundation Initiative, Erie County ASSETS Inc. Inc. Inc. PPS Inc. Inc. Inc. Current assets: Cash and cash equivalents $ 785 $ 283 $ 19 $ - $ 795 $ 287 $ 36 Investments - - 1, ,021 Assets whose use is limited Other receivables 641 1, , Prepaids and other Total current assets 2,338 1,386 1,057-2, ,057 Non-current assets: Other receivables 1, Endowment and other investments 58 10, ,515 - Equipment and vehicles, net Total assets $ 4,447 $ 11,980 $ 1,057 $ - $ 4,256 $ 10,802 $ 1,057 LIABILITIES AND NET POSITION Current liabilities: Accounts payable $ 22 $ 1,103 $ - $ - $ 15 $ 242 $ - Funds held in custody for others Total liabilities 364 1, Long term: Related party Interest payable Net position: Restricted for other purposes 2,683 10, ,379 10,000 - Unrestricted , ,057 Total net position 3,416 10,877 1,057-3,235 10,560 1,057 Total liabilities and net position $ 4,447 $ 11,980 $ 1,057 $ - $ 4,256 $ 10,802 $ 1,057 See accompanying notes 13

16 STATEMENTS OF REVENUES, EXPENSES AND CHANGES IN NET POSITION COMPONENT UNITS For the Years Ended December 31, 2014 and 2013 (000 s omitted) ECMC The Research for Millennium ECMC The Research for Lifeline Grider Health in Collaborative Lifeline Grider Health in Foundation, Initiative, Erie County, Care Foundation Initiative, Erie County Inc. Inc. Inc. PPS Inc. Inc. Inc. Operating revenues: Grants, contributions, and special events $ 2,603 $ - $ - - $ 2,042 $ - $ - Other operating revenue - net Total operating revenues 2, , Operating expenses: Program services and grants Fundraising Other operating expenses Total operating expenses 2, , Operating income (loss) 173 (865) (42) - (59) (745) (19) Non-operating revenue: Investment income Change in net position 181 (786) - - (38) (573) 6 Net position beginning of year 3,235 10,560 1,057-3,273 9,998 1,123 Transfers from (to) Erie County Medical Center - 1, ,135 (72) Net position end of year $ 3,416 $ 10,877 $ 1,057 $ - $ 3,235 $ 10,560 $ 1,057 See accompanying notes 14

17 STATEMENTS OF CASH FLOWS COMPONENT UNITS For the Years Ended December 31, 2014 and 2013 (000 s omitted) ECMC The Research for Millennium ECMC The Research for Lifeline Grider Health in Collaborative Lifeline Grider Health in Foundation, Initiative, Erie County, Care Foundation Initiative, Erie County Inc. Inc. Inc. PPS Inc. Inc. Inc. Reconciliation of operating income (loss) to net cash provided by (used in) operating activities: Operating income (loss) $ 173 $ (865) $ (42) $ - $ (59) $ (745) $ (19) Adjustments to reconcile operating income (loss) to net cash provided by (used in) operating activities: Depreciation (Increase) decrease in assets (402) (1,103) ,243 - Increase (decrease) in liabilities (42) (1,638) (2) Net cash provided by (used in) operating activities (68) (1,107) (42) (1,140) (21) Cash flows from financing activities: Transfers (to) from Erie County Medical Center - 1, ,135 (72) Net cash provided by (used in) financing activities - 1, ,135 (72) Cash flows from investing activities: (Increase) decrease in assets whose use is limited 50 (79) (17) (467) 53 Purchases of capital assets (26) - - Disbursement of note receivable torelated party (500) - - Interest received Net cash provided by (used in) investing activities (355) (295) 78 Net change in cash and cash equivalents (10) (4) (17) - (15) (300) (15) Cash and cash equivalents: Beginning of year End of year $ 785 $ 283 $ 19 $ - $ 795 $ 287 $ 36 See accompanying notes 15

18 NOTE 1. ORGANIZATION The Corporation - Erie County Medical Center Corporation (referred to as the Corporation ) is a public benefit corporation created by the Erie County Medical Center Corporation Act, Chapter 143 of the Laws of New York State, 2003 (Title 6 of Article 10-C of the Public Authorities Law) (the Act ). The Corporation was created under the Act to secure a form of governance which permits the Corporation to have the legal, financial, and managerial flexibility to operate its health care facilities for the benefit of the residents of New York State (the State ), the County of Erie (the County ), and Western New York, including persons in need who lack the ability to pay. The Corporation s Health Care Facilities consist of the Medical Center, a 569-bed acute tertiary care facility located on Grider Street in the City of Buffalo providing inpatient, emergency, outpatient, primary care and specialty clinic services, a new (2013) 390-bed residential health care facility ( Terrace View ) replacing the Erie County Home (the Home ), a residential health care facility located in Alden, New York operational through mid-february 2013, a primary care clinic located in the City of Buffalo, and four chemical dependency and alcohol rehabilitation clinics located throughout the County. The Corporation serves as the region s only trauma center, burn center, comprehensive traumatic brain injury and spinal cord injury rehabilitative center, Comprehensive Psychiatric Emergency Program provider for acute psychiatric emergencies, Regional Center of Excellence for Transplantation and Kidney Care, and is the primary provider of HIV inpatient and outpatient specialty care. The Corporation has the power under the Act to acquire, operate, and manage its facilities and to issue bonds and notes to finance the costs of providing such facilities. The Act specifically provides that the Corporation s corporate existence shall continue until terminated by law; provided, however, that no such termination shall take effect so long as the Corporation shall have bonds or other obligations outstanding unless adequate provision has been made for the payment or satisfaction thereof. The Corporation s primary purpose is the operation of the Medical Center and Terrace View, and its powers, duties, and functions are as set forth in the Act and other applicable laws. The Corporation is a component unit of the County and accordingly is included in the County s Comprehensive Annual Financial Report. The Corporation is subject to civil service law. Governance - The Corporation is governed by its Board of Directors (the Board ) consisting of fifteen voting directors, eight (8) of whom are appointed by the Governor of the State of New York and seven (7) of whom are appointed by the Erie County Executive. There are four appointed non-voting representatives, as well. The Directors and non-voting members serve staggered five year terms and continue to hold office until their successors are appointed. Directors have experience in the fields of health care services, quality and patient safety, human resources, strategic growth, and financial management and reflect a broad representation of the community served by the Corporation. Regular meetings of the Board are scheduled eleven (11) times per year. Corporation officers are appointed by the Board. Great Lakes Heath System - The Corporation is a member of Great Lakes Health System of Western New York ( Great Lakes ). Great Lakes is a not-for-profit, community-based corporation comprised of unified partners whose objective is to provide the highest quality of healthcare to the residents of Western New York. Great Lakes is comprised of the Corporation, Kaleida Health including four hospitals as well as a long term care facility, ambulatory health and community based clinics, and the State University of New York at Buffalo (the University ). 16

19 NOTE 1. ORGANIZATION (CONTINUED) Medical School Affiliation - The Corporation serves as a primary teaching hospital for the State University of New York at Buffalo School of Medicine and Biomedical Sciences (the Medical School ). An affiliation agreement governs the relationship between the Corporation and the Medical School. As an affiliate of the Medical School, the Corporation serves as an integral part of the education and research mission of the University by providing the clinical settings for the University s public mission to educate and train physicians, nurses and other healthcare professionals, conduct clinical research programs and deliver healthcare services to patients. There are currently 166 full-time equivalent residents assigned to the Corporation in various Academic College of Graduate Medical Education accredited residency programs. Discretely Presented Component Units U.S. GAAP (as defined in Note 2) requires the inclusion within the Corporation s financial statements of certain organizations as component units based on the nature and significance of the Corporation s relationship with these organizations. The component unit information in the accompanying basic financial statements includes the financial data of the Corporation s four discretely presented component units. These units are reported separately to emphasize that they are legally separate from the Corporation. ECMC Lifeline Foundation, Inc. - The ECMC Lifeline Foundation, Inc. (the Foundation ) is a nonprofit organization exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. The Foundation was formed for the purpose of supporting Corporation programs. The financial statements of the Foundation have been prepared on an accrual basis. The annual financial report can be obtained by writing to: Executive Director, ECMC Lifeline Foundation, Inc., 462 Grider Street, Buffalo, NY The Grider Initiative, Inc. - The Grider Initiative, Inc. (the Physician Endowment ) is a nonprofit organization exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. The Physician Endowment was funded in 2010, for the purpose of recruiting physicians who shall practice on the Grider Street campus of the Corporation. The entity was funded with an initial transfer of $10,000 from the Corporation. Earnings from the investment of the initial transfer may be used only for physician recruitment and reasonable and necessary expenses of the entity. The financial statements of The Grider Initiative, Inc. have been prepared on an accrual basis. The annual financial report can be obtained by writing to: Chair, The Grider Initiative, Inc. 424 Main Street, Suite 2000, Buffalo, NY Research for Health in Erie County, Inc. - Research for Health in Erie County, Inc. ( RHEC ) is a nonprofit organization dedicated to developing and improving the facilities of the public health institutions, agencies, and departments of the County. Additionally, RHEC is committed to provide more extensive conduct of studies and research into the causes, nature, and treatment of diseases, disorders, and defects of particular importance to the public health. RHEC s revenue comes primarily from investment income. RHEC is exempt from income tax as a not-for-profit corporation under Section 501(c)(3) of the Internal Revenue Code and is incorporated under the laws of the State of New York. The financial statements of RHEC have been prepared on an accrual basis. The entity has not received funding in recent years. The annual financial report can be obtained by writing to: Grant Administration, Research for Health in Erie County, Inc., 462 Grider Street, Buffalo, NY Millennium Collaborative Care, LLC Millennium Collaborative Care, LLC ( Millennium ) is a LLC formed to function as the Delivery System Reform Incentive Payment (DSRIP) entity for ECMCC. The DSRIP program will promote community-level collaborations and focus on system reform, specifically a goal to achieve a 25% reduction in avoidable hospital use over five years. Safety net providers will be required to collaborate to implement innovative projects focusing on system transformation, clinical improvement and population health improvement. The entity had no substantial operations in Revenues and expenses were still being borne by ECMCC. 17

20 NOTE 2. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Accounting - The Corporation uses the accrual basis of accounting. Revenue is recognized in the period it is earned and expenses are recognized in the period incurred. For financial accounting and reporting purposes, the Corporation follows all pronouncements of the Governmental Accounting Standards Board ( GASB ), as well as the pronouncements of the Financial Accounting Standards Board ( FASB ), including those FASB pronouncements issued after November 30, 1989 that do not conflict with or contradict GASB pronouncements. All references to relevant authoritative literature issued by both the GASB and the FASB with which the Corporation must comply are hereinafter referred to generally as U.S. GAAP. Use of Estimates - The preparation of the 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 in the financial statements and accompanying notes. The reserve for uncollectible accounts, contractual allowances, amounts payable to third-party payors, workers compensation, malpractice reserves and self-insured retiree health benefits, as well as Disproportionate Share ( DSH ) revenue and certain other accounts, require the significant use of estimates. Actual results could differ from those estimates. Cash and Cash Equivalents - The Corporation s cash and cash equivalents include cash on hand and cash in checking and money market accounts. Monies deposited in Federal Deposit Insurance Corporation insured commercial banks are collateralized with specifically designated securities held by a pledging financial institution, as required by State regulations. Fair Value of Financial Instruments - The Corporation s financial instruments consist of cash, investments, and any short-term debt. The carrying amounts of these financial instruments approximate their fair value due to the short-term nature of the financial instruments. Patient Accounts Receivable - Patient accounts receivable are reported net of both an estimated allowance for contractual adjustments and an estimated allowance for uncollectible accounts. The contractual allowance represents the difference between established billing rates and estimated reimbursement from Medicare, Medicaid and other third party payor programs. Current operations are charged with an estimated provision for bad debts estimated based on the age of the account, prior experience and any other circumstances which affect collectability. The Corporation s policy does not require collateral or other security for patient accounts receivable and the Corporation routinely accepts assignment of, or is otherwise entitled to receive, patient benefits payable under health insurance programs, plans or policies. The allowance for estimated doubtful accounts at December 31, 2014 and 2013 was approximately $21,969 and $21,466, respectively. Investments and Assets Whose Use is Limited Such assets are comprised of cash and cash equivalents, including time deposits and money market funds, fixed income securities, commercial paper and equity funds. Assets classified as investments are unrestricted. Assets classified as limited as to use are restricted under Board designation or terms of agreements with third parties and include unspent proceeds from 2011 bond financing (year end 2013 only), debt service funds, funds for self-insured workers compensation costs and medical malpractice costs, collateral for insured workers compensation programs, patient and resident monies, funding for future retiree health costs, and funds limited as to use for the acquisition of property, plant and equipment. Also included is $21,837 of securities guaranteed by Governmental National Mortgage Association and insured by the U.S. Department of Housing and Urban Development related to an investment in Kaleida Health s Gates Vascular Institute located on the Buffalo Niagara Medical Campus. 18

21 NOTE 2. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) Investment securities are exposed to various risks, such as interest rate, market and credit risk. Due to the level of risk associated with certain investment securities and the level of uncertainty related to changes in the fair value of investment securities, it is at least possible that changes in risks in the near term could materially affect the net position of ECMCC. Other Receivables - The composition of other receivables, as of December 31, 2014 and 2013, respectively, is as follows: Disproportionate share revenue ( DSH ) $ 55,690 $ 42,836 NY State Department of Corrections 4,083 - Receivables from Erie County 899 1,011 FICA tax refund due receivable - 1,513 Other 6,511 5,028 $ 67,183 $ 50,388 Capital Assets - Capital assets are stated at cost. Depreciation is computed under the straight-line method over the estimated useful life of the asset. Estimated useful lives of assets have been established as follows: Land and land improvements Buildings and improvements Fixed equipment Movable equipment 5 25 years years years 3 20 years When assets are retired, or otherwise disposed of, the cost and related accumulated depreciation are removed from the accounts, and any resulting gain or loss is reflected for the period. Amortization of capital leases is computed using the straight-line method over the lease term or the estimated useful life of the asset, whichever is shorter. Maintenance and repairs are charged to expense as incurred with significant renewals and betterments being capitalized. During periods of construction the Corporation capitalizes interest incurred with borrowings for construction. Interest of $5,075 was capitalized during the year ended December 31, 2014 ($ ) for the construction period of Terrace View and the Comprehensive Psychiatric Emergency Program building. Capital assets that are donated (without restriction) are recorded at their fair market values as a direct increase to the component of invested in capital assets, net of related debt. Other Assets - Ownership interests in various business enterprises and prepaid bond insurance premiums are included in other assets. Prepaid bond insurance premiums are being amortized over the term of the related indebtedness using the straight-line method, which is not materially different from the effective interest method. 19

22 NOTE 2. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) Compensated Absences - The Corporation has accrued liabilities for certain compensated absences earned by its employees, to include vacation, sick, and compensatory time. The Corporation s employees are permitted to accumulate unused vacation and sick leave time up to certain maximum limits. The Corporation accrues the estimated obligation related to vacation pay based on pay rates currently in effect. Sick leave credits, if accumulated above certain prescribed levels, may be the basis of a supplemental payment to employees upon retirement. The Corporation accrues an estimated liability for these estimated terminal payments. These amounts have been included in the statements of net position at December 31, 2014 and 2013, within the caption accrued salaries, wages and employee benefits in the amount of approximately $11,144 and $10,527, respectively. Net Position - Net assets are classified into three categories according to external donor restrictions or availability of assets for satisfaction of the Corporation s obligations. The Corporation s net position is described as follows: Net Investment in Capital Assets - This represents the Corporation s total investment in capital assets, net of outstanding debt obligations related to those assets. To the extent debt has been incurred but not yet expended for capital assets, such amounts are not included as a component of net investment in capital assets. Restricted - This includes assets in which the Corporation is legally or contractually obligated to spend in accordance with restrictions imposed by third parties. Unrestricted - This represents resources derived from services rendered to patients and other operating revenues. These resources are used for transactions relating to the general health care operations of the Corporation, and may be used at the discretion of the Board of Directors to meet current expenses for any purpose. Net Patient Service Revenue - Net patient service revenue is reported as services are rendered at estimated net realizable amounts, including estimated retroactive revenue adjustments under reimbursement agreements with third party payors. Estimated settlements under third party reimbursement agreements are accrued in the period the related services are rendered and adjusted in future periods as final settlements are determined. An estimated provision for bad debts is included in net patient service revenue. Charity Care - The Corporation provides care to patients who meet certain criteria under its charity care policy, without charge or at amounts less than established rates. Because the Corporation does not pursue collection of amounts determined to qualify as charity care, they are not reported as net patient service revenue in the accompanying Statements of Revenues, Expenses, and Changes in Net Position. The estimated costs (unaudited) of caring for charity care patients were $17,400 and $16,124 for the year ended December 31, 2014 and 2013, respectively. Contributions - The Foundation reports gifts of cash or promises to give as restricted contributions when they are received with donor stipulations that limit the use of the donated assets. When the intent of the donor is that the assets are to remain in perpetuity and the Foundation does not have the right to invade the original principal, the assets are reported as permanently restricted. When a donor restriction expires, temporarily restricted net position are released to unrestricted net position and reported in the statements of activities as net position released from restrictions. 20

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