TY 2018 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) Alan Levine BH PresidentCEO...................................................................... Director	1.00 ................. 59.00	X	X			2,032,246	0	193,444
(2) Marvin Eichorn BH EVPCAO...................................................................... Director	1.00 ................. 59.00	X	X			1,011,865	0	36,694
(3) Eric Deaton BH EVPCOO...................................................................... Director	1.00 ................. 59.00	X	X			0	570,270	42,955
(4) Tim Belisle BH EVPGen Cncl...................................................................... Director	1.00 ................. 59.00	X	X			577,064	0	79,532
(5) Lynn Krutak...................................................................... BH EVP/CFO	1.00 ................. 59.00		X			854,023	0	90,292
(6) Dawn Trimbleterm 218...................................................................... CEO Wahington Co.	45.00 ................. 0.00			X		720,873	0	23,575
(7) Monty McLaurin...................................................................... CEO NW Mkt	34.30 ................. 10.70			X		558,099	0	42,029
(8) Shane Hilton...................................................................... SVP, CFO Mkt Ops	48.50 ................. 1.50			X		530,280	0	73,798
(9) Stan Hickson...................................................................... VP SW Mkt	45.00 ................. 0.00			X		430,310	0	34,702
(10) Richard Booneterm 418...................................................................... CFO Washington Co.	45.00 ................. 0.00			X		369,130	0	18,800
(11) Melissa Carr...................................................................... SVP Financial Mgmt	50.00 ................. 0.00			X		355,904	0	61,808
(12) Patricia Baise...................................................................... VP, CEO Behavioral Health	44.50 ................. 0.50			X		306,357	0	32,602
(13) Lemmie Taylor...................................................................... VP, CEO SE Mkt	45.00 ................. 0.00			X		287,942	0	49,220
(14) Andrew Wampler...................................................................... VP, CFO NW Mkt	44.80 ................. 0.20			X		199,825	0	31,448
(15) Devin McFall...................................................................... VP, CFO SW Mkt	40.50 ................. 4.50			X		225,924	0	36,297
(16) Morgan May...................................................................... VP, CNO JCMC	45.00 ................. 0.00			X		193,055	0	25,707
(17) Morris Seligman MDterm 218...................................................................... EVP & CMO	0.50 ................. 59.50				X	800,387	0	24,560

(A) Name and business address	(B) Description of services	(C) Compensation
Layton Construction Co LLC 9090 Sandy Parkway Sandy,UT84070	Construction Service	11,962,674
Anesthesia & Pain Cnsltnts 1009 Lark St Ste 2 Johnson City,TN37604	Anesthesia Service	5,861,327
Advisory Board Co 2445 M Street NW Washington,DC20037	Data Svcs/Consulting	3,430,657
Allscripts Healthcare LLC 8529 Six Forks Road Raleigh,NC27615	Elec Med Recrds/Main	2,848,247
Change Healthcare LLC PO Box 98347 Chicago,IL606938347	Hlthcare Tech Mgt	2,375,368
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 107

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2018

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv), 170(b)(1)(A)(vi), and 170(b)(1)(A)(ix)
(Complete only if you checked the box on line 5, 7, 8, or 9 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2018 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2017 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2018. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2017. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2018. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2017. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2018

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose
3	Gross receipts from activities that are not an unrelated trade or business under section 513 .....
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge
6	Total. Add lines 1 through 5
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support. (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2018 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2017 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2018 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2017 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2018. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2017. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2018

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2018

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2018

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2018

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2018 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2018	(iii) Distributable Amount for 2018
1 Distributable amount for 2018 from Section C, line 6
2 Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2018:
a From 2013.......
b From 2014.......
c From 2015.......
d From 2016.......
e From 2017.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2018 distributable amount
i Carryover from 2013 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2018 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2018 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2019. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2014......
b Excess from 2015.....
c Excess from 2016.....
d Excess from 2017.....
e Excess from 2018.....

Schedule A (Form 990 or 990-EZ) (2018)

Schedule A (Form 990 or 990-EZ) 2018

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution. An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018) Page 2

Name of organization Mountain States Health Alliance dba Johnson City Medical Center

Part I	Contributors (See instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 3

Name of organization Mountain States Health Alliance dba Johnson City Medical Center		Employer identification number 62-0476282

Part II	Noncash Property (See instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 4


Name of organization Mountain States Health Alliance dba Johnson City Medical Center			Employer identification number 62-0476282
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2018

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ...............................
c	Total lobbying expenditures (add lines 1a and 1b) ...................................................................
d	Other exempt purpose expenditures ........................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................	Yes No

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2018

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Yes

70,184

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Total. Add lines 1c through 1i ....................................................................................................

70,184

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Part II-B, Line 1i - Other Activities Description	MSHA had lobbying expenses of $70,184 which represents the portion of dues paid to Tennessee Hospital Association and Virginia Hospital and Healthcare Association attributable to direct lobbying.

Schedule C (Form 990 or 990EZ) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
SchDMd Bullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2018

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....

Part V

Endowment Funds. Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations .................

3a(i)

(ii) related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....	22,004,663		22,004,663
b	Buildings ....	506,458,801	220,206,884	286,251,917
c	Leasehold improvements	4,707,359	2,522,504	2,184,855
d	Equipment ....	467,578,073	386,353,599	81,224,474
e	Other .....	8,237,481	4,816,820	3,420,661
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				395,086,570

Schedule D (Form 990) 2018

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Investment in CrestPoint	1,464,725	C
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
Due to Affiliates	6,255,940
Due to Third-Party Payors	4,887,898
Professional Liabilities & Other	3,731,209
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	14,875,047
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2018

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1..................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b....................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d....................		2e
3	Subtract line 2e from line 1...................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.....................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference

Explanation

Part X : FIN48 Footnote

Mountain States Health Alliance is included in the audited consolidated financial statements of Ballad Health. The footnote explanation relative to income taxes reads: "Ballad is classified as an organization exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. As such, no provision for federal income taxes is included in the accompanying consolidated financial statements. Taxable subsidiaries are discussed in Note K. No significant uncertain tax positions exist at June 30, 2019. Tax returns for 2016 through 2018 are subject to examination by the Internal Revenue Service."

Schedule D (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other 22500.0000000 %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other 45000.0000000 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	10,312,579		10,312,579	1.580 %
b	Medicaid (from Worksheet 3, column a) . . . . .	121,318,772	101,891,812	19,426,960	2.970 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	131,631,351	101,891,812	29,739,539	4.550 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	4,863,842	822,026	4,041,816	0.620 %
f	Health professions education (from Worksheet 5) . . .	13,901,087	3,207,317	10,693,770	1.630 %
g	Subsidized health services (from Worksheet 6) . . . .	12,836,629	10,440,686	2,395,943	0.370 %
h	Research (from Worksheet 7) .	14,831		14,831
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	1,199,373		1,199,373	0.180 %
j	Total. Other Benefits . .	32,815,762	14,470,029	18,345,733	2.800 %
k	Total. Add lines 7d and 7j .	164,447,113	116,361,841	48,085,272	7.350 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2018

Schedule H (Form 990) 2018

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	67,348	67,348	0.010 %
3	Community support	65,032	65,032	0.010 %
4	Environmental improvements	5,300	5,300
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other	250	250
10	Total	137,930	137,930	0.020 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

64,739,783

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

23,953,720

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

159,181,429

Enter Medicare allowable costs of care relating to payments on line 5.....

155,735,748

Subtract line 6 from line 5. This is the surplus (or shortfall)........

3,445,681

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1Medl Spec of JC LLC	Medical Services	51.000 %	49.000 %
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2018

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?7Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)									Other (describe)	Facility reporting group
1	Johnson City Medical Center 400 N State of Franklin Road Johnson City,TN37604 balladhealth.org 00000121	X	X	X	X		X	X	Mental Health	A
2	Indian Path Community Hospital 2000 Brookside Drive Kingsport,TN37660 balladhealth.org 00000134	X	X		X			X		A
3	Franklin Woods Comm Hospital 300 Med Tech Parkway Johnson City,TN37604 balladhealth.org 00000123	X	X		X			X		A
4	Sycamore Shoals Hospital 1501 W Elk Avenue Elizabethton,TN37643 balladhealth.org 00000012	X	X					X		A
5	Russell County Hospital 58 Carroll Street Lebanon,VA24266 balladhealth.org H 1892	X	X					X		A
6	Johnson County Comm Hospital 16901 S Shady Street Mountain City,TN37683 balladhealth.org 00000039	X				X		X		A
7	Unicoi County Hospital 100 Greenway Circle Erwin,TN37650 balladhealth.org 00000119	X	X					X		A

Schedule H (Form 990) 2018

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	A
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

123456

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): balladhealth.org/locations#hospitals

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 19

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

If "Yes" (list url):

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Yes

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2018

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	A
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 225.0000% and FPG family income limit for eligibility for discounted care of 450.0000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

balladhealth.org

The FAP application form was widely available on a website (list url):

balladhealth.org

A plain language summary of the FAP was widely available on a website (list url):
balladhealth.org

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 6

Part VFacility Information (continued)

Billing and Collections

	A
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs

Made a reasonable effort to orally notify individuals about the FAP and FAP application process

Processed incomplete and complete FAP applications

Made presumptive eligibility determinations

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	A
Name of hospital facility or letter of facility reporting group

Yes

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2018

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Facility: A 1,2,3,4,5,6,7 - Part V, Section B, Line 3j	Facility/Group A includes the following facilities:Johnson City Medical Center, Indian Path Community Hospital, Franklin Woods Community Hospital, Sycamore Shoals Hospital, Russell County Hospital, Johnson County Community Hospital and Unicoi County Hospital During FY19, MSHA hospitals were operating under the community health needs assessments (CHNAs) approved by its board of directors at the end of FY18. Priorities established for our CHNAs were determined by the most significant health needs of each community. For the FY18 CHNAs, Ballad Health, our health system's parent, and its hospitals and entities agreed to focus on an index of 25 active population health index measures (plus an additional 31 measures for monitoring). The population health index itself is based on the focus areas outlined in the previous (FY15 for MSHAs hospitals) CHNAs and align with national health improvement efforts, such as Healthy People 2020. MSHA's affiliates, Wellmont Health System and its hospitals, focused on the same population health index measures determined by Ballad Health when completing their individual FY19 CHNA's.To understand each communitys individual needs, Ballad Health conducted a CHNA for each Ballad hospital to profile the health of the residents within its service area. Throughout the CHNA process, high priority was given to determining the health disparities and available resources within each community. Community members from each county met with Ballad representatives to discuss current health priorities and identify potential solutions.The CHNA community members for each facility evaluated measures that make up Ballad Healths population health index and a few additional measures related to access to health screenings. The groups members completed a survey relative to what health priorities should be a focus for their specific community over the next three years. Johnson City Medical Centers (JCMC) CHNA was conducted with Franklin Woods Community Hospital (FWCH). FWCH is located in the same service area as JCMC so the two hospitals community demographics and health needs are the same. JCMC includes Niswonger Childrens Hospital and Woodridge Hospital, a behavioral health facility. After all the details and data collection was complete and interviews with various focus groups were complete, the Washington County representatives identified their top focus areas. Four key priorities were identified:-Smoking-Substance abuse and mental health-Obesity-Early intervention: vaccinations, screenings, third-grade reading level for third-graders, and diabetes counselingAfter all the details and data collection was complete, the Indian Path Community Hospital community board voted to approve their selected priorities. Four key priorities were identified:- Smoking- Substance abuse and mental health- Obesity- Early intervention: vaccinations and third-grade reading level for third-gradersAfter all the details and data collection was complete, the Sycamore Shoals Hospital community board voted to approve their selected priorities.Four key priorities were identified:- Smoking- Substance abuse and mental health- Obesity- Early intervention vaccinations, screenings and diabetes counselingAfter all the details and data collection was complete, the Russell County Hospital community board voted to approve their selected prioritiesFour key priorities were identified:- Smoking- Physical activity/obesity- Screenings for diabetes and cancer- Substance abuseAfter all the details and data collection was complete, the Johnson County Community Hospital community board voted to approve their selected priorities. Three key priorities were identified:- Smoking- Substance abuse/mental health- ObesityAfter all the details and data collection was complete, the Unicoi County Hospital community board voted to approve their selected priorities. Four key priorities were identified:- Obesity- Behavioral/mental health- Smoking- Early intervention; screening rates (mammography, colorectal cancer and lung cancer) and third-grade reading level for third-graders
Facility: A 1,2,3,4,5,6,7 - Part V, Section B, Line 5	Activities associated with the June 2018 assessments took place from the fall of 2017 through the spring of 2018. Ballad conducted localized community focus groups with organization representatives such as those from local health departments, school systems, health clinics, emergency services, businesses, and philanthropic boards. The individuals in each community were selected for participation by the hospitals CEO.Washington County, Tennessee: (Johnson City Medical Center and Franklin Woods Community Hospital)JCMC includes Woodridge Hospital, its behavioral health facility, and Niswonger Childrens Hospital. The JCMC/FWCH focus group members were represented by Washington County Health Department, Johnson City Mayors Office, East Tennessee State University (ETSU) Community Health Center, Ballad Health employees, members of the Washington County Foundation Board, members of the Washington County Community Board, and members of the Washington County Medical Executive Committee. Low income, minority and medically underserved populations were represented by Washington County Health Department and ETSU Community Health Center. ETSUs Community Health Center is an interdisciplinary facility for the delivery of primary health care services and education of ETSU College of Nursing students. The Health Center provides health care to the uninsured, underinsured, TennCare enrollees, a growing Hispanic population and medically indigent individuals.Sullivan County, Tennessee (Indian Path Community Hospital)IPCHs focus group members were represented by Sullivan County Department of Education, Healthy Kingsport, Health Resources Center Kingsport, Sullivan County Health Department, Kingsport Board of Mayor & Aldermen, Kingsport Chamber of Commerce, United Way, Girls Inc., members of IPCH Foundation Board, and members of IPCH Community Board. The Health Resources Center, Sullivan County Health Department, United Way of Kingsport, and Girls Inc. of Kingsport represented low-income, minority and medically underserved populations. Also, between the foundation board and the community board, there are a number of individuals that sit on each of these boards that represent low income, minority populations, and medically underserved.Carter County, Tennessee (Sycamore Shoals Hospital)SSHs focus group members were represented by Signature Healthcare, Carter County Health Department, Carter County EMS, SSH team members, Primary Care (a medical practice), members of the SSH Foundation Board, and members of the SSH Community Board. Low-income, minority and medically underserved populations were represented by Carter County Health Department. Also, between the foundation board and the community board, there are a number of individuals that sit on each of these boards that represent low income, minority populations, and medically underserved.Russell County, Virginia (Russell County Hospital)RCHs focus group members were represented by Virginia Cooperative Extension, Russell County Health Coalition, Cumberland Mountain Community Services, Russell County Health Department Cumberland Plateau, RCH Foundation Board, United Way of Southwest Virginia, Appalachian Agency Senior Citizens, and RCH Community Board. Low-income, minority populations and medically underserved were represented by Cumberland Plateau Health Department, United Way of Southwest Virginia, and Russell County Health Coalition. Also, between the foundation board and the community board, there are a number of individuals that sit on each of these boards that represent low income, minority populations, and medically underserved.Johnson County, Tennessee (Johnson County Community Hospital)JCCHs focus group members were represented by Johnson County Health Department, Johnson County Emergency Medical Services, East Tennessee State Universitys Mountain City Extended Hours Clinic, JCCH team members, members of JCCH Foundation Board, and members of JCCH Community Board. Johnson County Health Department and the ETSU after hours clinic represented low income, medically underserved and minority populations. Johnson Countys MUA (medically underserved area) is 100% according to the U.S. Department of Health & Human Services Health Resources & Services Administration. Also, between the foundation board and the community board, there are a number of individuals that sit on each of these boards that represent low income, minority populations, and medically underserved.Unicoi County, Tennessee (Unicoi County Hospital)UCHs focus group members were represented by Unicoi County Department of Education, Unicoi County Chamber of Commerce, Unicoi County Health Department, Town of Erwin, Telamon Head Start, YMCA, UCH team members, and the UCHs Board. Unicoi County Health Department, YMCA of Erwin, and Telamon Head Start represented low-income, minority and medically underserved populations. Also, between the foundation board and the community board, there are a number of individuals that sit on each of these boards that represent low income, minority populations, and medically underserved.
Facility: A 1,2,3,4,5,6,7 - Part V, Section B, Line 6a	Each hospital within Mountain States Health Alliance completed a CHNA. Johnson City Medical Center (includes Niswonger Children's Hospital and Woodridge Hospital), Franklin Woods Community Hospital, Indian Path Community Hospital, Johnson County Community Hospital, Johnston Memorial Hospital, Norton Community Hospital, Dickenson Community Hospital, Russell County Hospital, Smyth County Community Hospital, Sycamore Shoals Hospital, and Unicoi County Hospital.
Facility: A 1,2,3,4,5,6,7 - Part V, Section B, Line 11	During the year, MSHA hospitals continued to focus on their CHNA priorities as identified in their FY18 CHNA report. Many additional community needs exist in the regions we serve. It is fiscally impossible for a hospital to address every health need in a community, which is why the CHNA process is used to identify and prioritize areas of focus. A thoughtful CHNA evaluates overall community health needs to determine which ones the hospital can best influence in a positive way. Consideration is given to other organizations in the hospitals geographic area that already offer services addressing specific health needs. In some cases, it is best to simply support an identified health need through a financial donation to another nonprofit organization skilled in certain areas: teen pregnancy, dental health, fighting homelessness, etc. MSHAs leaders also lend support to other nonprofit organizations by serving on their boards, committees, and assisting with fundraising efforts. HOW MSHA IS ADDRESSING THE SIGNIFICANT NEEDS IDENTIFIED IN OUR MOST RECENT CHNA's:All MSHA hospitals have been diligent in their goal to ensure appropriate prescribing of opioids and a reduction in opioids in our region. The result is a significant reduction in prescribing rates. Our Health Resources Centers (Johnson City Medical Center and Indian Path Community Hospital) provide numerous health screenings throughout the year and a wide range of free health education classes, most of which target health need priorities identified in the hospitals' CHNAs. For example, many classes and activities focus on healthy eating, obesity, heart health and diabetes. MSHA hospitals offer numerous support groups for various chronic conditions throughout the year.Our hospitals provide diabetes education and support to the community through support groups. Meetings offer participants the opportunity to learn more about how to manage their condition through lifestyle medication, diet and exercise. MSHA hospitals provide smoking cessation counseling to patients that have been admitted as an inpatient, seen in the emergency department or in ambulatory surgery. Patient education is provided through several avenues including in-hospital education, a toll-free number for information and additional counseling, and written material given to patients. The hospitals also provide community education on smoking cessation through events and local schools. The CHNA continues to encourage programmatic investments made by the hospitals such as free low-dose CT lung screening for cancer to detect cancer earlier. During FY19, IPCH provided 387 free lung screening scans; Sycamore Shoals Hospital provided 148 scans. Supporting our CHNA, a focus on cancer rates within our community led to MSHAs cancer navigator program which continues to provide support for patients needing assistance, such as transportation to doctor visits and treatments as well as prescription needs. Free medications were provided to some low-income patients at the time of their discharge from several MSHA hospitals.JCMCs Niswonger Childrens Hospital launched Families Thrive last year. This program is part of our neonatal abstinence syndrome (NAS) program for babies who are exposed to addictive substance before birth. The program provided counseling for addiction recovery, tools for parenting skills and connections to other community services that can assist families after the baby leaves the hospital. The goal is to provide addicted mothers with treatment plans for narcotic recovery if they are not in a program already. JCMC opened a CDU (clinical decision unit) last year. The CDU is an extension of the emergency department specially designed to serve patients needing behavioral health care. Some of these patients may be transitioned to inpatient psychiatric care while others will be discharged to outpatient service once stabilized. JCMC also provided free lab services to a nonprofit clinic that provides primary health care services and engages in many outreach contacts each year to individuals on the street, in shelters and in farm worker camps. Our Parish Nurse program offers health education within places of worship. The nurses also conduct health screenings that detect health issues that need attention.Our Childrens Hospital provides many activities throughout the year to engage children and their families in physical activities. Examples include hosting a race in the fall and organizing a childrens physical activity event at a local festival. In addition, the hospital supports Morning Mile, a partnership with local elementary and middle schools to offer exercise in the mornings before classes begin. Many of our hospitals have now implemented the Morning Mile program in local schools.Indian Path Community Hospital is very active in the community. One example of that is the much-anticipated annual 9-day Fun Fest Festival in Kingsport. Every year, Indian Path is very involved in the festival, offering many activities for children that involve physical activity. Over 1,000 children participated in our Fun Fest activities this year. To better manage certain heart disease patients, last year Indian Path Community Hospital implemented disease managers and a transitional care clinic. Both programs facilitate care for patients that may lack the necessary resources to properly treat their conditions. Sycamore Shoals Hospital provided an RN to work with and role model professional behaviors and life skills to young women in the community that are in recovery from drug and/or alcohol abuse. The RN worked with the participants on health, wellness, career opportunities, and hygiene. The programs goal is to assist the women in re-entering society as drug/alcohol free citizens and to boost their self-confidence. Sycamore Shoals Hospitals lab department provided free lab testing for two local nonprofit organizations. One nonprofit serves two rural impoverished counties in East Tennessee by providing food, health screenings, a dental clinic, and other essential services. The other nonprofit offers medical care to persons with incomes 150% or below the poverty level. Johnson County Community Hospitals rural community suffers from high rates of diabetes, cancer, obesity and tobacco use. And our isolated area poses a challenge to access to health care. In response to the unique challenges of rural life, East Tennessee State University operates an extended hours clinic located inside our hospital, with the hospital providing some financial support. The clinic treats acute and chronic conditions and is open 5 days a week. The hospital also provides telemedicine services for some specialties, further improving access to medical specialists. Our hospital operates an emergency department at a financial loss. We also provide a much-needed outpatient behavioral health program for older adults, which also operates at a loss. Similar to many of Mountain States Health Alliances hospitals, Russell County Hospital in Virginia is located in a medically underserved and rural population. Our community has high rates of obesity, cancer, cardiovascular disease and substance abuse. The hospital works with the Russell County Prevention Coalition, whose mission is to promote wellness within Russell County. The organization works to reduce tobacco use (including e-cigarettes) and reduce underage alcohol and drug abuse. Russell County Hospitals Clearview Behavioral Health Center offers mental and behavioral health care for people in crisis situations at a significant financial loss to the hospital. There is not another inpatient mental health facility in our area. Russell County Hospital continues to hold their annual Health Fair to educate the public on a variety of health topics and perform health screenings. We also established a Celebrate Women Night of Hope to support funding and education for cancer prevention and treatment. The hospital continued its practice of providing medications and supplies to area rescue squads this year. Unicoi County Hospital, along with many MSHA hospitals, is involved with the Morning Mile, a program that encourages physical activity through partnership with local schools. The goal of the program is to reduce childhood obesity, while improving grades and decreasing absenteeism. Kids engaged with Morning Mile are able to exercise before classes begin, which has shown to reduce stress and improve mood. Partnerships are formed with other organizations including the local Chamber of Commerce and Little League with the same goal of increasing physical activity.Our hospitals made financial contributions to other nonprofit organizations providing community services that support our CHNAs. Examples include contributions to organizations addressing the opioid crisis, a significant donation to an organization that provides access to health care for low income residents in Appalachia, an organization focused on expanding health care to all Am
Facility: A 1,2,3,4,5,6,7 - Part V, Section B, Line 13h	Ballad Health's financial assistance policy allows for some exceptions to strictly adhering to federal poverty guidelines when awarding financial assistance. Unique circumstances may be weighed and assessed for financial assistance consideration on a case-by-case basis. Also, there are some services where financial assistance may be provided outside of federal poverty guidelines. These are noted in Ballad Health's financial assistance policy.

Schedule H (Form 990) 2018

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1	JCMC Ambulatory Surgery Center 400 N State of Franklin Road Johnson City,TN37604	Licensed Ambulatory Surgery Center
2	Mountain States Imaging Center 301 Med Tech Parkway Suite 100 Johnson City,TN37604	Licensed Outpatient Diagnostic Center
3	Indian Path Transitional Care 2000 Brookside Drive Kingsport,TN37660	Licensed Skilled Nursing Facility
4	Medical Cntr Home Care-Johnson City 509 Med Tech Parkway Suite 200 Johnson City,TN37604	Licensed Home Health Agency
5	Medical Cntr Home Care-Kingsport 2020 Brookside Drive 28 Kingsport,TN37660	Licensed Home Health Agency
6	Russell Co Home Health & Hospice 116 Flannagan Avenue Lebanon,VA24266	Licensed Home Health Agency
7	Medical Center Hospice 509 Med Tech Parkway Suite 300 Johnson City,TN37604	Licensed Hospice Agency
8	Johnson County Home Health 1987 South Shady Street Mountain City,TN37683	Licensed Home Health Agency
9	Unicoi County Long Term Care 100 Greenway Circle Erwin,TN37650	Licensed Long Term Care Facility
10	Dickenson Co Home Health & Hospice 312 Hospital Drive Suites 1A 1B Clintwood,VA24228	Licensed Home Health Agency

Schedule H (Form 990) 2018

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
Part I, Line 3c - Charity Care Eligibility Criteria (FPG Is Not Used)	Financial assistance approval can apply to an assortment of patients such as those who have exhausted their TennCare/Medicaid benefits, those who qualified for TennCare/Medicaid after the date of service, deceased patients with no estate or assets, uninsured patients, and underinsured patients. While Ballad Healths qualifications for financial assistance is based on federal poverty guidelines, asset values may also be used to determine eligibility. Unique circumstances may be assessed on a case-by-case basis. Charity approval covers current or active patient balances when they are approved and there is no limitation or cap on the amount of charity that a patient may receive. Ballad Health hospitals do not stop approving financial assistance for patient accounts if a hospitals charity write-offs exceed the hospitals charity budget.All Ballad Health hospitals provide an uninsured discount; the current uninsured discount is 85% with the exception of critical access hospitals. The uninsured discount for Johnson County Community Hospital, a designated Critical Access Hospital, was 71% through 9/30/18, when it increased to 73%. In addition to the uninsured discount, many patients will further qualify for additional financial assistance. All patients seeking financial assistance must submit an application for financial assistance and submit documents in support of the information on the application, unless specifically excluded according to our policy guidelines. Medicaid eligible patients will qualify for 100% financial assistance and not be required to complete the required documentation when: a) Medicaid eligibility requirements are met after the service is provided, b) non-covered charges occur on a Medicaid eligible encounter, or c) benefits have been exhausted. Deceased patients with no estate also qualify for 100% financial assistance.Financial assistance determinations may be retroactive for all outstanding balances. In addition, we have a number of programs with special discounts such as lactation consultation services; oncology treatment regimens; enrollment in various community programs, and prescription drugs filled post-discharge.
Part I, Line 7 - Explanation of Costing Methodology	The cost to charge ratio (worksheet 2 "ratio of patient care cost to charges") was used to calculate line 7a financial assistance (charity care) cost. Our cost accounting system was used to determine losses from Tenncare and Medicaid reported on line 7b, with the exception of home health, a small physician clinic and UCH we used the cost to charge ratio for their data because these are smaller divisions not available in our cost accounting software. Line 7e community health improvement includes costs that are taken directly from departmental operating reports or expenses specific to a community health event, with no additional overhead included in the cost. Line 7f health professions education is comprised of internships (primarily internal medicine residents, nursing, pharmacy, and therapy students) with schools and universities, allowing their health profession students to get hands-on training in a hospital setting. Our Medicare-approved programs include medical residents, pharmacy and pastoral care at JCMC and IPCH. For these programs, Medicare-approved costs and Medicare reimbursement comes from filed Medicare cost reports. The Ballad Health Organizational Development Department (OD) maintains records for the non-Medicare programs. OD keeps records of the number of students receiving training at our hospitals and the amount of hours the students spend at our hospitals. Hours may differ based on the school and the type of program (RN, radiology, lab, etc.). The number of team members that provide training to students will also vary based on where the student is training. For example, an RN trainer on a medical floor may have 3 or 4 students under his/her direction, while an RN trainer in a specialty area such as ICU or the ER may be training one-on-one with a single student. We only include labor costs for our hospital team members that provide training (i.e. no overhead is applied) and we only attribute a percentage of our team members time to actual training. For line 7g subsidized health care services, we use our cost accounting system because we have established, standard costing reports for these services. There are three exceptions where we do not use our cost accounting system. We have a small clinic inside JCCH, a federally designated critical access hospital. JCCH subsidizes the clinic and we use the clinics departmental operating report to compute the clinics community benefit. The second exception is a palliative care program. For this program, we use the departments operating report. The third exception relates to low-dose CT scans for lung cancer. Patient charges for this screening event were written-off as an administrative adjustment (not as charity). We used the cost to charge ratio to determine the cost of the free scans. The scans were performed in support of our cancer CHNA priority. We are careful to ensure no double counting of cost. Although we have other service lines within our hospital that lose money, we do not report services that hospitals are required by state licensure to provide, routine services or ancillary services. Line 7h research represents MSHA's expense allocation from Ballad Health for research. Line 7i cash and in-kind contributions include cash disbursements and in-kind donations of medications to local nonprofit rescue squads and fire departments. In-kind donations of medications are based on our actual cost for these items.
Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense	Self-pay balances include accounts after payments and contractual adjustments (discounts) have been applied from all third-party payers such as Medicare, TennCare, commercial insurers, and others - generally leaving the patient responsible for any remaining deductible and/or co-payment. Other self-pay accounts are from patients with no insurance or other third-party coverage. Under Ballad Healths system-wide self-pay policy, any patient who has no insurance and is ineligible for any government assistance program received an 80% discount until September 30, 2018, at which time the uninsured discount increased to 85%. Many self-pay patients will further qualify for financial assistance (sometimes referred to as charity care) if they provide the financial information we need to deem them eligible.After the normal collection process has indicated an account is uncollectible, MSHA writes the account off to bad debt. The hospital's overall self-pay accounts receivable balance is evaluated on an ongoing basis to evaluate the age of accounts receivable, historical write-offs and recoveries and any unusual instances (such as local, regional or national economic conditions) which affect the collectability of receivables.
Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit	Our primary external collection agency estimates that 37% of MSHAs bad debt would likely qualify for financial assistance if patients had provided our hospitals with a financial assistance application and required documentation. The agency based their likely eligible for charity assumption on individuals with a low score. An individuals score is based on an algorithm that includes data points such as FICO credit score, property value, years at current residence, number of times an individual has moved and an individuals propensity to pay score. Just over 94% of completed financial assistance applications processed during FY19 received a full discount (complete write-off). An additional 5% received a partial discount, resulting in an overall approval rate of 99% for completed applications. Therefore, only 1% of completed financial assistance applications were denied. Unfortunately, many patients either do not submit an application for financial assistance or do not provide a complete application. A letter is sent to the patient outlining missing information on incomplete applications. The letter also provides a contact phone number patients may call for assistance in completing the application. All self-pay patients receive follow up calls from a company MSHA pays to process charity care applications for uninsured patients and to offer patients enrollment assistance in TennCare (TN) or Medicaid (VA). The follow up calls are as follows: every 31 days, 31-60 days up to 3 calls are made, after 60 days up to 2 additional calls are made. Our financial counselors follow up with patients that have a balance after insurance has paid. We have many instances of patients with large account balances and no health insurance coverage that we believe would qualify for financial assistance. Although patients are encouraged to apply for assistance, many will not do so. MSHA would prefer for patients to submit completed financial assistance applications given that historical data clearly indicates that most uninsured patients and many underinsured will qualify for financial assistance under our program. Without a completed application, we have no choice other than to record an unpaid account as bad debt instead of charity care.
Part III, Line 4 - Bad Debt Expense	Ballad Healths audited financial statements include a footnote on page 13 that describes bad debt. MSHA is included in the June 30, 2019 audited financial statements of Ballad Health (attached).
Part III, Line 8 - Explanation Of Shortfall As Community Benefit	Excluding Medicare losses reported in Part I subsidized health, the Part III Medicare gain is reported using MSHA's filed Medicare cost report (C/R). The C/R uses a cost to charge ratio based on a step-down allocation methodology. We believe Medicare losses should be allowed as a reportable community benefit, similar to governmental programs such as Medicaid. As a participating provider in the Medicare program, hospitals are required to provide the full regimen of care for the Medicare population. There are a number of care regimens that are compensated by the Medicare program at levels below cost. Therefore, it is only logical to allow hospitals to report these uncompensated services as a community benefit. By making this change, nonprofit providers will be encouraged to continue important care delivery models for our aging population in spite of the fact it may be economically injurious.
Part III, Line 9b - Provisions On Collection Practices For Qualified Patients	Requests for financial assistance are evaluated using established guidelines, while allowing for unique financial circumstances - for example, medically indigent patients with catastrophic medical costs that would threaten the patients household financial viability. When a patient requests financial assistance or when an application has been received, the patient's account is placed in a hold status to prevent further collection activities until financial assistance eligibility is determined. All Ballad Health hospitals comply with IRS 501(r) regulatory guidelines.Our collection policy clearly states that all patients are treated equally - with dignity and respect. We ensure that outside collection agencies used by our hospitals adhere to our billing and collection guidelines. Our collection program includes communicating expected financial responsibility prior to service. Our hospitals provide assistance to help underinsured and uninsured patients determine sources of payment for medical bills and to help patients determine eligibility for programs such as TennCare or Medicaid.After insurance benefit verification, our hospitals bill insurance carriers. If the insurance carrier denies payment of the service/procedure as non-covered or the patient has exceeded their maximum benefits, the service/procedure will qualify for the uninsured discount.Financial counselors are available to discuss financial assistance with patients and their families. Our hospitals provide a number of payment options:- a pre-service discount may be offered- a discount in excess of established discounting rates may be granted for catastrophic high dollar accounts- our hospitals accept all non-contracted and out-of-network payers and will make attempts to work with these payers regarding appropriate reimbursement and billing to their members- payment arrangements are available as long as the account is not with a collection agencyReasonable efforts are made to determine if a patient is eligible for financial assistance - see Schedule H, Part VI, line 3 for information on how patients are informed about our financial assistance policy.
Part VI, Line 2 - Needs Assessment	Focusing on 25 active population health index measures allows Ballad Health to further engage the efforts of its hospitals in partnership with communities in our service areas. It has helped Ballad to better identify health disparities that appear across the individual communities and has helped Ballad to prioritize issues that are most important in each hospital's community. Engaging local community organizations will expand partnerships so that organizations work together more to address community health needs.Ballad Health developed a comprehensive process to gather input for and draft a population health plan. An executive steering team was established, aided by national experts with experience in large-scale population health improvement. Because our hospitals are located in a region with many chronic disease challenges, Ballad Health's goal is to target population health issues to make lasting improvements. Ballad conducted approximately 150 interviews and held 40 meetings with external groups, including the regional health departments, United Way agencies, chambers of commerce, schools and community organizations, the regional accountable care community steering committee, as well as internal groups such as our population health and social responsibility committee of the Ballad Health board of directors, the Ballad Health population health clinical committee, and our hospital community boards.
Part VI, Line 3 - Patient Education of Eligibility for Assistance	Consistent with the Ballad Health financial assistance policy, MSHA communicates with and provides education to our patients through various avenues regarding governmental assistance programs and hospital financial assistance. Various educational and application documents related to obtaining financial assistance are widely available at MSHA and all documents are available on the Ballad Health website. Printed financial assistance educational materials are part of each registration packet and posters are displayed in highly visible areas of the hospital. Our financial assistance policy and documents are available in our emergency departments and admitting areas. We are also happy to mail all documents to patients. We offer a plain language summary and all of our documents are available in English and Spanish. Financial assistance information is available during pre-registration, registration and/or during financial counseling. We offer governmental program eligibility representatives to assist patients in securing eligibility for TennCare or Medicaid, federal disability and other governmental assistance programs. Additionally, if a patient or community resident expresses an interest in the ACA healthcare exchange, our representatives have the qualifications and experience to assist them through the entire process. Our financial counselors offer financial assistance applications to patients who do not qualify for governmental assistance programs and are unable to pay for some or all of their healthcare.All patient billing statements have verbiage discussing financial assistance along with contact information. Our last letter to the patient displays the plain language summary. In all oral correspondences with a patient, if it is identified the patient cannot meet payment requirements on their account, financial assistance is discussed as an option. Applicants are notified of financial assistance determination in writing.
Part VI, Line 4 - Community Information	MSHA serves the healthcare needs of 29 Appalachian counties in Tennessee, Southwest Virginia, Kentucky, and North Carolina. All of the counties MSHA serves are federally designated as medically underserved areas. MSHAs largest hospital, Johnson City Medical Center, is a tertiary referral center and level one trauma center. All of MSHAs wholly owned hospitals are located in federally designated medically underserved areas. Medically underserved areas are designated by the U.S. Department of Health and Human Services. Shortage areas are identified through analysis of physician to population ratios depending on whether an area is considered to have a high need. Criteria used to determine high need are poverty rates, the percent of the population over age 65, infant mortality rates and fertility rates. MSHA operates 2 critical access hospitals: wholly-owned Johnson County Community Hospital in Tennessee and majority-owned Dickenson County Community Hospital in Virginia.Many rural residents must travel a greater distance to access different points of the health care delivery system. Due to geographic distance, sometimes extreme weather conditions, lack of public transportation and challenging roads, rural residents may be limited, and in some instances, even prohibited from accessing health care services. Although 19% of people in the U.S. live in rural areas and 30% of the vehicle miles traveled occur in rural areas, almost half of crash deaths occur there. Within our counties in MSHAs service area, unintentional injury deaths are much higher than the statewide rates. For example, in Tennessee Unicoi County's rate is 35% higher and Johnson County's rate is 13% higher. In Virginia, Russell Countys rate is 48% higher than the statewide rate. A CDC (Centers for Disease Control and Prevention) study demonstrated there is a significant gap in health between rural and urban Americans. The CDC noted that demographic, environmental, economic, and social factors may put rural residents at higher risk of death. Residents in rural areas tend to be older and sicker than their urban counterparts. They have higher rates of cigarette smoking, high blood pressure and obesity. Rural residents also report less leisure-time physical activity and lower seatbelt use. They have higher rates of poverty, less access to healthcare, and are less likely to have health insurance. The CDC study found that unintentional injury deaths were significantly higher in rural areas, partly due to a greater risk of motor vehicle crashes and opioid overdoses. The CDC believes the gaps in health between rural and urban can be addressed by:-Screening patients for high blood pressure-Increasing cancer prevention and early detection-Encouraging physical activity and healthy eating-Promoting smoking cessation - cigarette smoking is the leading cause of preventable disease death in the U.S.-Promoting motor vehicle safety-Engaging providers in safer prescribing of opioids for pain and educating citizens on the risks of opioidsAnd, while our area has generally unfavorable health statistics, there are far fewer primary care physicians per resident in some of our counties than the states average. For example, in Carter County, our ratio of population to primary care physicians is 85% higher than the states average and Unicois ratio is 82% higher. Both of these counties are more than double the ratio of U.S. top performers according to the Robert Wood Johnson Foundations County Health Rankings. Recruiting physicians to rural areas is often challenging due to a myriad of factors, such as geography, economics, culture and education. Geographically, rural communities are often far removed from suburban and urban centers that provide access to educational, cultural and economic opportunities. These limitations influence the relocation decision of the physician candidate and his/her spouse/children to locate to a rural area. The health status of the population in MSHA'S service area is generally poor. A number of factors contribute to a unique and challenging environment that influence the overall health standing for counties included in the MSHA service area. Obesity increases the risk for many health conditions such as coronary heart disease, type 2 diabetes, hypertension, stroke, cancer, sleep apnea and respiratory problems, and osteoarthritis. Evidence indicates physical activity, independent of its effect on weight, has substantial benefits for health. Relative to obesity and physical activity levels, many of our counties have high levels of obesity combined with high levels of physical inactivity as shown below. -The percentages of adult obesity: Johnson County 31%, Unicoi County 34%, Carter County 36%, Sullivan County 33% and Russell County 32%. The adult obesity rate for U.S. top performers is 26% according to the Robert Wood Johnson Foundations County Health Rankings.-The percentages of physical inactivity: Carter County 29%, Sullivan County 28%, Unicoi County 27%, Johnson County 29%, and Russell County 33%. The physical inactivity rate for U.S. top performers is 19% according to the Robert Wood Johnson Foundations County Health Rankings. Our service area extends to some of the poorest rural counties in the region with a poverty rate of almost 30% in some areas. The census bureau estimates county median household incomes are: Johnson County - $34,151; Carter County - $36,589 and Unicoi County - $39,851, averaging approximately 42% below the State of Tennessee median household income. Some of the most well-off counties in MSHA'S service area still have a median household income lower than state and national averages. For instance, Washington Countys median household income is 7.5% below the State of Tennessee and Sullivan Countys is 17.3% below the state. Children in poverty in some areas is approximately 30%. For example, the percentage of children living in poverty in Johnson County is 33%, Carter County is 29%, Unicoi County is 25% and Russell County is 25%. The latest census bureau data estimates the median age of residents of Unicoi County is 46.6, Johnson County is 46.1, and Carter County is 44.9, all significantly older than the median age of 38.9 in Tennessee. All of our communities have a large elderly population, far exceeding that of the country. Persons 65 years and older in the counties MSHAs hospitals are located in range from 18.3% to 23.2% compared to 16.0% for the U.S.
Part VI, Line 4 - Community Building Activities	MSHA leaders support and encourage all team members to volunteer time, money and skills to community service projects and charitable organizations. Senior leaders and board members set a positive example for MSHA team members, serving voluntarily on committees and boards of local service and nonprofit organizations. Some also serve as members and consultants on professional committees and task forces that affect regional development in healthcare and education. We do not capture costs associated with team members that serve on other nonprofit boards or provide services to other nonprofits.MSHA, in collaboration with area health agencies and providers, may offer assistance with coordination, advocacy, or contribute supplies to support groups for their program activities that serve to assist special populations within our area. Most of these organizations work to improve the lives of community members that have limited, or no, financial resources.
Part VI, Line 5 - Promotion of Community Health	MSHA is dedicated to operating efficiently so that waste is minimized. MSHAs leadership remains mindful of managing limited resources so that adequate facilities and equipment are available for the care of our patients. Surplus funds are invested into improving treatment options for our patients through new technologies, recruiting physicians and trained staff in shortage areas, and improving our facilities. Various checks and balances are established to ensure that expenditures for operating expenses and capital costs are reasonable and necessary.MSHA has several hospitals with Medicare-approved health profession education programs. In addition, our hospitals serve as training sites for many types of health professions: nursing, pharmacy, psychology, lab, respiratory therapy, EMT, public health, etc. Students from numerous colleges, universities, and programs receive training and experience in our hospitals. We devote resources to health conferences for local health professionals, operate two health resources centers conveniently located in a shopping mall and a wellness center; provide for media coverage to educate our residents on health issues; offer events to the public that combine fun activities with health education; and many other programs focused on improving the health of our residents. While we operate hospitals in predominantly low-income, rural and isolated areas, we continue to offer services that operate at a loss to MSHA because residents would otherwise need to leave their home town or county to receive needed care. Mountain States merged with Wellmont Health System in February 2018 to form Ballad Health healthcare system. Mountain States and Wellmont still exist as legal entities and continue to operate multiple hospitals. MSHA's governing body is comprised of persons who reside in the organization's primary service areas. Physicians that request privileges who are qualified and credentialed are extended privileges by MSHA.
Part VI, Line 6 - Affilated Health Care System	Mountain States merger with Wellmont opened up many opportunities not previously available to two competing health systems. Collaboration started post-merger and we continue to see progress towards improving efficiencies within our health system, activities consistent with Ballad Healths population health initiative, sharing best practice quality improvements, and other benefits related to operating as one rather than operating in a competitive environment. A new clinical council was formed immediately following the merger. The council includes physicians nominated from the leadership of all Ballad hospitals. A new Community Benefit and Population Health Committee of the board was established and various other infrastructures have been established since the merger.Across MSHAs hospitals, there were many projects, programs, and collaborative efforts that took place during the year. Some examples include:A new hospital was opened in Unicoi County, Tennessee A plan was approved to adopt an integrated technology platform bringing all of our hospitals and points of service together as an integrated system. Consolidation of Level III NICU, Cardiac Cath, and other services to enhance quality of care and patient outcomesOpioid prescribing reduction across all MSHA hospitalsMSHA hospitals shared successful achievements from value optimization team projectsMSHA provides care to people in 29 counties in Tennessee, Virginia, Kentucky and North Carolina. Each hospital is fully accredited by The Joint Commission, with the exception of JCCH. JCCH receives certification through the State of Tennessee since it is a critical access hospital. MSHA, based in Johnson City, Tennessee includes 7 wholly-owned hospitals. In addition to its wholly-owned hospitals, MSHA has majority ownership in 4 hospitals located in Southwest Virginia, each of which file separate returns. In addition to our acute care hospitals, our system includes such services as:primary/specialty physician practices, emergency departments, occupational medicine, rehabilitation, outreach laboratory, mental health, neonatal intensive care, a NACHARI-affiliated children's hospital, renal dialysis, St. Jude's Oncology, inpatient/outpatient surgery, skilled nursing, long-term care, home health, and more. With these additional facilities and services, MSHA extends a highly effective health care delivery system. Since our system is both horizontally and vertically integrated, patients can be efficiently moved along an integrated, comprehensive continuum of care as their health status dictates. Our flagship facility, Johnson City Medical Center is at the core of our system offering full-service tertiary care. In addition to our hospitals, MSHA is the sole member of Blue Ridge Medical Management Corporation (BRMMC). MSHA extends an integrated healthcare delivery system through BRMMC to include multiple primary and specialty care patient access centers and numerous outpatient care sites, including urgent care centers, occupational medicine services, a same day surgery center and rehabilitation.MSHA partnered with East Tennessee State University to open Overmountain Recovery, an opioid addiction recovery facility located in Gray, Tennessee.MSHA is the sole member of Integrated Solutions Health Network, LLC. (ISHN). ISHN operates Anewcare Collaborative, the region's first accountable care organization, bringing together community health care providers to provide better outcomes and improved patient satisfaction at a lower cost.MSHA county-specific operations are governed by a community board of directors. County boards report to a system level board of directors. All boards are primarily composed of local community residents.Hospitals in the Ballad Health system work closely with one another to share expertise and resources.
Part VI, Line 7 - States Filing of Community Benefit Report	TN VA
Part VI - Additional Information	Ballad Health is required to report community benefit estimates on a quarterly basis with the states of Tennessee and Virginia. The reporting includes all of Ballad's hospital organizations and is reported using IRS Form 990, Schedule H instructions for reporting community benefit. Ballad operates under a Certificate of Public Advantage (COPA) in Tennessee and a Cooperative Agreement (CA) in Virginia as obligated by agreements between Ballad and the two states to allow Mountain States Health Alliance and Wellmont Health System to merge.

Schedule H (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization
Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number
62-0476282

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient

that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC section (if applicable)	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) American Heart Association 208 Sunset Drive Suite 113 Johnson City,TN37604	13-5613797	501C3	25,000	Program Support
(2) Appalchn Mtn Project Access 809 S Roan Street Suite 4 Johnson City,TN37601	26-2102040	501C3	78,077	Health Access
(3) Barter Theatre PO Box 867 Abingdon,VA24212	54-6000120	501C3	9,000	Sponsorship
(4) Blue Plum Organization 325 1/2 E Main Street Johnson City,TN37601	31-1704906	501C3	13,500	Sponsorship
(5) Boys & Girls Club of Eliz 104 Hudson Drive Elizabethton Elizabethton,TN37643	62-0502737	501C3	7,500	Program Support
(6) Bristol Family YMCA 400 ML King Jr BLVD Bristol,TN37620	62-0521204	501C3	10,000	Annual Donation
(7) City of Johnson City 601 E Main Street Johnson City,TN37601	62-6000320	501C3	252,000	Physical Hlth/Sprshp
(8) Comm in Schools of SW VA PO Box 1042 Johnson City,TN37605	46-1775208	501C3	10,000	Education programs
(9) Crumley House Brain Injury 300 Urbana Road Limestone,TN37681	58-1988511	501C3	15,500	Program Support
(10) East Tennessee State Univ P O Box 70732 Johnson City,TN37614	62-6021046	501C3	49,157	Health Research
(11) Friends in Need Health Center 1105 W Stone Dr Kingsport,TN37660	62-1541637	501C3	30,000	Health and Dental Care
(12) Governors Fndtn for Health 511 Union Street Suite 720 Nashville,TN37219	45-3635908	501C3	25,000	Healthier Tennessee
(13) Healing Hands Health Center 245 Midway Medical Park Bristol,TN37620	62-1677000	501C3	9,370	Medical & Dental
(14) Holy Friendship Summit 1241 Volunteer Parkway Bristol,TN37620	81-3718877	501C3	25,000	Sponsorship
(15) Junior Achievement Tri-Cities 330 Broad Street Suite 1 Kingsport,TN37660	84-1267604	501C3	10,000	Program Support
(16) Junior League of Kingsport 418 Shelby St Kingsport,TN37660	62-0634742	501C3	10,000	Program Support
(17) Kingsport Chamber Foundation 400 Clinchfield St Ste 100 Kingsport,TN37660	58-1453565	501C3	122,800	Sponsorship
(18) Komen East Tennessee 318 Nancy Lynn Lane 13 Knoxville,TN37919	75-2854955	501C3	20,000	Sponsorship
(19) K-Play SportsMiracle Field 400 Clinchfield St Ste 100 Kingsport,TN37660	41-2045125	501C3	6,705	Adaptive Playground
(20) Lipscomb University One University Park Drive Nashville,TN37204	62-0485733	501C3	10,000	Sponsorship
(21) March of Dimes Foundation 1275 Mamaroneck Avenue White Plains,NY10605	13-1846366	501C3	5,900	Sponsorship
(22) Milligan College PO Box 189 Mllgn College,TN37682	62-0535755	501C3	13,410	Program Support
(23) Niswonger Foundation Inc Tusculum College PO Box 5112 Greeneville,TN37743	62-1871605	501C3	15,000	Student Career Development
(24) Second Harvest Food Bank 127 Dillon Court Gray,TN37615	62-1303822	501C3	28,000	Food Pantries
(25) Speedway Childrens Charities 151 Speedway Boulevard Bristol,TN37620	56-1331429	501C3	50,000	Sponsorship
(26) Sullivan Co Anti Drug 3193 Highway 126 Blountville,TN37617	47-2607914	501C3	24,500	Prevent Youth Substance Abuse
(27) Tennessee Medical Foundation 216 Centerview Drive Ste 304 Brentwood,TN37027	62-0541813	501C3	6,000	Program Support
(28) TN for Quality Early Educ 22 North Front St Ste 670 Memphis,TN38103	82-1352671	501C3	10,000	Sponsorship
(29) Town of Lebanon PO Drawer 309 Lebanon,VA24266	54-6026883	501C3	7,500	Sponsorship
(30) United Way of Southwest VA 1096 Ole Berry Dr Abingdon,VA24210	54-0718860	501C3	50,250	Economic Development
(31) US of Care 1015 15th St NW Ste 600 Washington,DC20005	82-2860302	501C3	300,000	Healthcare Access

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2018

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a) Type of grant or assistance	(b) Number of recipients	(c) Amount of cash grant	(d) Amount of noncash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of noncash assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)

Part IV

Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.

Return Reference

Explanation

Grantmaker's Description of How Grants are Used

The Community Benefit and Population Health Committee for Ballad Health is comprised of members from Tennessee and Virginia. Committee members have various perspectives on community health improvement and work to develop an understanding of population health, philanthropy, community benefit obligations and the role Ballad Health plays in health access improvement. The senior leadership for Ballad Health, including the President and CEO and COO, attend the meetings. Among the responsibilities of the committee is ensuring charitable contributions comply with Ballad Health Board policies.All requests are submitted electronically with the required information to determine eligibility. After the committee has reviewed requests, various levels of approval are required, including the Ballad Health CEO or Ballad Health Board, based on the level of commitment. Applicants requesting funding for a specific event or program should include the following information:-Mission statement of organization-Year organization was founded-Tax status and federal taxpayer ID number -Website-Description of the event/program-Event/program budget-Other sources of income-Impact of the event/program on the health of residents in our region-Beneficiaries of contribution-Number of people served annually -Event/program accomplishments-Measure of accomplishments

Schedule I (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .........

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..

Yes

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2018

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Alan Levine BH PresidentCEO Director	(i) (ii)	1,101,957 -------------	750,000 -------------	180,289 -------------	172,174 -------------	21,270 -------------	2,225,690 -------------	150,202 -------------
2Andrew Wampler VP, CFO NW Mkt	(i) (ii)	192,873 -------------	-------------	6,952 -------------	19,327 -------------	12,121 -------------	231,273 -------------	-------------
3Anthony Keck EVP, CPHO	(i) (ii)	413,343 -------------	192,790 -------------	6,777 -------------	57,114 -------------	13,819 -------------	683,843 -------------	-------------
4Clay Runnels MD VP Svc Line Mgmt	(i) (ii)	391,478 -------------	30,000 -------------	4,425 -------------	13,499 -------------	23,027 -------------	462,429 -------------	-------------
5Dawn Trimbleterm 218 CEO Wahington Co.	(i) (ii)	59,394 -------------	225,000 -------------	436,479 -------------	5,244 -------------	18,331 -------------	744,448 -------------	-------------
6Devin McFall VP, CFO SW Mkt	(i) (ii)	219,445 -------------	-------------	6,479 -------------	13,970 -------------	22,327 -------------	262,221 -------------	-------------
7Eric Deaton BH EVPCOO Director	(i) (ii)	------------- 497,063	------------- 40,165	------------- 33,042	------------- 26,522	------------- 16,433	------------- 613,225	-------------
8James Parsonsterm 418 VP HR	(i) (ii)	84,172 -------------	71,250 -------------	468,747 -------------	7,748 -------------	15,903 -------------	647,820 -------------	29,259 -------------
9Lemmie Taylor VP, CEO SE Mkt	(i) (ii)	225,731 -------------	57,837 -------------	4,374 -------------	27,921 -------------	21,299 -------------	337,162 -------------	-------------
10Lynn Krutak BH EVP/CFO	(i) (ii)	585,707 -------------	250,000 -------------	18,316 -------------	72,647 -------------	17,645 -------------	944,315 -------------	-------------
11Marvin Eichorn BH EVPCAO Director	(i) (ii)	678,984 -------------	300,000 -------------	32,881 -------------	12,241 -------------	24,453 -------------	1,048,559 -------------	-------------
12Melissa Carr SVP Financial Mgmt	(i) (ii)	289,103 -------------	62,500 -------------	4,301 -------------	42,750 -------------	19,058 -------------	417,712 -------------	-------------
13Monty McLaurin CEO NW Mkt	(i) (ii)	357,053 -------------	157,624 -------------	43,422 -------------	18,299 -------------	23,730 -------------	600,128 -------------	16,160 -------------
14Morgan May VP, CNO JCMC	(i) (ii)	187,638 -------------	-------------	5,417 -------------	5,779 -------------	19,928 -------------	218,762 -------------	-------------
15Morris Seligman MDterm 218 EVP & CMO	(i) (ii)	53,686 -------------	250,000 -------------	496,701 -------------	9,266 -------------	15,294 -------------	824,947 -------------	-------------
16Patricia Baise VP, CEO Behavioral Health	(i) (ii)	286,466 -------------	10,000 -------------	9,891 -------------	11,358 -------------	21,244 -------------	338,959 -------------	-------------
17Paul Merrywell CIO	(i) (ii)	32,876 -------------	150,000 -------------	395,205 -------------	4,688 -------------	15,088 -------------	597,857 -------------	24,225 -------------
18Richard Booneterm 418 CFO Washington Co.	(i) (ii)	87,817 -------------	70,000 -------------	211,313 -------------	3,621 -------------	15,179 -------------	387,930 -------------	-------------
19Shane Hilton SVP, CFO Mkt Ops	(i) (ii)	356,020 -------------	170,760 -------------	3,500 -------------	50,554 -------------	23,244 -------------	604,078 -------------	-------------
20Stan Hickson VP SW Mkt	(i) (ii)	408,432 -------------	-------------	21,878 -------------	12,307 -------------	22,395 -------------	465,012 -------------	-------------
21Tim Belisle BH EVPGen Cncl Director	(i) (ii)	400,672 -------------	161,656 -------------	14,736 -------------	56,640 -------------	22,892 -------------	656,596 -------------	-------------

Schedule J (Form 990) 2018

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference

Explanation

Part I, Line 1a: Relevant information in regards to selections on 1a.

Unless expressly approved by the Ballad Health Executive Chair/President, first-class transportation is generally not permitted. The Executive Chair/President may utilize first class travel for flights of a long duration. The Vice Chair/Lead Independent Director of the Board of Directors reviews and determines approval for expense reimbursement requests made by the Executive Chair/President. Charter flights must be approved in advance by the Executive Chair/President and are limited to business trips that can be justified based on financial savings, essential time savings and meeting logistics. On an annual basis, the Internal Audit Department of Ballad Health validates all charter travel was for valid business purposes and in compliance with the Ballad Health senior executive travel and business reimbursement policy.

Schedule J (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization
Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number
62-0476282

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	Hlth & Edu Facil Bd 2012	62-1464028	478271JV2	09-18-2012	94,745,050	Construction & Equip		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	37,880,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	95,337,514
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	1,889,665
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	89,474,759
11 Other spent proceeds .............
12 Other unspent proceeds .............
13 Year of substantial completion .............	2016
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? ....		X
15 Were the bonds issued as part of an advance refunding issue? .....		X
16 Has the final allocation of proceeds been made? ..........	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2018

Page 2

Part Ⅲ

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............	X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?	X
c Are there any research agreements that may result in private business use of bond-financed property? .............		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........
6 Total of lines 4 and 5 .............
7 Does the bond issue meet the private security or payment test? ...		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X
b Exception to rebate? ........		X
c No rebate due? .........	X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2018

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...	X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?	X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions).

Return Reference

Explanation

Part VI

Schedule K - Date Rebate Computation Performed Hlth & Edu. Facil. Bd. 2012A&B&C 11/28/17Schedule K - Additional Information Hlth & Edu. Facil. Bd. 2012A&B&CConstruct and equip surgery center at Johnson City Medical Center;Construct and equip hospital facilities, including refinancing of taxble indebtedness relating thereto1. Comment on Part I, Line A.In 2012, when the bonds referenced in Schedule K were issued, Mountain States Health Alliance owned and/or operated hospitals in a number of different locations both in Tennessee and in Virginia. As a result, Mountain States Health Alliance utilized conduit governmental bond issuers in multiple jurisdictions in order to finance improvements to its hospital facilities. In 2012, Mountain States Health Alliance was the conduit borrower of tax-exempt bonds issued by multiple issuers in Tennessee and Virginia. For federal tax purposes, even though different government issuers were involved, these multiple issues in each year were required to be treated, and were treated, as a single "issue" because they met the single "issue" test under the applicable federal tax regulations. Therefore, multiple issuers are listed under Line A because the bonds that were issued were part of a single "issue" for federal tax purposes.Additional Issuer EIN: 54-1276910Additional CUSIP#s: 478271JWO; 977220AA02. Comment on Part II, Line 3. Line 3 for the listed bond issues does not match the applicable issue price for such bond issue because of interest earnings earned on the proceeds of such bonds.

Schedule K (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Return Reference	Explanation
Form 990, Part VI, Line 4: Description of Significant Changes to Organizational Documents	Mountain States Health Alliance and Wellmont Health System merged on February 1, 2018 to form Ballad Health (BH), a tax-exempt healthcare delivery system. At time of merger, the BH Board of Directors became the directors of Mountain States Health Alliance and Wellmont Health System. BH is the sole member of Mountain States Health Alliance and Wellmont Health System. In FY19, BH appointed four BH officers to serve as the board of directors for Mountain States Health Alliance and Wellmont Health System.
Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder	Mountain States Health Alliance is a Tennessee non-stock, nonprofit organization with Ballad Health as its sole member.
Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body	Ballad Health has the authority to appoint Mountain States Health Alliance board members. The President and CEO of Ballad Health serves as the President and CEO for Mountain States Health Alliance.
Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders	Decisions of the Mountain States Health Alliance Board of Directors are subject to approval by the Ballad Health Board of Directors.
Form 990, Part VI, Line 11b: Form 990 Review Process	Ballad Healths EVP/CFO reviewed the Form 990 with the board of directors prior to the return being filed with the IRS. The return was made available to each board member in an electronic format prior to the review.
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts	Ballad Health has a conflict of interest policy for all members of the Board of Directors, the Executive Chair/President, Executive Vice Presidents, Senior Vice Presidents, and Vice Presidents, and applies to all Ballad Health organizations. All persons covered by this policy are required to complete a conflict of interest disclosure form on an annual basis. Should a conflict arise, it is the responsibility of the conflicted individual to update his or her disclosure immediately. All meetings of the board or board committees have a standing agenda item first on the agenda titled Conflicts of Interest. If a member of the board or board committee has a conflict of interest involving any issue on the board agenda, he or she must declare the conflict of interest during the period allotted for disclosure. If any issue arises during a meeting in which the board member has a conflict of interest, he or she must immediately declare the conflict. While each member of the board or board committee is responsible for disclosing conflicts of interest, it is also the responsibility of any board member aware of a conflict which has not been disclosed to ensure the board is made aware. The presiding officer of a board or board committee meeting may ask a conflicted member to excuse themselves from the meeting during the discussion related to the issue with which the conflict of interest applies. Under no circumstances shall a member vote on a matter that gives rise to a potential conflict.
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available	Governing documents and conflict of interest policy are made available upon request to the appropriate parties requesting them. Financial statements are made available upon request to appropriate parties requesting them, and they are made available to those parties who own indebtedness of the company on a quarterly basis.
Other Changes In Net Assets Or Fund Balances - Other Decreases	Capital infusion to parent organization = -$XXX-XX-XXXX
Other Changes In Net Assets Or Fund Balances - Other Increases	Elimination of Intercompany Receivable = $1289166
Other Changes In Net Assets Or Fund Balances - Other Increases	Partnership Capital Contributions - not on books = $168694
Other Changes In Net Assets Or Fund Balances - Other Decreases	Partnership Dissolutions = -$1952670
Other Changes In Net Assets Or Fund Balances - Other Decreases	Partnership Interest Income - not on books = -$56860
Other Changes In Net Assets Or Fund Balances - Other Decreases	Partnership Ordinary Income - not on books = -$1605984
Other Changes In Net Assets Or Fund Balances - Other Increases	Temporarily Restricted Grants = $71706
AWARDS AND RECOGNITIONS	Overmountain Recovery achieved a three-year accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF). This accreditation is a tremendous achievement after one year of operation. Most newly operational addiction treatment facilities are awarded certification for only one year.All the MSHA hospitals are accredited by the Joint Commission (TJC) with many of the hospitals designated with advanced gold seal certifications for various programs. TJC is an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. TJC is the nations largest standard-setting and accrediting body in health care. Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months to evaluate standards compliance. All regular Joint Commission accreditation survey visits are unannounced. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects on an organizations commitment to meeting certain performance standards. The security, safety & emergency management force at both Ballad Health and MSHA has been recognized by Security magazine as part of the 2018 Security 500 rankings. Security magazine remarked: We are recognizing your organization for your safety and security policies and efforts to keep patients, staff and visitors safe. Our team has been monitoring your work in this area, and we wanted to recognize you.For the second year in a row, Indian Path Community Hospital was named as one of Americas 250 Best Hospitals by Healthgrades. The designation of Americas 250 Best Hospitals is based on clinical quality outcomes for 32 conditions and procedures. This premier distinction rewards hospitals in the top 5% in the nation that consistently exhibit exceptional, comprehensive quality care.For the fourth straight year, Franklin Woods Community Hospital has been selected as one of 100 Great Community Hospitals by Beckers Hospital Review one of only two hospitals in the state to receive this recognition for four consecutive years. Beckers designation is based on outside rankings and awards from organizations such as the IBM Watson Health 100 Top Hospitals, iVantage Health Analytics, The Chartis Center for Rural Healths Top 100 Rural & Community Hospitals, CareChex ratings, Healthgrades awards and CMS stars, Leapfrog Group grades, among other considerations. Beckers defines a community hospital as one with fewer than 550 beds.JCMC achieved U.S. News & World Reports highest rating for the treatment of two conditions in their 2018-2019 best hospital rankings: COPD and Heart Failure. The joint replacement program at Johnson City Medical Center has had phenomenal patient outcomes. For three years, and still counting, there were no knee replacement infections and for two and one-half years there were no hip replacement infections.Blue Cross Blue Shield recognized Indian Path Community Hospital, Johnson City Medical Center and Sycamore Shoals Hospital with Blue Distinction Plus Specialty Care recognition. Blue Distinction Plus facilities are healthcare facilities recognized for their expertise and efficiency in delivering specialty care. IPCH was recognized for maternity care, JCMC for spine surgery and SSH for knee and hip replacement.Consistent with prior years, Mountain States Health Alliance hospitals received excellent 2019 hospital quality ratings from CareChex. CareChex scores, rates, ranks, and compares inpatient quality performance across general, acute, and non-federal hospitals. Hospital ratings incorporate a detailed composite evaluation of clinical outcomes including patient safety indicators, inpatient quality indicators, risk-adjusted mortality, complications, and readmissions. In addition, patient experiences (patient satisfaction scores) are used. An analysis by clinical category, MS-DRG, principal diagnosis and procedure, discharge status, and trends over time are also utilized. MSHA team member recognitions:Dr. Molly Lassiter, cardiovascular clinical pharmacy specialist at Johnson City Medical Center, was awarded recognition as a board-certified cardiology pharmacist (BCCP) by the Board of Pharmacy Specialties. Dr. Lassiter is one of only 182 BCCPs worldwide, and one of 10 in Tennessee. The Board of Pharmacy Specialties (BPS) was established in 1976 to improve patient care and increase awareness of the need for board-certified pharmacists as integral members of multidisciplinary healthcare teams. BPS board certification is considered the gold standard when determining a pharmacists qualifications and capabilities within a specialty area. Dr. Lassiter is the preceptor for the required cardiology rotation for the PGY1 pharmacy residency program and offers an advanced pharmacy practice experience for Doctor of Pharmacy (PharmD) students. She is also a board-certified pharmacotherapy specialist with added qualifications in cardiology and a board-certified critical care pharmacist.Heatherly Sifford, trauma injury prevention program coordinator for Johnson City Medical Center, was recently appointed to the Governors Council on Suicide Prevention. Sifford also serves as the Northeast Regional Chair for the Tennessee Suicide Prevention Network (TSPN). Sifford became a passionate advocate for suicide prevention in part after her best friends son died by suicide. Sifford works to educate young people on the signs to look for in their peers, and how to get involved in preventing suicide. In the U.S. right now, we lose one young person between the ages of 10-24 every 108 minutes, Sifford said. We owe it to our children to do better. Sifford is a certified QPR (Question, Persuade and Refer) trainer.
CARTER COUNTY, TN: SYCAMORE SHOALS HOSPITAL (SSH)	121-bed acute care facility Offers complete inpatient and outpatient surgical services including general surgery, surgical oncology, orthopedics (including hand and extremities), plastic surgery and gynecological surgeryCertified chest pain and heart failure program by the Joint CommissionA certified acute stroke-ready program by the Joint CommissionNew Leaf Senior Care offers inpatient psychiatric treatment to adults 55 and older Campus includes a regional cancer center clinic, an outpatient rehabilitation clinic, and comprehensive primary care and specialist care
CHARITY AND OTHER UNREIMBURSED COSTS	While reimbursement for healthcare services rendered is critical to the operation and sustainability of the organization, MSHA recognizes its obligation to provide care to individuals who cannot afford essential medical services, including emergency care. MSHA accepts all patients regardless of their ability to pay. A patient is classified as a charity patient when they meet the established policies of Ballad Health and guidelines outlined by the federal government. However, financial assistance decisions are not solely based on income. Unique financial circumstances are weighed with verified patient assets which can determine financial assistance eligibility. It is not until after verification of income and assets that a decision regarding the amount of financial assistance can be made. In fiscal year 2019, MSHA incurred a loss of $10,312,579 attributable to the provision of charity care. This amount does not include the costs associated with accounts classified as bad debt. TENNCARE/MEDICAID: MSHA provides care to persons covered by governmental programs, such as TennCare (Tennessee residents) and Medicaid. MSHA incurred a loss of $19,426,960 providing care to this population of patients during the year. UNINSURED DISCOUNT: Uninsured patients received an 80% discount through September 30, 2018 and this discount increased to 85% effective October 1. The uninsured discount is applied to all uninsured patients at MSHA hospitals except for the Critical Access designated Johnson County Community Hospital. Johnson County Community Hospitals uninsured discount was 71% through September 30, 2018, and thereafter increased to 73%. Certain elective procedures are not eligible for the uninsured discount. The uninsured discount is calculated each year in accordance with Tennessee regulations and without regard to a patients income or assets. Although the uninsured discount is not required by the Commonwealth of Virginia, Ballad Health applies the same discount to the uninsured patients receiving care in the Virginia hospitals, both wholly and majority owned. The approximate cost (calculated by using a cost to charge ratio) of the uninsured discount in FY19 was $26,030,036 for the hospitals included in this Form 990 return.
COMMUNITY CONTRIBUTIONS	As the largest employer in the region, Ballad Health is one of the areas principal benefactors and has made corporate citizenship an integral part of its culture. From system-wide initiatives at Ballad Health and MSHA hospitals to individual efforts of caring team members, the aim is to enrich the communities that are served. This commitment includes direct financial contributions to support community healthcare needs and those to non-profit agencies that advocate the health and well-being of community members.In FY19, MSHA made donations to numerous health and human service organizations, social and well-being non-profits, and others within the service area.Donations to local organizations provide health care, work to increase access to health care and/or conduct research with the aim of improving health, or promote a healthy community included: $78,000 to Appalachian Mountain Project Access (matches low income patients with providers willing to donate their care, offers insurance premium assistance to qualifying individuals, and other programs to increase access to medical services), $15,500 to Crumley House Brain Injury Rehabilitation Center, $30,000 to Friends in Need Healthcare (provides medical and dental care to working uninsured/underinsured), $25,000 to the Governors Foundation for Health & Wellness, $25,000 to Holy Friendship Summit (to fight opioid epidemic/support addiction recovery), $100,000 to the Kingsport Chamber Foundations Healthy Kingsport Initiative, $10,000 to Lipscomb University (Sam Quinones Partnership-addressing the opioid crisis), $23,000 to Second Harvest Food Bank, $24,500 to the Sullivan County Anti-Drug Coalition, and smaller contributions to other local organizations that promote health. MSHA provided medications from our hospital pharmacies to local rescue squads at a cost of $11,795. MSHA also contributed $100,000 to United States of Care (focused on expanding health care to all Americans).Throughout the year, MSHA makes contributions to local schools and organizations that provide educational, health, and social support to youth. Many of the donations to benefit young people are restricted to services focusing on healthy eating and physical activities, after school and summer programs providing at-risk children a safe environment, and literacy programs. Studies show a correlation between literacy and medical compliance/overall health.MSHA donations during FY19 to organizations that provide educational, health, and social support to youth included: $10,000 to Bristol Family YMCA, $10,000 to Communities in Schools in Southwest Virginia (program to connect students with basic needs), $10,000 to Junior Achievement of Tri-Cities TN/VA, $10,000 to Junior League of Kingsport (Children Exceeding Expectations program), $15,000 to Niswonger Foundation (CareerConnect program for students), $5,000 to Second Harvest Food Bank (Food for Kids program in Hancock & Hawkins Counties), $50,000 to Speedway Childrens Charities, $10,000 to Tennesseans for Quality Early Education Policy & Research, $50,000 to United Way of Southwest Virginia (Ignite program providing summer internships for students) and other schools and organizations that promote the health and well-being of youth. MSHA contributes annually to national non-profit organizations whose research focuses on those diseases and conditions most prevalent in our region. In FY19, donations were made as follows: $20,000 to the American Heart Association, $5,000 to the Juvenile Diabetes Research Foundation, $25,000 to Susan G Komen and $5,000 to the March of Dimes Foundation.MSHA also contributes to the arts, festivals, churches/ministries and other organizations in the local communities.MSHA has a long-running program, Servant Heart Award, to recognize MSHA team members, physicians, and volunteers who represent exceptional service to their community. Award recipients select non-profit charities they wish to reward and MSHA makes a charitable contribution to the selected charities on behalf of the servant heart award winners. Memorials are also made routinely. Our board of directors and senior management encourage team members to devote time to local community service projects, task forces, committees, boards, volunteer programs, and other charitable organizations that benefit local communities. Team members are allowed to serve as representatives of MSHA. Team members serve as a healthcare representative on local chamber of commerce boards, local county economic boards, participate in school health programs, assist charitable organizations with fundraising activities, work at food pantries and meal service organizations feeding low income residents, speak at local clubs/churches/groups on healthcare topics, collect and provide supplies to local schools and charities, provide assistance to local organizations at Thanksgiving and Christmas, provide health education and/or first aid at local festivals, and many other predominantly health related activities. The medical oncology team at Johnson City Medical Center helped spearhead a drive at Christmas to buy gifts and vital items needed by their patients, especially some of their youngest patients. The donations were used to purchase clothes, toys, school supplies, coats, blankets and more for 18 children being treated, plus three other patients.There are many other examples of activities performed by the team members at all MSHA hospitals that demonstrate the spirit of giving during the holidays and throughout the year to their patients.
COMMUNITY RESOURCES	Ballad Health supports its parish nurse program, which is designed to provide holistic ministry and special promotion services within the faith community. The parish nurse program assists individuals in gaining optimal mental, physical and spiritual health by complementing the ministry provided by pastors and other lay ministers. Some of the services and programs provided include screenings for blood pressure, cholesterol, diabetes, glaucoma and overall fitness, classes for all age groups offered on health related issues (nutrition, exercise, parenting, care for elderly parents, stress management, CPR), hospital, nursing home and home visits for assessment of health care needs, referrals to appropriate community resources and the creation of health tips in congregational newsletters, bulletin boards and other forms of communication. In FY19, MSHAs parish nurse program provided 649 home visits, accompanied community members to 1,772 clinic visits and visited community members while in the hospital or nursing home on 933 occasions. The program offered 243 blood pressure screening clinics, 412 glucose screenings, 80 health fairs and one blood drive, resulting in identification and referral of 296 people with abnormal results to physician services. The program offered health education to parishioners through 329 educational sessions, 233 newsletter articles, 22 church bulletin articles and 110 bulletin board displays. The cost for MSHA to provide this program was $91,492.MSHA operates emergency transport dispatch services as the state designated Regional Medical Communications Center (RMCC) for Tennessee Region 1. As a RMCC, MSHA coordinates hospitals, ambulance services and other medical resources in real time, to optimize emergency patient care in situations where local governments and health care providers request assistance. The communication center is operational 24 hours daily and provides communication services to both air and ground emergency transport systems in the region. MSHAs unreimbursed cost to provide this service during FY19 was $190,847.MSHA gifts a land lease to the Ronald McDonald House at an annual fair market value of $60,000. The Ronald McDonald House, which opened in 1996, sits on the campus of Niswonger Childrens Hospital and Johnson City Medical Center. Though located on campus, the Ronald McDonald House provides a temporary home for children and families of seriously ill children throughout the Southern Appalachian region. Forty counties located throughout Northeast Tennessee, Southwest Virginia and Eastern Kentucky, covering a 125-mile radius outside the city limits of Johnson City, are served by this regional facility. Thousands of children, along with parents and extended family members, have been served at the house. MSHA, in collaboration with area health agencies and providers, helps with coordination, advocacy and publicity; provides space; or contributes supplies to support groups for their program activities.The Health Resources Center (HRC) is a community outreach service provided in two locations. The Johnson City HRC is located inside the Wellness Center. The Kingsport HRC is in the Fort Henry Mall. The centers are staffed by a registered nurse and other health professionals, including a registered dietitian. The HRC offers free classes, screenings, blood pressure checks, support groups, nutritional education, informational materials and resources and other services to meet community members health and health education needs. During FY19, the Johnson City HRC had 5,671 visits to the office, including 59 wig fittings. This HRC also hosted 1,959 attendees who participated in monthly health education or screening programs. The registered dietitian provided 38 individual nutrition education sessions. The center also provided outreach services, connecting with an additional 7,138 community members. The uncompensated cost of the Johnson City HRC in FY19 was $241,408. The HRC in Kingsport had 10,983 office visits and hosted 1,978 attendees at monthly health education or screening programs, 32 individual nutrition sessions with the registered dietitian, and provided outreach services to another 15,320 community members. During FY19, the Kingsport HRCs uncompensated cost was $266,440. The Johnson City Health Resources Center participated in this years pink party to kick off Breast Cancer Awareness Month. This event provided visitors with breast cancer nutrition education, free samples, as well as local vendor booths and information. The team offered information about the HRCs wig service, answered questions regarding mammography and breast cancer and much more. The event attracted more than 250 visitors. The Johnson City Health Resources Center hosted a senior expo this year. More than 250 senior community members took advantage of this free event; which included health and wellness information, free health screenings, such as vision, hearing, allergy, blood pressure, blood sugar and more. There was also dancing, door prizes and giveaways. The Indian Path Medical Center Official Fun Fest Block Party, held at the Kingsport Health Resources Center, had over 250 guests in attendance. Fun Fest is a 9-day festival in Kingsport, Tennessee, with an attendance of over 180,000. The team was very active in the Kids Central Extreme Challenge and during the three-day event engaged over 900 children in physical activity and educated them about meal planning, using the My Plate method. The Kingsport team was also very active with the Feeding America initiative in Southwest Virginia and educated 200-300 community members regarding health and wellness. In addition, the HRC dietitian was involved in the annual Remote Area Medical clinic in Gray, Tennessee. More than 250 community members were present for nutrition education. Examples of the variety of classes, screenings, support groups, and health education events MSHA offered throughout the year include: Taste of the World - a series offered each month highlighting the cuisine of different countries.Savvy Senior - a four-part series to teach seniors how to navigate through their computer and smart phone to gain more functionality with their electronic devices.De-Stress & Worry Less material presented by a registered nurse and a registered dietitian for simple tips on how to slow down and relax. Self Defense for Women a course designed to offer women more confidence and skills to protect themselves. The program offers tips to improve safety awareness to avoid potential attacks plus effective offensive strategies to use when needed. Nail Salon SafetyVarious mental health topics Almost all of these courses are offered free of charge except for a small fee that may be imposed for lab charges or guidebooks. Other classes offered to the public include: diabetes education and management; nutrition and healthy cooking; CPR training; exercise; weight loss; lung health; green cleaning using simple cleaning recipes; avoiding seasonal allergies; glaucoma; colorectal cancer; stress in seniors; elder concerns; sleep health; drug addiction; cancer education; heart health; foot care; safe babysitting; breastfeeding; techniques for managing chronic pain; Medicare information sessions for seniors turning 65; relaxation training; sleep apnea screening; vaccines; balance and falls prevention; child illnesses and special needs programs and classes; suicide prevention; and, many other disease-specific classes and screenings, including stroke risk. Some of the many support groups sponsored by MSHA include: Alzheimers & Dementia, Celiac Disease, Parkinsons disease, cancer, senior caregiver, Better Breathers Club (pulmonary). Classes offered monthly include: arthritis, asthma, atrial fibrillation, blood pressure management, blood clot prevention, cardiomyopathy, chest pain & palpitations, cholesterol management, COPD, heart failure, home safety, medication management, osteoporosis, pneumonia, post-partum recovery, smoking cessation, stress management, and thyroid disorders. Class offerings, along with the presenters and a brief description of the class, are posted each month on the Ballad Health website. On average 45 to 50 events are offered to the public each month. MSHA provided a variety of wellness and health information regarding community-specific health issues throughout the year to educate area residents. Information was provided through printed materials, radio and television, and health events, such as free screenings and health fairs. Some of the topics covered this year included:Breast health & other womens health issuesHealth Watch radio spot Baby and child health events for the publicStroke education/signs and symptoms as outlined by the American Stroke Association (the MSHA service area falls within the U.S. Stroke Belt; Tennessee has the third highest rate of stroke deaths in the country)In addition to our Health Resources Centers in Johnson City and Kingsport, the Ballad Hea
d/b/a - Additional names:	Niswonger Children's Hospital;Woodridge Hospital;Franklin Woods Community Hospital;Indian Path Community Hospital;Sycamore Shoals Hospital;Johnson County Community Hospital;Russell County Hospital;Unicoi County Hospital
Franklin Woods Community Hospital	Franklin Woods Community Hospital (FWCH) hosted a SAFE (Self-defense Awareness & Familiarization Exchange) seminar for women. The free event, taught by a sergeant of the East Tennessee State University Department of Public Safety, included strategies, techniques and the physical aspects of self-defense and prevention. The seminar was part of the National Self-Defense Institute SAFE program and provides women with solid public safety-awareness information to incorporate into their everyday lives. FWCH became certified this year with The Joint Commission for their Minimally Invasive Colorectal Program; the only hospital in Tennessee and one of five hospitals in the nation to have this disease-specific certification.
IMPROVING ACCESS TO HEALTHCARE	OPENING OF NEW RURAL HOSPITAL IN UNICOI COUNTY - Ballad Health officially opened the new Unicoi County Hospital in October 2018. The 40,000-square-foot facility includes a 24-hour emergency department with a telemedicine connection to Niswonger Childrens Hospital; 10 inpatient beds; pulmonary, cardiac and acute care services; a chest pain center; standard and advanced diagnostics, including nuclear medicine; and outpatient services.
IMPROVING HEALTHCARE QUALITY	QUALITY METRICS - Ballad Healths Board of Directors has adopted a zero-harm culture for the organization, and processes have commenced to institutionalize this objective. This focused effort on quality improvement significantly benefitted patients. Specific examples include: zero infections for abdominal hysterectomy cases across the system; 47% reduction in pressure injury rate; 42% reduction in clostridium difficile infections; 39% reduction in iatrogenic pneumothorax rate; and 13% reduction in central line bloodstream infections.During FY19, there has been a 10 percent reduction in the hospital readmission rate over the prior year, and a 25 percent reduction among legacy hospitals since 2015 as evidence that physician and administrative partnership is resulting in lower cost and lower risk to patients. Ballad Health achieved the lowest readmission rate in either legacy health systems histories. NATIONAL RECOGNITION FOR QUALITY IMPROVEMENTS U.S. News & World Report named flagship hospitalJohnson City Medical Center as top-performing hospital in Tennessee in several specialties, providing top performing services and programs in heart failure and COPD. Less than 30% of all hospitals had any top-performing programs. And recently, Forbes Magazine named Johnson City Medical Center as one of the best employers in Tennessee among all employers.ONGOING QUALITY IMPROVEMENT PROGRAMS RECEIVE PRAISE FROM NATIONAL EXPERTS - Ballad Health has instituted a comprehensive quality improvement program systemwide based on the FOCUS PDCA modela model designed to empower team members to identify opportunities for improvement and measurably implement those opportunities. These efforts are organic and driven by staff at all levels. The Ballad Health approach to quality improvement was recently praised by national experts who facilitate and assess organizational commitment to quality. For instance, in the past year, a total of 130 quality improvement projects across the system qualified at various levels of improvement for recognition, with 42 national judges evaluating the projects and awarding recognition for the results. Examples of improvement projects include: A 91.6% reduction in restraint use and 18 months of zero restraints for adolescents at the Willow Unit at Woodridge Hospital; a 95% reduction in the amount of oral contrast used for outpatients and inpatients prior to receiving a CT scan at Indian Path Community Hospital, which produced $139,000 in annual cost savings; and a 50% reduction in hospital-acquired Clostridium difficile (C.diff) across all hospitals within three months.
IMPROVING THE COMMUNITY'S HEALTH STATUS	Mountain States Health Alliance (Mountain States) is one of only 29 organizations in the country participating in the Centers for Medicare & Medicaid Services (CMS) new initiative, Accountable Health Communities Model (referred to as AHC Program), aimed at improving the health of eligible Medicare and Medicaid beneficiaries. The AHC Program is designed to integrate care for health-related social needs into usual care by implementing systematic screening, referral, and patient navigation services for needs such as food insecurity, housing instability, safety, transportation needs, and utility assistance. Mountain States serves as the Bridge Organization for the AHC Program locally, leading a collaborative of multiple organizations and clinical delivery sites to bring needed services to beneficiaries residing in Southwest Virginia. Full implementation of the AHC Program was achieved during FY19. There are nine full-time team members for the program, whose positions are financed by federal funds, (six Navigators, one Lead Navigator, one Screening and Referral Specialist, and one Program Manager), while two part-time Navigator positions remain open. Fifty-two locations serve as clinical delivery sites in Southwest Virginia and Northeast Tennessee and have processes in place to identify health-related social needs. Patients that screen positive for health-related social needs are given a Community Referral Summary, which contains contact and program information for relevant resources that assist with the needs identified by the screening. Since formal go-live of the AHC Program on November 17, 2018 through June 30, 2019 there have been 61,705 offered screenings, 35,544 answered screenings, 9,050 needs identified, 5,030 Community Referral Summaries given to patients, and 2,142 navigated patients. The stats provided are inclusive of the Ballad Health Virginia hospitals plus three Tennessee hospitals located close to Southwest Virginia. Mountain States also created an internally-produced data system for the screening, referral, and navigation services in lieu of using the CMS AHC Data System. This data system improved operational efficiency by at least five-fold over the CMS Data System. Patient Navigators have been re-deployed from five Virginia Community Services Boards in our service area to hospital emergency departments and primary care offices. This allows the Navigators to establish initial contact with a patient and complete a personal interview and action plan related to the health-related social needs identified by the patient. Laptops and cell phones were purchased for the Navigators to have the ability to work at the clinical delivery sites and from other locations, as needed.
Indian Path Community Hospital	Indian Path Community Hospital (IPCH) participates in the American Lung Associations Better Breathers Club. IPCH hosts the monthly support group meetings for patients that have chronic lung disease. Physicians speak on different pulmonary related topics and offer wellness activities to encourage members in their mission to better control disease. The support group is led by a respiratory therapist with extensive experience educating patients with chronic lung disease and is a free service to the community. In order to increase public awareness of early detection for lung cancer, IPCH offered low-dose CT lung screenings at no charge to 387 people. The hospital notified the public and local physician offices of the free lung screenings. Following the screenings at IPCH, other MSHA hospitals now offer free screenings. Sycamore Shoals Hospital offered 148 free low-dose scans in FY19. Last year IPCH began using advanced technology, Helios ultraviolet disinfection system, to clean hospital rooms and better protect patients against potentially deadly infections. The system emits powerful yet safe ultraviolet energy to combat bacteria, spores and viruses, including superbugs. Independent studies have shown the system reduces hospital-acquired infections and significantly lowers infection rates. Ultraviolet energy has been used for decades to kill organisms and the technology is now being used to kill organisms on hospital surfaces, such as bed rails, remotes, patient tray tables, guest chairs, countertops, and bathrooms. MSHA is now incorporating the same technology in all other hospitals.
INVESTMENTS	COMMON ELECTRONIC HEALTH RECORD - Ballad Health made progress in FY19 toward establishing a common clinical platform and electronic health record (EHR). An implementation plan was developed to include infrastructure enhancements to support the expansion. A common EHR across the new health system will allow patient information to be shared immediately at the point of service regardless of where a patient enters the Ballad system, providing clinical staff with information to better manage patients in the emergency room, clinics, acute and post-acute settings.
Johnson City Medical Center	According to the U.S. Centers for Disease Control and Prevention, every 40 seconds someone in the US has a stroke. The Northeast Tennessee and Southwest Virginia region has one of the highest rates of stroke in the country. Quick access to the best stroke treatment can mean the difference between life and death. According to the American Heart Association, people with hemorrhagic stroke are more likely to survive if they are treated at a comprehensive stroke center. Last year, Johnson City Medical Center (JCMC) earned The Joint Commissions gold seal of approval and the American Heart Association/American Stroke Associations heart-check mark for advanced certification for comprehensive stroke centers. This designation is the highest level of stroke certification available, earned by meeting stringent standards for treatment of the most complex ischemic (clotting) and hemorrhagic (bleeding) stroke cases. With this certification, JCMC joins an elite group of approximately 150 healthcare organizations in the nation able to provide advanced, highly-specialized stroke care. To be eligible, hospitals must demonstrate compliance with stroke-related standards as a primary stroke center and meet additional requirements, including those related to advanced imaging capabilities, 24/7 availability of specialized treatments, and staff with the unique education and competencies to care for complex stroke patients. Mountain States network of stroke centers includes Indian Path Community Hospital and Johnston Memorial Hospital, certified primary stroke centers and Franklin Woods Community Hospital and Sycamore Shoals Hospital, certified as acute stroke ready. By linking our community hospitals and using standardized, evidence-based imaging, treatment and transfer protocols, Mountain States can create a complete continuum of care for stroke patients. The goal of the stroke network is that all Mountain States hospitals comply with a set of strict protocols when patients present with stroke symptoms. JCMC opened its Clinical Decision Unit (CDU) in May 2018. The CDU is an extension of the emergency department specially designed to serve those patients needing behavioral health care. Once medically cleared, JCMC ED patients may be accepted into the unit and will receive care and treatment from Woodridge Hospital (our behavioral health facility) physicians, nurse practitioners, therapists, nurses, behavioral health technicians and discharge planners. Some of these patients may be transitioned to inpatient psychiatric care while others will be discharged to outpatient service once stabilized. Our number one priority for the new unit is safety. If the patient has a medical condition, an attending ED provider will cover the patients medical needs. The CDU provides services to both voluntary and committed patients and is staffed with behavioral health trained nurses and techs 24/7. The staff has extensive training in dealing with behavioral health emergencies. CDU patients will receive discharge planning services, psychiatric consultations, therapeutic counseling, and crisis intervention. The Northeast Tennessee Regional Perinatal Center at JCMC is one of only five state-designated tertiary centers in the State of Tennessee. It is the referral hub for pregnant women in the Northeast Tennessee region who need higher level obstetrical services and/or neonatology services through our Niswonger Childrens Hospital Level III Neonatal Intensive Care Unit. Along with JCMC, Niswonger Childrens Hospital and Franklin Woods Community Hospital also have Perinatal Care Advanced Certification from The Joint Commission the premier healthcare quality improvement and accrediting body in the United States.The perinatal center also provides outreach education - thousands of obstetrics educational hours were provided to patients throughout the region. Over the course of the year, thousands of hours of neonatal education were provided to the region, including high-fidelity patient simulation (HPS). HPS is the use of computerized manikins to simulate real-life scenarios promoting skills acquisition, development of clinical judgement, and simulation of complex clinical situations with lifelike examples. The unreimbursed cost (net of a grant from the State of Tennessee) for these services was $92,602. The Family Birth Centers offer many classes such as: infant care (diapering, swaddling, bathing) proper use of car seats, day care, and choosing a pediatrician; a childbirth preparation multi-week series of classes; a one-day fast-paced childbirth class for those who are unable to attend the series classes; an interactive class to promote family bonding and decrease sibling anxiety; infant CPR; maternal pain management, and postpartum care; and, a class to promote successful newborn breastfeeding. According to the U.S. Department of Health & Human Services, breastfeeding helps protect babies from an array of illnesses. There are also health benefits for the mother including promotion of health and healing after childbirth leading to a lower risk of Type 2 diabetes, certain types of breast cancer, and ovarian cancer. In addition to lactation consultations for inpatients, the JCMC lactation consultants provide education to expectant mothers on benefits of breastfeeding before the delivery at the hospital. Data from a U.S. Department of Health and Human Services Office on Womens Health project in 2013 indicated education to expectant mothers before they come to the hospital for delivery increases the rate of breastfeeding. The lactation consultants strive to reach more women prior to delivery by visiting area OB/GYN practices throughout the year and by engaging in outreach activities such as:Presentations at community breastfeeding conferencesEducation at community health fairsClasses offered at the Health Resources CenterEducation provided for the Nurse-Family Partnership, an East Tennessee State University Department of Nursing program offered to women prior to 28 weeks gestation that follows their children to 2 years of ageBreastfeeding prenatal classes scheduled throughout the year at all Ballad Health hospitalsEducational spots are featured on local television programsStorytelling is proven to improve healing. Based on this evidence, Mountain States Health Alliance started a storytelling program, Healing Moments, at several of the hospitals. The program, produced by International Storytelling Center founder Jimmy Neil Smith, is designed to inspire, relax, and encourage hospital patients and guests with stories from nationally known storytellers and inspiring stories from Ballad Health team members, volunteers and patients. In addition, Conquering Our Challenges includes uplifting stories by Venus Williams, Michael J. Fox and others who are successfully managing or have overcome medical challenges. The program is captioned for the hearing impaired. A JCMC team worked on a process to communicate and educate on palliative care. Palliative care impacts patients by supporting holistic care, symptom management, an improvement in quality of life, and reduces readmissions. The palliative care program works with patients to offer care-planning, complex pain and symptom management and to help patients and their families or significant others navigate difficult situations. Frontline clinical and nonclinical employees complete required education, in the forms of computer-based learnings, staff meetings, handouts and visual aids, to understand palliative care. The team works to help patients and families develop realistic goals for chronic conditions and helps them address the need for a change in treatment philosophy from curative to supportive. Last year, the Regional Cancer Center at JCMC began offering pet therapy for patients. The goal of pet therapy is to ease patients anxiety while receiving chemotherapy. Studies show that dogs reduce fear, pain, anxiety and stress in patients undergoing treatment. All the therapy dogs complete training and receive designation as a certified therapy dog. MSHA offers pet therapy at every hospital.
Johnson County Community Hospital	Johnson County Community Hospital (JCCH) is a Critical Access Hospital, a federal designation given to eligible rural hospitals by the Centers for Medicare and Medicaid Services (CMS). Congress created the Critical Access Hospital designation in 1997 in response to a string of rural hospital closures during the 1980s and early 1990s. The designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. Like many other rural hospitals, JCCH is in a low-income community in one of Tennessees poorest counties. The median income in Johnson County is 35 percent lower than the median income in Tennessee with 33 percent of the children (under 18 years) living in poverty, as contrasted to 42.8 percent of children under 5 years living in poverty, according to U.S. Census 2018 estimates. The county also has an older population with the median age at 46.1 compared to 38.9 for the rest of the state. The primary care physician ratio in Johnson County is 2,960:1 compared to 1,390:1 for the entire state of Tennessee. JCCH operates a rural health and physician specialty clinic inside the hospital. The clinics are a valuable resource to the residents of this rural area. The clinics address transportation issues (other physician offices are located more than an hour away) and access limitations by providing relief to the special health problems of a largely elderly population. The specialty clinic includes oncology and cardiology services. The clinic also provides telemedicine services to include: diabetes, cardiology, and other specialty services. JCCH incurred a loss of $14,390 operating the clinic. The hospital operates, at a loss, an emergency department and a much-needed outpatient behavioral health program for older adults. Outreach programs offered by JCCH include: partnerships with several other organizations, such as GoJoCo, a Johnson County-wide initiative to improve the health of residents by focusing on increasing physical activity, reducing tobacco use, and improving nutrition in the region. JCCH also partnered with A.C.T.I.O.N. to promote education in schools aimed at preventing tobacco and substance use and provided inpatient and outpatient smoking cessation counseling. JCCH sponsored health topics on local radio and supported health fairs and community events.
JOHNSON COUNTY, TN: JOHNSON COUNTY COMMUNITY HOSPITAL (JCCH)	Federally designated Critical Access Hospital serving residents of the upper northeast tip of Tennessee, parts of North Carolina and Southwest VirginiaLocated in one of Tennessees poorest counties providing care to the rural and medically underservedOffers 24/7 emergency care, inpatient and outpatient care, cardiac rehabilitation, various diagnostic services, physical therapy, a primary care clinic, and Senior Life Solutions, a behavioral health program for seniors
MEDICAL EDUCATION	The Center for Pulmonary Medicine at Johnson City Medical Center presented the annual two-day symposium for respiratory therapists, physicians, nurses, physical therapists, occupational therapists and speech-language pathologists. The event, organized by a multidisciplinary team, was designed to provide the most recent scientific advancements involving the management of pulmonary and critical care patients and futuristic trends. Two tracks were present throughout the two-day conference: one for adult patients and the other for neonatal/pediatrics. Guest speakers covered an array of clinical topics and vendor exhibitors displayed the latest products and technology. The symposium offered continuing education hours for health professionals. MSHA participates in Ballad Healths Nurse Intern II program, overseen by Ballad Healths Clinical Education team. The program pairs each nurse intern with a registered nurse (RN) preceptor on a designated hospital unit. The interns work with their preceptor to gain valuable clinical skills to assist in the transition from nursing student to licensed nurse. The interns are under no obligation to work for Ballad Health although many of them choose to do so. Interns who complete the program become a Nurse Intern III and advance to a Nurse Intern IV upon graduation and move to RN status upon passing of the NCLEX (National Council Licensure Examination). MSHA created an administrative residency program. This program enables recent masters graduates to experience one-on-one training with an administrative leader at Mountain States. The program includes hands-on learning, career planning guidance and practical application of their degree in health administration or business. Each resident has a preceptor for the year-long residency. The residency application process requires letters of recommendation, a high GPA, and phone and panel interviews. The number of graduate applicants was excellent. MSHA serves as an educational environment for the training of medical residents of the James H. Quillen College of Medicine at East Tennessee State University (ETSU). Residents receive supervised, hands-on training in a particular area of expertise, such as primary care or surgery. Hospitals incur significant costs beyond those customarily associated with providing patient care to train residents. In addition to medical residents, MSHA provides training for other Medicare-approved programs including allied health programs for pharmacy and pastoral care. MSHA incurred $6,937,477 in unreimbursed costs for these programs in FY19. MSHA facilities serve as clinical training areas for health professional education students. Dedicated staff work with regional colleges and universities to coordinate the placement of healthcare professional students as part of their educational curriculum. Health care students entering the system are required to have orientation and training. Included in the number of participants receiving clinical experience at MSHA were 1,894 nursing students from various colleges, universities and programs. This nursing clinical experience required extensive MSHA nursing staff involvement at MSHA facilities, with some students also rotating through home health. The clinical setting and hands-on instruction cost MSHA $2,722,675.MSHA provided a clinical setting for another 681 students training in health-related programs such as biomed engineering, radiology, pharmacy, respiratory therapy, physician assistant, nurse practitioner, laboratory, occupational therapy, social work, public health, EMT/paramedic, and other allied-health disciplines. This additional clinical training cost MSHA $1,033,618.Mountain States continues to offer free Certified Nursing Assistant (CNA) classes to the public. The program includes classroom sessions followed by clinical experience. There is no requirement for participants to work for Mountain States upon completion of the program. The training opportunity often leads to job opportunities for graduates of the program. In FY19, over 81 percent of the graduates were hired by MSHA. The Learning Resource Center (LRC), located at Johnson City Medical Center, is a medical library that provides access to medical databases and various print publications. The library subscribes to several online medical databases as well as printed medical education materials, and online journal subscriptions. The medical library is utilized by physicians, nurses, pharmacists, medical residents, nursing students and physical/occupational/speech therapy students. In addition, the LRC provides medical information to patients and patients families, teachers from local schools and to other libraries. The LRC is also available to the general public and responds to many inquiries regarding the hospitals history, physicians histories and the history of medicine for the region as well as the surrounding Appalachian mountain region. Each year, thousands of articles are supplied to numerous patrons.
Niswonger Children's Hospital	Niswonger Childrens Hospital (NsCH) continues to offer students virtual access to a physician or nurse practitioner remotely from the school nurses office through Ballad Healths Connected Care telehealth program. More than 100 schools are currently connected to the system to provide care and diagnostics to keep children healthier and in the classroom. Parents enroll their children through their school nurse office. Parents can join the visit through their computer or smartphone, enabling them to be a part of the virtual exam without having to leave work. If a prescription is needed, it is sent electronically to the pharmacy chosen by the parent. The provider and the school nurse will determine if the student needs to recover at home. After the visit is complete, the provider contacts the childs pediatrician or primary care provider to communicate the care provided and determine any necessary follow-up appointments. The program often provides medical services for children who do not normally have access to doctors. Babies born with neonatal abstinence syndrome (NAS) need extra care while they are in the hospital. On average, NAS affects nearly 30 percent of the babies in the neonatal intensive care unit at NsCH. NAS occurs when babies are exposed to addictive substances before birth. Babies with NAS often have high-pitched cries, suffer from tremors and have difficulty eating as they go through withdrawal. To support the parents and relatives of newborns with NAS, NsCH launched its innovative Families Thrive program. The hospital stay at birth offers a unique window of time where mothers are exceptionally focused on their babies needs and futures. Families Thrive offers counseling, a motivational group day, and other activities. Program coordinators facilitate connections to resources that can help mothers and babies after their hospital discharge. The coordinators refer families to programs such as the Tennessee Early Intervention System, as well as outpatient treatment options at local behavioral health centers and pediatricians with NAS expertise. The functions and services of Families Thrive are staffed by Families Free, a local nonprofit organization that provides treatment, intervention services, employment through social enterprise opportunities and support for women and families affected by substance abuse, incarceration and domestic instability. The goal of the program is to provide mothers with treatment plans for narcotic recovery if they are not already in a program. As the babies grow, the goal is that families will continue to connect with ongoing medical and social support to help navigate any challenges associated with NAS.Niswonger Childrens Hospital recognizes that many things influence the health of the people in our region. One of the most important ways to improve the health of the community is through the children. The Childrens Resource Center supports child-related safety, learning, wellness and advocacy. The Center works with many outside groups and organizations, such as the regional Departments of Health in Tennessee and Virginia, to promote comprehensive good health; the school systems and Boys and Girls Clubs to offer additional help in reading skills; and law enforcement, East Tennessee State University and development groups to expose youth to role models and career options to make good life choices. We also collaborate with area organizations working to combat child abuse and address the opioid problem plaguing the service area. Some of our programs include: Dental: a program to increase awareness of the importance of good dental care from birth by collaborating with other dental initiatives. Dental kits including toothbrushes and toothpaste are distributed to resource poor areas and families. Regional School Nursing Conference: co-sponsor, with Kingsport City Schools, annual conference. Local school nurses attend the conference to receive education on various topics, such as diabetes and mental health. Other organizations are invited to participate and promote awareness on services offered to assist school systems. Nurses attending the program receive continuing education credits. Child passenger safety: coordinate with the State of Tennessee through a grant to provide car seats to families receiving government financial assistance within our regionProvided nutrition/health education to kids in a kid-friendly atmosphere of learning at booths at local festivalsThe Morning Mile program is focused on encouraging elementary and middle school students to get in some exercise before classes begin. Exercising before school provides numerous benefits for students such as increased oxygen flow to the brain, reduced stress and improvement in mood. The Childrens Resource Center at NsCH has promoted the Morning Mile for six years. Over 85 schools, throughout Northeast Tennessee and Southwest Virginia, now participate. Partnered with Levis Legacy, a non-profit group, to educate parents and families on water safetyNiswonger Childrens Hospital offers many other programs, activities and events throughout the year. Some of those taking place during FY19 included:Over 200 people attended the fourth annual Scarecrow Skedaddle & Shindig at Founders Park in Johnson City. The day included a 1-mile fun run, a 200-meter modified race and a 5k race. The modified race is designed for those athletes that may require the use of hand-held assistance, walkers, wheelchairs, power chairs or a personal coach. Immediately following the races, the hospital hosted a shindig, including agility challenges, dancing, educational and health-related events, at the parks amphitheater pavilion. Washington County annual Trunk or Treat attracted excited kids in Halloween attire. The event is open to the public and organized by Mountain States team members. Mountain States team members donate candy and treats for the event and volunteer, along with East Tennessee State University students, for the evening event. Patients at NsCH didnt miss Halloween treats and fun. Team members and volunteers throughout our community made sure pediatric patients were not excluded from the holiday festivities. The Spooky Trail, in its eighth year, provided the patients a place to trick-or-treat throughout the hospital. Characters from emojis to super heroes were present. Costumes were donated and made available to ensure each child had a costume. Booths, each with a different fun theme, were present and covered multiple safety topics. The Christmas season was kicked off with the annual tree lighting ceremony, which included storytelling, decorating Christmas ornaments, and Christmas caroling by local talent. An annual toy drive is hosted to ensure children have presents. Thousands of gifts for young patients, including toys for all ages, blankets, books, and even toiletries and necessities for patients parents, were donated by numerous local businesses, schools, and current and former patients and families.Niswonger Childrens Hospital hosts an annual fundraising radiothon. Funds raised have been used to purchase important items such as a pediatric ambulance and incubators as well as the creation of a special unit dedicated to caring for babies born with NAS. Team members, community volunteers, student groups, and community officials come together in the lobby of the hospital to assist with the fundraiser.
OTHER ACCOMPLISHMENTS	MSHAs grants and awards department works throughout the year writing grant applications to benefit communities throughout the large service area. Some examples of this reporting period include:Grant renewal to pay the salary and benefits for a medication assistance caseworker to expand a medication assistance program to Norton Community Hospital, serving Wise, Dickenson, and Russell Counties. The program in Southwest Virginia enables the health system to serve uninsured and underinsured patients; thus, playing a significant role in improving patients health, reducing hospital readmissions, and assisting doctors in providing proper treatment to patients who otherwise could be non-compliant with medications due to cost-prohibitive prescriptions.Awarded a grant for Car Seats and Teen Driver Safety to provide car seats to people in the community and to educate teen drivers on safe driving habits (such as dont text and drive). Received a grant that provides funding (in addition to our Ballad Health Cancer Patient Assistance Fund) for 75 additional patients to overcome barriers to breast cancer treatment through meeting their basic needs and/or improving their quality of life (i.e. rent/mortgage, groceries, utilities, transportation vouchers, gas cards, etc.). The Cancer Navigation program provides a single point of contact to help patients coordinate their care and understand their treatment plan. The Navigators often determine obstacles, such as the need for financial assistance, that keep patients from receiving treatment. The Komen/Virginia Blue Ridge Mobile Mammography grant was utilized to provide mammograms to women who may otherwise not receive them due to cost or access issues, along with helping to arrange financial assistance for additional diagnostic studies and further treatment, where applicable. Patients needing additional studies and treatment were assisted by our Cancer Navigators if they did not have a primary care provider.MSHA continues the Value Optimization System (VOS). The goal of the system is to accelerate achievement of patient-centered care to meet patients expectations of high quality, high satisfaction, and efficient care. Each VOS team meets over an intense four-day period to identify waste/inefficiencies, develop an improved work plan, and then implement the plan immediately. The results are referred to as value streams. Specific to FY19, some of the value streams that specifically address improvements in patient health:Franklin Woods Community Hospital (FWCH) worked to implement a process for global communication on inpatient units to expedite the discharge of patients. The team created visual management for the patients journey through the continuum of care. Daily review of the planned discharge date leveraged a multi-disciplinary approach with pharmacy, case management, nursing, and other ancillary departments to ensure the patient is on track for discharge with a coordinated care plan. This plan resulted in a reduction in time from discharge order to patient discharge and improved patient satisfaction. FWCH created a visual management process on the inpatient units to track the status of catheters, oxygen, and central lines. Daily review of these items aided in the reduction of Catheter Associated Urinary Tract Infections and Hospital Acquired Infections. The process reduced potential harm and increased patient safety. The FWCH team created visual management for the patients status and conducted a Room Readiness event to improve communication at the time of patient discharge with Environmental Services (EVS). Standard work was updated for EVS and developed for nursing regarding room prep prior to EVS arrival. Discharge communication was consistently improved by 33%. Time to clean rooms improved dramatically, resulting in decreased hold times for patients being admitted.Indian Path Community Hospital (IPCH) worked to ensure that patients were placed in the right level of care with the Acuity Adjusted Unit (AAU). The project created a unit that housed both the Progressive Care Unit (PCU) and the Intensive Care Unit (ICU) together to better fit the needs of the patients being served. The restructuring of the units ensured the patients were placed in the appropriate level of care upon arrival resulting in less patient movement during the patient stay. The data shows a 600% improvement in the movement within the levels of care within the first 12 hours of admission. IPCH standardized criteria pre-admission testing (PAT) for patients via phone assessments. Pre-admission testing for anesthesia was created for IPCH and Holston Valley Medical Center (HVMC). Prior to this event, IPCH only conducted phone assessments, forcing patients needing an anesthesia consultation prior to surgery to travel to another location. In contrast, HVMC only conducted in-person assessments. The new process provides the same level of care at both facilities, timely flow of care for the patient, and avoids unnecessary patient visits to the hospital. As a result, pre-admission testing length-of-stay at HVMC decreased by 8.9% and day-of-surgery cancellation rates dropped by 13.9%.IPCH created a standard scheduling document for physician offices to ensure required documentation, necessary to schedule a patient procedure, was received at time of scheduling. This resulted in a decrease of incorrect and/or missing patient procedure information and scheduling errors decreased by 51%. IPCH eliminated lengthy patient discharge wait times by implementing several visual/electronic notifications of milestones needed for discharge completion. Durable medical equipment needs are identified earlier, and notifications are sent resulting in equipment delivery to the patient prior to discharge order completion. Surgical pathways and documents providing a tentative daily guide for medical care expectations are provided for nursing staff. These documents are provided to patients to foster transparency and proactively plan the discharge. The time the patient spends in recovery, prior to going to the floor, has decreased by 9.4%. These process improvements have expedited patient discharges.IPCH created a standard process for daily charge reconciliation that ensured that information needed for charge creation and processing is communicated timely and effectively. The new process continues to decrease the number of unbilled claims.
Part III, Program Service Accomplishments	Ballad Health (Ballad) is a tax-exempt entity and the parent corporation of both Mountain States Health Alliance (MSHA) and Wellmont Health System (WHS). The two healthcare systems came together on February 1, 2018 as a result of a merger approved by both Tennessee and Virginia Departments of Health. Ballad operates under a Certificate of Public Advantage (COPA) in Tennessee and a Cooperative Agreement (CA) in Virginia. Pursuant to the COPA and CA, MSHA and WHS are required to fulfill the obligations, commitments and covenants set forth in the COPA. Such obligations include that Ballad Health shall meet, over the ten-year period beginning July 1, 2018, established minimum spending criteria on initiatives for expanded access to healthcare services, health research and graduate medical education, population health improvement, and a region-wide health information exchange. The full text of the COPA can be found on the Tennessee Department of Health's website, while the CA can be found on the Virginia Department of Health's website.Ballad Health is a healthcare delivery system serving 1.2 million residents from 29 counties in Northeast Tennessee, Southwest Virginia, Northwest North Carolina, and Southeastern Kentucky. Ballad operates 3,162 licensed beds in 21 hospitals, including a dedicated children's hospital, community hospitals, three critical access hospitals, a behavioral health hospital, an addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, outpatient services and a comprehensive medical management corporation. Form 990 for MSHA includes seven wholly-owned hospitals including a childrens hospital and a behavioral health hospital; four others, majority owned by MSHA, each file a separate return. Laughlin Memorial Hospital, wholly-owned by MSHA, also files a separate return. MSHA is sole shareholder of Blue Ridge Medical Management Corporation (BRMMC), a for-profit entity that owns and manages physician practices and real estate and provides other health care services to patients in Tennessee and Virginia. MSHA is the sole member of Integrated Solutions Health Network, LLC (ISHN). ISHN, also included in this Form 990, is a regional health solutions company headquartered in Johnson City, Tennessee. ISHN is an expansive network of providers serving residents of Northeast Tennessee and Southwest Virginia and consists of provider groups, primary care physicians, specialists, and allied health providers. Specific to the hospitals included in this Form 990, services were provided to: 43,164 inpatients 739,743 outpatient visits 162,833 emergency visits 116,942 home health visits 3,309 deliveries
Part VI, Line 15a Compensation Process for Top Official	The executive committee serves as the compensation committee of Ballad Health's Board of Directors. The compensation plan for Alan Levine, Ballad Health's President and CEO, was reviewed and approved by the executive committee. An outside and independent compensation consultant was used to determine his compensation and benefits. Studies and surveys were used to ensure his pay is comparable to like positions at similarly situated organizations.
Part VI, Line 15b - Compensation Process for Officers	The executive committee reviewed and approved compensation for all Ballad Health executives at the vice-president level and above during FY19 using the same methodology used to determine the CEO's compensation.
PROGRAMS FOR SPECIAL POPULATIONS	One of the Ballad Health Foundations fundraising activities is for the benefit of the Circle of Hope program. The Circle of Hope is a program specifically designed to provide financial assistance to oncology patients in active treatment at one of the Mountain States cancer centers (Johnson City Medical Center, Indian Path Community Hospital, Russell County Hospital, Johnston Memorial Hospital, and Smyth County Community Hospital). The program assists patients with transportation to and from appointments by providing gas cards or transportation vouchers. Other assistance may include mediation assistance, housing, meal vouchers and accommodation stays. The Circle of Hope has assisted head, neck, and throat cancer patients in need of immediate dental care prior to the start of radiation treatment. Thousands of patients have been helped since program inception. MSHA assisted some patients not able to pay for prescriptions at discharge. The unreimbursed cost for these prescriptions was $40,626.MSHA partnered with Bolder Outreach Solutions to assist patients without insurance. Representatives were available for these patients at all MSHA facilities in order to determine sources of possible governmental medical assistance (TennCare or Medicaid) and to assist in the application process and follow-up. 7,442 patients were approved for coverage during FY19. MSHA incurred expense of $879,208 during FY19 to provide this service.
PROGRAMS TO IMPROVE CHILDHOOD LITERACY	Since 2014, Niswonger Childrens Hospital has reached outside the hospital walls and into the community to improve child literacy through the B.E.A.R. Buddies reading program, which pairs volunteer mentors with elementary school students who need a boost in their reading skills. When five new schools recently requested to join the program, Ballad Health Chairman and CEO Alan Levine issued a call to Ballad Health team members to help fill the gap. To date, 100 volunteers for the 2020 school year have signed up.Ballad Health is participating in a new initiative called STRONG Kids, which stands for Striving Toward Resiliency and Opportunities for the Next Generation, that brings together and assists regional organizations that support children. The program will enable Ballad Health, Niswonger Childrens Hospital and the Bristol chapter of Speedway Childrens Charities to share ideas and best practices that will help children in the region reach their potential through expanded opportunities in health, education and economic vitality. The partnership is designed to bring a new level of support to these organizations that are on the front lines serving children.
Russell County Hospital	Russell County Hospital, located in rural Southwest Virginia, held their seventh annual health fair on the hospital campus. Local physicians and hospital staff were on hand to offer screenings at a reduced cost of $15 to the community. Screenings included complete blood count, chemistry profile (including glucose), lipid profile (including cholesterol) and thyroid test. For an additional $10 a prostate cancer screening (PSA blood work) was provided.Other outreach programs provided by Russell County Hospital include:-Continued to provide medications and supplies to area rescue squads -Provided flu vaccinations to local emergency medical service volunteers and local police departments-Provided free health screenings for Southwest Virginia veterans and health care provider talks on a variety of topics including post-traumatic stress-Partnering with the Ballad Health foundation to provide a Trunk or Treat giving children a safe and fun alternative to traditional door-to-door trick or treating-Supported and encouraged team members to participate in the Relay for Life fundraiser for the American Cancer Society-Participated in October National Breast Cancer Awareness Month events
RUSSELL COUNTY, VA: RUSSELL COUNTY HOSPITAL (RCH)	78-bed acute care hospital located in Southwest Virginia Offers a full array of primary care services and some specialty services such as Clearview Psychiatric Center, hospice care, center for sleep disorders, direct lab testing, and a cancer center
SULLIVAN COUNTY, TN: INDIAN PATH COMMUNITY HOSPITAL (IPCH)	239-bed acute care hospital Provides advanced services including lung nodule clinic, an accredited joint replacement program and a dedicated spine centerCampus offers a regional cancer center, a sleep center for both adults and children, a full range of surgical services, a family birth center and many other service lines Primary stroke center received advanced certification from the Joint Commission Chest pain center is also certified by the Joint Commission
Unicoi County Hospital	The new Unicoi County Hospital opened in October 2018. With many rural hospital closures or reductions in services throughout the nation recently, Ballad Health implemented its vision for a new kind of rural health access. The new rural hospital in Unicoi County replaced an aging facility originally constructed in 1953. While the hospital is not financially feasible as a stand-alone entity, Ballad Health committed to keep the communitys hospital open and is introducing new services to the community in a new state-of-the-art facility that houses some of the most advanced technology within the health system. The new hospital features limited, low-acuity inpatient acute care services, a 24-hour emergency department, physician office space, a chest pain center and standard and advanced diagnostics. Among the outpatient diagnostic offerings is CT Scanning, ED mammography and a virtual theater MRI featuring a built-in movie screen and music to create a relaxing virtual experience for patients undergoing scans. The advanced technology encourages patients to remain still longer and results in more efficient, high-quality images and patient satisfaction. The virtual theater MRI is the first of its kind in the Ballad Health system.In addition to these services, the new hospital introduced nuclear medicine services, allowing patients to receive cardiac stress tests close to home. The hospital also offers inpatient cardiology coverage seven days a week.The hospital has a unique partnership with the International Storytelling Center (ISC) to embed a storytelling culture for staff, patients, visitors and the community. The storytelling culture improves patient and staff satisfaction and wellbeing, patient education, and provides more meaningful community engagement. The hospital is working toward an ISC Site of Excellence designation, an honor earned by organizations that incorporate storytelling into their core missions, planning, training programs, programming and community outreach. The designation certifies that Unicoi County Hospital has created a sustainable storytelling culture, one that can be perpetuated through multiple generations.
UNICOI COUNTY, TN: UNICOI COUNTY HOSPITAL (UCH)	10-bed acute care hospital opened in October 2018 Services include 24/7 emergency care, cardiology services, radiology and diagnostic imaging, laboratory, respiratory, sleep lab, and rehabilitation
WASHINGTON COUNTY, TN: FRANKLIN WOODS COMMUNITY HOSPITAL (FWCH)	80-bed acute care hospital First Leadership in Energy and Environmental Design (LEED) certified hospital in Tennessee, setting the precedent for environmentally friendly designs, and named one of Soliant Healths 2016 Most Beautiful HospitalsFirst hospital in Tennessee to earn Perinatal Care Certification from the Joint Commission Achieved the Pathway to Excellence designation by the American Nurses Credentialing Center (ANCC), designating the hospital as one of the best places to work for nursesCertified with The Joint Commission for their Minimally Invasive Colorectal Program - only hospital in Tennessee and one of five hospitals in the nation to have this disease-specific certification
WASHINGTON COUNTY, TN: JOHNSON CITY MEDICAL CENTER (JCMC)	585-bed regional tertiary referral center 432 acute care beds, a 69-bed dedicated childrens hospital and an 84-bed behavioral health hospitalTeaching hospital affiliated with James H. & Cecile C. Quillen College of Medicine at East Tennessee State University (ETSU)Second hospital built in TennesseeLevel I trauma center one of only six in Tennessee Regional Cancer CenterRanked by U.S. News and World Report as one of the top 10 hospitals in Tennessee Niswonger Childrens Hospital (NsCH) is a 69-bed childrens hospital within a hospital located on the campus of Johnson City Medical Center serving more than 200,000 children in the four-state, 29-county region. Regions only dedicated hospital for children providing comprehensive services with access to more than 20 pediatric subspecialties One of only eight clinics in the nation affiliated with St. Jude Childrens Research Hospital located on the campus. Staffed by pediatric hematology-oncology physicians and other clinic support team members, the Tri-Cities affiliate is a partnership among the St. Jude Childrens Research Hospital, East Tennessee State University and NsCH. The outpatient clinic, established in 1999, is part of the St. Jude mission to extend the protocol-structured treatment and research at St. Jude through clinical, research and academic partnerships with pediatric programs. More than 300 children with malignancies are followed each year and more than 3,000 outpatient visits occur annually, including treatment of many children with congenital bleeding disorders and a variety of other hematological problems. The First Regional Hemophilia Program, a state sponsored program for congenital bleeding disorders, is housed in the St. Jude Tri-Cities Affiliate and provides programs for both children and adults with hemophilia. Only childrens hospital in the region affiliated with the Childrens Hospital Association Neonatal intensive care unit, with Level III designation, is one of only five state-designated perinatal centers in Tennessee and is the regional referral center for neonatal patients Regions only pediatric emergency department serving patients from birth to 18 years of age 24 hours a day from specially trained personnel partners with med flight provider to provide a specialty crew for neonates requiring isolette transports The Northeast Tennessee Regional Perinatal Center located at JCMC is one of five state-designated tertiary centers for high-risk maternal fetal care. State designation is based on guidelines for the service provisions and designations of levels of care governed and reviewed by a state appointed committee through Tennessee Department of Health. Woodridge Hospital, a service of JCMC, is an 84-bed inpatient behavioral health hospital serving a wide region in Northeast Tennessee and Southwest Virginia. Woodridge is the only dedicated inpatient behavioral health hospital in the region providing mental health and chemical dependency services for adults, adolescents, and children ages 6 and older. The hospital provides a 24/7 intervention helpline. For three consecutive years, Woodridge has received the Guardian of Excellence Award from Press Ganey Associates, Inc., given to organizations achieving the 95th percentile or higher in designated survey results.
Woodridge Hospital	At Woodridge Hospital team members participate in a training program to reduce the use of restraints. The use of restraints can cause injury to patients and staff, psychological harm and loss of dignity. While sometimes restraints are necessary to ensure patient safety, the goal is to use them only when they are absolutely necessary. The focus of the de-escalation program is the early recognition of tension, identifying triggers, de-escalating aggression and implementing safe, effective restraint techniques. With the training, the team is given confidence to handle difficult situations resulting in a dramatic reduction in restraint rates.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

Mountain States Health Alliance
dba Johnson City Medical Center

Employer identification number

62-0476282

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity
(1) Integrated Solutions Health Network 509 Med Tech Parkway Suite 100 Johnson City,TN37604 62-1711997	Hlth Netwk	TN	3,058,391	184,595	MSHA

Part II

Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)MSHA Auxiliary 400 N State of Franklin Road Johnson City,TN37604 58-1418345	Supp. Org.	TN	501C3	12a	MSHA	Yes
(2)Smyth County Community Hospital 245 Medical Park Drive Marion,VA24354 54-0794913	Hospital	VA	501C3	3	MSHA	Yes
(3)Norton Community Hospital 100 15th Street NW Norton,VA24273 54-0566029	Hospital	VA	501C3	3	NA		No
(4)Dickenson Community Hospital 312 Hospital Drive Clintwood,VA24228 77-0599553	Hospital	VA	501C3	3	NCH		No
(5)Johnston Memorial Hospital 16000 Johnston Memorial Drive Abingdon,VA24211 54-0544705	Hospital	VA	501C3	3	NA		No
(6)Abingdon Physician Partners 16000 Johnston Memorial Drive Abingdon,VA24211 20-5485346	Med. Serv.	VA	501C3	12a	JMH		No
(7)Ballad Health 303 Med Tech Parkway Suite 220 Johnson City,TN37604 61-1771290	Supp. Org.	TN	501C3	12b	NA		No
(8)East TN Healthcare Holdings Inc 203 Gray Commons Circle Gray,TN37615 81-5475903	Opioid Trt	TN	501C3	3	MSHA	Yes
(9)Wellmont Health System 1905 American Way Kingsport,TN37660 62-1636465	Hosp. Sys.	TN	501C3	3	BALLAD		No
(10)Wellmont Hawkins Co Memorial Hosp 851 Locust Street Rogersville,TN37857 62-1816368	Hospital	TN	501C3	3	WHS		No
(11)Takoma Regional Hospital Inc DBA GCH 1420 Tusculum Boulevard Greeneville,TN37745 51-0603966	Hospital	TN	501C3	3	WHS		No
(12)Wellmont Cardiology Services 1905 American Way Kingsport,TN37660 26-3557623	Med. Serv.	TN	501C3	10	WHS		No
(13)Wellmont Medical Associates 1905 American Way Kingsport,TN37660 27-0898372	Med. Serv.	TN	501C3	7	WHS		No
(14)Ballad Health Foundation 1019 West Oakland Ave Suite 2 Johnson City,TN37604 58-1594191	Fundraiser	TN	501C3	7	BALLAD		No
(15)Wellmont Madison House 2000 Greenway Street Kingsport,TN37660 62-1308216	Asst. Liv.	TN	501C3	10	WHS		No
(16)Wellmont Wexford House 2421 N John B Dennis Hwy Kingsport,TN37660 58-1859039	Nsg. Home	TN	501C3	10	WHS		No
(17)Wellmont Imaging Services Inc 1905 American Way Kingsport,TN37660 86-1103148	Healthcare	TN	501C3	12a	WHS		No
(18)Wellmont Sleep Services 1905 American Way Kingsport,TN37660 27-3777167	Med. Serv.	TN	501C3	3	WHS		No
(19)Laughlin Memorial Hospital Inc 1420 Tusculum Boulevard Greeneville,TN37745 62-0701119	Hospital	TN	501C3	3	MSHA	Yes
(20)Laughlin Healthcare Foundation 1420 Tusculum Boulevard Greeneville,TN37745 58-2105493	Fundraiser	TN	501C3	12a	MSHA	Yes

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2018

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Emmaus Community Healthcare PLLC 6070 Hwy 11E Piney Flats,TN37686 20-0577483	Med. Serv.	TN	NA	N/A				No			No
(2) Medical Specialists of JC LLC 2528 Wesley Street Suite 2 Johnson City,TN37601 27-2199037	Med. Serv.	TN	MSHA	excluded	-304,442	290,188		No			No	51.000 %
(3) East TN Ambulatory Surgery Cntr 701 Med Tech Parkway Suite 100 Johnson City,TN37604 62-1787537	Med. Serv.	TN	NA	N/A				No			No
(4) Greeneville Physician Services LLC 1905 American Way Kingsport,TN37660 45-5070419	Med. Serv.	TN	NA	Related	-14	81,260		No			No	25.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets		Yes	No
(1) Blue Ridge Medical Management Corp 1905 American Way Kingsport,TN37660 62-1490616	Med. Serv.	TN	MSHA	C	150,465,309	228,009,590	100.000 %		No
(2) Mediserve Medical Equipment 1905 American Way Kingsport,TN37660 62-1212286	DME	TN	BRMMC	C	379,349	4,924,892	100.000 %		No
(3) Mountain States Properties 1905 American Way Kingsport,TN37660 62-1845895	Prop. Mgmt.	TN	BRMMC	C	17,456,548	147,692,320	100.000 %		No
(4) Mountain States Physician Grp 1905 American Way Kingsport,TN37660 62-1700412	Med. Serv.	TN	BRMMC	C	74,592,246	7,348,809	100.000 %		No
(5) Community Home Care Inc 1490 Park Avenue NW Suite B Norton,VA24273 54-1453810	DME	VA	NCH	C	178,353	461,624	50.100 %		No
(6) Wilson Pharmacy Inc PO Box 5289 Johnson City,TN37604 62-0329587	Pharmacy	TN	BRMMC	C	6,269,865	6,591,077	100.000 %		No
(7) Crestpoint Health Insurance Company 509 Med Tech Parkway Suite 100 Johnson City,TN37604 62-0381170	Insurance	TN	ISHN	C	180,945	1,464,726	100.000 %		No
(8) Wellmont Inc 1905 American Way Kingsport,TN37660 62-1320035	Med. Serv.	TN	NA	C					No
(9) Wellmont Collections Inc 2004 American Way Suite 101 Kingsport,TN37660 62-1325938	Bus. Serv.	TN	NA	C					No
(10) Medical Mall Pharmacy Inc 1905 American Way Kingsport,TN37660 62-1565006	Med. Serv.	TN	NA	C					No
(11) Wellmont Physician Services 1905 American Way Kingsport,TN37660 62-1567353	Med. Serv.	TN	NA	C					No
(12) WPS Providers Inc 1905 American Way Kingsport,TN37660 20-5564642	Med. Serv.	TN	NA	C					No
(13) Wellmont Health Services Inc 1905 American Way Kingsport,TN37660 62-1254373	Med. Serv.	TN	NA	C					No
(14) Nolichuckey Mgmt Svcs Inc 1420 Tusculum Blvd Greeneville,TN37745 62-1776681	Med. Serv.	TN	LMH	C			100.000 %		No
(15) Wellmont Insurance Co SPC LTD PO Box 30600 Grand Cayman KY1-1203 CJ 98-1195624	Insurance	CJ	N/A	C					No

Schedule R (Form 990) 2018

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

Yes

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

Yes

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

Yes

h Purchase of assets from related organization(s) ............................

Yes

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

Yes

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

Yes

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

Yes

r Other transfer of cash or property to related organization(s) ............................

Yes

s Other transfer of cash or property from related organization(s) ............................

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) Smyth County Community Hospital	q	183,894	Cost
(2) Norton Community Hospital	o	230,587	Cost
(3) Norton Community Hospital	q	233,193	Cost
(4) Dickenson Community Hospital	o	75,480	Cost
(5) Johnston Memorial Hospital	h	164,683	FMV
(6) Johnston Memorial Hospital	p	112,252	Cost
(7) Ballad Health Foundation	c	318,925	Cash
(8) Blue Ridge Medical Management Corp	a	399,340	FMV
(9) Blue Ridge Medical Management Corp	g	1,195,000	FMV
(10) Blue Ridge Medical Management Corp	l	423,797	FMV
(11) Blue Ridge Medical Management Corp	m	44,150,883	FMV
(12) Blue Ridge Medical Management Corp	o	284,987	Cost
(13) Blue Ridge Medical Management Corp	q	1,129,730	Cost
(14) Blue Ridge Medical Management Corp	r	233,944	Cash
(15) Blue Ridge Medical Management Corp	s	274,681	Cash
(16) Mediserve Medical Equipment	k	158,025	FMV
(17) Mediserve Medical Equipment	o	53,433	Cost
(18) Mountain States Properties	k	1,273,336	FMV
(19) Mountain States Properties	m	151,685	FMV
(20) Mountain States Properties	o	390,687	Cost
(21) Wilson Pharmacy Inc	o	317,619	Cost
(22) Wilson Pharmacy Inc	q	694,248	Cost

Schedule R (Form 990) 2018

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2018

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2018

Additional Data

Software ID:	18007218
Software Version:	2018v3.1

1	Briefly describe the organization’s mission or most significant activities: Our mission: Honor those we serve by delivering the best possible care. Our vision: To build a legacy of superior health by listening to and caring for those we serve.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	4
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	0
5	Total number of individuals employed in calendar year 2018 (Part V, line 2a) ......	5	8,880
6	Total number of volunteers (estimate if necessary) .............	6	1,007
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	1,452,155
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	434,941

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,818,566	1,375,070
9	Program service revenue (Part VIII, line 2g) .........	704,253,585	739,728,327
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	16,903,072	1,668,201
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	5,510,600	3,618,374
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	729,485,823	746,389,972
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	978,764	1,411,256
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	309,858,627	287,123,848
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	417,612,646	430,950,718
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	728,450,037	719,485,822
19	Revenue less expenses. Subtract line 18 from line 12.......	1,035,786	26,904,150
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	1,534,285,953	545,631,938
21	Total liabilities (Part X, line 26).............	992,458,877	93,749,190
22	Net assets or fund balances. Subtract line 21 from line 20.....	541,827,076	451,882,748

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 591,962,043 including grants of $ 1,411,256 ) (Revenue $ 741,210,284 )
	See Schedule O

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses591,962,043

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) James Parsonsterm 418........................................................................ VP HR	0.50 .......................44.50	X	624,169	0	23,651
(19) Anthony Keck........................................................................ EVP, CPHO	0.50 .......................59.50	X	612,910	0	70,933
(20) Paul Merrywell........................................................................ CIO	0.50 .......................44.50	X	578,081	0	19,776
(21) Clay Runnels MD........................................................................ VP Svc Line Mgmt	0.50 .......................44.50	X	425,903	0	36,526

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	11,694,347	570,270	1,048,349

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	333,710
e	Government grants (contributions)		1e	592,802

f	All other contributions, gifts, grants, and similar amounts not included above		1f	448,558

g	Noncash contributions included in lines 1a - 1f:$
h Total. Add lines 1a-1f.......		1,375,070

		Business Code
2a	Hospital Patient Revenue	900099	731,331,937	731,331,937
b	Lab Outreach Income	621500	816,386		816,386
c	P/S Ordinary Income	541900	1,498,540	1,498,540
d	Wellness Revenue	900099	6,081,464	6,081,464
e
f	All other program service revenue.
g	Total. Add lines 2a–2f ....		739,728,327

3 Investment income (including dividends, interest, and othersimilar amounts) ......			186,244			186,244
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		763,450
b	Less: rental expenses		347,864
c	Rental income or (loss)		415,586
d	Net rental income or (loss)......			415,586		113,721	301,865
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	2,483,998
b	Less: cost or other basis and sales expenses	1,002,041
c	Gain or (loss)	1,481,957
d	Net gain or (loss).....			1,481,957	1,481,957
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	Daycare		624410	310,685			310,685
b	Dietary, Security, Engin.		900099	758,282			758,282
c	Revenue from Parent		900099	1,442,862			1,442,862
d	All other revenue ....			690,959		522,048	168,911
e	Total. Add lines 11a–11d ......			3,202,788
12	Total revenue. See Instructions......			746,389,972	740,393,898	1,452,155	3,168,849

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	1,411,256	1,411,256
2	Grants and other assistance to domestic individuals. See Part IV, line 22	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, line 15 and 16.	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	4,545,397	215,928	4,329,469
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	225,319,538	190,257,092	35,062,446
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	5,872,833	4,897,640	975,193
9	Other employee benefits .......	36,543,705	22,960,283	13,583,422
10	Payroll taxes ...........	14,842,375	13,894,070	948,305
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	229,041	1,025	228,016
c	Accounting ...........	35,021	5,142	29,879
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	10,000	7,662	2,338
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	125,397,552	116,354,603	9,042,949
12	Advertising and promotion ....	639,932	70,624	569,308
13	Office expenses .......	5,319,263	4,752,884	566,379
14	Information technology ......	10,744,577	9,616,433	1,128,144
15	Royalties ..	0
16	Occupancy ...........	10,381,749	9,579,885	801,864
17	Travel ............	1,396,848	1,232,383	164,465
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	26,935,067	1,288,522	25,646,545
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	34,824,269	31,828,370	2,995,899
23	Insurance ...	910,373	79,263	831,110
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	Medical Supplies and Drugs	157,971,752	157,971,752
b	Management Fees	28,528,349		28,528,349
c	Maintenance & Repair	21,676,045	21,075,420	600,625
d	Dues & Subscriptions	2,293,754	854,675	1,439,079
e	All other expenses	3,657,126	3,607,131	49,995
25	Total functional expenses. Add lines 1 through 24e	719,485,822	591,962,043	127,523,779	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			10,808,245	1	2,269,056
2	Savings and temporary cash investments .........			5,506,817	2	0
3	Pledges and grants receivable, net ......			443,373	3	157,943
4	Accounts receivable, net .............			112,430,519	4	104,889,743
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L .............
				11,977,590	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L ..............
					6	0
7	Notes and loans receivable, net ....			18,827,128	7	8,457,586
8	Inventories for sale or use ........			18,615,225	8	18,917,882
9	Prepaid expenses and deferred charges ......			6,994,594	9	2,684,840
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	1,008,986,377
b	Less: accumulated depreciation	10b	613,899,807	495,679,035	10c	395,086,570
11	Investments—publicly traded securities .			334,991,957	11	0
12	Investments—other securities. See Part IV, line 11 .....				12	0
13	Investments—program-related. See Part IV, line 11 ..			339,717,493	13	1,464,725
14	Intangible assets ...............			145,025,185	14	11,698,593
15	Other assets. See Part IV, line 11 ...........			33,268,792	15	5,000
16	Total assets. Add lines 1 through 15 (must equal line 34)...			1,534,285,953	16	545,631,938

17	Accounts payable and accrued expenses .....	100,285,014	17	66,157,491
18	Grants payable ...		18
19	Deferred revenue .........	4,513,039	19
20	Tax-exempt bond liabilities .........	150,252,709	20	12,716,652
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	737,408,115	25	14,875,047
26	Total liabilities. Add lines 17 through 25..	992,458,877	26	93,749,190

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	541,800,639	27	451,809,561
28	Temporarily restricted net assets ...........	26,437	28	73,187
29	Permanently restricted net assets		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	541,827,076	33	451,882,748
34	Total liabilities and net assets/fund balances ........	1,534,285,953	34	545,631,938