Charity Care at Missouri Hospitals

Transcription

1 Health Policy Publication Missouri Foundation for Health Charity Care at Missouri Hospitals Prepared by the St. Louis Area Business Health Coalition for the Missouri Foundation for Health February 2010

2 Table of Contents Phase III Report Introduction Executive Summary Section I Section II Endnotes Appendices Phase III Appendix A 2006 Public Program Utilization Emergency Department Use profile Emergency Department Use profile Emergency Department Use by Payer SSM Health Care ED Use by Payer and Visit Type Charity Care Profile Charity Care as a Percentage of Operating Revenue Bad Debt Profile Bad Debt as a Percentage of Operating Revenue Uncompensated Care as a Percentage of Operating Expense Fiscal Year 2006 Financial Data Operating Margin Trends Profit Margin Trends Total Reserves and Debt-to-Equity Ratios Capacity Levels and Productivity Phase III Appendix B Methodology and Data Sources Charity Care Cost Differences, BHF and MHA Glossary Phase III Appendix C Emergency Department Use Rates Previous Reports Phase I Baseline Report Phase I Appendix A , 63, 65, 67, 69 Phase I Appendix B Phase II Report Phase II Appendix A Phase II Appendix B

3 Acknowledgements BHF would like to acknowledge the hospital representatives who voluntarily provided BHF with financial and utilization information. Hospital representatives and their staff worked extensively with BHF to verify the accuracy of the data. The additional time and effort they spent analyzing and verifying the data was invaluable to the success of this project. BHF would also like to acknowledge the assistance of the following individuals at the Missouri Department of Health and Senior Services for providing certain data, analysis, recommendations or consultation: Susan Elder, Bureau Chief of Health Informatics, and Alice Kempker, Research Analyst. BHF especially thanks staff member Melanie Watson, Project Assistant, for her important contribution in verifying the accuracy of the data entered in the body of the report and the numerous tables in the Appendix. BHF would also like to thank the Missouri Foundation for Health, the St. Louis Area Business Health Coalition, and other St. Louis organizations that provided funding to the BHC Foundation (BHF) to make this project possible. 3

4 Introduction In 2005, the Missouri legislature approved significant cuts to the state s Medicaid program. While many studies have examined the effect of those cuts on the newly uninsured, there has been less research on how this loss of coverage impacted hospitals. This project examines whether hospitals suffered an increased financial burden, how hospital utilization patterns changed, and the ability of one hospital to meet the challenge with an innovative strategy to improve service to the uninsured in its area. Findings Hospitals provided more uncompensated care, as defined by charity care and bad debt, following the Medicaid cuts. However, for most hospitals, this increase did not significantly jeopardize the institution s overall financial health. Hospital utilization patterns changed with more patients seeking care from the emergency department. While this increase in emergency department usage was most pronounced among the uninsured, it occurred across payors. For a few Missouri hospitals, many of which already faced high levels of charity care and bad debt, the Medicaid cuts resulted in significant financial hardship. One hospital s challenges are explored in this report. Data Limitations To measure the impact of the 2005 Medicaid cuts for this project, the Business Health Coalition (BHF) reviewed data from 2004 to 2006 for 41 hospitals in 10 counties and the St. Louis metropolitan area in Missouri (referred to as study hospitals ). There were a number of limitations encountered related to data availability and the narrow data timeframe that made absolute statements about impacts and trends difficult. Some important examples of those limitations are noted below, as well as in appropriate sections of the report, and in the conclusion. For example, the lack of data prior to 2004 does not allow an understanding of normal yearto-year fluctuations in the level of charity care and bad debt over a longer period of time, and coupled with the lack of data related to hospital-specific care for the uninsured; it makes it difficult to determine the significance of annual increases in charity care and bad debt. Also, the number of uninsured in a geographic area can be affected by many factors, such as the loss of an employer, in addition to reductions in Medicaid eligibility. Analysis of emergency department (ED) data were particularly challenging due to: Gaps in data availability: Estimates of emergent and urgent ED visits were not available for some hospitals. Although aggregate percentages of emergent and urgent ED visits were adjusted for missing data, comparisons of year-to-year results must be made with those limitations in mind. 4

5 A lack of common standards in ED research and reporting: The method used in this report to define emergent and urgent (non-emergent) ED utilization was developed by ThomsonReuters Solucient (TR). One must use care when evaluating the results since the method used in this report may differ from other methods. Please read the appendices to become familiar with the technical discussion while reviewing or interpreting the data in this report. Executive Summary More Missouri families joined the ranks of the uninsured in The percentage increased from 13.6 percent in 2004 to 15.3 percent in 2006, primarily from the loss of Medicaid and SCHIP coverage and to a lesser extent from the loss of employer-sponsored coverage. The percentage of uninsured in low income families increased the most from 25.3 percent in 2004 to 28.2 percent in Rising Charity Care, Bad Debt Charity care at study hospitals increased from $73.8 million in 2005 to $113.8 million in Aggregate hospital charity care accounted for 1.3 percent of total operating revenue in 2006, up from 0.9 percent in Charity care has grown steadily since Variation was dramatic across hospitals and some, but not all, could be explained by race and income disparities in hospital service areas. About 44 percent of the hospitals provided charity care as a percentage of operating revenue in the low range, from 0 1 percent. About 46 percent provided charity care in the mid-range, from 1 2 percent. Only 10 percent provided charity care in the highest range, at or above 2 percent of operating revenue. Clearly, the charity care burden is not spread equally within regions or across the state. Bad debt expense at study hospitals jumped in 2006 to $219 million, up from $163.8 million the prior year. Hospital bad debt expense accounted for 2.5 percent of operating revenue, up from 2 percent in Since 2004, bad debt has grown, and overall, continues to outpace reported charity care by more than 50 percent. Interestingly, hospitals reporting the lowest charity care, reported high and rising amounts of bad debt. Designating services as bad debt rather than charity care previously gave hospitals the opportunity to collect on past due accounts or sell them to a financial services company. Yet those incentives are changing. Reporting Policies in Transition Recent controversy over non-profit hospitals tax-exempt status has resulted in revised charity care and bad debt policies, especially for large urban hospitals. Many now utilize better methods to determine upon admission if a patient qualifies for charity care. At the same time, some hospitals have adopted more conservative bad debt classification methods or moved expenses initially accounted for as bad debt to charity care. Since policies and practices related to charity care and bad debt are in flux, it is difficult to evaluate the significance of large, year-toyear changes. Variation in reporting is expected to diminish in 2009 when non-profit hospitals transition to new Internal Revenue Service guidelines for community benefit reporting. Hospital Utilization Patterns Change In Missouri, more patients sought care in the ED in 2006 increasing 7 percent from Uninsured ED visits sustained the largest increase of any group during the period of 28 percent. The insured 5

6 used the ED the most at 36 percent, followed by Medicaid at 28 percent, the uninsured at 16 percent, and Medicare at 15 percent in The change in overall hospital discharges was relatively flat for all payors during the period with the exception of the uninsured that increased 23 percent. On average, uninsured discharges represented only a small portion (5%) of all discharges at Missouri hospitals in Patients had more than twice as many urgent (non-emergent) care visits to the ED as compared to emergent care visits for study hospitals during the most recent years available, 2005 and Medicaid urgent and emergent ED use fell slightly in 2006 while uninsured use of the same services increased. The Haves, The Have Nots Aggregate financial results for study hospitals from 2004 to 2006 were relatively stable. Although average operating and profit margins dipped slightly in 2005, they recovered in 2006 to about the same level as 2004, and generally outperformed Missouri and national averages. 2 Urban hospitals typically fared better than rural hospitals. Though most were profitable, charity care and bad debt increases from 2004 to 2006 contributed to a rise in expenses that resulted in serious financial pressure for certain hospitals and regions (see pages 22 26). Audrain Medical Center in Audrain County was profoundly affected by the loss of a large local employer in the last 10 years. The 2005 Medicaid cuts caused further sharp increases in uncompensated care. Despite these challenges, Audrain has made significant long-term investments to better cope with the increase in the number of uninsured seeking care. Audrain s story is explored on page 27. This study sheds more light on the effects of the 2005 Medicaid cuts on the level of uncompensated care at study hospitals from 2004 to During the period, uncompensated care rose and remained unevenly distributed. Yet, on average, Missouri hospitals uncompensated care burdens were relatively low. Meanwhile, hospital policies related to classifying uncompensated care were in transition. Most of the hospitals were financially stable through Increases in uncompensated care from lower Medicaid enrollment and the weakening economy are expected to put more financial pressure on hospitals in 2007 and

7 Section I This project was commissioned by the Missouri Foundation for Health (MFH) to measure the impact of the 2005 Medicaid cuts on the level of charity care and bad debt expense for 41 hospitals in 10 Missouri counties and the St. Louis metropolitan area (referred to as study hospitals ). In the first two years, baseline and comparative financial, utilization, charity care and bad debt statistics were provided for fiscal years 2004 and 2005 (see Phase I and II reports, Appendix A and B). Following this, the scope of the project was expanded to highlight additional research and analysis related to the changes in utilization resulting from the Medicaid cuts. First, since the uninsured frequently use the hospital ED for primary care, ED utilization by hospital is provided to more fully understand the patterns of urgent (non-emergent) use of the ED. Second, Section II provides the results of research conducted by the Business Health Foundation (BHF) to learn more about hospitals efforts to cope with the Medicaid cuts and improve service to the uninsured in their geographic areas. Uninsured Increase in Missouri As reported in a research article published recently in Health Affairs, more Missouri families joined the ranks of the uninsured in 2006 as a result of Medicaid eligibility reductions by the Missouri General Assembly in 2005 and the loss of employer-sponsored health insurance coverage. 3 The following points highlight the study s findings and the table in Exhibit 1 below regarding the distribution of health insurance coverage by age and income before and after the Medicaid cuts: In 2006, the year immediately following the Medicaid cuts, the number of uninsured people rose 103,500 causing the percentage to rise from 13.6 percent in 2004 to 15.3 percent in Medicaid and SCHIP coverage for Missouri families fell at twice the rate of employersponsored coverage, from 12.7 percent in 2004 to 9.8 percent in The percentage of low income uninsured families increased the most from 25.3 percent in 2004 to 28.2 percent in The increase in low-income uninsured would have been higher except for gains in other types of insurance coverage. 7

8 Exhibit 1: Health Insurance Coverage Distribution Among the Nonelderly Population in Missouri, by Age and Health Insurance Unit Income, All nonelderly Adults Children Coverage distribution within income category % Change Coverage distribution within income category % Change Coverage distribution within income category % Change All incomes (millions) Employer 66.2% 64.9% % 66.3% % 61.7% -2.6 Medicaid/State(SCHIP) ** ** TRICARE/Medicare * Private nongroup * * Uninsured Less than 200% of poverty (millions) Employer 31.3% 33.7% % 31.3% % 37.9% 6.0 Medicaid/State(SCHIP) ** ** ** TRICARE/Medicare Private nongroup Uninsured % of poverty or more (millions) Employer 83.3% 81.9% % 82.4% % 80.5% -5.1% Medicaid/State(SCHIP) ** TRICARE/Medicare Private nongroup Uninsured Source: Urban Institute, 2007, based on data from 2005 and 2007 Annual Social and Economic Supplement to the Current Population Survey. Notes: Excludes people age 65 and older and people in the armed forces. A health insurance unit is those eligible as a group for family coverage in a health plan. *p<0.10 **p<0.05 8

9 Uninsured Discharges Increase in Missouri MHA Hospital Inpatient Discharges, All Missouri Hospitals Self-pay (uninsured) discharges increased 23% (in thousands) Medicare & Medicaid discharges increased slightly at 2% Commercially insured discharges were relatively unchanged Medicare Medicaid Commercial Other Self Pay (Uninsured) Source: S. Zuckerman, D.M. Miller, E.S. Pape, Missouri s 2005 Medicaid Cuts: How Did They Affect Providers?, Health Affairs, 28, no. 2 (2009): w 341. Urban Institute estimates based on data from the Missouri Hospital Association (MHA). It is important to look at hospital utilization by payer type to understand whether the increases in uninsured are driving changes in inpatient care. Medicaid discharges were expected to fall. However, they increased slightly based on data for all Missouri hospitals from the Missouri Hospital Association (MHA) shown in the chart above. Given those results and the increase in uninsured discharges shown in the chart, it is interesting to draw a parallel with the study hospitals shown in Exhibit 2 on page four that presents data by payer type and county based on Medicare Cost Report data (MCR). Exhibit 2 shows the change in utilization for the study hospitals both before and after the Medicaid cuts. Utilization by payer varied significantly by hospital and region. When looking at the change in Aggregate utilization from 2004 to 2006, highlights include: Medicaid patient days and discharges declined (8%) and (4%) respectively, MCR data does not report uninsured separately. The Other category is comprised of commercial insurance, other programs (e.g. workers compensation), self-pay, and uninsured utilization. Other days and discharges rose 4 percent and 5 percent respectively, and, since uninsured utilization is included, one can infer that part of the increase represents uninsured days and discharges. 9

10 Hospital Utilization Pattterns Change Greene County had the largest decline in Medicaid where patient days fell (20%). Medicaid patient days fell at all three hospitals in Greene County; Cox Health Systems (22%), St. John s Regional Health Center (19%), and Ozarks Community Hospital (10%). Aggregate Medicaid utilization decreased in the St. Louis region, though Medicaid admissions increased at the two largest hospital systems, BJC HealthCare and SSM Health Care. Closure of Forest Park Hospital s obstetrics practice and expansion of the Illinois Medicaid program may partially explain the increases at BJC and SSM. Exhibit 2: Percentage Change in Medicare, Medicaid, Other, and Total Utilization Missouri Hospitals Medicare Utilization % Change Medicaid Utilization % Change Other Utilization % Change Total Utilization % Change Days Discharge Days Discharge Days Discharge Days Discharge Adair -1% -2% 15% -5% 15% -6% 4% -3% Audrain -7% -1% 5% -5% 19% -16% 1% -8% Boone 9% 12% 1% 7% 14% 22% 10% 16% Callaway* 28% 38% -36%* 90%* 7% 63% 16% 49% Cape Girardeau -4% -1% 1% -11% 13% 7% 1% 0% Cole -8% 2% 7% 36% -4% -4% -5% 1% Greene -6% -4% -20% -3% 16% 3% -1% -1% Marion -11% -9% 10% 6% -12% -3% -9% -5% Perry -6% -19% -9% -27% 16% -25% -3% -23% Polk -12% -7% -3% 11% 44% 7% 1% 1% St. Louis MSA** 0% 2% -7% -6% 1% 5% -1% 2% Aggregate -1% 2% -8% -4% 4% 5% 0% 2% * Medicare & Medicaid utilization unavailable for Percent change was based on 2005 and 2006 utilization. Low percentages of Medicaid days and discharges at 4% and 6% respectively in 2006 skewed the results. Medicaid days fell from 324 in 2005 to 206 in Medicaid discharges increased from 39 in 2005 to 74 in ** St. Louis Metropolitan Statistical Area (MSA) figures include only Missouri hospitals for this report. Uninsured Emergency Department Visits Increase ED visits in Missouri increased by more than 167,000, or 7 percent, from 2004 to 2006 based on MHA data. The majority of ED visits were among Medicaid and the commercially insured. While the number of ED visits covered by Medicaid fell by 30,000, there was a steep and significant increase in ED visits among those without insurance of almost 85,000 (see graph on page 12). One of the most surprising findings from these data was that ED visits covered by Medicare increased by more than 55,000 and those covered by Commercial insurance increased by almost 57,000 from 2004 to Were most of those visits for emergent or urgent (non-emergent) care? This question will be explored in more depth in the following section. 10

11 (in thousands) MHA Emergency Department Visits, All Missouri Hospitals, Fiscal Years Self-pay (uninsured) emergency department (ED) visits increased 28% Medicare ED visits increased 18% Commercially insured ED visits increased 7% Medicaid ED visits decreased 4% Medicare Medicaid Commercial Other Self Pay (Uninsured) Source: S. Zuckerman, D.M. Miller, E.S. Pape, Missouri s 2005 Medicaid Cuts: How Did They Affect Providers?, Health Affairs, 28, no. 2 (2009): w 341. Urban Institute estimates based on data from the Missouri Hospital Association. Most Emergency Department Visits Were Not Emergent The majority of ED visits in the United States and for study hospitals were for urgent rather than emergent care. The average percentage of urgent ED visits in U.S. hospitals was approximately 58 percent. 5 Based on data submitted by study hospitals and estimates provided by ThomsonReuters Solucient (see pages 52 54), the average percentage of urgent ED visits for the study hospitals exceeded the U.S. average at 70 percent in 2005 and 64 percent in 2006 (see graph on page 14). For the study hospitals, the percentage of emergent and urgent visits to the ED did not appear to follow any particular pattern. Hospitals located in urban areas had similar distributions of emergent and urgent visits as hospitals in rural areas. Also, the relative size of the hospital or the complexity of the inpatient care they provide, such as care at academic medical centers or tertiary care hospitals, did not seem to have an effect on the percentage of emergent and urgent visits. A leading cause of urgent ED use is poor access to primary care providers. In the United States, the number of physicians entering primary care residency programs has declined steadily since The shortage of primary care physicians became particularly problematic with universal health care coverage in Massachusetts. One of the unintended consequences was that the newly insured were unable to find primary care physicians that were open to adding new patients to their practices. For those patients fortunate enough to find a doctor, some were put on year-long waiting lists for an appointment. A recent report published in the Boston Globe indicates ED visits in Massachusetts grew 7 percent from 2005 to 2007 and the percentage of visits in which a patient did not require immediate treatment or could have been treated in a doctor s office remained constant at 47 percent. 6 11

12 A well-recognized study published in the Annals of Emergency Medicine in 2008 found that the biggest proportional increases in ED use were among higher income people (equal to or greater than 400 percent of the federal poverty level) and people whose regular source of care was a doctor s office. 7 While it is true that increasing numbers of the uninsured are going to the ED for care, they are not the primary cause of the increase in ED use or overcrowding. 8 While not the focus of this report, it would be interesting to understand the relationship between urgent ED use and the shortage of primary care physicians in the community and how it affects access to care for everyone, including the uninsured. The data in the graph below provide an early look at emergent and urgent use of the ED in 2005 and 2006 by region for study hospitals. One must use caution when viewing these results given that certain hospitals did not provide their emergent and urgent ED visit data for each year and this may affect the averages (see page 32). Also, there are currently no common standards for ED research and reporting. Thus, the procedure code method developed by ThomsonReuters Solucient (TR) to define emergent and urgent ED visits for this report (see Appendix E) may produce results that differ from other methods. Urgent use of the ED was substantially higher than emergent ED use in both years and total ED visits rose in 2006 in most regions. The average percentages for urgent ED visits of 70 percent in 2005 and 64 percent in 2006 for hospitals in this study may appear high as compared to percentage estimates of urgent ED use cited in other well-recognized national and local studies due to methodological differences. For example, one widely-accepted method developed by John Billings, MD at New York University uses a patient s primary diagnosis code at discharge to apportion ED visits into five emergent and non-emergent categories. 9 A national study conducted by George Washington University researchers using the Billings algorithm resulted in a 21.4 percent rate of non-emergent ED use. 10 In a recent St. Louis area study by the St. Louis Regional Health Commission (RHC), non-emergent ED use for 2006 was estimated at 34 percent. The RHC method requests hospitals report triage-level ED data instead of billing or procedure code data. Non-emergent ED visits are defined by the two lowest acuity triage levels. 11 Callaway County had the highest percentage of urgent ED use in Audrain and Greene counties had the largest percentage increases in urgent ED visits from 2005 to Urgent ED visits fell for most of the other regions including the St. Louis area in Statistics for individual study hospitals within each region are listed on page 32. Emergency department visits by payer (i.e., Medicare, Medicaid, Commercial, and Self Pay/ Uninsured) were unavailable for most study hospitals for 2005 and 2006 except for St. Louis hospitals within the BJC HealthCare and SSM Health Care systems. Commercial and Medicaid ED visits fell slightly at BJC and SSM with a corresponding rise in ED visits for self pay/ uninsured patients. Medicare ED visits were unchanged for both systems. SSM provided further detail for emergent and urgent ED visits by payer. At SSM, commercial and Medicaid emergent and urgent ED visits fell while Medicare results were mixed. Self pay/uninsured emergent and urgent ED visits rose 31 percent and 34 percent respectively in 2006 (see page 35). 12

13 Emergent and Urgent Emergency Department Visits by Region, % 80% 2005 Urgent ED Visit Average = 70% 2005 Emergent 2006 Emergent 2005 Urgent 2006 Urgent 60% 40% 2006 Urgent ED Visit Average = 64% 20% 0% Adair (est)1 Marion (est)1 Perry (est)1 Polk (est)1 Cape Girardeau (est)1 Cole (est)1 St. Louis Metro (est)1,2 Boone (est)1 Greene (est)1 Audrain Callaway 2005 Emergent 10% 5% 26% 25% 28% 18% 29% 30% 28% 33% 4% 2006 Emergent 43% 42% 38% 30% 24% 22% 18% 2005 Urgent 90% 95% 74% 75% 72% 82% 71% 70% 72% 67% 96% 2006 Urgent 57% 58% 62% 70% 76% 78% 82% 1 Source: Emergency department (ED) visits self-reported by hospital for 2005 & 2006 unless noted otherwise & were not audited. For a complete listing by hospital, see Appendix C, p The 2005 source for non-reporting hospitals was ThomsonReuters (TR) Solucient Market Planner Plus Outpatient Profiles and are denoted with an (est.*)1. Estimated ED visit data for 2006 were not available from TR Solucient for those hospitals. For a description of TR Solucient methodology, see pages St. Louis Metro area figures include only Missouri hospitals for this report. BJC hospitals in Boone county & St. Louis Metro did not provide their volume of emergent and urgent ED visits. Cox Health System and Citizens Memorial in Greene and Polk counties respectively did not provide their volume of emergent and urgent ED visits in These data seem to support anecdotal evidence that the 2005 reductions in Medicaid have led to increasing numbers of uninsured seeking care in the ED. Unfortunately, the lack of data prior to 2005 that would allow comparison of normal year-to-year fluctuations in emergent and urgent ED use along with data limitations related to hospital-specific ED utilization by payer make it difficult to draw firm conclusions. Further analysis of hospital-specific emergent and urgent ED utilization by payer in 2007 and beyond is needed to better understand the full impact of the 2005 Medicaid reductions. Regional Snapshots As part of the study, hospitals were asked to describe the effects of the 2005 reductions in Medicaid eligibility on their numbers Medicaid and uninsured patients. The following hospitals provided information and narrative descriptions of the impact on their hospital: Audrain Medical Center in (Mexico, MO) Audrain County, and Cox Health System, Ozarks Community Hospital, and St. John s Regional Health Center in (Springfield, MO) Greene County. Information on St. Louis metropolitan area hospitals is supported by reports from the St. Louis Regional Health Commission (RHC). 13

14 Audrain County Audrain Medical Center (AMC) is a community safety net hospital that has seen a record number of visits to its ED since the Medicaid cuts became effective. In a letter from the President and CEO of Audrain Medical Center, David Neuendorf reports, Regarding the impact of the 2005 Medicaid cuts on Audrain Medical Center I can only think of one descriptive word, devastating. The surge in uninsured not only placed a heavy financial burden on the hospital, but also extended waiting times for other patients seeking care in the ED and overwhelmed hospital staff. More information on this hospital is provided in Section II of this report. Greene County Cox Health Systems (CHS) reported a significant increase in the amount of care provided to the underserved. More than 65 percent of 2006 neonatal ICU discharges at CHS were Medicaid and uninsured. CHS provides access to primary care through its Federally Designated Rural Health Clinics. Although CHS s charity care in 2006 was the second highest in Greene County at $6.5 million or, 0.95 percent of operating revenue, it was below the average for study hospitals of 1.3 percent. Bad debt was the highest in the county at $23.7 million or, 3.42 percent of operating revenue. In a position paper from the CEO of Ozarks Community Hospital (OCH), Paul Taylor reports, Before the Medicaid program was reformed in 2006 by reducing the number of covered beneficiaries state-wide and entirely eliminating certain benefits such as physical therapy and wound care, over 40 percent of our patients were covered by Medicaid. Following the Medicaid reforms, the percentage of our patients covered by Medicaid declined dramatically and we saw a corresponding increase in the percentage of uninsured patients. By September 2006, the percentage of uninsured patients seeking treatment in our emergency room (ER) had climbed to more than 50 percent. At OCH, given the fact that a large percentage of our ER patients were uninsured, and in need of follow-up care by a primary care provider, we created a primary care follow-up clinic. While we did not offer the care free of charge, we did not require payment at the time of service and we billed for the services provided at a substantial discount. St. John s Regional Health Center (SMHS) provided the largest amount of charity care in Greene County at $9.3 million, or 1.51 percent of operating revenue, and bad debt was the second highest in the county at $21.5 million, or 3.52 percent of operating revenue. At the time this report was written, St. John s provided a general description of a future plan to conduct a medical management demonstration project to provide access to health care for adults (18-64 years of age) that suffer from chronic disease and have annual household incomes equal to or below 150 percent of the Federal Poverty level. The demonstration project will be limited to a maximum of 25 patients per quarter and 100 per year. Patients will be eligible for this project if they have utilized St. John s provider network or ED in the past. Patients will be required to apply for enrollment, and make co-payments for care. Specific details on the type or amount of any additional payments required of enrollees were not provided. St. Louis City and County Although volumes at some St. Louis hospitals increased significantly, the total number of hospital ED visits in St. Louis City and County remained constant between 2001 and Barnes-Jewish, Christian, DePaul and St. Louis University hospitals accounted for 61 percent of all ED visits among uninsured and underinsured (Medicaid) adult populations. St. Louis 14

15 Children s and Cardinal Glennon Children s hospitals accounted for 66,000 uninsured and Medicaid ED visits in Non-emergent ED visits increased 5 percent from 2001 to In 2006, uninsured and Medicaid patients accounted for 17 percent and 36 percent of non-emergent ED visits respectively. 12 In 2007, uninsured ED visits at St. Louis area hospitals increased 6.8 percent. Barnes-Jewish, Christian, St. Louis University, St. John s Mercy Medical Center, DePaul, St. Anthony s Medical Center, St. Mary s Health Center, and St Alexius hospitals provided 90 percent of the ED visits for the uninsured. Total non-emergent ED visits remained relatively constant from 2006 to Uninsured and Medicaid non-emergent ED visits also remained relatively constant from 2006 to According to the RHC, the numbers of uninsured ED visits to St. Louis area hospitals would have been higher except for the efforts of the St. Louis Integrated Health Network (IHN). IHN nurses work with the underserved seeking non-emergent care in hospital EDs. They have been able to significantly reduce non-emergent ED use by finding clinic appointments for underserved patients, sometimes the same day as the ED visit, and coordinating transportation if needed. This and other IHN efforts to coordinate primary/specialty care for the underserved has resulted in an increase in routine primary and preventive care visits of 23 percent from 2001 to 2006, and an additional increase of 3 percent in The St. Louis County clinics and federally qualified health centers (FQHC) provided 70 percent of these visits with the other 30 percent provided by private clinics staffed by volunteer providers, private physician offices, and hospital-based clinics. Improving access to specialty care proved to be more challenging and wait times did not improve until Despite these improvements, safety net care remains inadequate FQHCs in St. Louis are underfunded $166 million each year according to a 2003 RHC report. Coverage Matters Research has shown that health insurance coverage provides substantial health benefits, especially for children. Well-child care and immunizations prevent future illness, serious health conditions are identified earlier, hospitalizations are avoided, asthma outcomes are better, and fewer days of school are missed. Adults benefit from clinical preventive services that detect treatable conditions earlier, effective management of chronic conditions result in better outcomes, and mortality is lower. 14 Hospitalizations for heart disease, diabetes, and asthma chronic illnesses that can be controlled on an outpatient basis with adequate primary care are common among the uninsured. 15 The research is clear; health insurance coverage improves the life of the average person in terms of health status, productivity, and longevity, and is a worthwhile investment for employers and the public. Given the increase in Missouri s uninsured, one would expect an increase in hospital charity care and bad debt expense, and in fact, that is the case. While it seems there is a direct correlation between the rise in uninsured and uncompensated care, there are other factors that affect the amount reported. The level of uncompensated care at Missouri hospitals and the multiple factors affecting it will be considered in the following section. 15

16 What is Charity Care? Accounting rules define charity care as health care services that are never expected to result in payment. Charity care has become a controversial issue since non-profit hospitals are expected to provide community benefit, including charity care, in exchange for their tax-exempt status. In contrast, for-profit hospitals have no such requirement since they fulfill their community obligation by paying taxes. To ensure public access to emergency services regardless of a patient s ability to pay, both non-profit and for-profit hospitals are subject to a federal law, the Emergency Medical Treatment and Labor Act (EMTALA). How Is Charity Care Measured? MHA Charity Care as a Percentage of Operating Revenue, Fiscal Years % 1.75% 1.50% Average 1.25% 1.00% 0.75% 0.50% 0.25% 0.00% Callaway Adair Perry Polk Cape Girardeau Marion Cole Audrain Greene Boone St. Louis Metro % 0.04% 0.27% 0.58% 0.46% 0.69% 0.58% 1.04% 0.93% % 0.00% 0.00% 0.00% 0.48% 0.47% 0.75% 1.05% 0.70% 1.02% 1.03% % 0.11% 0.19% 0.61% 0.89% 0.96% 1.13% 1.19% 1.30% 1.47% Note: MHA charity care reported at cost. The following hospitals did not report to MHA Focus on Hospitals: Callaway Community (Callaway) 2006, Citizens Memorial (Polk) 2004, Kindred (St. Louis Metro) 2005, Northeast Regional Medical Center (Adair) 2004, Ozarks Community (Greene) 2004 and 2005, and St. Joseph-Wentzville (St. Louis Metro) 2004 & With the exception of Kindred Hospital, all hospitals reported charity care on MHA/AHA Annual Licensing Surveys (see BHC Charity Care, pages 32 45). According to guidelines issued by the Catholic Health Association (CHA), MHA and others, charity care should be reported at cost, not billed charges, and exclude bad debt and other expenses such as Medicare shortfalls. In addition, it is important to evaluate charity care amounts as a percentage of operating revenue and not in direct dollars. When reported as a percentage of revenue, meaningful comparisons of charity care can be made between hospitals, regions, and even other states. Charity care cost at study hospitals increased from $73.8 million in 2005 to $113.8 million in Aggregate hospital charity care accounted for an average of 1.3 percent of operating revenue, up from 0.9 percent in 2005, an increase of 43 percent. As illustrated in the chart above, charity care has increased steadily in most regions, a total of 57 percent since

17 Charity Care Varies Yet Remains Low The degree of variation in charity care was dramatic across hospitals in Northeast Regional Medical Center in Adair County had the lowest percentage at 0.06 percent and Missouri Baptist Hospital Sullivan, a rural BJC network hospital in the St. Louis Metro area, had the highest at 3.2 percent. Approximately 44 percent of the hospitals provided charity care as a percentage of operating revenue in the low range, from 0 1 percent, and about 46 percent of them provided charity care in the mid-range, from 1 2 percent. Only four hospitals (10%) provided charity care in the highest range, at or above 2 percent of operating revenue. The St. Louis metropolitan area, Boone, Greene, and Audrain reported aggregate charity care burdens above 1 percent of operating revenue in Their average annual increases in charity care as a percentage of operating revenue from 2004 to 2006 were: Greene (52%), Audrain (31%), St. Louis metro (29%), and Boone (12%). With the exception of Audrain County, each region had at least one academic medical center (AMC). It is interesting to note that two community hospitals, one urban and one rural, provided more charity care than the AMCs, Christian Hospital in St. Louis at 3.1 percent and Missouri Baptist in Sullivan at 3.2 percent. It is unclear why there is so much variation among hospitals whether they are rural, urban, non-academic or academic. Some, but not all, of the variation can be explained by race and income disparities in hospital service areas. Clearly the charity care burden is not spread equally within regions or across the state. Another interesting observation is that counties having the lowest charity care, such as Adair and Polk, report high and rising amounts of bad debt (see chart below). A past rationale for assigning services to bad debt rather than charity care might have been the opportunity to seek collection of past due accounts or to sell the bad debt to a financial service company. Yet, due to the controversy over non-profit hospitals tax-exempt status and the provision of charity care, those incentives are changing. Most of the larger hospitals have changed their charity care policies in recent years. Smaller, rural hospitals may decide at some point in the future to change their policies as well. Since policies and practices related to charity care are in a state of transition, it is difficult to evaluate the meaning of large changes in reported charity care from year to year. Charity care amounts reported by BHF continue to be generally higher than MHA (see pages 32 45). There is a slight methodological difference in the BHF and MHA methods (see pages for detailed description of methods). Despite the differences, for the past two years, BHF and MHA have reported similar amounts of charity care. This changed in 2006 when MHA reported charity care for BJC HealthCare system in St. Louis at a notably higher level than BHF reported. According to BJC, during 2008 some of its hospitals 2006 bad debt was retroactively reclassified as charity care after collection efforts found that patients could not pay. Although other hospitals in St. Louis and Missouri are facing similar issues, charity care amounts for most of them did not change. It is expected that this is a one year event. Many hospitals are now implementing methods to better determine if a patient qualifies for charity care upon admission. 17

18 Bad Debt Expense Growth Accelerates in 2006 MFH Bad Debt as a Percent of Operating Revenue, Fiscal Years % 8.00% % 4.00% 2006 Average 2.00% 0.00% Callaway Boone Audrain St. Louis Metro Cole Perry Marion Cape Girardeau Adair Greene Polk % 1.53% 1.69% 1.63% 1.61% 2.27% 2.56% 2.56% NR 2.58% 2.01% % 1.99% 2.44% 1.77% 1.40% 2.54% 2.29% 2.76% 1.47% 3.10% 3.01% % 2.30% 2.30% 2.35% 2.41% 2.66% 2.74% 2.75% 3.50% 4.33% Note: The following hospitals did not report bad debt expense to MHA Focus on Hospitals: Callaway Community (Callaway) 2006, Northeast Regional Medical Center (Adair) 2004, Ozarks Community (Greene) 2004 and 2005, and St. Joseph-Wentzville (St. Louis Metro) With the exception of St. Joseph Hospital -Wentzville, all of them reported bad debt on MHA/AHA Annual Surveys for those years. Bad debt expense at study hospitals jumped in 2006 to $219 million, up from $163.8 million the prior year. Hospital bad debt expense accounted for 2.5 percent of operating revenue, up from 2 percent in 2005, an increase of 24 percent. Since 2004, bad debt grew 38 percent. Bad debt as a percentage of operating revenue has grown steadily since At least two factors contributed to this increase; the rise in the uninsured, and changing hospital policies and practices on bad debt and charity care. Some providers have adopted more conservative bad debt methodologies leading to large increases in bad debt in a single year. Others have moved expenses initially accounted for as bad debt to charity care. As discussed earlier in this report, after BJC HealthCare reported 2006 charity care and bad debt to BHF, they retroactively reclassified some of the bad debt to charity care and reported a higher 2006 amount to MHA. See pages for other disclosures prior to Polk, Greene, Adair, Cape Girardeau, and Marion counties reported above average bad debt as a percentage of operating revenue in 2006 according to MHA. Their average annual increases in bad debt as a percentage of operating revenue from 2004 to 2006 were: Polk (58%), Greene (18%), Cape Girardeau (4%), and Marion (2%). Northeast Regional Medical Center (Adair) did not report to MHA in 2004, yet the hospital sustained a large increase from 2005 to 2006 (87%). Bad debt reported by BHF continues to be higher than MHA (see pages 32 45) due to slight methodological differences (see pages 46 51). 18

19 Overall, bad debt at study hospitals continued to outpace reported charity care by more than 50 percent. As noted on page 10, it is paradoxical that the counties with the largest amounts of bad debt as a percentage of operating revenue were the same regions reporting the lowest amounts of charity care, with the exception of Greene. The gap between bad debt and charity care is expected to narrow in 2009 when all non-profit hospitals transition to the new Internal Revenue Service (IRS) guidelines for IRS Form 990, Section H that require more detailed charity care and community benefit reporting. Uncompensated Care and Community Benefit MHA Uncompensated Care as a Percentage of Operating Expense, Fiscal Years % U.S. Average 6.0% 2006 All Missouri Hospital Average 4.0% 2.0% 0.0% Callaway Perry Adair Cole Audrain Cape Girardeau Marion % 2.6% 2.1% 2.3% 3.0% 3.1% 2.8% 2.7% 1.9% 3.3% % 2.8% 1.6% 2.2% 3.1% 3.4% 2.9% 3.3% 2.9% 2.9% 4.0% % 3.1% 3.2% 3.4% 3.6% 3.8% 3.9% 3.9% 4.5% 4.9% Boone St. Louis Metro Polk Greene Note: The following hospitals did not report to MHA Focus on Hospitals: Callaway Community (Callaway) 2006, Northeast Regional Medical Center (Adair) 2004, Ozarks Community (Greene) 2004 and 2005, and in St. Louis Metro, Kindred 2005 and 2006 and St. Joseph-Wentzville 2004 and 2005 (see Appendix C). The American Hospital Association (AHA) considers bad debt and charity care expense together as total uncompensated care and expresses it as a percentage of total expense. It is important to look at them together given state of transition in hospital policies and practices, and also because of the significant variation between charity care and bad debt among hospitals. Uncompensated care expressed as a percentage of total expenses results in a slightly higher number when compared to the same measure as a percentage of operating revenue though the trends are directionally similar. To compare the results of Missouri hospitals using the AHA method, bad debt and charity care were combined and expressed as a percentage of total expenses shown in the chart above. It is interesting that the 2006 uncompensated care aggregate percentage for study hospitals of 4 percent based on MHA data (not shown) is slightly below the average of 4.2 percent for all hospitals in Missouri 16 amount, and well below the U.S. average 19

20 of 5.7 percent 17 suggesting that hospitals outside of Missouri have a bigger problem or they measure uncompensated care differently. Bad Debt and Charity Care An Important Distinction Individual hospitals and regions had higher percentages. Greene and Polk counties exceeded the aggregate percentage for study hospitals and the all Missouri hospital average for uncompensated care as a percentage of operating expense in Why is their uncompensated care so much higher? Exhibit 3 below shows the service area of hospitals located in Greene and Polk, indicated by a circle on the Missouri map. Many of the counties they serve are in the lowest per capita income category. Exhibit 3: Missouri Per Capita Income 2006 ATCHISON HOLT NODAWAY ANDREW BUCHANAN PLATTE WORTH GENTRY DE KALB CLINTON CLAY JACKSON CASS BATES VERNON BARTON JASPER NEWTON MCDONALD HARRISON DAVIESS CALDWELL RAY LAFAYETTE JOHNSON HENRY ST. CLAIR CEDAR DADE LAWRENCE BARRY MERCER GRUNDY LIVINGSTON CARROLL SALINE PETTIS BENTON HICKORY POLK GREENE STONE PUTNAM SULLIVAN LINN CHRISTIAN CHARITON DALLAS TANEY COOPER MORGAN CAMDEN WEBSTER ADAIR HOWARD SCHUYLER MACON RANDOLPH MONITEAU LACLEDE DOUGLAS BOONE MILLER WRIGHT OZARK SCOTLAND COLE KNOX PULASKI SHELBY MONROE AUDRAIN CALLAWAY OSAGE MARIES PHELPS TEXAS HOWELL CLARK LEWIS MARION RALLS MONTGOMERY GASCONADE DENT CRAWFORD SHANNON OREGON PIKE WARREN LINCOLN FRANKLIN IRON REYNOLDS CARTER Per Capita Income ST. CHARLES WASHINGTON RIPLEY ST. LOUIS JEFFERSON Greater than $27,000 $24,000 - $27,000 $21,000 - $24,000 Less than $21,000 ST. FRANCOIS WAYNE STE. GENEVIEVE MADISON BUTLER ST. LOUIS CITY BOLLINGER PERRY STODDARD CAPE GIRARDEAU SCOTT MISSISSIPPI Source: OSEDA NEW MADRID DUNKLIN PEMISCOT Concern over community benefit provided by non-profit hospitals remains on the national agenda and has prompted some health care organizations to take positions on what should be counted as community benefit. The Catholic Health Association (CHA) has taken a position and issued guidelines that exclude bad debt and other expenses (i.e., shortfalls from Medicare, 20

21 programs designed for marketing purposes, etc.) from consideration as charity care. For details on these guidelines, go to the CHA website at Why is bad debt excluded from consideration as charity or community benefit? Accounting rules define charity care as health care services that are never expected to result in payment. Therefore, these services should never be booked as a receivable or revenue in a financial statement. This is an important distinction since bad debt is accounted for as a receivable until collection efforts are unsuccessful. Moving bad debt to charity care is inconsistent with accepted accounting standards. And for patients, the consequences of collection efforts can be harsh. According to the research of Sydney Watson of St. Louis University School of Law and others, when medical bills go to collection agencies or attorneys, patients frequently feel pressured to put medical debt on credit cards or take out loans. They may also find themselves facing legal judgments that garnish wages, attach bank accounts, place liens on homes, or even force foreclosure. 18 While it can be difficult for hospitals to ascertain if a patient qualifies for assistance upon admission, the heavy penalties of the collection process make it prudent for hospitals to find better means of identifying patients that qualify for charity care. Impact on Hospital Specific Financial Performance Exhibit 4: Operating and Profit Margin Trends Missouri Hospitals Operating Margins Profit Margins Adair 8.42% 8.82% 10.53% 8.42% 8.78% 10.49% Audrain -2.49% % -0.60% -2.41% -4.31% 0.14% Boone 7.84% 7.59% 8.62% 6.37% 5.30% 6.95% Callaway -1.69% 11.55% 0.58% -1.69% 12.77% 0.58% Cape Girardeau 6.41% 5.85% 8.24% 9.70% 8.08% 10.85% Cole 1.77% 1.59% -2.14% 1.93% 2.02% -1.70% Greene 5.51% 4.47% 3.62% 7.09% 4.50% 4.40% Marion -0.23% 4.95% 7.31% 1.47% 6.07% 9.17% Perry 11.24% 7.64% 3.66% 11.25% 7.71% 3.74% Polk -3.34% -4.01% -0.62% -3.10% -3.71% 0.01% St. Louis MSA* 4.06% 3.58% 4.09% 6.86% 5.24% 7.22% Aggregate 4.55% 4.03% 4.45% 6.70% 5.11% 6.62% Missouri Average % 2.96% 3.16% 5.08%** 4.10%** 5.19%** U.S. Average % 3.70% 4.00% 5.20% 5.30% 6.00% * St. Louis MSA hospitals include only Missouri hospitals for this report. ** Source: DHSS. Operating margins obtained from a different source see Endnotes, page 30. Note: Changes to previously reported data are based on the most current information including numerous restatements. See Appendix D for disclosures. 21

22 Financial performance in aggregate for the three-year period from 2004 to 2006 was fairly stable. Sharp increases in charity care and bad debt expense did not result in serious financial strain for the majority of study hospitals. Although average operating and profit margins dipped slightly in 2005, in 2006 they recovered to about the same level as 2004, and generally outperformed both the Missouri and national averages (Exhibit 4, page 22). 19,20 In general, urban hospitals fared better than rural hospitals. Even though most were relatively profitable, charity care and bad debt increases from 2004 to 2006 added to expenses resulting in serious financial pressure on certain individual hospitals and regions. Their stories are told below. Audrain County As mentioned earlier in this report, Audrain Medical Center (AMC) was profoundly impacted by the sharp increase in charity care and bad debt expenses. Following losses in 2004, the hospital had the lowest operating and profit margins in 2005 for an independent hospital in this study. In 2006, AMC had $24.5 million in reserves equivalent to slightly less than five months of operating revenue (see Exhibit 5, page 24). AMC s debt-to-equity ratio was nearly twice the Missouri average, making them more vulnerable financially and less able to withstand abrupt increases in expenses. Fortunately, AMC was able to reduce their operating loss substantially in More information on this hospital is provided in Section II of this report. Greene County Financial performance for certain hospitals in Greene County was also impacted. Charity care nearly tripled at Cox Health System (CHS) from 2005 to 2006 and bad debt increased by a third operating and profit margins were 0.90 percent and 2.47 percent respectively. Yet, in 2006 CHS had $476 million in reserves, equivalent to about eight months of operating revenue. CHS s 2006 debt-to-equity ratio of 0.6 was slightly below the Missouri average. Similarly, St. John s Regional Health System provided the highest amount of charity care as a percentage of operating revenue in the county and bad debt increased 21 percent from 2005 to However, St. John s was financially strong and, although operating results were affected, they were able to achieve a 7.3 percent operating and profit margin, well above state and national averages. Non-operating revenue was not reported by the hospital. In 2006, St. John s had $350 million in reserves, equivalent to about five months of operating revenue, and a debtto-equity ratio of 0.3, well below the Missouri average. Also mentioned previously, Ozarks Community Hospital (OCH) experienced a large increase in uninsured patients resulting in a 52 percent and 7.5 percent increase in bad debt and charity care respectively from 2005 to OCH lost more than $2 million resulting in a negative (6.5%) operating margin in OCH s low level of reserves fell to approximately $1.7 million in 2006, on average equivalent to less than one month of operating revenue. OCH had high levels of debt with a debt-to-equity ratio of 8.3, up from 3.0 in 2005, more than 13 times the state average. Polk County Citizens Memorial Hospital (CMH) has seen a steady rise in bad debt. Operating and profit margins were negative in 2004 and 2005, yet financial performance improved in CMH has had high levels of debt indicated by double digit debt-to-equity ratios, more than 35 times the state average in Reserves are among the lowest of the study hospitals at $1.5 million, equivalent to about one week of operating revenue. CMH declined to provide information regarding the impact of the 2005 Medicaid eligibility reductions on their financial performance. 22

23 It is reasonable to conclude that the steady rise in uncompensated care has contributed to the financial strain on the hospital. While the level of public support they receive remains unclear, in January 2009 CMH reported they were proceeding on a range of projects including an ophthalmology clinic, remodeling of clinic space and the hospital radiology department, and remodeling for the new 64-slice CT. 21 Cape Girardeau and Marion counties Cape Girardeau and Marion counties had higher than average levels of bad debt as a percentage of operating revenue, yet provided little charity care. Hospitals in these counties were very profitable with operating and profit margins well above state and national averages. Levels of reserves and debt-to-equity ratios appeared to be adequate as well (see pages 32 45). Perry County Perry County Memorial Hospital (PCMH) has reported above average levels of bad debt and below average charity care since Medicare, Medicaid, and overall utilization declined significantly from 2004 to Despite this, operating and profit margins were strong in 2004 and 2005 and did not dip below average until Reserves appeared to be adequate as well, equivalent to more than eight months of operating revenue, and debt-to-equity ratios were well below aggregate and state averages. PCMH s is designated a Medicare Critical Access Hospital (CAH) since its percentage share of Medicare patient days ranges from 76 percent 77 percent. Medicare pays CAHs for most services to Medicare beneficiaries on the basis of 101 percent of their allowable and reasonable costs. CAHs may also receive other special payments, such as those that benefit physicians and Medicare beneficiaries. The CAH designation has likely contributed to PCMH s financial strength and stability. Exhibit 5: Total Reserves and Debt-to-Equity Ratios Missouri Hospitals Reserves (Fund Balance)* Debt-to-Equity Ratios Adair $19 $24 $ Audrain Boone Callaway Cape Girardeau Cole Greene Marion Perry Polk St. Louis MSA** 3,300 3,656 4, Aggregate $4,697 $5,191 $5, Missouri Average 22 n/a n/a n/a * All figures are in millions of dollars ** St. Louis MSA hospitals include only Missouri hospitals for this report. 23

24 St. Louis City and County In 2006 BJC HealthCare s Christian and Missouri Baptist Sullivan hospitals had significantly lower financial performance as compared to other system hospitals. This was due in part from rising charity care and bad debt expenses according to BJC. Both hospitals are located in areas that serve lower income populations. Despite the financial impact of higher charity care and bad debt, BJC was the most profitable hospital system in St. Louis. System-level operating and profit margins were substantially higher than state and national averages. In 2006, BJC had $2.4 billion in system-level reserves, equivalent to about 13 months of operating revenue, and a debt-toequity ratio below the state average. SSM Health Care s bad debt and charity care rose 76 percent and 23 percent respectively from 2005 to It appears the increase in uncompensated care shown in this report had an important impact on SSM Health Care s 2006 operating and profit margins. SSM s $461 million in reserves were equivalent to about five months of operating revenue. Debt-to-equity ratios were slightly below the state average. Any added support SSM may receive from its parent company, Sisters of St. Mary, remains unclear. Historically, Tenet Health System s St. Louis University Hospital (SLU) has provided levels of charity care at around 3 percent operating revenue, well above the average for study hospitals. Since SLU is part of the for-profit Tenet Health System, they also pay taxes equivalent to approximately 4 percent of operating revenue. SLU has also had higher than average levels of bad debt. Operating and profit margins at SLU have improved since 2004 despite average annual increases in bad debt and charity care during the period of 13 percent and 46 percent respectively. Since SLU is part of Tenet, reserves of individual hospital facilities are consolidated at the central corporate level making comparisons among individual hospitals difficult. In 2006, SLU internal financial statements disclosed $121 million in reserves equivalent to about four months of operating revenue. Debt-to-equity ratios of 0.2 were well below the state average. Since Tenet is publicly traded, consolidated financial statements indicate an accumulated deficit in 2006 reserves (retained earnings) of ($2.6) billion. Forest Park and St. Alexius hospitals were two of the most financially troubled institutions in the St. Louis area. Bad debt as a percentage of operating revenue has doubled since 2004 at both hospitals and is well above average. Surprisingly, charity care as a percentage of operating revenue was below average. Operating and profit margins at St. Alexius have improved slightly since 2004 but remain well below average. They have few reserves and debt-to-equity ratios indicate high levels of debt. Forest Park has reduced its losses since 2004 mainly by eliminating services such as obstetrics. Yet operating and profit margins as well as reserves and debt-to-equity ratios have remained negative since Both facilities were owned formerly by Tenet Health System and served mainly low income populations. Tenet sold them in 2004 to Envision Hospitals of America (formerly Doctors Community Healthcare Corporation). In December 2008, both hospitals were acquired by Success Healthcare, and the new owner stated that its immediate goal is to assess current operations and in the next six months, to implement a turnaround plan and financial strategy that will support the immediate and long-term objectives of both hospitals. 23 The long-term viability of these institutions remains uncertain. 24

25 Summary The data show Medicaid hospital utilization fell and uninsured hospital use increased steeply in 2006 for study hospitals as well as for all hospitals in Missouri. As expected, charity care and bad debt expense as a percentage of operating revenue increased in 2006, yet remained relatively low. Looking at charity and bad debt together, total uncompensated care as a percentage of operating expense also rose at study hospitals in 2006, and rested slightly below the state average and about 30 percent below the national average. Results for a number of study hospitals were higher and indicate that charity and bad debt burdens are unevenly distributed across the state. At the same time, hospital policies and practices related to uncompensated care continue to be in a state of transition, given the controversy over non-profit hospitals tax-exempt status. Unfortunately, the lack of data before 2004 does not allow a comparison of normal year-to-year fluctuations in the levels charity care and bad debt over a longer period of time, and, coupled with data limitations related to hospital-specific care for the uninsured, make it difficult to determine the significance of the increases. Putting the total picture together, however, it seems reasonable to conclude that uncompensated care has increased as a result of the Medicaid reductions. Financial performance was relatively stable from 2004 to 2006, and study hospitals generally outperformed both the Missouri and national averages. It is my expectation that charity care and bad debt expenses at study hospitals will be higher in 2007 and 2008 as the numbers of uninsured increase stemming from the combination of lower Medicaid enrollment and job loss from the weakening economy. Based on correspondence with hospital CEOs and reports from the media, the financial status of some of the study hospitals deteriorated further in A more in-depth assessment of the impact of the uninsured on one of the more financially vulnerable hospitals identified in this report follows in Section II. 25

26 Section II The purpose of this project is to more fully understand the extent that hospital charity care and bad debt expense, or uncompensated care, has been affected by the 2005 Medicaid reductions. As part of the analysis for this report, the scope of the research was expanded to learn more about hospitals efforts to cope with the cuts and whether they have been able to improve service to the uninsured population in their geographic areas. Research on this section of the report began in mid-year Since that time, BHF has contacted each hospital or hospital system in the study to determine how the 2005 reductions in Medicaid eligibility have affected their numbers of Medicaid and uninsured patients and to learn about any innovations that were implemented in response. Based on numerous conversations and correspondence on-going since 2007, the majority of the hospitals are using the same strategies to respond to the increase in the uninsured they have used in the past; assisting eligible patients to enroll in Medicaid, offering care at a substantial discount, and referring non-emergent patients to an alternative health care site after an ED visit such as a hospital-based primary care or other clinic. Two health care providers have implemented innovative strategies. The first provider is not a hospital or hospital system, yet the work of the St. Louis IHN is perhaps the best innovation to share. As mentioned earlier in the report, IHN nurses work with the underserved who seek non-emergent care in the hospital ED. IHN nurses have been able to significantly reduce non-emergent ED use by finding clinic appointments for underserved patients, sometimes the same day as the ED visit, coordinating transportation if needed. Although their efforts are not explored in this section, the St. Louis Regional Health Commission can provide indepth information on their efforts. Another is a relatively small hospital serving a low income population in Audrain County that has provided detailed information on operational changes it has made in response to the impact of rising uninsured. These are difficult times, and Audrain Medical Center has made innovative changes to operations to improve access to primary care and on-going health care management for the region s uninsured. Audrain Medical Center Audrain Medical Center (AMC) is a non-profit full-service hospital located in Mexico, Missouri, established in AMC is located approximately 40 miles from the nearest tertiary care hospital. AMC s service area consists of all or portions of seven counties: Audrain, Monroe, Montgomery, Callaway, Pike, Ralls, and Boone. The primary county AMC serves is Audrain; the only county among the seven that lost population in the last decade. Median family income fell over the last ten years and is now well below the state average for most of the counties in their service area. Other demographics in their service area, such as percent of births to mothers with fewer than 12 years of education and children in poverty, were higher than the state average. 24 Audrain Medical Center Patient Services AMC Cancer Center Diabetes Education Emergency Department Healthworks: Outpatient Rehabilitation Services Inpatient Psychiatric Services Jordan Waters Heart Center Lab Services LifeLine Support: Personal response service MedChoice Clinics Medical Imaging Sleep Lab 26

27 AMC provides a number of other health care services in addition to hospital care (see above). AMC operates nine MedChoice rural health clinics. Audrain County has five clinics in Mexico, and one in Vandalia. Ralls County has one clinic in Perry, and Montgomery County has clinics in Montgomery and Wellsville. Over the last few years, AMC has closed its rural health clinics in Auxvasse, Centralia, and Paris, Missouri to direct financial resources to their other clinics. Exhibit 6: Audrain Medical Center Medicaid Discharges, Medicaid discharges fell 5% from 2005 to 2006 at Audrain Medical Center Audrain was profoundly affected by the collapse of the refractory brick business and the closure of the two A.P. Green and National Refractory facilities in Mexico over the last ten years. The loss of those jobs, and the generous health care benefits that went with them, increased AMC s number of uninsured since the service industry jobs that replaced them (i.e., Wal-Mart) pay less and often provide no health benefits. The 2005 Medicaid eligibility reductions added to AMC s problems. In response to BHC s request for information regarding the effect of the cuts on the hospital, President and CEO David Neuendorf reports, Regarding the impact of the 2005 Medicaid cuts on Audrain Medical Center, I can only think of one descriptive word, devastating. As a community safety net hospital with razor thin margins to begin with, an increase of $2 million in bad debt and charity care at cost has pushed us perilously close to default on our bond obligations and forced us to reduce services and eliminate jobs. As Medicaid coverage declined (page 28), utilization fell resulting in a record number of uninsured visits to the ED. The surge in uninsured not only placed a heavy financial burden on the hospital, but also extended waiting times for other patients seeking care in the ED and overwhelmed hospital staff. Adding more staff only exacerbated their financial losses. Under normal circumstances hospitals are expensive to operate and maintain. A small rural hospital has fewer beds and other services to spread the usual cost of operations much less the abrupt increase in expenses from a surge in uncompensated care. As mentioned on page 18, AMC had sustained losses for the two years prior to the effective date of the Medicaid cuts and their level of debt as compared to their reserves was nearly twice the Missouri average. 27

28 AMC Takes Action According to CEO, David Neuendorf, The ED is an extremely inefficient way to care for people because if they had insurance and a primary care provider their care would be less expensive with more effective follow-up. Despite financial challenges, AMC has added primary care providers to their rural health clinics in an effort to improve primary care services. Early reports indicate their strategy to improve access to primary care has begun to pay off. In 2008, ED visits were down 3 percent while clinic visits increased 7 percent. AMC reports that it is very difficult to measure the exact impact of this strategy because of turnover among providers in the clinics, and changes in demographics of their service area. In addition to improving access to primary care, AMC has also invested in promoting wellness and diabetes education. The benefits from these initiatives will be realized over the long term. Another strategy AMC used to lessen the financial burden of the uninsured was to turn to the community to seek more tax support for the hospital by starting an ambulance district. In 2009, the hospital will no longer subsidize ambulance services as this responsibility will be shifted to the new ambulance district. This report suggests AMC may have achieved some early success as operating losses were reduced in 2006; however it appeared to be short-lived as the hospital reported further financial problems in 2007 and Charity care and uncompensated care levels did not increase in 2008, however they remained at more than double the level of 2004 prior to the Medicaid cuts. The doubling of uncompensated care between 2005 and 2007 coupled with the collapse of the financial markets resulting in pension and operating fund investment losses in 2008 created extraordinary financial hardships. On January 1, 2009, the hospital reduced its bed size to 49, reduced staff and employee benefits, froze wages, and turned to outsourcing companies in several key areas to stem their losses. According to CEO, David Neuendorf, The long term answer to this dilemma is more and better jobs in rural Missouri that include affordable health insurance benefits. We must also increase wellness activities and improve the health of the people who live here. Unfortunately these types of changes take a long time to materialize. I hope the doors to this hospital are still open when they do. In the face of significant financial challenge, AMC made a decision to invest in the health of people that live in the community and appears to have made some good long-term decisions. AMC is now looking for a source of support to stem short-term losses until a long-term solution is realized. In the short-term it would also be important for the state to pursue extending health coverage to more of the uninsured, especially in low-income rural areas. 28

29 Endnotes 1. S. Zuckerman, D.M. Miller, E.S. Pape, Missouri s 2005 Medicaid Cuts: How Did They Affect Providers?, Health Affairs, 28, no. 2 (2009): w335 w345 (published online 18 February 2009; /hlthaff.2.w335). 2. Average operating margins for Missouri hospitals were obtained from the following report: Analyzing the Impact of the 2005 Medicaid Changes on the Financial and Service Health of Missouri Hospitals, Missouri Foundation for Health, Source for Missouri hospitals average profit margins: Missouri Department of Health and Senior Services (DHSS) and Missouri Hospital Association (MHA). Profit margins exclude Government, Psychiatric, and Rehabilitation hospitals. 3. S. Zuckerman, D.M. Miller, E.S. Pape, Missouri s 2005 Medicaid Cuts: How Did They Affect Providers?, Health Affairs, 28, no. 2 (2009): w335 w345 (published online 18 February 2009; /hlthaff.2.w335). 4. Ibid. 5. Nonemergency visits clog emergency departments, Healthcare Financial Management Association, September Estimates of nonemergency visits provided by Solucient using similar methodology as in this study. 6. L. Kowalczyk, ER visits, costs in Mass. Climb, Boston Globe, April 24, E.J. Weber, J.A. Showstack, K.A Hunt, D.C. Colby, B. Grimes, P. Bacchetti, M.S. Callaham, Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?, Annals of Emergency Medicine, M.F. Newton, C.C. Keirns, R. Cunningham, R.A. Hayward, R. Stanley, Uninsured Adults Presenting to US Emergency Departments, Assumptions vs. Data, Journal of the American Medical Association, 2008;300(16): J. Billings, N. Parikh, and T. Mijanovich, Emergency Room Use: The New York Story, New York University: The Commonwealth Fund, November M. Regenstein, L. Nolan, M. Wilson, H. Mead, B. Siegel, Walking a Tightrope: The State of the Safety Net in Ten U.S. Communities, Urgent Matters Safety Net Assessment Team, George Washington University Medical Center, School of Public Health and Health Services, Department of Public Policy, May 2004; p Progress Toward Building a Healthier St. Louis, Report to the Community , St. Louis Regional Health Commission, Building a Healthier St. Louis, A Report on the Integrity of St. Louis Health Care Safety Net, 2003, St. Louis Regional Health Commission. 13. Progress Toward Building a Healthier St. Louis, Report to the Community , St. Louis Regional Health Commission, America s Uninsured Crisis: Consequences for Health and Health Care, National Academies of Science, pre-publication copy, February 24, A. Elixhauser, C.A. Russo, Conditions Related to Uninsured Hospitalizations, 2003, H-CUP Statistical Brief #8, May Agency for Healthcare Research and Quality. 16. S. Zuckerman, D.M. Miller, E.S. Pape, Missouri s 2005 Medicaid Cuts: How Did They Affect Providers?, Health Affairs, 28, no. 2 (2009): w335 w345 (published online 18 February 2009; /hlthaff.2.w335). Uncompensated care as a percentage of operating expenses provided by the Missouri Hospital Association. 17. American Hospital Association, Trendwatch Chartbook, S. Watson, M. Jorge, A. Cohen, R. Seifert, Living in the Red, Medical Debt and Housing Security in Missouri, 2007, The Access Project. 19. Average operating margins for Missouri hospitals were obtained from the following report: Analyzing the Impact of the 2005 Medicaid Changes on the Financial and Service Health of Missouri Hospitals, Missouri Foundation for Health, Source for Missouri hospitals average profit margins: Missouri Department of Health and Senior Services (DHSS) and Missouri Hospital Association (MHA). Profit margins exclude Government, Psychiatric, and Rehabilitation hospitals. 20. American Hospital Association, Trendwatch Chartbook, K. O Dell, Crucial projects in the works; others delayed, Springfield News-Leader, January 2, Source for Missouri hospitals average debt-to-equity ratios: DHSS and MHA. Debt-to-equity ratios exclude Government, Psychiatric, and Rehabilitation hospitals. 23. St. Alexius, Forest Park hospitals sold, St. Louis Business Journal, December 17, Demographic information obtained from DHSS and OSEDA. 29

30 Phase III Appendices Appendix A 2006 Public Program Utilization Emergency Department Use profile Emergency Department Use profile Emergency Department Use by Payer SSM Health Care ED Use by Payer and Visit Type Charity Care profile Charity Care as a Percentage of Operating Revenue Bad Debt Profile Bad Debt as a Percentage of Operating Revenue Uncompensated Care as a Percentage of Operating Expense Fiscal Year 2006 Financial Data Operating Margin Trends Profit Margin Trends Total Reserves and Debt-to-Equity Ratios Capacity Levels and Productivity Appendix B Methodology and Data Sources Charity Care Cost Differences, BHF and MHA Glossary Appendix C Emergency Department Use Rates

31 Phase III Appendix A 2006 Public Program Utilization % % % % Missouri Medicare Medicare Medicaid Medicaid % Other % Other Total Total Missouri Hospital (system name) County Days Discharges Days Discharges Days Discharges Days Discharges Northeast Regional Medical Center Adair 64% 53% 12% 18% 24% 29% 17,903 3,928 Audrain Medical Center Audrain 57% 53% 10% 10% 33% 37% 15,672 4,162 Boone Hospital Center (BJC) Boone 59% 52% 4% 3% 36% 45% 80,401 17,199 Columbia Regional Hospital (U. of MO) Boone 40% 29% 14% 11% 47% 59% 31,404 7,422 University of Missouri Hospital and Clinics Boone 38% 33% 20% 17% 42% 50% 72,419 13,881 County Total Boone 48% 41% 12% 10% 40% 49% 184,224 38,502 Callaway Community Hospital Callaway 67% 57% 4% 6% 29% 37% 4,734 1,316 Southeast Missouri Hospital Cape Girardeau 59% 42% 16% 18% 25% 40% 46,639 11,752 St. Francis Medical Center Cape Girardeau 61% 59% 12% 13% 27% 28% 54,778 10,099 County Total Cape Girardeau 60% 50% 14% 16% 26% 35% 101,417 21,851 Capital Region Medical Center Cole 66% 50% 6% 4% 28% 46% 27,683 7,632 St. Mary's Health Center (SSMHC) Cole 59% 48% 9% 10% 32% 42% 40,812 10,534 County Total Cole 62% 49% 8% 8% 31% 43% 68,495 18,166 Cox Health Systems Greene 41% 33% 18% 18% 41% 49% 149,102 30,381 Ozarks Community Hospital 1 Greene 77% 69% 9% 13% 14% 18% 8,240 1,431 St. Johns Regional Health Center (SMHS) Greene 43% 35% 16% 22% 41% 42% 148,848 34,981 County Total Greene 43% 35% 17% 20% 40% 45% 306,190 66,793 Hannibal Regional Hospital Marion 61% 49% 14% 18% 24% 34% 23,198 5,549 Perry County Memorial Hospital Perry 74% 50% 7% 16% 19% 35% 4, Citizens Memorial Health Care Polk 56% 47% 15% 33% 28% 20% 15,289 3,277 St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 44% 39% 18% 21% 38% 40% 292,989 53,931 Barnes-Jewish Hospital - St. Peters St. Charles 54% 40% 5% 7% 41% 54% 28,498 7,002 Barnes-Jewish Hospital - West County W. St. Louis Cnty 43% 45% 2% 3% 55% 53% 16,237 3,529 Christian Hospitals N. St. Louis Cnty 65% 57% 13% 11% 22% 32% 88,397 14,687 Missouri Baptist Hospital - Sullivan Crawford 68% 54% 11% 18% 21% 28% 7,731 1,854 Missouri Baptist Medical Center W. St. Louis Cnty 58% 46% 3% 3% 39% 50% 101,462 21,398 St. Louis Children's Hospital St. Louis City 0% 0% 37% 36% 63% 64% 67,262 11,633 BJC HealthCare Total 45% 39% 16% 16% 39% 44% 602, ,034 SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 1% 1% 37% 36% 62% 63% 46,264 6,843 DePaul Health Center N. St. Louis Cnty 49% 44% 22% 18% 28% 37% 106,127 22,475 St. Joseph Health Center 2 St. Charles 52% 46% 18% 15% 30% 38% 70,805 14,802 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 69% 54% 5% 6% 26% 40% 31,772 8,695 St. Joseph West - Lake St. Louis St. Charles 51% 40% 11% 13% 39% 47% 25,643 7,786 St. Mary's Health Center W. St. Louis Cnty 55% 41% 16% 16% 29% 43% 88,016 22,774 SSM Health Care Total 47% 41% 20% 17% 33% 42% 368,627 83,375 St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 39% 33% 15% 12% 46% 54% 206,972 39,032 St. John's Mercy Hospital - Washington Franklin 58% 49% 11% 14% 31% 36% 21,850 6,493 St. John's Mercy Health Care Total 40% 36% 15% 13% 45% 52% 228,822 45,525 Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 70% 60% 6% 5% 24% 34% 39,960 9,366 St. Louis University Hospital St. Louis City 43% 40% 23% 21% 34% 38% 84,963 14,045 Tenet HealthSystem Total 52% 48% 18% 15% 31% 37% 124,923 23,411 Independent Forest Park Hospital St. Louis City 59% 54% 25% 29% 16% 18% 28,472 5,331 Jefferson Regional Medical Center Jefferson 70% 53% 9% 11% 22% 36% 38,810 9,542 Kindred Hospital St. Louis City 64% 64% 12% 13% 24% 23% 21, Lincoln County Memorial Hospital Lincoln 66% 53% 6% 9% 29% 38% 5,724 1,034 St. Alexius Hospital St. Louis City 53% 43% 31% 31% 17% 26% 54,244 8,483 St. Anthony's Medical Center S. St. Louis Cnty 63% 51% 8% 9% 29% 41% 138,451 28,438 St. Luke's Hospital W. St. Louis Cnty 66% 53% 2% 2% 32% 45% 82,856 18,259 St. Louis Area Aggregate 49% 42% 16% 15% 35% 43% 1,694, ,184 1 On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became tax-exempt. Due to economic challenges & a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 2 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center

32 2005 Emergency Department Use Profile Emergency % Emergency % Total Missouri Dept. Visit Emergent Dept. Visit Urgent Emergency Missouri Hospital (system name) County Emergent 1 Visits Urgent 1 Visits Dept. Visits 1 Northeast Regional Medical Center (est.*) 1 Adair 1,905 10% 17,200 90% 19,105 Audrain Medical Center Audrain 2,428 33% 4,881 67% 7,309 Boone Hospital Center (BJC) Boone n/a n/a n/a n/a 29,880 Columbia Regional Hospital (U. of MO) Boone 1,813 22% 6,348 78% 8,161 University of Missouri Hospital and Clinics Boone 8,056 33% 16,310 67% 24,366 County Total 3 Boone 9,869 30% 22,658 70% 62,407 Callaway Community Hospital (est.*) 1 Callaway 559 4% 12,810 96% 13,370 Southeast Missouri Hospital (est.*) 1 Cape Girardeau 6,107 19% 25,956 81% 32,063 St. Francis Medical Center (est.*) 1 Cape Girardeau 10,155 40% 15,143 60% 25,298 County Total Cape Girardeau 16,262 28% 41,099 72% 57,362 Capital Region Medical Center (est.*) 1 Cole 4,886 17% 24,590 83% 29,475 St. Mary's Health Center (SSMHC) Cole 7,363 19% 32,138 81% 39,501 County Total Cole 12,249 18% 56,728 82% 68,976 Cox Health Systems (est.*) 1 Greene 13,753 13% 96,179 87% 109,932 Ozarks Community Hospital (est.*) 1, 2 Greene 2,613 15% 15,004 85% 17,618 St. Johns Regional Health Center (SMHS) Greene 37,971 55% 30,501 45% 68,472 County Total Greene 54,337 28% 141,684 72% 196,021 Hannibal Regional Hospital (est.*) 1 Marion 1,111 5% 20,823 95% 21,933 Perry County Memorial Hospital (est.*) 1 Perry 2,991 26% 8,536 74% 11,527 Citizens Memorial Health Care (est.*) 1 Polk 5,225 25% 15,675 75% 20,900 St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City n/a n/a n/a n/a 72,985 Barnes-Jewish Hospital - St. Peters St. Charles n/a n/a n/a n/a 29,638 Barnes-Jewish Hospital - West County W. St. Louis Cnty n/a n/a n/a n/a 8,095 Christian Hospitals N. St. Louis Cnty n/a n/a n/a n/a 72,494 Missouri Baptist Hospital - Sullivan Crawford n/a n/a n/a n/a 16,049 Missouri Baptist Medical Center W. St. Louis Cnty n/a n/a n/a n/a 28,935 St. Louis Children's Hospital St. Louis City n/a n/a n/a n/a 60,033 BJC HealthCare Total n/a n/a n/a n/a 288,229 SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 10,593 27% 28,449 73% 39,042 DePaul Health Center N. St. Louis Cnty 26,732 56% 21,261 44% 47,993 St. Joseph Health Center St. Charles 18,053 52% 16,863 48% 34,916 St. Joseph Health Center - Wentzville (est.*) 1 St. Charles 2,285 18% 10,571 82% 12,857 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 21,638 98% 389 2% 22,027 St. Joseph West - Lake St. Louis St. Charles 14,852 46% 17,230 54% 32,082 St. Mary's Health Center W. St. Louis Cnty 21,760 55% 18,023 45% 39,783 SSM Health Care Total 115,914 51% 112,785 49% 228,700 St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 29,413 32% 61,160 68% 90,573 St. John's Mercy Hospital - Washington Franklin 12,705 24% 41,056 76% 53,761 St. John's Mercy Health Care Total 19,181 26% 54,881 74% 74,062 Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 4,424 37% 7,542 63% 11,966 St. Louis University Hospital St. Louis City 7,494 26% 21,513 74% 29,007 Tenet HealthSystem Total 9,648 23% 32,677 77% 42,326 Independent Forest Park Hospital (est.*) 1 St. Louis City 4,265 13% 27,733 87% 31,998 Jefferson Regional Medical Center (est.*) 1 Jefferson 9,206 24% 28,824 76% 38,030 Kindred Hospital 1 St. Louis City n/a n/a n/a n/a n/a Lincoln County Memorial Hospital Lincoln 805 7% 11,235 93% 12,040 St. Alexius Hospital (est.*) 1 St. Louis City 5,450 18% 24,211 82% 29,661 St. Anthony's Medical Center (est.*) 1 S. St. Louis Cnty 13,202 19% 58,009 81% 71,211 St. Luke's Hospital W. St. Louis Cnty 7,254 34% 14,251 66% 21,505 St. Louis Area Aggregate 3 286,637 29% 691,026 71% 1,316,672 1 Source: Emergency department (ED) visit utilization was self-reported by hospital unless otherwise noted. The source of ED utilization for those hospitals denoted with an (est.*) was ThomsonReuters (TR) Market Planner Plus Outpatient Profiles for non-reporting hospitals. Estimates are based on TR proprietary methodology. For description, see Appendix E. Kindred Hospital does not have an ED. 2 Formerly Doctor's Hospital of Springfield (DHS). See other disclosures associated with this hospital on page Since emergent and urgent ED visits were not available for BJC HealthCare hospitals, St. Louis Area Aggregate Emergent and Urgent ED visits do not add up to the Total Aggregate ED visits. St. Louis Area Aggregate Emergent and Urgent ED visit percentages were adjusted to exclude the total ED visits of those hospitals

33 2006 Emergency Department Use Profile Emergency % Emergency % Total Missouri Dept. Visit Emergent Dept. Visit Urgent Emergency Missouri Hospital (system name) County Emergent 1 Visits Urgent 1 Visits Dept. Visits 1 Northeast Regional Medical Center 1 Adair n/a n/a n/a n/a n/a Audrain Medical Center Audrain 2,015 22% 7,201 78% 9,216 Boone Hospital Center (BJC) Boone n/a n/a n/a n/a 30,928 Columbia Regional Hospital (U. of MO) Boone 1,652 20% 6,516 80% 8,168 University of Missouri Hospital and Clinics Boone 8,420 33% 17,353 67% 25,773 County Total 4 Boone 10,072 30% 23,869 70% 64,869 Callaway Community Hospital Callaway 1,818 18% 8,268 82% 10,086 Southeast Missouri Hospital 1 Cape Girardeau n/a n/a n/a n/a n/a St. Francis Medical Center Cape Girardeau 7,553 43% 10,040 57% 17,593 County Total 4 Cape Girardeau 7,553 43% 10,040 57% 17,593 Capital Region Medical Center 1 Cole n/a n/a n/a n/a n/a St. Mary's Health Center (SSMHC) Cole 15,710 42% 21,769 58% 37,479 County Total 4 Cole 15,710 42% 21,769 58% 37,479 Cox Health Systems Greene n/a n/a n/a n/a 109,299 Ozarks Community Hospital 2 Greene 918 4% 24,547 96% 25,465 St. Johns Regional Health Center (SMHS) Greene 23,129 31% 50,810 69% 73,939 County Total 4 Greene 24,047 24% 75,357 76% 208,703 Hannibal Regional Hospital 1 Marion n/a n/a n/a n/a n/a Perry County Memorial Hospital 1 Perry n/a n/a n/a n/a n/a Citizens Memorial Health Care Polk n/a n/a n/a n/a 20,750 St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City n/a n/a n/a n/a 77,847 Barnes-Jewish Hospital - St. Peters St. Charles n/a n/a n/a n/a 29,888 Barnes-Jewish Hospital - West County W. St. Louis Cnty n/a n/a n/a n/a 9,172 Christian Hospitals N. St. Louis Cnty n/a n/a n/a n/a 75,332 Missouri Baptist Hospital - Sullivan Crawford n/a n/a n/a n/a 16,425 Missouri Baptist Medical Center W. St. Louis Cnty n/a n/a n/a n/a 29,081 St. Louis Children's Hospital St. Louis City n/a n/a n/a n/a 58,480 BJC HealthCare Total n/a n/a n/a n/a 296,225 SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 10,173 26% 28,493 74% 38,666 DePaul Health Center N. St. Louis Cnty 28,264 56% 22,088 44% 50,352 St. Joseph Health Center 3 St. Charles 20,940 41% 30,354 59% 51,294 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 21,894 99% 292 1% 22,186 St. Joseph West - Lake St. Louis St. Charles 15,656 46% 18,405 54% 34,061 St. Mary's Health Center W. St. Louis Cnty 21,641 55% 17,933 45% 39,574 SSM Health Care Total 118,568 50% 117,565 50% 236,133 St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 34,103 35% 62,470 65% 96,573 St. John's Mercy Hospital - Washington Franklin 13,514 26% 37,652 74% 51,166 St. John's Mercy Health Care Total 47,617 32% 100,122 68% 147,739 Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 9,055 79% 2,437 21% 11,492 St. Louis University Hospital St. Louis City 7,940 24% 25,183 76% 33,123 Tenet HealthSystem Total 16,995 38% 27,620 62% 44,615 Independent Forest Park Hospital 1 St. Louis City n/a n/a n/a n/a n/a Jefferson Regional Medical Center Jefferson 11,203 37% 18,869 63% 30,072 Kindred Hospital 1 St. Louis City n/a n/a n/a n/a n/a Lincoln County Memorial Hospital Lincoln 974 7% 12,954 93% 13,928 St. Alexius Hospital 1 St. Louis City n/a n/a n/a n/a n/a St. Anthony's Medical Center S. St. Louis Cnty 18,802 22% 65,623 78% 84,425 St. Luke's Hospital W. St. Louis Cnty 7,764 37% 13,461 63% 21,225 St. Louis Area Aggregate 1,4 221,923 38% 356,214 62% 874,362 1 Source: Emergency department (ED) visit utilization was self-reported by hospital unless otherwise noted. Northeast Regional, Southeast Missouri, Capital Region, Hannibal, Perry County, Forest Park, & St. Alexius hospitals did not report the requested ED data nor could ThomsonReuters (TR) Market Planner Plus Outpatient Profiles provide estimates. Kindred Hospital does not have an ED. 2 Formerly Doctor's Hospital of Springfield (DHS). See other disclosures associated with this hospital on page St. Joseph Health Center and St. Joseph Hospital Wenzville began reporting on a combined basis in Since emergent and urgent ED visits were not available for BJC, Cox, and Citizens hospitals, St. Louis Area Aggregate Emergent and Urgent ED visits do not add up to the Total Aggregate ED visits. St. Louis Area Aggregate Emergent and Urgent ED visit percentages were adjusted to exclude the total ED visits of those hospitals

34 Emergency Department Use by Payer BJC HealthCare (BJC) 1 Missouri County Barnes-Jewish Hospital St. Louis City 28% 27% 22% 22% 31% 30% 19% 22% Barnes-Jewish Hospital - St. Peters St. Charles 63% 62% 12% 14% 15% 14% 10% 11% Barnes-Jewish Hospital - West County W. St. Louis Cnty 57% 56% 27% 26% 8% 8% 9% 10% Christian Hospitals N. St. Louis Cnty 34% 33% 20% 20% 30% 28% 17% 20% Missouri Baptist Hospital - Sullivan Crawford n/a n/a n/a n/a n/a n/a n/a n/a Missouri Baptist Medical Center W. St. Louis Cnty 58% 57% 32% 32% 6% 5% 4% 5% St. Louis Children's Hospital St. Louis City 35% 35% 0% 0% 62% 62% 3% 4% BJC HealthCare Total 39% 38% 17% 17% 32% 31% 12% 14% SSM Health Care (SSMHC) Commercial, Managed Care & Other Medicare Traditional & Managed Care Medicaid Traditional & Managed Care Self Pay/ Uninsured Cardinal Glennon Hospital St. Louis City 24% 24% 0% 0% 73% 73% 2% 4% DePaul Health Center N. St. Louis Cnty 38% 36% 23% 22% 25% 24% 14% 18% St. Joseph Health Center 2 St. Charles 44% 43% 23% 22% 21% 20% 12% 15% St. Joseph Hospital - Kirkwood S. St. Louis Cnty 56% 53% 26% 27% 12% 11% 7% 9% St. Joseph West - Lake St. Louis St. Charles 56% 53% 17% 18% 19% 17% 9% 13% St. Mary's Health Center W. St. Louis Cnty 38% 36% 32% 32% 18% 17% 12% 15% SSM Health Care Total 41% 39% 20% 20% 30% 28% 10% 13% SSM Health Care ED Use by Payer & Visit Type Commercial & Other Medicare Missouri Emergent Emergent Urgent Urgent Emergent Emergent Urgent Urgent County Cardinal Glennon Hospital St. Louis City 35% 34% 21% 20% 0.2% 0.2% 0.1% 0.0% DePaul Health Center N. St. Louis Cnty 36% 34% 40% 38% 33.5% 32.1% 33.0% 31.1% St. Joseph Health Center 2 St. Charles 42% 42% 46% 44% 35% 33% 11% 12% St. Joseph Hospital - Kirkwood S. St. Louis Cnty 56% 53% 56% 47% 26% 27% 12% 11% St. Joseph West - Lake St. Louis St. Charles 55% 53% 57% 53% 25% 26% 9% 11% St. Mary's Health Center W. St. Louis Cnty 33% 32% 43% 42% 42% 42% 19% 18% SSM Health Care Total 42.6% 41.2% 39.1% 37.6% 29.8% 29.6% 8.9% 9.4% Medicaid Self Pay/Uninsured Missouri Emergent Emergent Urgent Urgent Emergent Emergent Urgent Urgent County Cardinal Glennon Hospital St. Louis City 63% 62% 77% 76% 2% 3% 2% 4% DePaul Health Center N. St. Louis Cnty 19% 18% 33% 31% 12% 16% 17% 21% St. Joseph Health Center 2 St. Charles 13% 13% 29% 27% 10% 12% 14% 18% St. Joseph Hospital - Kirkwood S. St. Louis Cnty 12% 11% 23% 21% 6% 9% 9% 21% St. Joseph West - Lake St. Louis St. Charles 13% 12% 24% 21% 7% 9% 10% 15% St. Mary's Health Center W. St. Louis Cnty 15% 14% 22% 20% 9% 12% 16% 19% SSM Health Care Total 19.1% 18.1% 41.1% 38.4% 8.5% 11.1% 10.9% 14.6% Source: Emergency department visits were self-reported by the hospitals and were not audited. 1 BJC HealthCare could not provide a breakdown of emergent and urgent ED visits. 3 St. Joseph Health Center and St. Joseph Hospital Wenzville began reporting on a combined basis in data for St. Joseph Hospital Wentzville were not available

35 2006 Charity Care Profile BHC BHC Charity MHA MHA Charity Missouri Operating Cost of as a % of Cost of as a % of Missouri Hospital (system name) County Revenue charity 1 op. rev charity 1 op. rev Northeast Regional Medical Center Adair $67,574,802 $44, % $42, % Audrain Medical Center Audrain 62,836, , % 709, % Boone Hospital Center (BJC) Boone 241,768,925 1,790, % 2,704, % Columbia Regional Hospital (U. of MO) Boone 103,764, , % 539, % University of Missouri Hospital and Clinics Boone 400,860,973 6,337, % 6,428, % County Total Boone $746,394,765 $8,671, % $9,672, % Callaway Community Hospital* Callaway 16,367,320 16, % n/a n/a Southeast Missouri Hospital Cape Girardeau 233,887,296 1,169, % 1,053, % St. Francis Medical Center Cape Girardeau 249,595,854 2,108, % 1,882, % County Total Cape Girardeau $483,483,150 $3,278, % $2,936, % Capital Region Medical Center Cole 120,268, , % 769, % St. Mary's Health Center (SSMHC) Cole 144,984,071 1,879, % 1,765, % County Total Cole $265,252,607 $2,634, % $2,534, % Cox Health Systems Greene 691,869,393 6,436, % 6,543, % Ozarks Community Hospital 2 Greene 38,120, , % 160, % St. Johns Regional Health Center (SMHS) Greene 612,730,456 8,910, % 9,260, % County Total Greene $1,342,719,963 $15,508, % $15,964, % Hannibal Regional Hospital Marion 76,731, , % 686, % Perry County Memorial Hospital Perry 26,485,788 33, % 29, % Citizens Memorial Health Care Polk 69,170, , % 130, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 1,158,919,842 18,542, % 23,216, % Barnes-Jewish Hospital - St. Peters St. Charles 108,655, , % 1,195, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 84,293, , % 596, % Christian Hospitals N. St. Louis Cnty 229,163,376 5,323, % 7,082, % Missouri Baptist Hospital - Sullivan Crawford 33,152, , % 1,065, % Missouri Baptist Medical Center W. St. Louis Cnty 340,320,357 2,139, % 3,587, % St. Louis Children's Hospital St. Louis City 330,521,249 2,540, % 3,652, % BJC HealthCare Total $2,285,026,647 $30,539, % $40,396, % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 203,359, , % 930, % DePaul Health Center N. St. Louis Cnty 260,780,898 3,784, % 3,525, % St. Joseph Health Center 3 St. Charles 178,308,733 3,316, % 3,255, % St. Joseph Hospital - Kirkwood S. St. Louis Cnty 97,990,722 1,118, % 1,125, % St. Joseph West - Lake St. Louis St. Charles 92,841,124 1,090, % 1,017, % St. Mary's Health Center W. St. Louis Cnty 258,327,720 3,899, % 3,770, % SSM Health Care Total $1,091,608,745 $14,087, % $13,624, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 637,890,033 9,382, % 8,849, % St. John's Mercy Hospital - Washington Franklin 86,326,656 1,385, % 1,246, % St. John's Mercy Health Care Total $724,216,689 $10,768, % $10,095, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 119,111, , % 357, % St. Louis University Hospital St. Louis City 333,636,564 10,308, % 9,669, % Tenet HealthSystem Total $452,747,750 $10,633, % $10,026, % Independent Forest Park Hospital St. Louis City 85,158, , % 853, % Jefferson Regional Medical Center Jefferson 92,616, , % 592, % Kindred Hospital* St. Louis City 31,892,283 n/a n/a n/a n/a Lincoln County Memorial Hospital Lincoln 25,888, , % 285, % St. Alexius Hospital St. Louis City 86,740, , % 285, % St. Anthony's Medical Center S. St. Louis Cnty 352,813,000 3,353, % 3,167, % St. Luke's Hospital W. St. Louis Cnty 320,783,000 1,765, % 1,795, % St. Louis Area Aggregate $5,549,492,627 $73,214, % $81,123, % * According to the MHA, these hospitals declined to participate in reporting Community Benefit. 1 For a detailed description of the BHF and MHA cost of charity methodologies, see pages On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became a tax-exempt organization. Due to conomic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 3 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center

36 Charity Care as a Percentage of Operating Revenue BHC 2005 BHC 2006 BHC 2004 MHA 2005 MHA 2006 MHA Charity Charity Charity Charity Charity Charity Missouri as a % of as a % of as a % of as a % of as a % of as a % of Missouri Hospital (system name) County op. rev op. rev op. rev op. rev op. rev op. rev Northeast Regional Medical Center* Adair 0.15% 0.00% 0.07% n/a 0.00% 0.06% Audrain Medical Center Audrain 0.73% 1.07% 1.15% 0.69% 1.05% 1.13% Boone Hospital Center (BJC) Boone 0.70% 0.58% 0.74% 0.64% 0.59% 1.12% Columbia Regional Hospital (U. of MO) Boone 1.31% 0.35% 0.52% 0.13% 0.34% 0.52% University of Missouri Hospital and Clinics Boone 2.78% 1.49% 1.58% 1.54% 1.47% 1.60% County Total Boone 1.86% 1.02% 1.16% 1.04% 1.02% 1.30% Callaway Community Hospital* Callaway 0.00% 0.00% 0.10% 0.00% 0.11% n/a Southeast Missouri Hospital Cape Girardeau 0.35% 0.45% 0.50% 0.29% 0.41% 0.45% St. Francis Medical Center Cape Girardeau 0.33% 0.60% 0.84% 0.26% 0.54% 0.75% County Total Cape Girardeau 0.34% 0.53% 0.68% 0.27% 0.48% 0.61% Capital Region Medical Center Cole 0.22% 0.13% 0.63% 0.22% 0.18% 0.64% St. Mary's Health Center (SSMHC) Cole 0.83% 1.31% 1.30% 0.69% 1.27% 1.22% County Total Cole 0.53% 0.75% 0.99% 0.46% 0.75% 0.96% Cox Health Systems Greene 0.17% 0.28% 0.93% 0.15% 0.28% 0.95% Ozarks Community Hospital* 2 Greene 0.32% 0.37% 0.42% n/a n/a 0.42% St. Johns Regional Health Center (SMHS) Greene 1.13% 1.10% 1.45% 1.14% 1.24% 1.51% County Total Greene 0.58% 0.64% 1.15% 0.58% % % Hannibal Regional Hospital Marion 0.61% 0.50% 0.87% 0.58% 0.47% 0.89% Perry County Memorial Hospital Perry 0.04% 0.01% 0.13% 0.04% 0.00% 0.11% Citizens Memorial Health Care Polk 0.49% 0.00% 0.20% n/a 0.00% 0.19% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 2.15% 1.42% 1.60% 0.88% 1.42% 2.00% Barnes-Jewish Hospital - St. Peters St. Charles 0.40% 0.60% 0.89% 0.34% 0.58% 1.10% Barnes-Jewish Hospital - West County W. St. Louis Cnty 0.25% 0.37% 0.37% 0.24% 0.38% 0.71% Christian Hospitals N. St. Louis Cnty 1.79% 1.98% 2.32% 1.48% 1.88% 3.09% Missouri Baptist Hospital - Sullivan Crawford 0.55% 1.93% 2.16% 0.52% 1.87% 3.22% Missouri Baptist Medical Center W. St. Louis Cnty 0.29% 0.49% 0.63% 0.26% 0.50% 1.05% St. Louis Children's Hospital St. Louis City 0.50% 0.70% 0.77% 1.14% 0.67% 1.10% BJC HealthCare Total 1.41% 1.17% 1.34% 0.84% 1.15% 1.77% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 0.33% 0.15% 0.43% 0.24% 0.11% 0.46% DePaul Health Center N. St. Louis Cnty 1.69% 1.90% 1.45% 1.46% 1.46% 1.35% St. Joseph Health Center 3 St. Charles 1.42% 1.62% 1.86% 1.26% 1.25% 1.83% St. Joseph Health Center - Wentzville* 3 St. Charles 1.04% n/a n/a % n/a n/a 3 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 0.52% 1.18% 1.14% 0.46% 0.90% 1.15% St. Joseph West - Lake St. Louis St. Charles 1.16% 1.37% 1.18% 0.97% 1.08% 1.10% St. Mary's Health Center W. St. Louis Cnty 1.78% 1.47% 1.51% 1.78% 1.13% 1.46% SSM Health Care Total 1.24% 1.33% % 1.13% 1.02% % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 0.94% 0.97% 1.47% 1.08% 0.92% 1.39% St. John's Mercy Hospital - Washington Franklin 0.71% 1.00% 1.61% 0.65% 0.91% 1.44% St. John's Mercy Health Care Total 0.92% 0.98% 1.49% 1.03% 0.92% 1.39% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 0.17% 0.11% 0.27% 0.19% 0.11% 0.30% St. Louis University Hospital St. Louis City 1.96% 2.30% 3.09% 1.51% 2.13% 2.90% Tenet HealthSystem Total 1.52% 1.74% 2.35% 1.19% 1.62% 2.21% Independent Forest Park Hospital 4 St. Louis City 0.63% 1.31% 1.01% 0.86% 1.13% 1.00% Jefferson Regional Medical Center Jefferson 0.45% 0.35% 0.64% 1.01% 0.30% 0.64% Kindred Hospital* St. Louis City n/a n/a n/a 0.00% n/a n/a Lincoln County Memorial Hospital Lincoln 0.21% 0.51% 1.18% 0.22% 0.49% 1.10% St. Alexius Hospital 4 St. Louis City 1.26% 0.48% 0.36% 2.25% 0.45% 0.33% St. Anthony's Medical Center S. St. Louis Cnty 0.86% 0.86% 0.95% 0.77% 0.82% 0.90% St. Luke's Hospital W. St. Louis Cnty 0.32% 0.32% 0.55% 0.30% 0.29% 0.56% St. Louis Area Aggregate 1.19% % % % % % 5 * According to the MHA, the following hospitals declined to report for specific years: NE Regional for 2004, Ozarks for 2004 and 2005, Callaway for 2006, St. Jos.-Wentzville for 2005, & Kindred for 2005 and For a detailed description of the BHF and MHA uncompensated care methodologies, see pages See page 33 regarding transfer of ownership of Doctor's Hospital of Springfield (DHS) to Ozarks Community Hospital, Inc. (OCH). 3 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center. See Appendix D for other disclosures prior to St. Alexius and Forest Park hospitals were sold to Doctors Community Healthcare Corporation in 2004, and due to the transfer in ownership, 2004 data could not be verified. 5 When charity care amounts were not available, operating revenues were excluded from percentage totals, unless otherwise noted (see St. Joseph Health Center & St. Joseph - Wentzville). Note: Changes to previously reported data are based on the most current information including numerous restatements. See pages for disclosure of hospital revisions

37 2006 Bad Debt Profile BHC BHC bad debt MHA MHA bad debt Missouri Operating Cost of as a % of Cost of as a % of Missouri Hospital (system name) County Revenue bad debt op. rev bad debt op. rev Northeast Regional Medical Center Adair $67,574,802 $1,924, % $1,860, % Audrain Medical Center Audrain 62,836,212 1,475, % 1,443, % Boone Hospital Center (BJC) Boone $241,768,925 $1,969, % $2,766, % Columbia Regional Hospital (U. of MO) Boone 103,764,867 $1,539, % 1,526, % University of Missouri Hospital and Clinics Boone 400,860,973 12,405, % 12,582, % County Total Boone $746,394,765 $15,914, % $16,876, % Callaway Community Hospital* Callaway $16,367,320 $914, % n/a n/a Southeast Missouri Hospital Cape Girardeau $233,887,296 $7,198, % $6,483, % St. Francis Medical Center Cape Girardeau 249,595,854 7,575, % 6,763, % County Total Cape Girardeau $483,483,150 $14,774, % $13,246, % Capital Region Medical Center Cole $120,268,536 $2,426, % $2,472, % St. Mary's Health Center (SSMHC) Cole 144,984,071 3,994, % 3,750, % County Total Cole $265,252,607 $6,421, % $6,222, % Cox Health Systems Greene $691,869,393 $23,302, % $23,689, % Ozarks Community Hospital 1 Greene 38,120,114 2,378, % 1,709, % St. Johns Regional Health Center (SMHS) Greene 612,730,456 20,725, % 21,539, % County Total Greene $1,342,719,963 $46,405, % $46,939, % Hannibal Regional Hospital Marion $76,731,535 $2,037, % $2,038, % Perry County Memorial Hospital Perry 26,485, , % 638, % Citizens Memorial Health Care Polk 69,170,759 3,123, % 2,995, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $1,158,919,842 $23,047, % $28,493, % Barnes-Jewish Hospital - St. Peters St. Charles 108,655,438 2,144, % 2,944, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 84,293, , % 1,366, % Christian Hospitals N. St. Louis Cnty 229,163,376 7,939, % 11,613, % Missouri Baptist Hospital - Sullivan Crawford 33,152,839 1,813, % 2,421, % Missouri Baptist Medical Center W. St. Louis Cnty 340,320,357 2,259, % 3,986, % St. Louis Children's Hospital St. Louis City 330,521,249 2,063, % 2,650, % BJC HealthCare Total $2,285,026,647 $40,107, % $53,477, % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City $203,359,548 $496, % $527, % DePaul Health Center N. St. Louis Cnty 260,780,898 10,604, % 9,878, % St. Joseph Health Center 2 St. Charles 178,308,733 4,771, % 4,705, % St. Joseph Hospital - Kirkwood S. St. Louis Cnty 97,990,722 1,453, % 1,463, % St. Joseph West - Lake St. Louis St. Charles 92,841,124 3,071, % 2,865, % St. Mary's Health Center W. St. Louis Cnty 258,327,720 6,651, % 6,430, % SSM Health Care Total $1,091,608,745 $27,050, % $25,869, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $637,890,033 $10,483, % $9,887, % St. John's Mercy Hospital - Washington Franklin 86,326,656 2,525, % 2,271, % St. John's Mercy Health Care Total $724,216,689 $13,008, % $12,159, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $119,111,186 $587, % $644, % St. Louis University Hospital St. Louis City 333,636,564 5,297, % 13,806, % Tenet HealthSystem Total $452,747,750 $5,885, % $14,451, % Independent Forest Park Hospital St. Louis City $85,158,550 $3,885, % $3,846, % Jefferson Regional Medical Center Jefferson 92,616,379 2,707, % 2,787, % Kindred Hospital* St. Louis City 31,892,283 24, % n/a n/a Lincoln County Memorial Hospital Lincoln 25,888, , % 779, % St. Alexius Hospital St. Louis City 86,740,747 5,544, % 5,131, % St. Anthony's Medical Center S. St. Louis Cnty 352,813,000 5,862, % 5,748, % St. Luke's Hospital W. St. Louis Cnty 320,783,000 2,610, % 2,714, % St. Louis Area Aggregate $5,549,492,627 $107,522, % $126,966, % * According to the MHA, these hospitals declined to participate in reporting Community Benefit. 1 On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became a tax-exempt organization. Due to conomic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 2 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center

38 Bad Debt as a Percentage of Operating Revenue BHC 2005 BHC 2006 BHC 2004 MHA 2005 MHA 2006 MHA Bad Debt Bad Debt Bad Debt Bad Debt Bad Debt Bad Debt Missouri as a % of as a % of as a % of as a % of as a % of as a % of Missouri Hospital (system name) County op. rev op. rev op. rev op. rev op. rev op. rev Northeast Regional Medical Center* Adair 1.75% 1.65% 2.85% n/a 1.47% 2.75% Audrain Medical Center Audrain 1.78% 2.49% 2.35% 1.69% 2.44% 2.30% Boone Hospital Center (BJC) Boone 1.07% 0.97% 0.81% 0.99% 0.99% 1.14% Columbia Regional Hospital (U. of MO) Boone 1.27% 1.39% 1.48% 1.16% 1.36% 1.47% University of Missouri Hospital and Clinics Boone 2.37% 2.82% 3.09% 1.98% 2.80% 3.14% County Total Boone 1.77% 2.01% 2.13% 1.53% 1.99% 2.26% Callaway Community Hospital* Callaway 4.82% 4.16% 5.59% 8.88% 4.02% n/a Southeast Missouri Hospital Cape Girardeau 3.29% 3.22% 3.08% 2.75% 2.89% 2.77% St. Francis Medical Center Cape Girardeau 3.07% 2.92% 3.03% 2.38% 2.64% 2.71% County Total Cape Girardeau 3.17% 3.07% 3.06% 2.56% 2.76% 2.74% 4 Capital Region Medical Center Cole 1.62% 1.69% 2.02% 1.64% 1.62% 2.06% St. Mary's Health Center (SSMHC) Cole 1.90% 1.23% 2.76% 1.59% 1.19% 2.59% County Total Cole 1.76% 1.45% 2.42% 1.61% 1.40% 2.35% Cox Health Systems Greene 3.13% 2.86% 3.37% 1.85% 2.81% 3.42% Ozarks Community Hospital* 1 Greene 4.07% 3.90% 6.24% n/a n/a 4.49% St. Johns Regional Health Center (SMHS) Greene 2.93% 3.09% 3.38% 3.54% 3.47% 3.52% County Total Greene 3.07% 3.00% 3.46% 2.58% % % Hannibal Regional Hospital Marion 2.69% 2.44% 2.66% 2.56% 2.29% 2.66% Perry County Memorial Hospital Perry 2.53% 2.82% 2.75% 2.27% 2.54% 2.41% Citizens Memorial Health Care Polk 1.95% 3.15% 4.52% 2.01% 3.01% 4.33% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 1.75% 1.75% 1.99% 1.62% 1.75% 2.46% Barnes-Jewish Hospital - St. Peters St. Charles 1.88% 2.06% 1.97% 1.59% 2.00% 2.71% Barnes-Jewish Hospital - West County W. St. Louis Cnty 1.00% 1.09% 1.00% 0.94% 1.11% 1.62% Christian Hospitals N. St. Louis Cnty 3.04% 3.42% 3.46% 2.56% 3.25% 5.07% Missouri Baptist Hospital - Sullivan Crawford 2.98% 3.05% 5.47% 2.82% 2.95% 7.30% Missouri Baptist Medical Center W. St. Louis Cnty 0.56% 0.58% 0.66% 0.50% 0.60% 1.17% St. Louis Children's Hospital St. Louis City 0.48% 0.52% 0.62% 0.43% 0.50% 0.80% BJC HealthCare Total 1.54% 1.59% 1.76% 1.38% 1.57% 2.34% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 0.18% 0.70% 0.24% 0.13% 0.64% 0.26% DePaul Health Center N. St. Louis Cnty 2.43% 2.52% 4.07% 2.00% 1.78% 3.79% St. Joseph Health Center 2 St. Charles 1.77% 2.27% 2.68% 1.51% 1.77% 2.64% St. Joseph Health Center - Wentzville* 2 St. Charles 4.03% n/a n/a % n/a n/a 2 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 1.16% 1.16% 1.48% 1.01% 0.78% 1.49% St. Joseph West - Lake St. Louis St. Charles 1.59% 2.56% 3.31% 1.29% 1.92% 3.09% St. Mary's Health Center W. St. Louis Cnty 1.14% 1.62% 2.57% 1.06% 1.22% 2.49% SSM Health Care Total 1.45% 1.80% % 1.18% 1.35% % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 1.73% 1.82% 1.64% 1.88% 1.71% 1.55% St. John's Mercy Hospital - Washington Franklin 3.05% 3.00% 2.93% 2.82% 2.72% 2.63% St. John's Mercy Health Care Total 1.88% 1.95% 1.80% 1.99% 1.83% 1.68% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 0.90% 0.93% 0.49% 0.78% 0.92% 0.54% St. Louis University Hospital St. Louis City 3.03% 2.18% 1.59% 3.27% 3.61% 4.14% Tenet HealthSystem Total 2.51% 1.86% 1.30% 2.67% 2.92% 3.19% Independent Forest Park Hospital 3 St. Louis City 2.77% 4.91% 4.56% 4.67% 4.25% 4.52% Jefferson Regional Medical Center Jefferson 2.86% 3.18% 2.92% 2.88% 2.76% 3.01% Kindred Hospital* St. Louis City 0.00% 0.51% 0.08% 1.49% n/a n/a Lincoln County Memorial Hospital Lincoln 3.14% 3.17% 3.23% 3.25% 3.02% 3.01% St. Alexius Hospital 3 St. Louis City 3.64% 5.29% 6.39% 3.69% 4.92% 5.92% St. Anthony's Medical Center S. St. Louis Cnty 1.45% 1.53% 1.66% 1.33% 1.47% 1.63% St. Luke's Hospital W. St. Louis Cnty 0.80% 0.79% 0.81% 0.69% 0.74% 0.85% St. Louis Area Aggregate 1.69% 1.82% % 1.63% 1.76% % 4 * According to the MHA, the following hospitals declined to report for specific years: NE Regional for 2004, Ozarks for 2004 and 2005, Callaway for 2006, St. Jos.-Wentzville for 2005, & Kindred for 2005 and See page 33 regarding transfer of ownership of Doctor's Hospital of Springfield (DHS) to Ozarks Community Hospital, Inc. (OCH). 2 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center. See pages for other disclosures prior to St. Alexius and Forest Park hospitals were sold to Doctors Community Healthcare Corporation in 2004, and due to the transfer in ownership, 2004 data could not be verified. 4 When bad debt amounts were not available, operating revenues were excluded from percentage totals, unless otherwise noted (see St. Joseph Health Center & St. Joseph - Wentzville), Note: Changes to previously reported data are based on the most current information including numerous restatements. See pages for disclosure of hospital revisions

39 Uncompensated Care as a Percentage of Operating Expense BHC 2005 BHC 2006 BHC 2004 MHA 2005 MHA 2006 MHA Uncompensated Uncompensated Uncompensated Uncompensated Uncompensated Uncompensated Missouri Care as % of Care as % of Care as % of Care as % of Care as % of Care as % of Missouri Hospital (system name) County oper. expense. 1 oper. expense. 1 oper. expense. 1 oper. expense. 1 oper. expense. 1 oper. expense. 1 Northeast Regional Medical Center Adair 2.1% 1.8% 3.3% N/A 1.6% 3.1% Audrain Medical Center Audrain 2.5% 3.2% 3.5% 2.3% 3.1% 3.4% Boone Hospital Center (BJC) Boone 1.9% 1.7% 1.7% 1.8% 1.7% 2.5% Columbia Regional Hospital (U. of MO) Boone 2.5% 1.7% 2.6% 1.3% 1.7% 1.9% University of Missouri Hospital and Clinics Boone 5.7% 4.8% 5.3% 3.9% 4.7% 5.3% County Total Boone 3.9% 3.3% 3.7% 2.8% 3.3% 3.9% Callaway Community Hospital* Callaway 4.7% 4.7% 5.7% 8.7% 4.7% n/a Southeast Missouri Hospital Cape Girardeau 3.8% 3.8% 3.8% 3.2% 3.4% 3.5% St. Francis Medical Center Cape Girardeau 3.7% 3.8% 4.3% 2.9% 3.5% 3.8% County Total Cape Girardeau 3.8% 3.8% 4.1% 3.0% 3.4% 3.6% Capital Region Medical Center Cole 1.9% 1.9% 2.7% 1.9% 1.9% 2.7% St. Mary's Health Center (SSMHC) Cole 2.8% 2.5% 3.9% 2.3% 2.4% 3.6% County Total Cole 2.3% 2.2% 3.3% 2.1% 2.2% 3.2% Cox Health Systems Greene 3.4% 3.2% 4.3% 2.1% 3.1% 4.4% Ozarks Community Hospital 2 Greene 5.3% 4.5% 6.3% n/a n/a 4.6% St. Johns Regional Health Center (SJMHC) Greene 4.4% 4.7% 5.2% 5.1% 5.2% 5.4% County Total Greene 3.9% 3.8% 4.8% 3.3% 4.0% 4.9% Hannibal Regional Hospital Marion 3.3% 3.1% 3.8% 3.1% 2.9% 3.8% Perry County Memorial Hospital Perry 2.9% 3.1% 3.0% 2.6% 2.8% 2.6% Citizens Memorial Health Care Polk 2.4% 3.0% 4.7% 1.9% 2.9% 4.5% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 4.0% 3.3% 3.7% 2.6% 3.3% 4.6% Barnes-Jewish Hospital - St. Peters St. Charles 2.6% 3.1% 3.3% 2.2% 3.0% 4.4% Barnes-Jewish Hospital - West County W. St. Louis Cnty 1.6% 1.7% 1.7% 1.5% 1.8% 2.9% Christian Hospitals N. St. Louis Cnty 5.1% 5.5% 5.5% 4.2% 5.2% 7.8% Missouri Baptist Hospital - Sullivan Crawford 4.1% 5.5% 7.7% 3.8% 5.4% 10.6% Missouri Baptist Medical Center W. St. Louis Cnty 1.0% 1.2% 1.4% 0.9% 1.3% 2.4% St. Louis Children's Hospital St. Louis City 1.1% 1.4% 1.5% 1.7% 1.3% 2.1% BJC HealthCare Total 3.2% 3.0% 3.3% 2.4% 2.9% 4.3% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 0.6% 0.9% 0.8% 0.4% 0.8% 0.8% DePaul Health Center N. St. Louis Cnty 4.3% 4.8% 5.5% 3.6% 3.5% 5.1% St. Joseph Health Center 3 St. Charles 3.2% 3.9% 4.5% 2.8% 3.1% 4.5% St. Joseph Health Center - Wentzville 3 St. Charles 4.1% n/a n/a n/a n/a n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty 1.7% 2.1% 2.4% 1.5% 1.5% 2.4% St. Joseph West - Lake St. Louis St. Charles 2.8% 4.2% 4.6% 2.3% 3.2% 4.3% St. Mary's Health Center W. St. Louis Cnty 3.1% 3.3% 4.2% 3.0% 2.5% 4.1% SSM Health Care Total 2.8% 3.3% 3 3.9% 2.4% 3 2.5% 3 3.7% St. John's Mercy Health Care (SJMHC) St. John's Mercy Medical Center W. St. Louis Cnty 2.8% 2.8% 3.3% 3.1% 2.7% 3.1% St. John's Mercy Hospital - Washington Franklin 3.9% 4.1% 4.8% 3.6% 3.7% 4.3% St. John's Mercy Health Care Total 2.9% 3.0% 3.5% 3.1% 2.8% 3.3% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 1.2% 1.1% 0.9% 1.1% 1.1% 1.0% St. Louis University Hospital St. Louis City 4.7% 4.2% 4.7% 4.5% 5.3% 7.0% Tenet HealthSystem Total 3.9% 3.5% 3.8% 3.8% 4.4% 5.6% Independent Forest Park Hospital 4 St. Louis City 2.7% 5.9% 5.4% 4.4% 5.1% 5.4% Jefferson Regional Medical Center Jefferson 3.3% 3.6% 3.6% 3.9% 3.1% 3.5% Kindred Hospital* St. Louis City n/a n/a 0.1% 1.9% n/a n/a Lincoln County Memorial Hospital Lincoln 3.4% 3.5% 4.3% 3.5% 3.3% 4.0% St. Alexius Hospital 4 St. Louis City 4.5% 5.8% 6.8% 5.5% 5.4% 6.3% St. Anthony's Medical Center S. St. Louis Cnty 2.4% 2.4% 2.7% 2.1% 2.3% 2.6% St. Luke's Hospital W. St. Louis Cnty 1.2% 1.1% 1.4% 1.0% 1.1% 1.5% St. Louis Area Aggregate 3.0% 5 3.1% 3 3.4% 2.7% 3 2.9% 3,4 3.9% 5 * According to the MHA, Callaway Community Hospital declined to participate in reporting for 2006 and Kindred Hospital declined to participate in reporting for 2005 and For a detailed description of the BHF and MHA uncompensated care methodologies, see pages See page 33 regarding transfer of ownership of Doctor's Hospital of Springfield (DHS) to Ozarks Community Hospital, Inc. (OCH). 3 St. Joseph-Wentzville (formerly Crossroads Reg. Hosp.) did not report to MHA in 2004 or to MHA or BHF in 2005 and They merged with SSM in 11/05 & 2006 data is combined with St. Joseph Health Ct 4 St. Alexius and Forest Park hospitals were sold to Doctors Community Healthcare Corporation in 2004, and due to the transfer in ownership, 2004 data could not be verified. 5 Operating revenue for Kindred Hospital was excluded from these figures since the hospital did not report charity care to BHF in 2004 and 2005 or to MHA in 2005 and

40 Fiscal Year 2006 Financial Data (000) (in thousands) Missouri Total Total Gain from Net Operating Profit Missouri Hospital (system name) County Revenue Expenses* Operations Profit margin margin Northeast Regional Medical Center Adair $67,575 $60,484 7,118 7, % 10.49% Audrain Medical Center Audrain 63,301 63, % 0.14% Boone Hospital Center (BJC) Boone 243, ,496 21,991 12, % 5.26% Columbia Regional Hospital (U. of MO) Boone 104, ,630-2,722-1, % -1.81% University of Missouri Hospital and Clinics Boone 403, ,169 45,087 41, % 10.24% County Total Boone $751,509 $699,295 $64,356 $52, % 6.95% Callaway Community Hospital Callaway 16,367 16, % 0.58% Southeast Missouri Hospital Cape Girardeau 237, ,794 16,093 19, % 8.18% St. Francis Medical Center Cape Girardeau 260, ,834 23,762 34, % 13.29% County Total Cape Girardeau $497,638 $443,628 $39,855 $54, % 10.85% Capital Region Medical Center Cole 121, ,646 1,691 2, % 2.41% St. Mary's Health Center (SSMHC) Cole 144, ,386-7,376-7, % -5.15% County Total Cole $266,499 $271,032 -$5,685 -$4, % -1.70% Cox Health Systems Greene 716, ,662 6,207 17, % 2.47% Ozarks Community Hospital 1 Greene 38,154 40,468-2,348-2, % -6.07% St. Johns Regional Health Center (SMHS) Greene 612, ,995 44,741 44, % 7.30% County Total Greene $1,367,229 $1,307,126 $48,600 $60, % 4.40% Hannibal Regional Hospital Marion 79,808 72,488 5,607 7, % 9.17% Perry County Memorial Hospital Perry 26,509 25, % 3.74% Citizens Memorial Health Care Polk 69,601 69, % 0.01% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 1,277,276 1,117,611 41, , % 12.50% Barnes-Jewish Hospital - St. Peters St. Charles 112,003 95,810 15,424 16, % 14.46% Barnes-Jewish Hospital - West County W. St. Louis Cnty 84,838 75,497 15,448 9, % 11.01% Christian Hospitals N. St. Louis Cnty 246, ,749-10,045 3, % 1.52% Missouri Baptist Hospital - Sullivan Crawford 33,153 33, % -0.38% Missouri Baptist Medical Center W. St. Louis Cnty 355, ,927 27,394 42, % 12.06% St. Louis Children's Hospital St. Louis City 349, ,514 33,126 52, % 14.94% BJC HealthCare Total $2,459,368 $2,175,385 $123,085 $283, % 11.55% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 209, ,027 28,333 34, % 16.38% DePaul Health Center N. St. Louis Cnty 260, , % -0.16% St. Joseph Health Center 2 St. Charles 177, , % -0.35% St. Joseph Hospital - Kirkwood S. St. Louis Cnty 97, ,746-7,755-8, % -8.79% St. Joseph West - Lake St. Louis St. Charles 92,223 90,084 2,757 2, % 2.32% St. Mary's Health Center W. St. Louis Cnty 262, ,455 6,873 11, % 4.23% SSM Health Care Total $1,098,937 $1,060,991 $30,618 $37, % 3.45% St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 638, ,551 37,892 37, % 5.89% St. John's Mercy Hospital - Washington Franklin 86,342 81,436 4,448 4, % 5.68% St. John's Mercy Health Care Total $724,492 $681,987 $42,340 $42, % 5.87% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 119, ,619 14,454 7, % 6.29% St. Louis University Hospital St. Louis City 333, ,118-1,481-1, % -0.44% Tenet HealthSystem Total $452,748 $446,737 $12,973 $6, % 1.33% Independent Forest Park Hospital St. Louis City 85,159 87,433-2,282-2, % -2.67% Jefferson Regional Medical Center Jefferson 94,200 91,237 1,379 2, % 3.14% Kindred Hospital St. Louis City 31,902 29,615 2,278 2, % 7.17% Lincoln County Memorial Hospital Lincoln 28,621 26, , % 7.07% St. Alexius Hospital St. Louis City 86,741 85, % 1.05% St. Anthony's Medical Center S. St. Louis Cnty 364, ,404 6,409 18, % 5.08% St. Luke's Hospital W. St. Louis Cnty 331, ,695 10,088 21, % 6.36% * Total expenses include non-operating expenses that may have an effect on profit margins. Non-operating expenses are not used in the calculation of operating margins. 1 On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became a tax-exempt organization. Due to economic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 2 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center

41 Operating Margin Trends Missouri Hospital (system name) Missouri County Northeast Regional Medical Center Adair 8.42% 8.82% 10.53% Audrain Medical Center Audrain -2.49% % -0.60% Boone Hospital Center (BJC) Boone 8.87% 7.40% 9.10% Columbia Regional Hospital (U. of MO) Boone -2.63% 0.38% -2.62% University of Missouri Hospital and Clinics Boone 9.89% 9.73% 11.25% County Total Boone 7.84% 7.59% 8.62% Callaway Community Hospital Callaway -1.69% 11.55% 0.58% Southeast Missouri Hospital Cape Girardeau 4.73% 3.04% 6.88% St. Francis Medical Center Cape Girardeau 7.94% 8.43% 9.52% County Total Cape Girardeau 6.41% 5.85% 8.24% Capital Region Medical Center Cole 2.98% 3.94% 1.41% St. Mary's Health Center (SSMHC) Cole 0.63% -0.55% -5.09% County Total Cole 1.77% 1.59% -2.14% Cox Health Systems Greene 2.73% 0.32% 0.90% Ozarks Community Hospital 1 Greene 16.67% 4.03% -6.16% St. Johns Regional Health Center (SMHS) Greene 8.45% 9.73% 7.30% County Total Greene 5.51% 4.47% 3.62% Hannibal Regional Hospital Marion -0.23% 4.95% 7.31% Perry County Memorial Hospital Perry 11.24% 7.64% 3.66% Citizens Memorial Health Care Polk -3.34% -4.01% -0.62% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 3.58% 3.75% 3.59% Barnes-Jewish Hospital - St. Peters St. Charles 13.04% 14.13% 14.19% Barnes-Jewish Hospital - West County W. St. Louis Cnty 23.29% 16.05% 18.33% Christian Hospitals N. St. Louis Cnty 4.78% 0.88% -4.38% Missouri Baptist Hospital - Sullivan Crawford 13.10% 10.18% 0.44% Missouri Baptist Medical Center W. St. Louis Cnty 15.36% 12.38% 8.05% St. Louis Children's Hospital St. Louis City 8.23% 10.08% 10.02% BJC HealthCare Total 7.56% 6.68% 5.39% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 14.16% 11.43% 13.93% DePaul Health Center N. St. Louis Cnty 4.88% 7.55% 0.11% St. Joseph Health Center 2 St. Charles 1.27% 1.29% 0.07% St. Joseph Hospital - Wentzville 2 St. Charles % % n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty -0.99% % -7.91% St. Joseph West - Lake St. Louis St. Charles 3.15% 5.82% 2.97% St. Mary's Health Center W. St. Louis Cnty 5.57% 7.00% 2.66% SSM Health Care Total 4.91% 3.68% 2.80% St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 3.67% 1.73% 5.94% St. John's Mercy Hospital - Washington Franklin 3.88% 3.25% 5.15% St. John's Mercy Health Care Total 3.70% 1.90% 5.85% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 8.06% 7.33% 12.13% St. Louis University Hospital St. Louis City -5.82% -7.86% -0.44% Tenet HealthSystem Total -2.44% -3.98% 2.87% Independent Forest Park Hospital St. Louis City % -6.03% -2.68% Jefferson Regional Medical Center Jefferson -0.66% 0.73% 1.49% Kindred Hospital St. Louis City 19.60% 7.63% 7.14% Lincoln County Memorial Hospital Lincoln -0.05% -5.19% -2.74% St. Alexius Hospital St. Louis City -8.23% 0.49% 1.05% St. Anthony's Medical Center S. St. Louis Cnty 2.06% 1.51% 1.82% St. Luke's Hospital W. St. Louis Cnty 3.37% 3.13% 3.14% St. Louis Area Aggregate 4.06% 3.58% 4.09% 1 On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became a tax-exempt organization. Due to economic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 2 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center. Note: Changes in previously reported data are based on the most current information including numerous restatements

42 Profit Margin Trends Missouri Hospital (system name) Missouri County Northeast Regional Medical Center Adair 8.42% 8.78% 10.49% Audrain Medical Center Audrain -2.41% -4.31% 0.14% Boone Hospital Center (BJC) Boone 3.59% 1.00% 5.26% Columbia Regional Hospital (U. of MO) Boone -2.41% 1.38% -1.81% University of Missouri Hospital and Clinics Boone 10.49% 9.07% 10.24% County Total Boone 6.37% 5.30% 6.95% Callaway Community Hospital Callaway -1.69% 12.77% 0.58% Southeast Missouri Hospital Cape Girardeau 5.32% 3.95% 8.18% St. Francis Medical Center Cape Girardeau 13.50% 11.78% 13.29% County Total Cape Girardeau 9.70% 8.08% 10.85% Capital Region Medical Center Cole 3.32% 4.69% 2.41% St. Mary's Health Center (SSMHC) Cole 0.61% -0.45% -5.15% County Total Cole 1.93% 2.02% -1.70% Cox Health Systems Greene 5.66% 0.45% 2.47% Ozarks Community Hospital 1 Greene 16.48% 4.13% -6.07% St. Johns Regional Health Center (SMHS) Greene 8.45% 9.73% 7.30% County Total Greene 7.09% 4.50% 4.40% Hannibal Regional Hospital Marion 1.47% 6.07% 9.17% Perry County Memorial Hospital Perry 11.25% 7.71% 3.74% Citizens Memorial Health Care Polk -3.10% -3.71% 0.01% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 11.58% 7.11% 12.50% Barnes-Jewish Hospital - St. Peters St. Charles 14.35% 13.63% 14.46% Barnes-Jewish Hospital - West County W. St. Louis Cnty 16.02% 15.42% 11.01% Christian Hospitals N. St. Louis Cnty 8.73% 2.23% 1.52% Missouri Baptist Hospital - Sullivan Crawford 11.11% 10.05% -0.38% Missouri Baptist Medical Center W. St. Louis Cnty 17.08% 13.77% 12.06% St. Louis Children's Hospital St. Louis City 15.19% 14.65% 14.94% BJC HealthCare Total 12.86% 9.30% 11.55% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 16.04% 13.77% 16.38% DePaul Health Center N. St. Louis Cnty 4.87% 7.81% -0.16% St. Joseph Health Center 2 St. Charles 1.21% 1.32% -0.35% St. Joseph Hospital - Wentzville 2 St. Charles % % n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty -0.74% % -8.79% St. Joseph West - Lake St. Louis St. Charles 2.92% 5.76% 2.32% St. Mary's Health Center W. St. Louis Cnty 6.86% 8.15% 4.23% SSM Health Care Total 5.62% 4.50% 3.45% St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 3.37% 1.79% 5.89% St. John's Mercy Hospital - Washington Franklin 3.82% 3.48% 5.68% St. John's Mercy Health Care Total 3.43% 1.98% 5.87% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 4.18% 3.29% 6.29% St. Louis University Hospital St. Louis City -5.82% -7.86% -0.44% Tenet HealthSystem Total -3.38% -5.01% 1.33% Independent Forest Park Hospital St. Louis City % -6.03% -2.67% Jefferson Regional Medical Center Jefferson 0.45% 2.01% 3.14% Kindred Hospital St. Louis City 19.64% 7.66% 7.17% Lincoln County Memorial Hospital Lincoln 0.05% 3.20% 7.07% St. Alexius Hospital St. Louis City -8.23% 0.49% 1.05% St. Anthony's Medical Center S. St. Louis Cnty 7.79% 6.40% 5.08% St. Luke's Hospital W. St. Louis Cnty 4.06% 4.20% 6.36% St. Louis Area Aggregate 6.89% 5.24% 7.22% 1 On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became a tax-exempt organization. Due to economic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 2 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center. Note: Changes in previously reported data are based on the most current information including numerous restatements

43 Total Reserves and Debt-to-Equity Ratios 2004 to Fund Fund Fund 2004 Debt 2005 Debt 2006 Debt Missouri Balance 1 Balance 1 Balance 1 to Equity to Equity to Equity Missouri Hospital (system name) County (in millions) (in millions) (in millions) Ratio Ratio Ratio Northeast Regional Medical Center Adair $19 $24 $ Audrain Medical Center Audrain Boone Hospital Center (BJC) Boone Columbia Regional Hospital (U. of MO) Boone University of Missouri Hospital and Clinics Boone County Total Boone $188 $228 $ Callaway Community Hospital Callaway Southeast Missouri Hospital Cape Girardeau St. Francis Medical Center Cape Girardeau County Total Cape Girardeau $263 $297 $ Capital Region Medical Center Cole St. Mary's Health Center (SSMHC) Cole County Total Cole $103 $108 $ Cox Health Systems Greene Ozarks Community Hospital 2 Greene St. Johns Regional Health Center (SMHS) Greene County Total Greene $742 $790 $ Hannibal Regional Hospital Marion Perry County Memorial Hospital Perry Citizens Memorial Health Care Polk St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $1,102 $1,181 $1, Barnes-Jewish Hospital - St. Peters St. Charles Barnes-Jewish Hospital - West County W. St. Louis Cnty Christian Hospitals N. St. Louis Cnty Missouri Baptist Hospital - Sullivan Crawford Missouri Baptist Medical Center W. St. Louis Cnty St. Louis Children's Hospital St. Louis City BJC HealthCare Total $1,899 $2,126 $2, SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City DePaul Health Center N. St. Louis Cnty St. Joseph Health Center 3 St. Charles St. Joseph Health Center - Wentzville 3 St. Charles n/a n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty St. Joseph West - Lake St. Louis St. Charles St. Mary's Health Center W. St. Louis Cnty SSM Health Care Total $391 $417 $ St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty St. John's Mercy Hospital - Washington Franklin St. John's Mercy Health Care Total $332 $398 $ Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty St. Louis University Hospital St. Louis City Tenet HealthSystem Total $120 $136 $ Independent Forest Park Hospital St. Louis City Jefferson Regional Medical Center Jefferson Kindred Hospital* St. Louis City Lincoln County Memorial Hospital Lincoln St. Alexius Hospital St. Louis City St. Anthony's Medical Center S. St. Louis Cnty St. Luke's Hospital W. St. Louis Cnty St. Louis Area Aggregate $3,300 $3,656 $4, Source: Medicare Cost Reports and audited financial statements. Fund Balances represent unrestricted hospital reserves. All figures are in millions of dollars. 2 On January 1, 2008, Doctor's Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH) a non-profit corporation when OCH became a tax-exempt organization. Due to conomic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously doing business as (dba) DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to "dba" OCH. 3 St. Joseph Hospital-Wentzville was acquired by SSM in 2005 and, in 2006, reported on a combined basis with St. Joseph Health Center

44 2006 Capacity Levels and Productivity Missouri Avail. Patient Avail. Avg. FTE per Missouri Hospital (system name) County beds days Discharges occup. % LOS occup. bed Northeast Regional Medical Center Adair ,903 3, % Audrain Medical Center Audrain 92 15,672 4, % Boone Hospital Center (BJC) Boone ,401 17, % Columbia Regional Hospital (U. of MO) Boone ,404 7, % University of Missouri Hospital and Clinics Boone ,419 13, % County Total Boone ,224 38, % Callaway Community Hospital Callaway 49 4,734 1, % Southeast Missouri Hospital Cape Girardeau ,639 11, % St. Francis Medical Center Cape Girardeau ,778 10, % County Total Cape Girardeau ,417 21, % Capital Region Medical Center Cole ,683 7, % St. Mary's Health Center (SSMHC) Cole ,812 10, % County Total Cole ,495 18, % Cox Health Systems Greene ,102 30, % Ozarks Community Hospital 1 Greene 45 8,240 1, % St. Johns Regional Health Center (SMHS) Greene ,848 34, % County Total Greene 1, ,190 66, % Hannibal Regional Hospital Marion ,198 5, % Perry County Memorial Hospital Perry 25 4, % Citizens Memorial Health Care Polk 74 15,289 3, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 1, ,989 53, % Barnes-Jewish Hospital - St. Peters St. Charles ,498 7, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 67 16,237 3, % Christian Hospitals N. St. Louis Cnty ,397 14, % Missouri Baptist Hospital - Sullivan Crawford 56 7,731 1, % Missouri Baptist Medical Center W. St. Louis Cnty ,462 21, % St. Louis Children's Hospital St. Louis City ,262 11, % BJC HealthCare Total 2, , , % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City ,264 6, % DePaul Health Center N. St. Louis Cnty ,127 22, % St. Joseph Health Center 2 St. Charles ,805 14, % St. Joseph Hospital - Kirkwood S. St. Louis Cnty ,772 8, % St. Joseph West - Lake St. Louis St. Charles ,643 7, % St. Mary's Health Center W. St. Louis Cnty ,016 22, % SSM Health Care Total 1, ,627 83, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty ,972 39, % St. John's Mercy Hospital - Washington Franklin ,850 6, % St. John's Mercy Health Care Total 1, ,822 45, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty ,960 9, % St. Louis University Hospital St. Louis City ,963 14, % Tenet HealthSystem Total ,923 23, % Independent Forest Park Hospital St. Louis City ,472 5, % Jefferson Regional Medical Center Jefferson ,810 9, % Kindred Hospital St. Louis City 94 21, % Lincoln County Memorial Hospital Lincoln 25 5,724 1, % St. Alexius Hospital St. Louis City ,244 8, % St. Anthony's Medical Center S. St. Louis Cnty ,451 28, % St. Luke's Hospital W. St. Louis Cnty ,856 18, % St. Louis Area Aggregate 7,841 1,694, , % See page 71 regarding transfer of ownership of Doctor's Hospital of Springfield (DHS) to Ozarks Community Hospital, Inc. (OCH). 2 Beginning in 2006, St. Joseph Health Center and St. Joseph Hospital-Wentzville reported on a combined basis. Note: St. Louis Area Aggregate ALOS excludes Kindred Hospital since it is a long-term acute care facility

45 Phase III Appendix B Data Sources Data for this report were gathered from a variety of sources including hospital audited financial statements, MHA/AHA Annual Licensing Surveys, AHA Trendwatch Chartbook, Centers for Medicare and Medicaid Services (CMS) Medicare Cost Reports (MCR), Health Affairs, the Missouri Department of Health and Senior Services (DHSS), the Missouri Hospital Association (MHA), OSEDA, hospital self-reported emergency department (ED) visits and ED visit estimates by ThomsonReuters. Information on charity care and bad debt expense were obtained from DHSS, MHA/AHA Annual Licensing Surveys, the MHA website, and internal accounting documents provided by individual hospitals. BHF Methods BHF s analysis focuses on non-government, acute-care general hospitals to achieve better comparability across facilities. As a result, the following types of facilities are excluded: Government hospitals (e.g., Veterans administration hospitals, Army hospitals) Psychiatric only hospitals Rehabilitation only hospitals Prison hospitals State institutions Nursing homes, skilled nursing, and longterm care facilities Charity care and bad debt amounts obtained from DHSS and MHA/AHA Annual Licensing Surveys are reported at full established rates (billed charge). Information provided by these sources is based on the AICPA Audits of Providers of Health Care Services and reflect standard accounting assumptions and procedures. All other financial measures presented in this report follow the same standard accounting assumptions and procedures. BHF charity care and bad debt expense are reported at cost by multiplying the billed charge amount by the global cost-to-charge ratio. Although beyond the scope of this report, fair assessment of a hospital s charitable commitment also includes evaluation of case-mix (especially as it relates to the Medicaid population), and other charitable programs in which significant allowances and discounts are provided. A financial and utilization profile is produced and each hospital is given the opportunity to verify its data. When an individual institution disagrees with the profile, supporting documentation is required to be submitted before changes are made. From the indivual reports, tables are produced reflecting information on charity care, bad debt, and public program utilization, and summary tables of key capacity, financial, and productivity indicators for hospitals in the following Missouri cities and counties: Cape Girardeau (Bollinger and Cape Girardeau counties) Columbia (Boone and Howard counties) Hannibal (Marion and Ralls counties) Jefferson City (Callaway, Cole, Moniteau, and Osage counties) Kirksville (Adair and Schuyler counties) Mexico (Audrain county) Perryville (Perry county) St. Louis metropolitan area (Missouri hospitals only) Springfield (Christian, Dallas, Greene, Polk, and Webster counties) 45

46 BHF has made every effort to provide accurate information. As with any analysis of healthcare industry data, a note of caution accompanies this report. BHF depends upon the accuracy of the individual sources of data and can not guarantee the complete accuracy of all the data in this report, in part, because MCR, MHA/AHA Annual Licensing Survey, and other data estimates may contain a level of error. Changes in previously reported data are based on the most current information available, including numerous restatements. All figures are not adjusted for inflation. Hospital network configurations are current as of MHA Methods Charity care is defined as the amount resulting from a provider s policy to provide health care services free of charge or a reduction in charges because of the indigence or medical indigence of the patients. Charity care should be reported in terms of cost, not charges, and net of any subsidies as reflected in the hospitals audited financial information. The MHA methodology for calculating charity care cost is different from the method that has been used by BHF. BHF has been tracking hospital charity care since fiscal year 1991 and during that time has used the global cost-to-charge ratio to reduce charity care charges to cost. On the new MHA website, the Medicare cost-to-charge ratio is used to calculate charity care cost and is more restricted than the global cost-to-charge ratio used by BHF. For community hospitals, the most significant difference between the global and Medicare cost-to-charge ratios is that the majority of Medicare bad debt expense (70%) is excluded from cost when calculating the Medicare cost-to-charge ratio. This results in a lower cost-to-charge ratio and lower reported charity care cost. Since teaching hospitals serve a different mix of patients and provide services of higher complexity, certain costs are added to their Medicare cost-to-charge ratios such as organ acquisition, intern/resident costs of services to Medicare and Medicaid patients, etc. In addition, certain teaching hospitals made adjustments to the historical MHA/AHA Annual Licensing Survey method of reporting charity care charges in 2004 to enhance comparability with hospitals within their networks and with other community hospitals (see page 49, Charity Care Cost Differences, BHF and MHA). Bad debt, as defined by MHA, is the amount for which the patient is personally responsible after any and all third party payers have been paid and the contractual allowance, if any booked, if the account is unpaid and determined to be uncollectible pursuant to the hospital s collection and write-off policy. Bad debt should not include the cost of caring for patients whose insurance covers the procedure although the total payments to the hospital are less than the actual cost of providing care. Bad debt does include patient co-pays, or out-of-pocket amounts, for which they are responsible. The value reported as bad debt should be adjusted from charges and reported at cost. After examining the differences between bad debt reported on the audited financial statements of certain hospitals and bad debt reported on the MHA website, there were variations in the way certain hospitals calculated bad debt. Provision for bad debt in audited financial statements makes an estimate of the amount that will be collected on outstanding accounts. In addition, hospitals may have classified some charity care as bad debt. The method used by some of the hospitals to calculate bad debt expense for the MHA website followed a more restricted method that in some cases resulted in a lower amount of bad debt reported (see Bad debt profile footnotes, pages 34, 63, and 64). 46

47 Fewer variations were found between the 2005 BHF and MHA charity care and bad debt expense amounts published in the Phase II report. In the Phase III report, some hospitals made retroactive changes to 2005 BHF data at the time they verified their 2006 BHF data (see charity care and bad debt cost differences, p. 49). Financial and Utilization Formulas (For Leap years: Use 366 for all formulas using days) Operating Margin (Total Operating Revenue - Operating Expense) Total Operating Revenue Profit Margin Excess of Revenue Over Expenses (Total Operating Revenue + Non-operating Revenue) Occupancy Percentage Patient Days Number of Beds x 365 FTE per Occupied Bed FTE x Inpatient % Gross Charges Number of Beds x Occupancy % Cost to Charge Ratio Total Operating Expense Total Gross Charges Charity Care and Bad Debt Cost Differences, BHF and MHA Charity care and bad debt expense listed on the MHA/AHA Annual Licensing Survey are based on a hospital s billed charges for services. As discussed previously, the variance between BHF and MHA charity care and bad debt is primarily due to the difference in the type of costto-charge ratio used to reduce charity and bad debt to cost. For a few hospitals, however, the differences were much greater and were the result of other adjustments Charity Care Differences Missouri Hospital 2004 BHF Charity Care Cost 2004 MHA Charity Care Cost Variance 1) Barnes Jewish Hospital $ 21,425,779 $ 8,804, % 2) St. Louis Children s Hospital 1,342,954 3,184,051 58% 3) Columbia Regional Hospital 1,130, , % 4) University of Missouri Hospital and Clinics 9,146,997 5,072,515 80% 1) Consistent with historical practice, Barnes-Jewish hospital included certain Medicaid write-offs in the amount of $27,383,847 as charity (billed charges) for purposes of the 2004 MHA/AHA Annual Licensing Survey. This amount was considered part of the teaching budget. A year later when the MHA Community Benefit report was prepared, these write-offs were no longer included in charity as it was the hospital s desire to state the information on a basis consistent with other BJC facilities. This method will be used in the future. 2) The 2004 MHA/AHA Annual Licensing Survey reported charity care charges that were later restated to correct various misclassifications. MHA Community Benefit figures were inadvertently not corrected to reflect the adjustments. 3) The 2004 MHA/AHA Annual Licensing Survey for Columbia Regional Hospital was completed prior to its acquisition by University of Missouri Hospital and may contain subsidies. The MHA charity care cost is a revised and more accurate figure. 4) University of Missouri Hospital revised their charity care figure to an amount they felt was more accurate. Specific details on the inaccuracies were not provided by the hospital. 47

48 2005 Charity Care and Bad Debt Differences In the 2007 report, 2005 BHF charity care and bad debt cost figures were more in line with 2005 MHA charity care and bad debt cost figures. During 2008, BJC HealthCare and SSM Health Care made retroactive changes to 2005 data at the same time they verified their 2006 BHF data. As a result, some of the amounts shown in the 2007 report changed significantly. Reductions in aggregate operating revenue ($36 million), bad debt expense ($688,685), and charity care ($420,364) at BJC HealthCare resulted in little or no change to charity care and bad debt as a percentage of operating revenue. SSM Health Care reduced aggregate operating revenue by ($40.6 million), increased charity care by $2.3 million, and increased bad debt by $3.7 million (see table below). As a result, charity care as a percentage of operating revenue rose from 1.05 percent to 1.33 percent and bad debt as a percentage of operating revenue rose from 1.38 percent to 1.80 percent. Hospital 2005 Operating Revenue 2005 BHF Charity Care 2005 BHF Bad Debt Before Changes After Changes Before Changes After Changes Before Changes After Changes SSM Health Care Cardinal Glennon $197,048,078 $181,132,164 $201,422 $263,011 $1,230,597 $1,259,825 DePaul Health Center 255,139, ,624,442 3,972,951 4,734,668 4,835,854 6,276,776 St. Joseph Health Ctr. 159,075, ,910,396 2,047,024 2,496,257 2,789,125 3,492,499 St. Joseph Kirkwood 102,714,920 98,733, ,720 1,164, ,078 1,144,903 St. Joseph West 73,399,939 71,520, , ,727 1,489,484 1,832,788 St. Mary s Health Ctr. 252,121, ,018,647 2,910,114 3,607,918 3,138,812 3,961,026 Totals 1,039,500, ,939,272 10,920,571 13,244,762 14,310,950 17,967, Charity Care and Bad Debt Differences In 2006, MHA reported charity care for BJC HealthCare at a notably higher level than BHF reported. According to BJC, during 2008 some of its 2006 bad debt was retroactively reclassified as charity care after collection efforts found that patients could not pay. Although other St. Louis hospitals are facing similar issues, MHA charity care amounts for those hospitals did not change. It is expected that this is a one year event. Other Disclosures On January 1, 2008, Doctor s Hospital of Springfield (DHS) agreed to transfer ownership to Ozarks Community Hospital, Inc. (OCH), a non-profit corporation, when OCH s application for tax-exempt status was approved by the Internal Revenue Service (IRS). Due to economic challenges and a delay in receiving the IRS tax determination, the physician-owned, for-profit corporation previously 48

49 doing business as DHS resumed control of the healthcare system effective July 1, In order to lessen public confusion, the for-profit corporation will continue to do business as OCH. For more information, go to Glossary Available Acute Bed: A hospital bed in a specific location in a health care institution for which the hospital is prepared to provide needed services when a patient is admitted as reported in Medicare Cost Report, Worksheet S-3. This was used to calculate available occupancy percentage and excess available acute beds. Licensed Acute Bed: A State authorized bed capacity of a health care institution as reported in Missouri Hospital Profiles, Illinois Department of Health Statistics or other State agency. The numeric counts of licensed beds are typically greater than for available acute beds (see above). Staffed Bed: A term used within the hospital industry to denote a bed which is fully staffed and ready to receive a patient. A staffed bed is similar to an available bed, but the numeric count is typically less than for available beds. Average Length of Stay: This figure is determined by dividing the number of patient days used by the number of discharges. Charity Care: Health services that were never expected to result in cash inflows. Charity care results from a provider s policy to provide health care services free of charge to individuals who meet certain financial criteria. (American Institute of Certified Public Accountants, 1990) Occupancy Rate: This figure is determined by dividing the number of patient days used by the number of available acute beds multiplied by the number of days in the year. Excluded are nursery, skilled nursing facility, and other long term non-acute days and beds. Operating Margin: The portion of a firm s operating revenue retained as income. See page 47 for formula. Profit (Loss): Excess (deficit) of revenue over expenses. Profit Margin: Excess of revenue over expenses divided by the sum of total operating revenue and non-operating revenue. 49

50 Phase III Appendix C Emergency Department Use Rates Data for 2005 emergency department (ED) use rates were provided by Solucient, a subsidiary of ThomsonReuters based on estimates from their Market Planner Plus Outpatient Profiles (data for 2006 could not be provided). 8 Outpatient Market Profiles estimates the total annual volume of ambulatory procedures by provider and site of service for every market in the United States. Procedures are reported by 197 procedure groups (categories of CPT-4 9 and HCPCS (Healthcare Common Procedure Coding System) codes). Solucient uses proprietary and public claims as well as Federal surveys to construct use rates for all payers and all ambulatory care settings. These use rates are then applied to demographic and insurance coverage projections by ZIP Code to estimate outpatient utilization for Solucient constructs provider and patient origin-based use rates to calculate utilization for individual hospital providers. Data Sources Solucient is committed to providing the most comprehensive and timely information available. To do so, Solucient utilizes data from a number of proprietary and public claims streams. Solucient leveraged over 505 million annual claims in construction of Outpatient Market Profiles. Solucient used the following data sources to construct 2005 Outpatient Market Profiles: Outpatient 100% SAF 10, CMS Proprietary Commercial Claims, Solucient Physician/Supplier Procedure Summary File, CMS Physician/Supplier Part B 5% SAF, CMS National Ambulatory Medical Care Survey National Hospital Ambulatory Medical Care Survey Medical Expenditure Panel Survey National Health Interview Survey 2005 Insurance Coverage Estimates, Solucient 2005/2010 Population and Income Demographic Estimates, Claritas, Inc. June 2004 CMS Medicaid State summaries January 2005 County surveyor data, HealthLeaders-Interstudy January 2005 HMO county files, HealthLeaders-Interstudy January 2005 State Medicaid agency data, HealthLeaders-Interstudy July 2004 Medicaid summary, Oregon Department of Human Services January 2005 Medicare county files, HealthLeaders-Interstudy 2004 Current Population Survey (CPS) From the March 2005 supplement 2005 & 2010 Demographic Projections, Claritas, Inc. 8 This description is an abbreviated version of ThomsonReuters Solucient The Market Planner Plus Source Notes-Market Profiles document. A copy of the complete document can be obtained from the BHF. 9 CPT codes, descriptions, and material only are copyright 2003 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained or not contained herein. CPT is a trademark of the American Medical Association. 10 SAF stands for Standard Analytical Files. The SAF are either a 5% sample or 100% of the claims data provided by CMS (formerly HCFA). The files contain final action, adjustments-resolved claims and are created annually in July for the prior calendar (January December) service year. SAF includes Inpatient claims (IP), Outpatient claims (OP), Home Health Agency claims (HHA), Hospice claims (HOSP), Physician/Supplier Part B claims (PH), Durable Medical Equipment (DME) and Skilled Nursing Facility claims (SNF). 50

51 Sites of Service Hospital Outpatient This setting comprises hospital-operated outpatient facilities and emergency departments. This setting may be physically located in a hospital or may be an off-campus or freestanding facility. All types of procedures can occur in this setting. Volumes of ED procedures include only cases that are discharged from the ED to return home. ED cases subsequently admitted as inpatient cases are excluded from this product. Methodology Outpatient Market Profiles was created in two stages. In the first stage, Solucient estimated market totals at the county level by age, sex, site of service, and payer. In the second stage, estimates were created for specific providers within each county. Validation In creating Outpatient Market Profiles, projected volumes for hospitals in the validation sample were compared with actual reported volumes. Emergent and Urgent Visits ThompsonReuters Solucient defines emergent and urgent emergency department visits by the following CPT-4 and HCPCS procedure codes: Emergency Department Visit, Emergent 99026: Hospital mandated on call service; in-hospital, each hour 99027: Hospital mandated on call service; out-of-hospital, each hour 99284: Emergency department visit for the evaluation and management of a patient, three key components: A detailed history; a detailed examination; and medical decision of moderate complexity : Emergency department visit for the evaluation and management of a patient, three key components: A comprehensive history; a comprehensive exam; and medical decision of high complexity : Physician direction of emergency medical systems (EMS) emergency care, advanced life support G0383: Level 4 hospital emergency visit provided in a type B department or facility of the hospital G0384 Level 5 hospital emergency visit provided in a type B department or facility of the hospital Emergency Department Visit, Urgent 99281: Emergency department visit for the evaluation and management of a patient, three 51

52 key components: A problem focused history; a problem focused examination; and straightforward medical decision : Emergency department visit for the evaluation and management of a patient, three key components: An expanded problem focused history; an expanded problem focused examination; and medical decision of low complexity : Emergency department visit for the evaluation and management of a patient, three key components: An expanded problem focused history; an expanded problem focused examination; and medical decision of moderate complexity. G0381: Level 1 hospital emergency visit provided in a type B department or facility of the hospital G0382: Level 2 hospital emergency visit provided in a type B department or facility of the hospital G0383: Level 3 hospital emergency visit provided in a type B department or facility of the hospital Percentage Distribution of Estimated Emergency Department Utilization by Procedure Code ThompsonReuters provided a percentage distribution of 2005 emergency department utilization estimated for the 41 hospitals in 10 counties and the St. Louis metropolitan area in Missouri for this report. The largest percentage of ED visits was for procedure code 99283, the highest urgent care code level. Whether or not code belongs in the emergent or urgent ED care category is beyond the scope of this report, however, its large volume may explain at least part of the relative difference between the proportion of urgent and emergent ED visits in this study as compared to other studies (see examples on page 12). Procedure Code Description Percentage Emergency Department Visit, Emergent; Medical Decision Moderate Complexity 21% Emergency Department Visit, Emergent; Medical Decision High Complexity 7% Emergency Department Visit, Emergent; Physician Direction of EMS; Advanced Life Support 0% Emergency Department Visit, Urgent; Straightforward Medical Decision 10% Emergency Department Visit, Urgent; Medical Decision Low Complexity 29% Emergency Department Visit, Urgent; Medical Decision Moderate Complexity 33% Total 100% Source: ThompsonReuters Solucient Market Planner Plus Outpatient Profiles Emergency Department Visits Reported by Hospital Study hospitals voluntarily provided emergent and urgent emergency department visit volumes unless otherwise noted (see pages 32 45). The method used to determine if an ED visit was emergent or urgent was based on the ThompsonReuters Solucient methodology (see procedure codes above) with the exception of Des Peres Hospital in the St. Louis Metro area. Des Peres hospital s methodology was based on a 5-tier triage level system that reported the volumes from the two lowest acuity triage levels as urgent (non-emergent). 52

53 Previous Reports Phase I Baseline Report Phase I Appendix A 2004 Charity Care Profile Bad Debt Profile Public Program Utilization Capacity Levels and Productivity Fiscal Year 2004 Financial Data Phase I Appendix B Methodology and Data Sources Charity Care Cost Differences, BHF and MHA Glossary Phase II Report Phase II Appendix A 2004 Charity Care Profile Charity Care Profile Bad Debt Profile Bad Debt Profile Public Program Utilization Public Program Utilization Capacity Levels and Productivity Capacity Levels and Productivity Fiscal Year 2004 Financial Data Fiscal Year 2005 Financial Data Phase II Appendix B Methodology and Data Sources Charity Care Cost Differences, BHF and MHA Glossary

54 Phase I Baseline Report Executive Summary Reductions in state funding of Missouri s Medicaid program in 2005 will leave many previously eligible Missourians without access to the program and/or services. This cutback in coverage will likely increase the level of uncompensated care, the need for free and low-cost primary preventive services and hospital care. The purpose of this project is to measure the extent that charity and uncompensated care are affected by Missouri s recent Medicaid reductions. This report provides a baseline assessment of the financial status and level of charity care provided by a broad range of non-government, acute-care general hospitals in Missouri for The effect of the Medicaid cuts will be determined when the baseline is compared to the same variables for 2005 data. Charity Care Missouri hospitals in this report provided nearly $60 million in charity care (at cost) in However, this represented less than 1 percent of operating revenue. According to the hospitals and the Missouri Hospital Association (MHA), the amount of charity care provided has fallen as a result of increased Medicaid enrollment. The amounts of charity care varied significantly by the type, size, and geographic location of individual hospitals. In general, Teaching hospitals with a broader range of services provided more charity care than community hospitals Hospitals in low income sections of large metropolitan areas and low income rural areas provided more charity care. Bad Debt Missouri hospitals wrote off over $140 million in bad debt expense (at cost) in 2004 that represented approximately 2 percent of operating revenue. Geographic location appeared to be the most significant driver of variation in the amount of bad debt expense. Hospitals in rural counties outside of the St. Louis and Kansas City metropolitan areas had higher bad debt. Hospitals in St. Louis City and low income areas of St. Louis County had higher levels of bad debt than hospitals located in more affluent suburban counties. For the first time ever in May 2006, the MHA reported publicly-available community benefit information on individual Missouri hospitals. Both MHA s new and BHF s traditional charity care and bad debt data are shown for comparison purposes with an explanation of the variance as understood at this time. Business Health Foundation (BHF) charity care and bad debt cost figures are generally higher than those reported by MHA. For trend and comparative purposes, BHF will continue to provide both calculations in the near term. For a discussion of these methodologies, see pages

55 Public Program Utilization Medicare and Medicaid make up more than half of hospital revenues. Variation in the amount of public program utilization for hospitals in this report was, in large part, dependent on geographic location. Rural hospitals had higher utilization in both the Medicare and Medicaid programs than hospitals located in St. Louis. Hospitals in St. Louis City and low income areas of St. Louis County had higher levels of both Medicare and Medicaid program utilization than more affluent suburban counties. Teaching hospitals (especially Pediatric) had higher Medicaid program utilization. These utilization patterns are consistent with geographic variations in health insurance coverage in Missouri. Small cities and rural communities have less commercial insurance coverage and more coverage through Medicaid and SCHIP. In addition, a greater share of people who live outside of large cities are enrolled in public programs than are enrolled in St. Louis and Kansas City. 1 As a result, hospitals in rural areas are more dependent on public programs for revenue than those located in urban areas. Financial and Capacity Measures Financial performance of hospitals located in rural areas in 2004 compared favorably to hospitals located in the St. Louis metropolitan area. Occupancy levels for hospitals located in these rural communities, however, were lower than in the St. Louis metropolitan area. In spite of lower occupancy, hospitals in the larger rural communities are proceeding with plans for expansion. 2 New capital spending is not a one-time expense and has the potential to increase excess capacity and operating expenses in the future. Capital expansion is a contributing factor to higher health care costs leading to higher insurance premiums that affects access to health care for low income individuals. Summary Charity care provided by Missouri hospitals in 2004 was small in comparison to operating revenue and may be a result of higher Medicaid enrollment. The Medicaid cuts of 2005 are expected to increase the level of the uninsured and the charity care burden. Increases in charity care accompanied by cost increases from capital expansion may also stimulate additional price increases through cost-shifting making private insurance less affordable further increasing the number of uninsured. Public health care program cuts are potentially far-reaching affecting both the insured and uninsured in Missouri. 1 Geographic Variations in Health Insurance: A Profile of Missouri, Missouri Foundation for Health, Cover Missouri Project: Report 8, March Johnson, Julia, Cox Health, St. John s plan $1 billion in expansions, St. Louis Business Journal, April 7,

56 Phase II Report St. Louis Area Business Health Foundation Charity Care at Missouri Hospitals May 30, 2007 Introduction Medicaid funding was significantly cut in the 2005 Missouri legislative session and reduced access to health care for many Missourians. Missouri s funding reductions were significant and resulted in the second largest cutback to a public program in the United States. The cuts became effective August 28, 2005 leaving many previously eligible Missourians without access to the program or ineligible for certain necessary services. In some cases, it affected individuals who are disabled or have life-threatening health conditions. As a result, the lack of access to primary and preventive care or inability to pay for essential medications has the potential to cause individuals to forego care until their illness requires urgent hospitalization. This is likely to increase the amount of charity and uncompensated care provided at Missouri hospitals. The purpose of this project is to measure the extent that charity and uncompensated care are affected by the 2005 Medicaid reductions. Phase I of this project was released in June 2006 and provided a baseline assessment of the financial status and level of charity care provided by a broad range of non-government, acute-care general hospitals in Missouri for In this report, the 2004 baseline is compared to the same variables for Charity Care Selected Missouri hospitals in this report provided over $73 million in charity care (at cost) in This represented 0.9 percent of operating revenue, up from 0.8 percent of operating revenue in 2004, an increase of 11 percent (Exhibit 1 of this report, page 59). Was this increase in charity care caused by a fall in Medicaid enrollment resulting from the 2005 legislation? An analysis of the utilization of hospital Medicaid patient days and discharges from 2004 to 2005 does not indicate a significant aggregate decline in these services. Since the effective date of the legislation was August 28, 2005, the true impact on Medicaid and uncompensated care would not have been reflected in hospitals fiscal year 2005 utilization. This suggests the rise in charity care in 2005 may be due to an increase in the number of the uninsured resulting from a fall in private health insurance coverage. In fact, the number of uninsured in Missouri is estimated to have increased 10 percent to 14.5 percent in 2005 from However, charity care reported by hospitals may have also been affected by increased public scrutiny causing them to revise their charity care policies resulting in lower income threshold requirements for patients to qualify for charity care, and reclassification of bad debt as charity care. 4 3 New Numbers on the Uninsured in Missouri, Show Me Fact Sheet January 2006, Missouri Foundation for Health. 4 Mission vs. Margin: Better Reporting of Community Benefits May Temper Scrutiny of Not-for-Profit Hospitals Tax-Exempt Status, Moody s Investors Service, April

57 Although BHF charity care as a percent of operating revenue continued to be generally higher than that reported by MHA, the BHF figure decreased by 12 percent in This difference is primarily the result of MHA s more restrictive definition of charity care reported on their website (for a more detailed discussion of BHF and MHA methodology, see pages 46 51). In addition, the 2005 data suggests many hospitals clarified their policies to more clearly identify charity care to become more consistent with the MHA reporting methodology than in Exhibit 1: Charity Care as a Percentage of Operating Revenue & Medicaid Utilization 2004 and 2005 Missouri County BHF Charity as a % of operating revenue MHA Charity as a % of operating revenue % Medicaid Days % Medicaid Discharges Adair* 0.15% 0.00% N/A 0.00% 11% 12% 18% 19% Audrain 0.73% 1.07% 0.69% 1.05% 9% 8% 9% 10% Boone 1.86% 1.02% 1.04% 1.02% 13% 11% 11% 9% Callaway** 0.00% 0.00% 0.00% 0.11% 18% 18% 18% 18% Cape Girardeau 0.34% 0.53% 0.27% 0.48% 14% 14% 18% 17% Cole 0.53% 0.75% 0.46% 0.75% 7% 7% 6% 8% Greene* 0.58% 0.64% 0.58% 0.70% 21% 20% 21% 19% Marion 0.61% 0.50% 0.58% 0.47% 12% 15% 16% 19% Perry 0.04% 0.01% 0.04% 0.00% 8% 9% 17% 19% Polk* 0.49% 0.00% N/A 0.00% 16% 13% 30% 31% St. Louis MSA+ 1.18% 1.06% 0.93% 1.01% 17% 16% 16% 16% Aggregate 1.06% 0.93% 0.83% 0.91% 16% 16% 16% 15% * According to MHA, certain hospitals declined to participate in reporting Community Benefit in either 2004, 2005, or both (see pages 63 and 64). ** Medicaid percentages are based on Medicaid Revenue as a percentage of Gross Revenue since Medicaid inpatient days and discharges were not available. + St. Louis MSA figures include only Missouri hospitals for this report. Bad Debt Missouri hospitals bad debt expense (at cost) grew to more than $163 million in 2005 representing 2 percent of operating revenue, an increase of 6.6 percent (Exhibit 2 of this report, page 60). Consistent with the findings of the Phase I report, the amount of expense reported as bad debt is more than twice as high as charity care. On a national basis, bad debt amounts are generally higher than charity care; however, the disparity is larger in this sample of Missouri hospitals. Factors driving the 2005 increase in bad debt at Missouri hospitals include a rise in the level of uninsured resulting from a fall in private health insurance coverage, and higher cost-sharing in private health insurance plans leaving workers with higher medical bills they are unable to pay. As a result of increased public scrutiny of uncompensated care, hospitals may have also revisited their bad debt methodologies and moved to a more conservative method leading to an increase in year-over-year bad debt. 5 In 2004, BHF bad debt cost figures 5 Mission vs. Margin: Better Reporting of Community Benefits May Temper Scrutiny of Not-for-Profit Hospitals Tax-Exempt Status, Moody s 57

58 were higher than those reported by MHA on their website. In Phase II, 2005 BHF bad debt cost figures were more in line with those reported by MHA. Exhibit 2: Bad Debt as a Percentage of Operating Revenue & Financial Performance 2004 & 2005 Missouri County BHF Bad Debt as a % of operating revenue MHA Bad Debt as a % of operating revenue Operating Margins Profit Margins Adair* 1.75% 1.65% N/A 1.47% 8.42% 8.82% 8.42% 8.78% Audrain 1.78% 2.49% 1.69% 2.44% -2.49% % -2.41% -4.31% Boone 1.77% 2.00% 1.53% 1.99% 7.84% 7.65% 6.37% 6.00% Callaway 4.82% 4.16% 8.88% 4.02% -1.69% 11.55% -1.69% 12.77% Cape Girardeau 3.17% 3.07% 2.56% 2.76% 6.41% 5.85% 9.70% 8.08% Cole 1.76% 1.45% 1.61% 1.40% 1.77% 1.59% 1.93% 2.02% Greene* 2.97% 3.00% 2.58% 3.10% 5.51% 4.47% 7.09% 4.50% Marion 2.69% 2.44% 2.56% 2.29% -0.23% 4.95% 1.47% 6.07% Perry 2.53% 2.82% 2.27% 2.54% 11.24% 7.64% 11.25% 7.71% Polk* 1.95% 3.15% 2.01% 3.01% -3.34% -4.01% -3.10% -3.71% St. Louis MSA** 1.69% 1.73% 1.71% 1.73% 4.05% 3.56% 6.86% 5.13% Aggregate 1.98% 2.03% 1.89% 2.02% 4.55% 4.01% 6.68% 5.10% * According to MHA, certain hospitals declined to participate in reporting Community Benefit in either 2004, 2005, or both (see pages 65 and 66). ** St. Louis MSA figures include only Missouri hospitals for this report. Financial Performance Missouri hospitals remained profitable with performance in 2005 that was slightly below that of 2004 (see Exhibit 2 above). Rural hospital performance continued to compare favorably to urban hospitals with a few exceptions. Aggregate operating margins of 4.6 percent in 2004 and 4.0 percent in 2005 exceeded national averages of 3.6 percent and 3.7 percent respectively. The aggregate profit margin of 6.7 percent in 2004 outperformed the national average of 5.2 percent. In 2005, the 5.1 percent profit margin was in line with national average of 5.3 percent. 6 Charity care and bad debt increases in 2005 contributed to a rise in expenses that impacted hospitals profitability. In Exhibit 3 on the following page, total uncompensated care (at cost) is shown as a percentage of total expenses for 2004 and As compared to figures published by the American Hospital Association, percentages for hospitals in this report fell substantially below the national average for uncompensated care as a percentage of total expenses for both years. BHC charity care and bad debt cost figures were used in order to achieve a more consistent comparison with the American Hospital Association. Overall utilization of inpatient hospital days and discharges was flat in 2005 as compared to 2004 except for a few counties that experienced increases (e.g., Adair, Callaway, Cole, and Greene Investors Service, April American Hospital Association, Trendwatch Chartbook

59 counties). As a result, occupancy percentages were relatively unchanged with a few exceptions in the counties previously mentioned that experienced an increase in inpatient utilization. Exhibit 3: Total Uncompensated Care as a Percentage of Total Expenses 2004 & 2005 Missouri County BHF Charity as a % of total expenses BHF Bad Debt as a % of total expenses Total Uncompensated Care as a % of total expenses Adair* 0.16% 0.00% 1.91% 1.81% 2.08% 1.81% Audrain 0.71% 0.95% 1.74% 2.22% 2.45% 3.17% Boone 1.98% 1.08% 1.88% 2.11% 3.86% 3.19% Callaway 0.00% 0.13% 4.74% 4.71% 4.74% 4.83% Cape Girardeau 0.36% 0.56% 3.39% 3.26% 3.75% 3.82% Cole 0.54% 0.76% 1.80% 1.47% 2.34% 2.23% Greene* 0.61% 0.66% 3.14% 3.10% 3.75% 3.76% Marion 0.61% 0.53% 2.68% 2.56% 3.29% 3.09% Perry 0.04% 0.01% 2.85% 3.06% 2.89% 3.06% Polk* 0.47% 0.00% 1.89% 3.03% 2.36% 3.03% St. Louis MSA** 1.23% 1.09% 1.76% 1.79% 3.00% 2.88% Aggregate 1.10% 0.96% 2.07% 2.10% 3.17% 3.06% American Hosp. Assoc. National Total Uncompensated Care (at cost) 5.60% 5.60% Source: BHC charity care and bad debt figures obtained from MHA/AHA Annual Licensing Surveys or audited financial statements. Summary In May 2007, MHA published community benefit information for Missouri hospitals on their website, for the second year. In Phase I of this project, both MHA s first year of community benefit information and BHF s traditional charity care and bad debt data were shown for comparison purposes. For trend and comparative purposes, both calculations are provided in this Phase II report. Charity care and bad debt reported by Missouri hospitals increased in 2005 according to MHA figures. Factors driving these increases include an increase in the uninsured population, rising consumer medical debt due to cost shifting from private insurance, and some late year effects of 2005 Medicaid reductions. At the same time, charity care and bad debt reporting are changing. Increased public scrutiny of charity care and bad debt has caused some hospitals to change their charity care and bad debt policies and accounting methods. For example, changes in charity care policy have caused some hospitals to lower income thresholds making more charity care available to the uninsured increasing amounts previously recognized. Similarly, bad debt accounting changes have become more conservative at some facilities shifting some bad debt to charity care and restructuring methodologies to recognize an increased amount of bad debt expense. Despite the increase in charity care and bad debt for 2005, Missouri hospitals provided charity care (at cost) at less than 1 percent and bad debt (at cost) at 2 percent of operating revenue, relatively low as compared to other regions. Total uncompensated care as a percentage of total 59

60 expenses was slightly more than half of the national average. While charity care and bad debt in 2004 and 2005 were at low levels, this is not likely to continue with the expected increase in the uninsured population in 2006 and beyond resulting from reductions in Medicaid enrollment and services. Missouri s significant funding cuts to the Medicaid program in May 2005 eliminated services for an estimated 100,000 individuals and left 250,000 with reduced services. 7 Although Medicaid hospital utilization in 2005 was relatively unchanged from 2004, the full effect of the cuts were not reflected in the 2005 hospital data in this report since the effective date of the Medicaid reductions occurred in the last four months of the year. Further analysis of hospital charity care, bad debt, and private and public utilization statistics are recommended to fully understand the effects of the 2005 Medicaid reductions. Hospitals across the nation continue to be in a state of transition with respect to charity care and bad debt reporting due to scrutiny from local, state, and federal constituents. The good news is Missouri hospitals, through the leadership of the MHA, are moving toward a common language and standard for charity care and bad debt reporting. This will become even more important in future years to assess the full effects of 2005 Medicaid reductions on the charity care and bad debt burdens of Missouri hospitals. 7 Feldstein, M, Hospitals charity care rises, St. Louis Post-Dispatch, May 10,

61 2004 Charity Care Profile BHC BHC Charity MHA MHA Charity Missouri Operating Cost of as a % of Cost of as a % of Missouri Hospital (system name) County Revenue charity 1 op. rev charity 1 op. rev Northeast Regional Medical Center Adair $57,758,363 $86, % n/a n/a Audrain Medical Center Audrain 51,396, , % 356, % Boone Hospital Center (BJC) Boone $219,210,441 $1,533, % $1,407, % Columbia Regional Hospital (U. of MO) 1 Boone 86,011,577 1,130, % 113, % University of Missouri Hospital and Clinics 1 Boone 329,499,799 9,146, % 5,072, % County Total Boone $634,721,817 $11,810, % $6,593, % Callaway Community Hospital Callaway $10,464,000 $0 0.00% $0 0.00% Southeast Missouri Hospital Cape Girardeau 176,489, , % 509, % St. Francis Medical Center Cape Girardeau 192,445, , % 495, % County Total Cape Girardeau $368,935,019 $1,248, % $1,005, % Capital Region Medical Center Cole $111,289,450 $246, % $249, % St. Mary's Health Center (SSMHC) Cole 117,126, , % 802, % County Total Cole $228,415,480 $1,218, % $1,052, % Cox Health Systems Greene $639,046,377 $1,114, % $943, % Doctors Hospital Springfield* Greene 30,475,470 96, % n/a n/a St. Johns Regional Health Center (SMHS) Greene 486,275,351 5,494, % 5,561, % County Total Greene $1,155,797,198 $6,705, % $6,505, % Hannibal Regional Hospital Marion $66,724,578 $407, % $389, % Perry County Memorial Hospital* Perry 22,809,350 8, % 8, % Citizens Memorial Health Care Polk 58,387, , % n/a n/a St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital 1 St. Louis City $996,684,525 $21,425, % $8,804, % Barnes-Jewish Hospital - St. Peters St. Charles 86,349, , % 290, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 78,024, , % 187, % Christian Hospitals N. St. Louis Cnty 248,509,158 4,436, % 3,668, % Missouri Baptist Hospital - Sullivan Crawford 31,292, , % 161, % Missouri Baptist Medical Center W. St. Louis Cnty 333,256, , % 869, % St. Louis Children's Hospital 1 St. Louis City 278,842,298 1,380, % 3,184, % BJC HealthCare Total $2,052,957,993 $28,919, % $17,166, % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 184,597,702 $618, % $445, % DePaul Health Center N. St. Louis Cnty 224,876,899 3,798, % 3,293, % St. Joseph Health Center St. Charles 142,922,207 2,030, % 1,800, % St. Joseph Health Center - Wentzville 2 St. Charles 22,956, , % n/a n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty 92,836, , % 422, % St. Joseph West - Lake St. Louis St. Charles 62,463, , % 608, % St. Mary's Health Center W. St. Louis Cnty 220,994,637 3,931, % 3,927, % SSM Health Care Total $951,648,496 $11,825, % $10,498, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $534,089,839 $5,041, % $5,778, % St. John's Mercy Hospital - Washington Franklin 72,706, , % 474, % St. John's Mercy Health Care Total $606,796,835 $5,554, % $6,252, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $98,414,763 $163, % $190, % St. Louis University Hospital St. Louis City 305,981,000 5,989, % 4,619, % Tenet HealthSystem Total $404,395,763 $6,152, % $4,809, % Independent Forest Park Hospital 3 St. Louis City $104,361,647 $655, % $900, % Jefferson Regional Medical Center Jefferson 91,395, , % 927, % Kindred Hospital St. Louis City 18,189,883 n/a n/a % Lincoln County Memorial Hospital Lincoln 22,517,906 48, % 49, % St. Alexius Hospital 3 St. Louis City 86,794,253 1,094, % 1,956, % St. Anthony's Medical Center S. St. Louis Cnty 314,980,000 2,697, % 2,423, % St. Luke's Hospital W. St. Louis Cnty 274,105, , % 829, % St. Louis Area Aggregate $4,928,143,730 $58,230, % $45,813, % * According to the MHA, these hospitals declined to participate in reporting Community Benefit. 1 For descriptions of BHF and MHA cost of charity methodologies and a more detailed explanation of differences for individual hospitals, see pages St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November St. Alexius and Forest Park hospitals were sold to Doctors Community Healthcare Corporation in 2004, and due to the transfer in ownership, 2004 data could not be verified

62 2005 Charity Care Profile BHC BHC Charity MHA MHA Charity Missouri Operating Cost of as a % of Cost of as a % of Missouri Hospital (system name) County Revenue charity 1 op. rev charity 1 op. rev Northeast Regional Medical Center Adair $62,908,872 $0 0.00% $0 0.00% Audrain Medical Center Audrain 49,853, , % 522, % Boone Hospital Center (BJC) Boone 226,969,323 1,311, % 1,340, % Columbia Regional Hospital (U. of MO) Boone 102,710,667 $357, % 349, % University of Missouri Hospital and Clinics Boone 365,624,881 5,440, % 5,389, % County Total Boone $695,304,871 $7,109, % $7,079, % Callaway Community Hospital Callaway $14,538,447 $0 0.00% $16, % Southeast Missouri Hospital Cape Girardeau 200,849, , % 816, % St. Francis Medical Center Cape Girardeau 218,107,713 1,308, % 1,181, % County Total Cape Girardeau $418,956,895 $2,217, % $1,997, % Capital Region Medical Center Cole $121,503,232 $153, % $220, % St. Mary's Health Center (SSMHC) Cole 133,026,503 1,742, % 1,688, % County Total Cole $254,529,735 $1,896, % $1,908, % Cox Health Systems Greene $644,179,564 $1,835, % $1,803, % Doctors Hospital Springfield* Greene 40,175, , % n/a n/a St. Johns Regional Health Center (SMHS) Greene 512,456,017 5,656, % 6,342, % County Total Greene $1,196,810,645 $7,642, % $8,146, % Hannibal Regional Hospital Marion $74,436,666 $372, % $349, % Perry County Memorial Hospital Perry 24,077,717 1, % 1, % Citizens Memorial Health Care Polk 63,403, % % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $1,075,362,035 $15,240, % $15,243, % Barnes-Jewish Hospital - St. Peters St. Charles 99,063, , % 579, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 76,926, , % 294, % Christian Hospitals N. St. Louis Cnty 244,192,451 4,843, % 4,596, % Missouri Baptist Hospital - Sullivan Crawford 31,564, , % 588, % Missouri Baptist Medical Center W. St. Louis Cnty 345,962,582 1,692, % 1,735, % St. Louis Children's Hospital St. Louis City 300,123,547 2,092, % 2,013, % BJC HealthCare Total $2,173,195,716 25,360, % $25,050, % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 181,132, , % $190, % DePaul Health Center N. St. Louis Cnty 248,624,442 4,734, % 3,632, % St. Joseph Health Center St. Charles 153,910,396 2,496, % 1,925, % St. Joseph Health Center - Wentzville 2 St. Charles 24,218, % n/a n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty 98,733,152 1,164, % 887, % St. Joseph West - Lake St. Louis St. Charles 71,520, , % 770, % St. Mary's Health Center W. St. Louis Cnty 245,018,647 3,607, % 2,779, % SSM Health Care Total $1,023,158,174 $13,244, % $10,186, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $590,246,406 $5,737, % $5,417, % St. John's Mercy Hospital - Washington Franklin 75,910, , % 688, % St. John's Mercy Health Care Total $666,156,587 $6,497, % $6,106, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $106,091,411 $118, % $117, % St. Louis University Hospital St. Louis City 308,619,020 7,110, % 6,582, % Tenet HealthSystem Total $414,710,431 $7,228, % $6,700, % Independent Forest Park Hospital St. Louis City $109,477,656 $1,429, % $1,237, % Jefferson Regional Medical Center Jefferson 101,001, , % 305, % Kindred Hospital* St. Louis City 25,801,060 n/a n/a n/a n/a Lincoln County Memorial Hospital Lincoln 23,072, , % 111, % St. Alexius Hospital St. Louis City 96,874, , % 431, % St. Anthony's Medical Center S. St. Louis Cnty 335,731,000 2,889, % 2,745, % St. Luke's Hospital W. St. Louis Cnty 307,192, , % 893, % St. Louis Area Aggregate $5,276,371,718 $58,562, % $53,769, % * According to the MHA, these hospitals declined to participate in reporting Community Benefit. 1 See pages for BHF and MHA cost of charity methodologies, and other disclosures regarding retroactive changes to data previously reported in this table. 2 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Due to the transfer in ownership, 2005 data for this hospital could not be verified. Community Benefit information for this hospital was not reported by MHA in

63 2004 Bad Debt Profile BHC BHC bad debt MHA MHA bad debt Missouri Operating Cost of as a % of Cost of as a % of Missouri Hospital (system name) County Revenue bad debt op. rev bad debt op. rev Northeast Regional Medical Center* Adair $57,758,363 $1,012, % n/a n/a Audrain Medical Center Audrain 51,396, , % 869, % Boone Hospital Center (BJC) Boone $219,210,441 $2,353, % $2,161, % Columbia Regional Hospital (U. of MO) Boone 86,011,577 1,093, % 997, % University of Missouri Hospital and Clinics Boone 329,499,799 7,809, % 6,527, % County Total Boone $634,721,817 $11,257, % $9,686, % Callaway Community Hospital Callaway $10,464,000 $504, % $929, % Southeast Missouri Hospital Cape Girardeau $176,489,707 $5,811, % $4,859, % St. Francis Medical Center Cape Girardeau 192,445,312 5,899, % 4,575, % County Total Cape Girardeau $368,935,019 $11,711, % $9,435, % Capital Region Medical Center Cole $111,289,450 $1,801, % $1,820, % St. Mary's Health Center (SSMHC) Cole 117,126,030 2,229, % 1,863, % County Total Cole $228,415,480 $4,031, % $3,684, % Cox Health Systems 1 Greene $639,046,377 $19,970, % $11,850, % Doctors Hospital Springfield* Greene 30,475,470 1,240, % n/a n/a St. Johns Regional Health Center (SMHS) Greene 486,275,351 14,258, % 17,198, % County Total Greene $1,155,797,198 $35,469, % $29,049, % Hannibal Regional Hospital Marion $66,724,578 $1,793, % $1,711, % Perry County Memorial Hospital* Perry 22,809, , % 516, % Citizens Memorial Health Care Polk 58,387,630 1,139, % 1,171, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $996,684,525 $17,436, % $16,153, % Barnes-Jewish Hospital - St. Peters St. Charles 86,349,397 1,620, % 1,374, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 78,024, , % 732, % Christian Hospitals N. St. Louis Cnty 248,509,158 7,561, % 6,366, % Missouri Baptist Hospital - Sullivan Crawford 31,292, , % 882, % Missouri Baptist Medical Center W. St. Louis Cnty 333,256,106 1,874, % 1,662, % St. Louis Children's Hospital 2 St. Louis City 278,842,298 1,342, % 1,203, % BJC HealthCare Total $2,052,957,993 $31,544, % $28,375, % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City $184,597,702 $325, % $235, % DePaul Health Center N. St. Louis Cnty 224,876,899 5,454, % 4,490, % St. Joseph Health Center St. Charles 142,922,207 2,528, % 2,157, % St. Joseph Health Center - Wentzville 3 St. Charles 22,956, , % n/a n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty 92,836,791 1,075, % 941, % St. Joseph West - Lake St. Louis St. Charles 62,463, , % 805, % St. Mary's Health Center W. St. Louis Cnty 220,994,637 2,529, % 2,332, % SSM Health Care Total $951,648,496 $13,829, % $10,962, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $534,089,839 $9,216, % $10,014, % St. John's Mercy Hospital - Washington Franklin 72,706,996 2,219, % 2,049, % St. John's Mercy Health Care Total $606,796,835 $11,435, % $12,063, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $98,414,763 $888, % $771, % St. Louis University Hospital St. Louis City 305,981,000 9,281, % 10,007, % Tenet HealthSystem Total $404,395,763 $10,169, % $10,778, % Indpendents Forest Park Hospital 4 St. Louis City $104,361,647 $2,894, % $4,874, % Jefferson Regional Medical Center Jefferson 91,395,954 2,615, % 2,628, % Kindred Hospital St. Louis City 18,189,883 0 N/A 271, % Lincoln County Memorial Hospital Lincoln 22,517, , % 731, % St. Alexius Hospital 4 St. Louis City 86,794,253 3,157, % 3,200, % St. Anthony's Medical Center S. St. Louis Cnty 314,980,000 4,553, % 4,186, % St. Luke's Hospital W. St. Louis Cnty 274,105,000 2,205, % 1,893, % St. Louis Area Aggregate $4,928,143,730 $83,112, % $79,964, % * According to the MHA, these hospitals declined to participate in reporting Community Benefit. Percentage totals exclude operating revenues for hospitals that did not report. 1 The BHF figure is based on the audited financial statement and includes an additional provision for uncollectible accounts. The MHA figure excludes the additional provision. 2 St. Louis Children's Hospital: According to BJC as of 6/22/06, MHA cost of bad debt of $5,207,582 originally posted on the focusonhospitals web site was incorrect. BJC provided a more accurate bad debt cost figure that is shown in this table. 3 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November St. Alexius and Forest Park hospitals were sold to Doctors Community Healthcare Corporation in 2004, and due to the transfer in ownership, 2004 data could not be verified

64 2005 Bad Debt Profile BHC BHC bad debt MHA MHA bad debt Missouri Operating Cost of as a % of Cost of as a % of Missouri Hospital (system name) County Revenue bad debt 1 op. rev bad debt 1 op. rev Northeast Regional Medical Center Adair $62,908,872 $1,040, % $924, % Audrain Medical Center Audrain 49,853,209 1,240, % 1,214, % Boone Hospital Center (BJC) Boone $226,969,323 $2,193, % $2,242, % Columbia Regional Hospital (U. of MO) Boone 102,710,667 $1,424, % 1,394, % University of Missouri Hospital and Clinics Boone 365,624,881 10,326, % 10,229, % County Total Boone $695,304,871 $13,944, % $13,866, % Callaway Community Hospital Callaway $14,538,447 $605, % $585, % Southeast Missouri Hospital Cape Girardeau $200,849,182 $6,467, % $5,811, % St. Francis Medical Center Cape Girardeau 218,107,713 6,379, % 5,759, % County Total Cape Girardeau $418,956,895 $12,846, % $11,570, % Capital Region Medical Center Cole $121,503,232 $2,055, % $1,972, % St. Mary's Health Center (SSMHC) Cole 133,026,503 1,632, % 1,580, % County Total Cole $254,529,735 $3,687, % $3,553, % Cox Health Systems Greene $644,179,564 $18,444, % $18,126, % Doctors Hospital Springfield* Greene 40,175,064 1,566, % n/a n/a St. Johns Regional Health Center (SMHS) Greene 512,456,017 15,855, % 17,777, % County Total Greene $1,196,810,645 $35,865, % $35,903, % Hannibal Regional Hospital Marion $74,436,666 $1,813, % $1,702, % Perry County Memorial Hospital Perry 24,077, , % 610, % Citizens Memorial Health Care Polk 63,403,610 1,995, % 1,910, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $1,075,362,035 $18,831, % $18,835, % Barnes-Jewish Hospital - St. Peters St. Charles 99,063,776 2,038, % 1,984, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 76,926, , % 857, % Christian Hospitals N. St. Louis Cnty 244,192,451 8,361, % 7,934, % Missouri Baptist Hospital - Sullivan Crawford 31,564, , % 931, % Missouri Baptist Medical Center W. St. Louis Cnty 345,962,582 2,011, % 2,062, % St. Louis Children's Hospital St. Louis City 300,123,547 1,566, % 1,507, % BJC HealthCare Total $2,173,195,716 $34,611, % $34,111, % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City $181,132,164 $1,259, % $1,163, % DePaul Health Center N. St. Louis Cnty 248,624,442 6,276, % 4,421, % St. Joseph Health Center St. Charles 153,910,396 3,492, % 2,719, % St. Joseph Health Center - Wentzville* 2 St. Charles 24,218,902 n/a n/a n/a n/a St. Joseph Hospital - Kirkwood S. St. Louis Cnty 98,733,152 1,144, % 769, % St. Joseph West - Lake St. Louis St. Charles 71,520,471 1,832, % 1,375, % St. Mary's Health Center W. St. Louis Cnty 245,018,647 3,961, % 2,997, % SSM Health Care Total $1,023,158,174 $17,967, % $13,447, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $590,246,406 $10,719, % $10,121, % St. John's Mercy Hospital - Washington Franklin 75,910,181 2,274, % 2,062, % St. John's Mercy Health Care Total $666,156,587 $12,994, % $12,184, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $106,091,411 $983, % $976, % St. Louis University Hospital St. Louis City 308,619,020 6,736, % 11,138, % Tenet HealthSystem Total $414,710,431 $7,719, % $12,114, % Indpendents Forest Park Hospital St. Louis City $109,477,656 $5,370, % $4,650, % Jefferson Regional Medical Center Jefferson 101,001,564 3,214, % 2,786, % Kindred Hospital* St. Louis City 25,801, , % n/a n/a Lincoln County Memorial Hospital Lincoln 23,072, , % 696, % St. Alexius Hospital St. Louis City 96,874,984 5,122, % 4,762, % St. Anthony's Medical Center S. St. Louis Cnty 335,731,000 5,146, % 4,949, % St. Luke's Hospital W. St. Louis Cnty 307,192,000 2,427, % 2,273, % St. Louis Area Aggregate $5,276,371,718 $95,438, % $91,977, % * According to the MHA, these hospitals declined to participate in reporting Community Benefit. Percentage totals exclude operating revenues for hospitals that did not report. 1 See pages for BHF and MHA cost of bad debt methodologies, and other disclosures regarding retroactive changes to data previously reported in this table. 2 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Due to the transfer in ownership, 2005 data for this hospital could not be verified. Community Benefit information for this hospital was not reported by MHA in

65 2004 Public Program Utilization % % % % Missouri Medicare Medicare Medicaid Medicaid % Other % Other Total Total Missouri Hospital (system name) County Days Discharges Days Discharges Days Discharges Days Discharges Northeast Regional Medical Center Adair 67% 52% 11% 18% 22% 30% 17,180 4,064 Audrain Medical Center Audrain 62% 49% 9% 9% 28% 41% 15,479 4,520 Boone Hospital Center (BJC) Boone 57% 49% 6% 5% 37% 46% 79,923 16,479 Columbia Regional Hospital (U. of MO) Boone 51% 46% 11% 10% 38% 44% 29,363 5,634 University of Missouri Hospital and Clinics Boone 34% 30% 25% 20% 41% 50% 58,443 11,060 County Total Boone 48% 42% 13% 11% 39% 47% 167,729 33,173 Callaway Community Hospital* Callaway n/a n/a n/a n/a n/a n/a 3,754 1,061 Southeast Missouri Hospital Cape Girardeau 60% 42% 16% 21% 24% 37% 47,801 12,022 St. Francis Medical Center Cape Girardeau 65% 61% 12% 13% 23% 26% 52,822 9,860 County Total Cape Girardeau 63% 50% 14% 18% 23% 32% 100,623 21,882 Capital Region Medical Center Cole 64% 53% 4% 4% 32% 43% 32,881 7,488 St. Mary's Health Center (SSMHC) Cole 63% 45% 9% 7% 28% 47% 39,526 10,456 County Total Cole 63% 49% 7% 6% 30% 46% 72,407 17,944 Cox Health Systems Greene 43% 33% 22% 23% 34% 44% 155,350 34,171 Doctors Hospital Springfield Greene 78% 67% 12% 18% 10% 15% 6,777 1,185 St. Johns Regional Health Center (SMHS) Greene 45% 38% 20% 18% 36% 44% 147,495 31,971 County Total Greene 45% 36% 21% 21% 34% 43% 309,622 67,327 Hannibal Regional Hospital Marion 63% 51% 12% 16% 25% 33% 25,507 5,828 Perry County Memorial Hospital Perry 77% 47% 8% 17% 16% 36% 4, Citizens Memorial Health Care Polk 64% 51% 16% 30% 20% 19% 15,171 3,239 St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 46% 40% 18% 19% 36% 41% 280,010 50,663 Barnes-Jewish Hospital - St. Peters St. Charles 52% 38% 6% 6% 43% 55% 24,417 6,432 Barnes-Jewish Hospital - West County W. St. Louis Cnty 56% 49% 1% 2% 42% 50% 13,047 3,426 Christian Hospitals N. St. Louis Cnty 66% 55% 13% 13% 21% 32% 101,680 16,965 Missouri Baptist Hospital - Sullivan Crawford 72% 57% 12% 18% 16% 25% 9,030 2,021 Missouri Baptist Medical Center W. St. Louis Cnty 56% 46% 3% 3% 41% 51% 106,825 21,955 St. Louis Children's Hospital St. Louis City 0% 0% 40% 39% 60% 60% 63,955 10,512 BJC HealthCare Total 47% 40% 16% 16% 37% 44% 598, ,974 SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 0% 1% 61% 55% 38% 44% 43,779 5,423 DePaul Health Center N. St. Louis Cnty 52% 41% 22% 29% 26% 30% 98,294 19,621 St. Joseph Health Center - St. Charles St. Charles 53% 46% 20% 10% 26% 44% 61,376 14,025 St. Joseph Health Center - Wentzville 1 St. Charles 69% 49% 6% 7% 26% 44% 10,840 2,279 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 60% 53% 4% 6% 36% 41% 35,521 8,250 St. Joseph West - Lake St. Louis St. Charles 49% 37% 22% 26% 30% 38% 16,605 5,642 St. Mary's Health Center W. St. Louis Cnty 55% 49% 13% 20% 32% 31% 84,229 18,358 SSM Health Care Total 48% 42% 22% 21% 30% 36% 350,644 73,598 St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 37% 32% 13% 13% 49% 55% 201,992 37,081 St. John's Mercy - Washington Franklin 59% 55% 10% 13% 32% 32% 21,879 6,200 St. John's Mercy Health Care Total 39% 35% 13% 13% 48% 52% 223,871 43,281 Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 69% 60% 7% 7% 24% 33% 36,693 8,542 St. Louis University Hospital St. Louis City 40% 38% 24% 23% 36% 40% 96,553 15,139 Tenet HealthSystem Total 48% 46% 19% 17% 33% 37% 133,246 23,681 Independents Forest Park Hospital 2 St. Louis City 56% 44% 30% 37% 13% 19% 47,096 10,243 Jefferson Regional Medical Center Jefferson 62% 47% 14% 15% 24% 38% 36,677 9,784 Kindred Hospital St. Louis City 72% 74% 5% 8% 22% 18% 10, Lincoln County Memorial Hospital Lincoln 69% 55% 3% 5% 28% 40% 4,729 1,098 St. Alexius Hospital 2 St. Louis City 51% 43% 31% 28% 18% 29% 81,784 11,384 St. Anthony's Medical Center S. St. Louis Cnty 57% 50% 9% 7% 34% 43% 136,053 27,856 St. Luke's Hospital W. St. Louis Cnty 63% 50% 1% 1% 36% 49% 83,415 18,533 St. Louis Area Aggregate 49% 42% 17% 16% 34% 42% 1,706, ,787 1 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Forest Park Hospital, and St. Alexius Hospitals (formerly Alexian Brothers & SouthPoint Hospitals) were sold to Doctors Community Healthcare Corporation (DCHC) in November 2004 by Tenet Healthcare Corporation. Due to the transfer in ownership in 2004, 2004 data for these hospitals could not be verified. * Callaway Community Hospital did not file a Medicare Cost Report in Data was obtained from the Missouri Department of Health and Senior Services (DHSS) and the Missouri Hospital Association (MHA)

66 2005 Public Program Utilization % % % % Missouri Medicare Medicare Medicaid Medicaid % Other % Other Total Total Missouri Hospital (system name) County Days Discharges Days Discharges Days Discharges Days Discharges Northeast Regional Medical Center Adair 72% 53% 12% 19% 16% 29% 18,574 4,412 Audrain Medical Center Audrain 62% 53% 8% 10% 30% 37% 15,415 4,162 Boone Hospital Center (BJC) Boone 59% 51% 5% 3% 36% 46% 78,493 16,525 Columbia Regional Hospital (U. of MO) Boone 48% 41% 11% 9% 41% 51% 31,244 6,274 University of Missouri Hospital and Clinics Boone 39% 33% 19% 17% 42% 50% 61,812 12,249 County Total Boone 50% 43% 11% 9% 39% 48% 171,549 35,048 Callaway Community Hospital* Callaway 61% 62% 8% 4% 31% 34% 4, Southeast Missouri Hospital Cape Girardeau 59% 42% 17% 20% 23% 38% 46,762 11,922 St. Francis Medical Center Cape Girardeau 65% 61% 11% 13% 24% 26% 52,767 10,137 County Total Cape Girardeau 62% 51% 14% 17% 24% 33% 99,529 22,059 Capital Region Medical Center Cole 63% 52% 4% 4% 32% 44% 32,086 7,626 St. Mary's Health Center (SSMHC) Cole 60% 48% 10% 12% 30% 40% 42,791 10,247 County Total Cole 61% 50% 7% 8% 31% 42% 74,877 17,873 Cox Health Systems Greene 43% 36% 22% 20% 35% 44% 152,522 29,897 Doctors Hospital Springfield Greene 81% 73% 11% 16% 8% 11% 7,868 1,316 St. Johns Regional Health Center (SMHS) Greene 46% 40% 19% 18% 35% 42% 147,171 32,153 County Total Greene 46% 39% 20% 19% 34% 42% 307,561 63,366 Hannibal Regional Hospital Marion 63% 51% 15% 19% 22% 30% 25,372 5,805 Perry County Memorial Hospital Perry 76% 47% 9% 19% 15% 34% 3, Citizens Memorial Health Care Polk 63% 50% 13% 31% 24% 20% 14,234 3,306 St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 43% 39% 20% 20% 37% 41% 285,899 52,760 Barnes-Jewish Hospital - St. Peters St. Charles 53% 40% 5% 6% 42% 54% 28,265 7,255 Barnes-Jewish Hospital - West County W. St. Louis Cnty 54% 46% 3% 2% 43% 51% 12,791 3,379 Christian Hospitals N. St. Louis Cnty 67% 57% 12% 10% 21% 33% 93,468 16,065 Missouri Baptist Hospital - Sullivan Crawford 75% 59% 10% 17% 15% 24% 8,227 1,893 Missouri Baptist Medical Center W. St. Louis Cnty 59% 46% 3% 3% 38% 50% 105,876 22,190 St. Louis Children's Hospital St. Louis City 0% 0% 37% 41% 62% 59% 67,495 10,396 BJC HealthCare Total 46% 40% 16% 16% 38% 44% 602, ,938 SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City 1% 1% 41% 38% 58% 61% 44,721 6,219 DePaul Health Center N. St. Louis Cnty 49% 44% 21% 18% 30% 38% 106,786 21,907 St. Joseph Health Center - St. Charles St. Charles 54% 47% 16% 12% 30% 41% 65,411 14,149 St. Joseph Health Center - Wentzville 1 St. Charles 63% 44% 7% 8% 31% 49% 9,071 2,160 St. Joseph Hospital - Kirkwood S. St. Louis Cnty 72% 55% 4% 5% 24% 39% 33,120 8,885 St. Joseph West - Lake St. Louis St. Charles 50% 41% 10% 12% 40% 48% 19,383 6,108 St. Mary's Health Center W. St. Louis Cnty 58% 51% 15% 16% 27% 33% 84,841 18,751 SSM Health Care Total 49% 44% 19% 16% 33% 40% 363,333 78,179 St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty 39% 34% 15% 12% 46% 54% 206,307 39,073 St. John's Mercy - Washington Franklin 59% 52% 11% 14% 30% 34% 21,426 6,055 St. John's Mercy Health Care Total 40% 36% 15% 12% 45% 51% 227,733 45,128 Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty 71% 60% 6% 6% 24% 34% 38,959 8,720 St. Louis University Hospital St. Louis City 44% 40% 24% 24% 32% 36% 89,213 14,706 Tenet HealthSystem Total 52% 48% 18% 17% 30% 35% 128,172 23,426 Independent Forest Park Hospital St. Louis City 60% 51% 28% 36% 12% 13% 39,943 9,358 Jefferson Regional Medical Center Jefferson 63% 47% 18% 21% 19% 32% 38,985 10,986 Kindred Hospital St. Louis City 68% 71% 6% 7% 26% 23% 15, Lincoln County Memorial Hospital Lincoln 67% 59% 1% 3% 32% 38% 5,781 1,151 St. Alexius Hospital St. Louis City 51% 43% 28% 28% 21% 29% 69,260 10,117 St. Anthony's Medical Center S. St. Louis Cnty 59% 51% 9% 8% 31% 41% 137,836 28,432 St. Luke's Hospital W. St. Louis Cnty 64% 51% 3% 4% 33% 45% 82,457 18,254 St. Louis Area Aggregate 49% 43% 16% 15% 34% 42% 1,711, ,471 * In 2008, Callaway Community Hospital voluntarily provided detailed information on 2005 Medicare and Medicaid utilization the was unavailable previously. Public program utilization has been restated to be consistent with the method used for all other hospitals in the report. The percentage shown here differs significantly from the percentage previously reported. 1 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Due to the transfer in ownership, 2005 data for this hospital could not be verified

67 2004 Capacity Levels and Productivity Missouri Avail. Patient Avail. Avg. FTE per Missouri Hospital (system name) County beds days Discharges occup. % LOS occup. bed Northeast Regional Medical Center Adair ,180 4, % Audrain Medical Center Audrain 92 15,479 4, % Boone Hospital Center (BJC) Boone ,923 16, % Columbia Regional Hospital (U. of MO) Boone ,363 5, % University of Missouri Hospital and Clinics Boone ,443 11, % County Total Boone ,729 33, % Callaway Community Hospital 1 Callaway 49 3,754 1, % 3.5 N/A Southeast Missouri Hospital Cape Girardeau ,801 12, % St. Francis Medical Center Cape Girardeau ,822 9, % County Total Cape Girardeau ,623 21, % Capital Region Medical Center Cole ,881 7, % St. Mary's Health Center (SSMHC) Cole ,526 10, % County Total Cole ,407 17, % Cox Health Systems Greene ,350 34, % Doctors Hospital Springfield Greene 45 6,777 1, % St. Johns Regional Health Center (SMHS) Greene ,495 31, % County Total Greene 1, ,622 67, % Hannibal Regional Hospital Marion ,507 5, % Perry County Memorial Hospital Perry 25 4, % Citizens Memorial Health Care Polk 74 15,171 3, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 1, ,010 50, % Barnes-Jewish Hospital - St. Peters St. Charles 95 24,417 6, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 67 13,047 3, % Christian Hospitals N. St. Louis Cnty ,680 16, % Missouri Baptist Hospital - Sullivan Crawford 59 9,030 2, % Missouri Baptist Medical Center W. St. Louis Cnty ,825 21, % St. Louis Children's Hospital St. Louis City ,955 10, % BJC HealthCare Total 2, , , % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City ,779 5, % DePaul Health Center N. St. Louis Cnty ,294 19, % St. Joseph Health Center - St. Charles St. Charles ,376 14, % St. Joseph Health Center - Wentzville 2 St. Charles 73 10,840 2, % St. Joseph Hospital - Kirkwood S. St. Louis Cnty ,521 8, % St. Joseph West - Lake St. Louis St. Charles 85 16,605 5, % St. Mary's Health Center W. St. Louis Cnty ,229 18, % SSM Health Care Total 1, ,644 73, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty ,992 37, % St. John's Mercy - Washington Franklin ,879 6, % St. John's Mercy Health Care Total 1, ,871 43, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty ,693 8, % St. Louis University Hospital St. Louis City ,553 15, % Tenet HealthSystem Total ,246 23, % Independents Forest Park Hospital 3 St. Louis City ,096 10, % Jefferson Regional Medical Center Jefferson ,677 9, % Kindred Hospital St. Louis City 56 10, % Lincoln County Memorial Hospital Lincoln 27 4,729 1, % St. Alexius Hospita 3 St. Louis City ,784 11, % St. Anthony's Medical Center S. St. Louis Cnty ,053 27, % St. Luke's Hospital W. St. Louis Cnty ,415 18, % St. Louis Area Aggregate 7,474 1,706, , % Callaway Community Hospital did not file a Medicare Cost Report for Source: DHSS and MHA 2 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Forest Park Hospital, and St. Alexius Hospitals (formerly Alexian Brothers & SouthPoint Hospitals) were sold to Doctors Community Healthcare Corporation (DCHC) in November 2004 by Tenet Healthcare Corporation. Due to the transfer in ownership, 2004 data for these hospitals could not be verified. Note: St. Louis area aggregate ALOS excludes Kindred Hospital since it is a long-term acute care hospital

68 2005 Capacity Levels and Productivity Missouri Avail. Patient Avail. Avg. FTE per Missouri Hospital (system name) County beds days Discharges occup. % LOS occup. bed Northeast Regional Medical Center Adair ,574 4, % Audrain Medical Center Audrain 92 15,415 4, % Boone Hospital Center (BJC) Boone ,493 16, % Columbia Regional Hospital (U. of MO Hosp) Boone ,244 6, % University of Missouri Hospital and Clinics Boone ,812 12, % County Total Boone ,549 35, % Callaway Community Hospital 1 Callaway 49 4, % 4.6 n/a Southeast Missouri Hospital Cape Girardeau ,762 11, % St. Francis Medical Center Cape Girardeau ,767 10, % County Total Cape Girardeau ,529 22, % Capital Region Medical Center Cole ,086 7, % St. Mary's Health Center (SSMHC) Cole ,791 10, % County Total Cole ,877 17, % Cox Health Systems Greene ,522 29, % Doctors Hospital Springfield Greene 45 7,868 1, % St. Johns Regional Health Center (SMHS) Greene ,171 32, % County Total Greene 1, ,561 63, % Hannibal Regional Hospital Marion ,372 5, % Perry County Memorial Hospital Perry 25 3, % Citizens Memorial Health Care Polk 74 14,234 3, % St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City 1, ,899 52, % Barnes-Jewish Hospital - St. Peters St. Charles ,265 7, % Barnes-Jewish Hospital - West County W. St. Louis Cnty 72 12,791 3, % Christian Hospitals N. St. Louis Cnty ,468 16, % Missouri Baptist Hospital - Sullivan Crawford 59 8,227 1, % Missouri Baptist Medical Center W. St. Louis Cnty ,876 22, % St. Louis Children's Hospital St. Louis City ,495 10, % BJC HealthCare Total 2, , , % SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City ,721 6, % DePaul Health Center N. St. Louis Cnty ,786 21, % St. Joseph Health Center - St. Charles St. Charles ,411 14, % St. Joseph Health Center - Wentzville 2 St. Charles 86 9,071 2, % St. Joseph Hospital - Kirkwood S. St. Louis Cnty ,120 8, % St. Joseph West - Lake St. Louis St. Charles ,383 6, % St. Mary's Health Center W. St. Louis Cnty ,841 18, % SSM Health Care Total 1, ,333 78, % St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty ,307 39, % St. John's Mercy - Washington Franklin ,426 6, % St. John's Mercy Health Care Total 1, ,733 45, % Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty ,959 8, % St. Louis University Hospital St. Louis City ,213 14, % Tenet HealthSystem Total ,172 23, % Independents Forest Park Hospital St. Louis City ,943 9, % Jefferson Regional Medical Center Jefferson ,985 10, % Kindred Hospital St. Louis City 94 15, % Lincoln County Memorial Hospital Lincoln 25 5,781 1, % St. Alexius Hospital St. Louis City ,260 10, % St. Anthony's Medical Center S. St. Louis Cnty ,836 28, % St. Luke's Hospital W. St. Louis Cnty ,457 18, % St. Louis Area Aggregate 7,682 1,711, , % Callaway Community Hospital did not file a Medicare Cost report for fiscal year 2005 until Data were revised from the previous report. 2 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Due to the transfer in ownership, 2005 data for this hospital could not be verified. Community Benefit information for this hospital was not reported by MHA in Note: St. Louis Area Aggregate ALOS excludes Kindred Hospitals since it is a long-term acute care facility

69 Fiscal Year 2004 Financial Data (000) Missouri Total Total Gain from Net Operating Profit Missouri Hospital (system name) County Revenue Expenses* Operations Profit margin margin Northeast Regional Medical Center Adair $57,758 $52,896 $4,863 $4, % 8.42% Audrain Medical Center Audrain $51,436 $52,675 -$1,278 -$1, % -2.41% Boone Hospital Center (BJC) Boone $219,991 $212,082 $19,434 $7, % 3.59% Columbia Regional Hospital (U. of MO) Boone 86,250 88,328-2,258-2, % -2.41% University of Missouri Hospital and Clinics Boone 331, ,999 32,585 34, % 10.49% County Total Boone $638,049 $597,409 $49,761 $40, % 6.37% Callaway Community Hospital Callaway $10,464 $10,641 -$177 -$ % -1.69% Southeast Missouri Hospital Cape Girardeau $177,699 $168,238 $8,355 $9, % 5.32% St. Francis Medical Center Cape Girardeau 204, ,158 15,288 27, % 13.50% County Total Cape Girardeau $382,517 $345,396 $23,643 $37, % 9.70% Capital Region Medical Center Cole $111,799 $108,092 $3,315 $3, % 3.32% St. Mary's Health Center (SSMHC) Cole 117, , % 0.61% County Total Cole $228,925 $224,509 $4,051 $4, % 1.93% Cox Health Systems Greene $658,857 $621,573 $17,473 $37, % 5.66% Doctors Hospital Springfield Greene 30,486 25,463 5,081 5, % 16.48% St. Johns Regional Health Center (SMHS) Greene 486, ,201 41,074 41, % 8.45% County Total Greene $1,175,618 $1,092,237 $63,628 $83, % 7.09% Hannibal Regional Hospital Marion $67,877 $66,880 -$155 $ % 1.47% Perry County Memorial Hospital Perry $22,813 $20,246 $2,564 $2, % 11.25% Citizens Memorial Health Care Polk $58,525 $60,339 -$1,952 -$1, % -3.10% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $1,086,906 $960,991 $35,694 $125, % 11.58% Barnes-Jewish Hospital - St. Peters St. Charles 89,880 76,980 11,257 12, % 14.35% Barnes-Jewish Hospital - West County W. St. Louis Cnty 77,911 65,433 18,174 12, % 16.02% Christian Hospitals NE/NW N. St. Louis Cnty 259, ,622 11,887 22, % 8.73% Missouri Baptist Hospital - Sullivan Crawford 31,294 27,817 4,101 3, % 11.11% Missouri Baptist Medical Center W. St. Louis Cnty 340, ,073 51,183 58, % 17.08% St. Louis Children's Hospital St. Louis City 301, ,883 22,959 45, % 15.19% BJC HealthCare Total $2,187,117 $1,905,799 $155,254 $281, % 12.86% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City $188,745 $158,465 $26,133 $30, % 16.04% DePaul Health Center N. St. Louis Cnty 224, ,905 10,972 10, % 4.87% St. Joseph Health Center - St. Charles St. Charles 142, ,112 1,810 1, % 1.21% St. Joseph Health Center - Wentzville 1 St. Charles 22,956 28,525-5,569-5, % % St. Joseph Hospital - Kirkwood S. St. Louis Cnty 93,064 93, % -0.74% St. Joseph West - Lake St. Louis St. Charles 62,317 60,495 1,969 1, % 2.92% St. Mary's Health Center W. St. Louis Cnty 224, ,687 12,307 15, % 6.86% SSM Health Care Total $958,832 $904,943 $46,706 $53, % 5.62% St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $534,619 $516,597 $19,617 $18, % 3.37% St. John's Mercy - Washington Franklin 72,720 69,941 2,820 2, % 3.82% St. John's Mercy Health Care Total $607,339 $586,537 $22,437 $20, % 3.43% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $98,415 $94,301 $7,930 $4, % 4.18% St. Louis University Hospital St. Louis City 305, ,783-17,802-17, % -5.82% Tenet HealthSystem Total $404,400 $418,084 -$9,872 -$13, % -3.38% Independents Forest Park Hospital 2 St. Louis City $104,362 $130,126 -$25,764 -$25, % % Jefferson Regional Medical Center Jefferson $92,415 $91,996 -$599 $ % 0.45% Kindred Hospital St. Louis City $18,199 $14,625 $3,565 $3, % 19.64% Lincoln County Memorial Hospital Lincoln $22,540 $22,528 -$10 $ % 0.05% St. Alexius Hospital 2 St. Louis City $86,794 $93,934 -$7,140 -$7, % -8.23% St. Anthony's Medical Center S. St. Louis Cnty $334,542 $308,496 $6,484 $26, % 7.79% St. Luke's Hospital W. St. Louis Cnty $276,078 $264,863 $9,242 $11, % 4.06% St. Louis Area Aggregate $5,092,619 $4,741,931 $200,302 $350, % 6.89% * Total expenses include non-operating expenses that may have an effect on profit margins. Non-operating expenses are not used in the calculation of operating margins. 1 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Forest Park Hospital, and St. Alexius Hospitals (formerly Alexian Brothers & SouthPoint Hospitals) were sold to Doctors Community Healthcare Corporation (DCHC) in November 2004 by Tenet Healthcare Corporation. Due to the transfer in ownership in 2004, 2004 data for these hospitals could not be verified

70 Fiscal Year 2005 Financial Data (000) Missouri Total Total Gain from Net Operating Profit Missouri Hospital (system name) County Revenue Expenses* Operations Profit margin margin Northeast Regional Medical Center Adair $62,909 $57,387 $5,548 $5, % 8.78% Audrain Medical Center Audrain 53,613 55,926-6,073-2, % -4.31% Boone Hospital Center (BJC) Boone $228,372 $226,097 $16,804 $2, % 1.00% Columbia Regional Hospital (U. of MO) Boone 103, , , % 1.38% University of Missouri Hospital and Clinics Boone 369, ,910 35,574 33, % 9.07% County Total Boone $701,669 $664,467 $52,765 $37, % 5.30% Callaway Community Hospital Callaway $14,742 $12,860 $1,679 $1, % 12.77% Southeast Missouri Hospital Cape Girardeau $202,748 $194,747 $6,102 $8, % 3.95% St. Francis Medical Center Cape Girardeau 226, ,711 18,396 26, % 11.78% County Total Cape Girardeau $429,116 $394,459 $24,498 $34, % 8.08% Capital Region Medical Center Cole $122,460 $116,713 $4,791 $5, % 4.69% St. Mary's Health Center (SSMHC) Cole 133, , % -0.45% County Total Cole $255,653 $250,501 $4,055 $5, % 2.02% Cox Health Systems Greene $658,097 $655,134 $2,045 $2, % 0.45% Doctors Hospital Springfield Greene 40,215 38,555 1,620 1, % 4.13% St. Johns Regional Health Center (SMHS) Greene 512, ,603 49,853 49, % 9.73% County Total Greene $1,210,769 $1,156,292 $53,519 $54, % 4.50% Hannibal Regional Hospital Marion $75,327 $70,755 $3,682 $4, % 6.07% Perry County Memorial Hospital Perry 24,094 22,238 1,840 1, % 7.71% Citizens Memorial Health Care Polk 63,582 65,943-2,539-2, % -3.71% St. Louis Metropolitan Area BJC HealthCare (BJC) Barnes-Jewish Hospital St. Louis City $1,114,191 $1,035,001 $40,364 $79, % 7.11% Barnes-Jewish Hospital - St. Peters St. Charles 101,333 87,522 13,999 13, % 13.63% Barnes-Jewish Hospital - West County W. St. Louis Cnty 76,927 65,061 12,346 11, % 15.42% Christian Hospitals NE/NW N. St. Louis Cnty 249, ,379 2,140 5, % 2.23% Missouri Baptist Hospital - Sullivan Crawford 31,565 28,392 3,213 3, % 10.05% Missouri Baptist Medical Center W. St. Louis Cnty 352, ,871 42,836 48, % 13.77% St. Louis Children's Hospital St. Louis City 316, ,869 30,255 46, % 14.65% BJC HealthCare Total $2,242,554 $2,034,094 $145,152 $208, % 9.30% SSM Health Care (SSMHC) Cardinal Glennon Hospital St. Louis City $186,039 $160,423 $20,709 $25, % 13.77% DePaul Health Center N. St. Louis Cnty 249, ,859 18,766 19, % 7.81% St. Joseph Health Center - St. Charles St. Charles 153, ,924 1,987 2, % 1.32% St. Joseph Health Center - Wentzville 1 St. Charles 24,219 35,653-11,434-11, % % St. Joseph Hospital - Kirkwood S. St. Louis Cnty 98, ,429-13,696-13, % % St. Joseph West - Lake St. Louis St. Charles 71,480 67,360 4,160 4, % 5.76% St. Mary's Health Center W. St. Louis Cnty 248, ,859 17,160 20, % 8.15% SSM Health Care Total $1,031,927 $985,507 $37,651 $46, % 4.50% St. John's Mercy Health Care (SMHS) St. John's Mercy Medical Center W. St. Louis Cnty $589,626 $579,091 $10,212 $10, % 1.79% St. John's Mercy - Washington Franklin 76,095 73,446 2,464 2, % 3.48% St. John's Mercy Health Care Total $665,721 $652,537 $12,676 $13, % 1.98% Tenet HealthSystem Des Peres Hospital W. St. Louis Cnty $106,091 $102,605 $7,773 $3, % 3.29% St. Louis University Hospital St. Louis City 308, ,878-24,259-24, % -7.86% Tenet HealthSystem Total $414,710 $435,484 -$16,486 -$20, % -5.01% Independents Forest Park Hospital St. Louis City $109,478 $116,080 -$6,602 -$6, % -6.03% Jefferson Regional Medical Center Jefferson 102, , , % 2.01% Kindred Hospital St. Louis City 25,808 23,832 1,969 1, % 7.66% Lincoln County Memorial Hospital Lincoln 25,071 24,270-1, % 3.20% St. Alexius Hospital St. Louis City 96,875 96, % 0.49% St. Anthony's Medical Center S. St. Louis Cnty 353, ,665 5,066 22, % 6.40% St. Luke's Hospital W. St. Louis Cnty 310, ,580 9,612 13, % 4.20% St. Louis Area Aggregate $5,378,337 $5,096,709 $189,057 $281, % 5.24% * Total expenses include non-operating expenses that may have an effect on profit margins. Non-operating expenses are not used in the calculation of operating margins. 1 St. Joseph Hospital Wentzville (formerly Crossroads Regional Hospital) was acquired by SSM Health Care in November Due to the transfer in ownership, 2005 data for this hospital could not be verified

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