4A (Expenses $ 186334365 including grants of $ 67457) (Revenue $ 245200332)
"EAST TENNESSEE CHILDREN'S HOSPITAL (""ETCH"") IS THE ONLY COMPREHENSIVE REGIONAL PEDIATRIC CENTER IN EAST TENNESSEE. SINCE 1937, ETCH HAS PROVIDED EXCELLENT PEDIATRIC HEALTH CARE FOR CHILDREN FROM BIRTH TO 21 YEARS OF AGE. ETCH OFFERS MORE PEDIATRIC SUBSPECIALTIES THAN ANY OTHER HOSPITAL IN THE REGION, SERVING CHILDREN FROM EAST TENNESSEE, SOUTHWEST VIRGINIA, SOUTHEAST KENTUCKY AND WESTERN NORTH CAROLINA. THE SUBSPECIALTIES AVAILABLE AT ETCH INCLUDE: ADOLESCENT GYNECOLOGYADOLESCENT MEDICINE(SUBSPECIALTY LIST CONTINUED ON SCHEDULE O)CHILD ABUSE PEDIATRICSDEVELOPMENTAL-BEHAVIORAL PEDIATRICSNEONATOLOGYPEDIATRICS/PRIMARY CAREPEDIATRIC ALLERGY & IMMUNOLOGYPEDIATRIC ANESTHESIOLOGYPEDIATRIC CARDIOLOGY CLINICAL GENETICSPEDIATRIC CRITICAL CAREPEDIATRIC DENTISTRY/PEDODONTICSPEDIATRIC DERMATOLOGYPEDIATRIC EMERGENCY MEDICINEPEDIATRIC ENDOCRINOLOGYPEDIATRIC FORENSIC MEDICINEPEDIATRIC GASTROENTEROLOGYPEDIATRIC AND ADOLESCENT GYNECOLOGYPEDIATRIC HEMATOLOGY/ONCOLOGYPEDIATRIC INFECTIOUS DISEASEPEDIATRIC NEPHROLOGYPEDIATRIC NEUROLOGYPEDIATRIC NEUROSURGERYPEDIATRIC OPHTHALMOLOGYPEDIATRIC ORTHOPEDICSPEDIATRIC OTOLARYNGOLOGYPEDIATRIC PHYSIATRYPEDIATRIC PLASTIC/RECONSTRUCTIVE SURGERYPEDIATRIC PULMONOLOGYPEDIATRIC RADIOLOGYPEDIATRIC REHABILITATION SERVICESPEDIATRIC RHEUMATOLOGYPEDIATRIC SLEEP MEDICINEPEDIATRIC SURGERYPEDIATRIC UROLOGYPERINATOLOGYPSYCHOLOGYIN ADDITION, ETCH PROVIDES THE FOLLOWING: MEDICAL/SURGICAL SERVICES:THE EMERGENCY DEPARTMENT IS STAFFED WITH BOARD CERTIFIED PEDIATRIC PHYSICIANS, NURSING STAFF, AND DIAGNOSTIC CAPABILITIES TO PROVIDE TREATMENT FOR ALL TYPES OF EMERGENCIES 24 HOURS A DAY, SEVEN DAYS A WEEK. THE DEPARTMENT PROVIDES EVALUATION AND TREATMENT FOR PATIENTS UP TO 21 YEARS OF AGE WITH VARYING LEVELS OF ILLNESS AND INJURY, FROM MINOR TO LIFE THREATENING. THE HOSPITAL'S PEDIATRIC INTENSIVE CARE UNIT (PICU) PROVIDES COMPREHENSIVE, 24-HOUR-A-DAY TREATMENT FOR CRITICALLY ILL AND INJURED CHILDREN. THE PICU IS STAFFED WITH FELLOWSHIP TRAINED, BOARD CERTIFIED, CRITICAL CARE PHYSICIANS AND NURSES SPECIFICALLY TRAINED AND EXPERIENCED IN THE CARE OF CRITICALLY ILL CHILDREN. PATIENTS IN THE PICU RECEIVE A HIGH LEVEL OF MONITORING AND/OR TREATMENT UNTIL THEY ARE WELL ENOUGH TO BE TRANSFERRED TO A REGULAR PATIENT ROOM OR DISCHARGED HOME.IN THE NEONATAL INTENSIVE CARE UNIT (NICU), TINY AND FRAGILE INFANTS BORN PREMATURELY OR FACING LIFE-THREATENING ILLNESSES RECEIVE TREATMENT FROM A TEAM OF BOARD-CERTIFIED NEONATOLOGISTS, WITH VALUABLE ASSISTANCE FROM SPECIALLY TRAINED NURSES, RESPIRATORY THERAPISTS, LACTATION CONSULTANTS, AND OTHER MEDICAL PROFESSIONALS. THE NICU TREATS MORE THAN 900 NEWBORNS EACH YEAR.AS A REGIONAL REFERRAL CENTER FOR EAST TENNESSEE, ETCH OFFERS NEONATAL AND PEDIATRIC TRANSPORT FROM OUTLYING HOSPITALS IN LIFELINE, A MOBILE INTENSIVE CARE UNIT SPECIALLY DESIGNED TO MAINTAIN THE SAME QUALITY OF CARE DURING TRANSPORT AS PATIENTS RECEIVE IN THE HOSPITAL'S CRITICAL CARE UNITS. LIFELINE CARRIES MORE THAN 1,000 SUPPLIES TO ADMINISTER CARE TO PATIENTS, FROM THE TINIEST PREMATURE INFANT TO AN ADULT-SIZE PEDIATRIC PATIENT, DURING TRANSPORT TO THE HOSPITAL. IN ADDITION TO THE SPECIAL EQUIPMENT, THE LIFELINE MEDICAL TEAM MAY INCLUDE A NEONATOLOGIST, NEONATAL NURSE PRACTITIONER, PEDIATRIC/NEONATAL RN, RESPIRATORY THERAPIST, AN EMT, A-EMT, AND PARAMEDICS, DEPENDING ON THE CONDITION OF THE PATIENT. THE HOSPITAL'S TWO LIFELINE VEHICLES TRAVELED MORE THAN 32,000 MILES IN FY20 TO DOZENS OF DIFFERENT HOSPITALS IN 16 COUNTIES IN TENNESSEE, VIRGINIA, AND KENTUCKY TO TRANSPORT HUNDREDS OF PEDIATRIC PATIENTS TO ETCH.ETCH MEETS A WIDE RANGE OF PEDIATRIC SURGICAL NEEDS, FROM COMMON OUTPATIENT PROCEDURES SUCH AS TONSILLECTOMIES TO MORE COMPLICATED PROCEDURES, SUCH AS RECONSTRUCTIVE SURGERY OR NEUROSURGERY. FIVE DEPARTMENTS COMPRISE ETCH'S SURGICAL SERVICES: OPERATING ROOM, PRE/POST SURGERY (OUTPATIENT SURGERY), INPATIENT SURGERY, ANESTHESIA, AND STERILE PROCESSING. THESE DEPARTMENTS WORK TOGETHER TO MAKE SURE EACH CHILD'S SURGERY AND RECOVERY IS AS QUICK AND PAINLESS AS POSSIBLE. THE DOCTORS, NURSES, ANESTHESIOLOGISTS AND OTHER SURGICAL STAFF ARE TRAINED IN PEDIATRIC MEDICINE. AT ANY GIVEN TIME AND FOR VARIOUS REASONS, A CHILD MAY NEED TO BE ADMITTED TO ETCH AS AN INPATIENT. DOCTORS AND NURSES CONTINUOUSLY MONITOR AND TREAT INPATIENTS ACCORDING TO THEIR INDIVIDUAL NEEDS. ALONG WITH PROVIDING COMPREHENSIVE MEDICAL AND NURSING CARE, ETCH IS DEDICATED TO MAKING A CHILD'S STAY IN THE HOSPITAL AS COMFORTABLE AS POSSIBLE. EACH ROOM HAS A TV WITH ACCESS TO MOVIE CHANNELS, AND PLAY ROOMS ARE LOCATED ON EACH FLOOR. OTHER SERVICES SUCH AS CHILD LIFE, NUTRITION, PASTORAL CARE. REHABILITATION AND SOCIAL WORK PROVIDE FOR THE PHYSICAL AND EMOTIONAL NEEDS OF THE CHILD. THE RESPIRATORY CARE DEPARTMENT AT ETCH IS STAFFED WITH LICENSED AND ACCREDITED RESPIRATORY THERAPISTS WHOSE ROLES INCLUDE TREATING PATIENTS WITH LUNG AND/OR HEART DISEASES SUCH AS ASTHMA, PNEUMONIA, PREMATURE LUNGS AND CYSTIC FIBROSIS. TREATMENTS PROVIDED BY RESPIRATORY THERAPISTS INCLUDE AEROSOL MEDICATIONS, DELIVERY OF OXYGEN AND OTHER MEDICAL GASES, VENTILATOR MANAGEMENT AND MANY OTHER PROCEDURES. RESPIRATORY THERAPISTS HELP PATIENTS THROUGHOUT THE HOSPITAL, FROM THE EMERGENCY DEPARTMENT TO THE NICU. THEY ARE ALSO MEMBERS OF THE PEDIATRIC TRANSPORT TEAM THAT HELPS BRING SICK AND INJURED CHILDREN TO THE HOSPITAL FOR SPECIALIZED CARE. EDUCATION IS ALSO A KEY ROLE OF RESPIRATORY THERAPISTS; THEY TEACH PATIENTS AND THEIR FAMILIES HOW TO CARE FOR CERTAIN CONDITIONS AT HOME. THE PULMONARY FUNCTION LAB, A VITAL PART OF THE RESPIRATORY CARE DEPARTMENT, PERFORMS TESTS TO DIAGNOSE LUNG AND HEART DISEASES. THE DEPARTMENT IS STAFFED BY SPECIALLY TRAINED RESPIRATORY THERAPISTS. SERVICES PROVIDED INCLUDE SPIROMETRY TESTING, METABOLIC STUDIES, CARDIAC STRESS TESTING, LUNG VOLUMES AND THE CYSTIC FIBROSIS CLINIC. ECHOCARDIOGRAMS ARE PERFORMED IN THE ECHO LAB. PATIENTS IN A VARIETY OF HOSPITAL DEPARTMENTS MAY BENEFIT FROM SEDATION DURING SOME PAINFUL TESTS AND PROCEDURES. IN ADDITION, YOUNG CHILDREN MAY NEED SEDATION TO REMAIN STILL DURING LONG TESTS, SUCH AS A MAGNETIC RESONANCE IMAGING (MRI). TO MEET THESE NEEDS, ETCH OFFERS PEDIATRIC ANALGESIA AND SEDATION SPECIALISTS (PASS). WHILE THE HOSPITAL CANNOT ELIMINATE PAIN FOR SOME CHILDREN, IT IS OUR GOAL TO KEEP PAINFUL OR UNCOMFORTABLE SITUATIONS TO A MINIMUM. PASS IS A DEDICATED SERVICE THAT UTILIZES THE MOST CURRENT SEDATION TECHNIQUES TO HELP CHILDREN UNDERGOING LENGTHY OR PAINFUL PROCEDURES AT ETCH. A MULTISPECIALTY TEAM SEES EACH CHILD, INCLUDING A PEDIATRIC SEDATION PHYSICIAN AND PEDIATRIC NURSES WHO ARE SPECIFICALLY PREPARED TO WORK WITH PEDIATRIC SEDATION. DIAGNOSTIC SERVICES:THE CLINICAL LAB IS RESPONSIBLE FOR ALL DIAGNOSTIC TESTING, WHICH INCLUDES THE FOLLOWING AREAS: HEMATOLOGY, CHEMISTRY, MICROBIOLOGY, IMMUNOLOGY, SEROLOGY AND BLOOD BANK.NEUROLOGY LAB - THE NEUROLOGY LAB OFFERS A VARIETY OF DIAGNOSTIC TESTS FOR PATIENTS DEALING WITH SEIZURES, HEARING PROBLEMS, SLEEP DISORDERS AND OTHER CONDITIONS INVOLVING THE BRAIN. THE MOST COMMON TESTS OFFERED IN THE NEUROLOGY LABORATORY ARE THE ELECTROENCEPHALOGRAM (EEG) FOR CHILDREN HAVING SEIZURES AND OTHER NEUROLOGICAL PROBLEMS AND THE BRAINSTEM AUDITORY EVOKED RESPONSE (BAER) HEARING TEST, OFFERED MOST OFTEN TO INFANTS WHO FAIL NEWBORN HEARING SCREENINGS AND TODDLERS WHO ARE SPEECH DELAYED. CHILDREN'S SLEEP MEDICINE CENTER - THE CHILDREN'S SLEEP MEDICINE CENTER OFFERS SLEEP STUDY TESTING FOR CHILDREN WHO ARE HAVING PROBLEMS WITH SLEEP. THE SLEEP STUDIES TAKE PLACE OVERNIGHT, DURING THE CHILD'S REGULAR SLEEP CYCLE, TO FIND THE CAUSE OF PROBLEMS SUCH AS SLEEP DISORDERED BREATHING AND PARASOMNIAS (NIGHT TERRORS, SLEEPWALKING). ETCH IS ACCREDITED BY THE AMERICAN ACADEMY OF SLEEP MEDICINE AS THE ONLY SLEEP MEDICINE CENTER DEDICATED TO PEDIATRICS IN EAST TENNESSEE.THE RADIOLOGY DEPARTMENT SERVES AS AN ""IMAGING"" CENTER FOR CHILDREN. THESE IMAGES INCLUDE X-RAY, ULTRASOUND, CT SCAN, NUCLEAR MEDICINE, MRI, AND FLUOROSCOPY."

EAST TENNESSEE CHILDREN'S HOSPITAL
PART V, SECTION B, LINE 5: THE FOLLOWING FOCUS GROUPS PARTICIPATED IN THE ETCH 2022 CHNA:FIVE FOCUS GROUPS WERE CONDUCTED BY EXPERT EVALUATORS FROM THE COLLEGE OF SOCIAL WORK OFFICE OF RESEARCH AND PUBLIC SERVICE (SWORPS) AT THE UNIVERSITY OF TENNESSEE. THE FOCUS GROUPS WERE CONDUCTED WITH: 1. EAST TENNESSEE CHILDREN'S HOSPITAL FAMILY ADVISORY COUNCIL2. REGIONAL COORDINATED SCHOOL HEALTH COORDINATORS3. REGIONAL HEALTH DEPARTMENT DIRECTORS4. PRIMARY CARE PHYSICIANS5. EAST TENNESSEE CHILDREN'S HOSPITAL PEER DIRECTOR GROUPA SURVEY FOR THE GENERAL POPULATION WAS CREATED TO GAIN INPUT FROM COMMUNITY RESIDENTS AND KEY STAKEHOLDERS ABOUT THE TOP HEALTH NEEDS AND PRIORITIES OF CHILDREN IN OUR COMMUNITY. A SURVEY WAS PROMOTED BY PROVIDING A SURVEY LINK ON THE CHILDREN'S HOSPITAL WEBSITE AND SOCIAL MEDIA OUTLETS TO ENCOURAGE PEOPLE TO TAKE A FEW MINUTES TO COMPLETE AN ONLINE, CONFIDENTIAL SURVEY.DATA FROM THE KEY INFORMANT INTERVIEWS, FOCUS GROUPS, AND COMMUNITY SURVEY WERE ANALYZED TO TRIANGULATE FINDINGS AND IDENTIFY COMMON THEMES. FOUR PRIMARY HEALTH ISSUES OF CONCERN EMERGED: NUTRITION, SUBSTANCE ABUSE, MENTAL AND BEHAVIORAL HEALTH, AND HEALTH CARE ACCESS.

EAST TENNESSEE CHILDREN'S HOSPITAL
PART V, SECTION B, LINE 11: WHILE NUTRITION, SUBSTANCE ABUSE, MENTAL AND BEHAVIORAL HEALTH, AND HEALTH CARE ACCESS HAVE BEEN THE MOST UNIVERSALLY IDENTIFIED THUS FAR, MANY OTHER IMPORTANT HEALTH ISSUES AND SOCIAL DETERMINANTS HAVE BEEN DISCUSSED IN THE COURSE OF THE CHNA PROCESS AND ARE WORTHY OF CONSIDERATION IN THE LATER STRATEGIC PLANNING PHASE. THESE ISSUES INCLUDE BUT ARE NOT LIMITED TO: - ACCESS TO TRANSPORTATION- EATING DISORDERS- POLITICIZATION OF HEALTHCARE ISSUES SUCH AS COVID-19, IMMUNIZATIONS, AND SEX EDUCATION- ACCIDENTAL INJURIES- FOOD DESERTS- POVERTY AND HOMELESSNESS- ADVERSE CHILDHOOD EXPERIENCES (ACES)- HEARING AND VISION CARE- PRENATAL CARE ACCESS- ASTHMA AND ALLERGIES- HYPERTENSION AMONG CHILDREN- REPRODUCTIVE HEALTH CARE AND SEX EDUCATION- COVID-19- IMMUNIZATIONS AND VACCINATIONS- SOCIAL ISOLATION- DENTAL CARE ACCESS- NEONATAL ABSTINENCE SYNDROME (NAS)- SUBSTANCE ABUSE- DIABETES- PARENTAL NEGLECT- TECHNOLOGY ISSUES- DOMESTIC ABUSE- PHYSICAL FITNESS- TOBACCO USE AND VAPINGWHILE CHILDREN'S HOSPITAL WOULD CONTINUE FOCUS ON THE MAJORITY OF EFFORTS OUTLINED IN OUR IMPLEMENTATION STRATEGY, ALL NEEDS IDENTIFIED WILL BE REVIEWED FOR FUTURE CONSIDERATION AND COLLABORATION. THESE AREAS, WHILE STILL IMPORTANT TO THE HEALTH OF CHILDREN IN THE COMMUNITY, WILL BE MET THROUGH OTHER HEALTH CARE ORGANIZATIONS WITH ASSISTANCE FROM CHILDREN'S HOSPITAL AS NEEDED. THE COMMUNITY NEEDS NOT ADDRESSED BY CHILDREN'S HOSPITAL WILL CONTINUE TO BE ADDRESSED BY GOVERNMENTAL AGENCIES AND EXISTING COMMUNITY-BASED ORGANIZATIONS.

PART I, LINE 7:
"A COST-TO-CHARGE RATIO, DERIVED FROM THE SCHEDULE H APPLICABLE WORKSHEETS, INCLUDING WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, WAS USED TO DETERMINE CHARITY CARE. ACTUAL EXPENSE DATA IS ACCUMULATED WITHIN THE ETCH GENERAL LEDGER WHICH ADDRESSES ALL PATIENT SEGMENTS INCLUDING INPATIENT, OUTPATIENT, EMERGENCY ROOM, COMMERCIAL INSURANCE, GOVERNMENT INSURANCE, UNINSURED AND SELF-PAY. THE TOTAL OPERATING EXPENSE WAS DIVIDED BY PATIENT REVENUES TO CALCULATE AN OVERALL RATIO THAT WAS THEN APPLIED TO INDIGENT AND CHARITY CARE CHARGES TO ARRIVE AT COST. THE STATE OF TENNESSEE'S COVERKIDS PROGRAM PROVIDES COVERAGE FOR THE VAST MAJORITY OF CHILDREN WHO REQUIRE MEDICAL CARE BUT ARE UNINSURED. ETCH REPRESENTATIVES WORK EXTENSIVELY WITH PATIENTS' FAMILIES TO HELP THEM UNDERSTAND AVAILABILITY OF STATE AID AND TO ASSIST THEM IN BECOMING ENROLLED IN THE PROGRAM. FOR THAT REASON, THE AMOUNT OF TRUE ""CHARITY CARE"" RENDERED BY ETCH IS CONSIDERABLY SMALLER THAN LEVELS EXPERIENCED BY COMMUNITY HOSPITALS OR OTHER FACILITIES SERVING THE ADULT POPULATION."

PART I, LINE 7, COLUMN (F):
THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 6,415,628.

PART II, COMMUNITY BUILDING ACTIVITIES:
ETCH PROVIDES NUMEROUS BENEFITS TO THE PUBLIC AND PROMOTES THE HEALTH OF THE COMMUNITY IN THE FOLLOWING WAYS:1. COMMUNITY SUPPORT: ETCH EMPLOYEES VOLUNTEER TIME TO THE FOLLOWING NEIGHBORHOOD SUPPORT GROUPS: RONALD MCDONALD HOUSE, SHOES FOR SCHOOLS, UNITED WAY AND BOARD SUPPORT FOR ORGANIZATIONS. 2. COALITION BUILDING AND COMMUNITY HEALTH IMPROVEMENT ADVOCACY: ETCH PARTICIPATED IN THE FOLLOWING COMMUNITY COALITIONS TO ADDRESS HEALTH AND SAFETY ISSUES SPECIFIC TO CHILDREN. A. EAST TENNESSEE CHILDHOOD OBESITY COALITION WHOSE MISSION IS TO PREVENT AND REDUCE CHILDHOOD OBESITY BY PROMOTING HEALTHY, ACTIVE LIFESTYLES THROUGH FAMILY, COMMUNITY AND INTER-PROFESSIONAL COLLABORATIONS. ETCH PROMOTES THESE ACTIVITIES THROUGH THE HEALTH KIDS CLUB PROGRAM TO AREA ELEMENTARY SCHOOLS. B. SAFEKIDS. THE ETCH INJURY PREVENTION PROGRAM IS THE LEADER OF A COALITION TO PREVENT ACCIDENTAL INJURY. THE SAFE TRAVELS PROGRAM TRAINS LOCAL AGENCY MEMBERS ON CHILD PASSENGER SAFETY AND DISTRIBUTES CAR SEATS TO THOSE IN NEED ALONG WITH INSTALLATION TRAINING. THE PROGRAM ALSO PROVIDES BIKE HELMETS AND HELPS EDUCATE KIDS AND PARENTS ABOUT HELMET USE AND INJURY PREVENTION. ALSO, WE PROVIDE A WIDE SCOPE OF PUBLIC EDUCATION ON WATER SAFETY AND HEAT STROKE PREVENTION. C. ETCH PROVIDES TRAINING FOR AED USAGE AND CPR ADMINISTRATION IN MANY PUBLIC SCHOOLS AND AREAS. D. ETCH PROVIDES ASTHMA SCREENINGS IN LOCAL COMMUNITY THROUGH THE BREATHE EASY PROGRAM ALONG WITH FOLLOW-UP CALLS TO THOSE WHO HAVE AN ABNORMAL SCREENING RESULT. E. OTHER ACTIVITIES INCLUDE SAFESITTER CLASSES, CPR TRAINING, CAMPS FOR CHILDREN, HELLO HOSPITAL, MEDIC BLOOD DRIVES, VOLUNTEEN PROGRAM AND INFANT AND CHILD TRAINING FOR ADULT HOSPITALS AND EMERGENCY AGENCIES.3. WORKFORCE DEVELOPMENT: ETCH RECRUITS PHYSICIAN SPECIALTIES AND OTHER HEALTH PROFESSIONALS DEDICATED TO SERVING THE CHILD & ADOLESCENT POPULATION TO MEDICAL SHORTAGE AREAS OR OTHER AREAS DESIGNATED AS UNDERSERVED. PROJECT SEARCH IS A YEAR-LONG PROGRAM PROVIDING ADULTS WITH DISABILITIES THE EDUCATION AND EXPERIENCE THEY NEED FOR SUCCESSFUL EMPLOYMENT. 4. EDUCATION OF HEALTH PROFESSIONALS: ETCH PROVIDES EDUCATIONAL PROGRAMS FOR PHYSICIANS, RESIDENTS, NURSES, NURSING STUDENTS AND OTHER HEALTH PROFESSIONALS. 5. RESEARCH: ETCH PARTICIPATES IN RESEARCH IN HEMATOLOGY, PULMONOLOGY AND ENDOCRINOLOGY.

PART III, LINE 4:
A COST-TO-CHARGE RATIO WAS ALSO USED TO DETERMINE BAD DEBT COST. THE TOTAL OPERATING EXPENSE WAS DIVIDED BY PATIENT REVENUES TO CALCULATE AN OVERALL RATIO THAT WAS THEN APPLIED TO THE BAD DEBT EXPENSE TO ARRIVE AT COST.ETCH'S FINANCIAL STATEMENTS READ AS FOLLOWS: USING A PORTFOLIO APPROACH, THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FROM THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. IN ADDITION, FOR UNINSURED PATIENTS, THE HOSPITAL REDUCES CHARGES FROM CURRENT RATES BASED ON AVERAGE DISCOUNTS PROVIDED TO CERTAIN THIRD-PARTY PAYERS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGE BY ANY EXPLICIT PRICE CONCESSIONS, DISCOUNTS, AND IMPLICIT PRICE CONCESSIONS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF THE CHANGE. ADJUSTMENTS FOR SUCH CHANGES IN THE ESTIMATED TRANSACTION PRICE WERE NOT SIGNIFICANT FOR THE YEARS ENDED JUNE 30, 2022 AND 2021. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. NO SIGNIFICANT AMOUNT OF BAD DEBT EXPENSE WAS REPORTED FOR THE YEARS ENDED JUNE 30, 2022 AND 2021.

PART VI, LINE 6:
ETCH IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM.

PART VI, LINE 7, REPORTS FILED WITH STATES
TN

PART III, LINE 8:
A COST-TO-CHARGE RATIO WAS USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS. THE TOTAL OPERATING EXPENSE WAS DIVIDED BY PATIENT REVENUES TO CALCULATE AN OVERALL RATIO THAT WAS THEN APPLIED TO MEDICARE CHARGES TO ARRIVE AT COST.THE SHORTFALL OF $103,244 AS REPORTED IN PART III, LINE 7, SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE, ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WOULD QUALIFY FOR CHARITY CARE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS. BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. ALSO, THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS, AND THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER CHARITY CARE AND OTHER COMMUNITY BENEFIT NEEDS.

PART III, LINE 9B:
UNDER ETCH'S POLICIES AND PROCEDURES, ETCH UNDERTAKES MEASURES TO COMMUNICATE WITH THE FAMILIES OF PATIENTS WITH SELF-PAY BALANCES. IN MANY CASES, ETCH AND FAMILIES WORK TOGETHER TO OBTAIN COVERAGE THROUGH THE STATE OF TENNESSEE'S COVERKIDS PROGRAM. IN CASES WHERE COVERKIDS COVERAGE IS NOT AVAILABLE, ETCH SEEKS TO OBTAIN INFORMATION NECESSARY TO DETERMINE THE PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE UNDER ETCH'S CHARITY CARE PROGRAM. ONCE A PATIENT'S ELIGIBILITY FOR FREE OR DISCOUNTED CARE HAS BEEN DETERMINED, THE BALANCE ON THE PATIENT'S ACCOUNT IS ADJUSTED ACCORDINGLY. IN ADDITION, ETCH PERSONNEL WORK CLOSELY WITH FAMILIES TO DETERMINE THEIR ABILITY TO PAY THE ADJUSTED BALANCES; SUCH EFFORTS OFTEN RESULT IN PAYMENT PLANS INTENDED TO PERMIT THE GRADUAL PAYMENT OF AMOUNTS DUE WITHOUT IMPOSING UNDUE FINANCIAL HARDSHIP ON FAMILIES ALREADY DEALING WITH THE CHALLENGES OF CHILDREN'S HEALTH ISSUES. UNFORTUNATELY, THERE REMAIN CIRCUMSTANCES WHERE PATIENTS CANNOT BE DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE DUE TO THE INACCESSIBILITY OF THE FAMILY OR THE FAMILY'S INABILITY OR REFUSAL TO PROVIDE THE REQUIRED INFORMATION. IN SUCH CASES, ETCH FOLLOWS AN ESTABLISHED MULTI-STEP PROCESS CONSISTING OF MAILED NOTICES AND PHONE CALLS IN AN EFFORT TO REACH OUT TO THE FAMILY AND PROVIDE THEM WITH INFORMATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE UNDER THE PROGRAM. ETCH'S COLLECTION PRACTICES APPLY TO ALL PATIENTS, CHARITY CARE AND NON-CHARITY CARE PATIENTS. ACCOUNTS ARE SENT TO COLLECTIONS (ETCH CONTRACTS WITH AN ORGANIZATION WITH SUBSTANTIAL EXPERIENCE IN COLLECTION OF PATIENT ACCOUNTS) ONLY AFTER ALL ESTABLISHED STEPS HAVE BEEN UNDERTAKEN, WITHOUT SUCCESS.

PART VI, LINE 2:
THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROCESS IS THE FOUNDATION FOR IMPROVING AND PROMOTING THE HEALTH STATUS OF OUR COMMUNITY'S CHILDREN. THE PLANNING, ACTIVITIES AND DATA REVIEW NECESSARY FOR THE DEVELOPMENT OF THE MOST RECENT ASSESSMENT TOOK PLACE BEGINNING EARLY JANUARY 2021 THROUGH SPRING 2022. THE PROCESS INCLUDED THE COLLECTION OF PRIMARY DATA OBTAINED THROUGH SURVEYS AND INTERVIEWS WITH INDIVIDUALS FROM LOCAL COMMUNITIES AND SECONDARY DATA FOR STATE AND COUNTY-SPECIFIC STATISTICS.THROUGHOUT THE CHNA, HIGH PRIORITY WAS GIVEN TO DETERMINING THE HEALTH STATUS AND AVAILABLE RESOURCES WITHIN A 16-COUNTY SERVICE AREA INCLUDING ANDERSON, BLOUNT, CAMPBELL, CLAIBORNE, COCKE, GRAINGER, HAMBLEN, JEFFERSON, KNOX, LOUDON, MONROE, MORGAN, ROANE, SCOTT, SEVIER AND UNION. THESE COUNTIES WERE IDENTIFIED AS CORE COUNTIES BASED ON PATIENT POPULATION DATA. AFTER CAREFUL EVALUATION OF ALL PRIMARY AND SECONDARY DATA, HEALTH PRIORITIES WERE IDENTIFIED. THE PLANNING PROCESS FOR THE FISCAL YEAR 2022 CHNA BEGAN IN JANUARY 2021. AN INTERNAL TEAM WAS FORMED TO IDENTIFY AND APPROVE RESOURCES AND TIMELINES FOR CONDUCTING THE NECESSARY STEPS FOR COMPLETION OF THE NEEDS ASSESSMENT. A TIMELINE WAS ESTABLISHED TO ALLOW SUFFICIENT TIME AND RESOURCES TO IDENTIFY AND ENGAGE COMMUNITY PARTNERS IN KEY INFORMANT INTERVIEWS AND FOCUS GROUPS. THE INTERNAL TEAM USED A MODIFIED VERSION OF THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) PROCESS. THIS PROCESS IS COMMONLY USED TO ASSIST COMMUNITY HEALTH ORGANIZATIONS DURING THE NEEDS ASSESSMENT PROCESS. THE MAPP PROCESS PROVIDED THE FRAMEWORK FOR CHILDREN'S HOSPITAL TO ORGANIZE, VISUALIZE, ASSESS, STRATEGIZE, FORMULATE GOALS AND TAKE ACTION. KEY INFORMANTS WERE IDENTIFIED IN SIXTEEN COUNTIES AND BY USING THE FOLLOWING CRITERIA:1. THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH; 2. AT LEAST ONE STATE, LOCAL, TRIBAL, OR REGIONAL GOVERNMENT PUBLIC HEALTH DEPARTMENT (OR EQUIVALENT DEPARTMENT OR AGENCY) OR STATE OFFICE OF RURAL HEALTH WITH KNOWLEDGE, INFORMATION, OR EXPERTISE RELEVANT TO THE HEALTH NEEDS OF THAT COMMUNITY; 3. MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS IN THE COMMUNITY SERVED BY THE HOSPITAL FACILITY, OR INDIVIDUAL OR ORGANIZATIONS SERVING OR REPRESENTING THE INTEREST OF SUCH POPULATIONS; 4. MEMBERS OF MEDICALLY UNDERSERVED POPULATIONS INCLUDE POPULATIONS EXPERIENCING HEALTH DISPARITIES OR AT RISK OF NOT RECEIVING ADEQUATE MEDICAL CARE AS A RESULT OF BEING UNINSURED OR UNDERINSURED OR DUE TO GEOGRAPHIC, LANGUAGE, FINANCIAL OR OTHER BARRIERS. EACH INTERVIEW WAS CONDUCTED USING A UNIFORM DISCUSSION POINT QUESTIONS. THESE FACE-TO-FACE INTERVIEWS WERE CONDUCTED BY CHILDREN'S HOSPITAL ADMINISTRATIVE AND COMMUNITY BENEFIT STAFF AT SCHEDULED TIMES.

PART VI, LINE 3:
ETCH RECOGNIZES THAT UNEXPECTED MEDICAL PROBLEMS CAN CREATE UNEXPECTED FINANCIAL PROBLEMS. ETCH IS AVAILABLE TO ASSIST PATIENTS' FAMILIES IN FINDING RESOURCES THAT HELP TO COVER MEDICAL EXPENSES. AS INDICATED ABOVE, ETCH WORKS CLOSELY WITH PATIENTS' FAMILIES TO HELP THEM UNDERSTAND AND ENROLL IN MEDICAL ASSISTANCE PROGRAMS AVAILABLE THROUGH THE STATE OF TENNESSEE AND, WHERE APPROPRIATE, FEDERAL PROGRAMS. WHERE SUCH PROGRAMS ARE NOT AVAILABLE, HOWEVER, PATIENTS MAY BE ELIGIBLE FOR FREE OR DISCOUNTED CARE UNDER ETCH'S ESTABLISHED POLICIES AND PROCEDURES. THE AVAILABILITY OF FINANCIAL ASSISTANCE IS PUBLICIZED THROUGHOUT THE ETCH FACILITY AND THROUGH VARIOUS MEASURES, INCLUDING INFORMATION ON ETCH'S WEBSITE AND WRITTEN BROCHURES OR OTHER MATERIALS PROVIDED TO PATIENT'S FAMILIES. INFORMATION (IN BOTH ENGLISH AND SPANISH) IS MADE AVAILABLE AT ALL POINTS OF REGISTRATION (INTAKE AND DISCHARGE) AS WELL AS ON THE ETCH WEBSITE. THE MOST SIGNIFICANT EDUCATION, HOWEVER, OCCURS IN DIRECT DIALOGUE BETWEEN PATIENT FAMILIES AND ETCH'S TRAINED PATIENT ACCOUNT REPRESENTATIVES. ETCH MAKES EXTENSIVE EFFORTS TO PERMIT FACE-TO-FACE DIALOGUE, AS WELL AS COMMUNICATION VIA TELEPHONE AND OTHER MEANS, AS NECESSARY TO ENSURE THAT FAMILIES ARE PROVIDED WITH SUFFICIENT INFORMATION REGARDING FREE OR DISCOUNTED CARE, AS WELL AS THE BILLING AND COLLECTION PROCESS. ALL STAFF WITH PATIENT CONTACT ARE KNOWLEDGEABLE ABOUT THE CHARITY CARE POLICY (ADMITTING AND BILLING CLERKS, NURSING AND MEDICAL STAFF, SOCIAL WORKERS, ETC.).

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ALTHOUGH ETCH SERVES THE ENTIRE EAST TENNESSEE REGION AS A COMPREHENSIVE REGIONAL PEDIATRIC CENTER, NEARLY HALF OF ETCH'S TOTAL PATIENT VISITS ARE FROM KNOX COUNTY RESIDENTS. CHILDREN RESIDING IN NEIGHBORING BLOUNT AND SEVIER COUNTIES GENERATE THE NEXT HIGHEST PATIENT VISITS.THERE ARE SIGNIFICANT DISPARITIES IN SOCIOECONOMIC CONDITIONS BETWEEN THE 16 COUNTIES SERVED BY EAST TENNESSEE CHILDREN'S HOSPITAL. THE RATE OF CHILDREN LIVING IN POVERTY IS EQUIVALENT OR EXCEEDS 25% OF THE CHILDHOOD POPULATION IN 10 OF THE 16 COUNTIES. THE PERCENTAGE OF CHILDREN WHO ARE PARTICIPATING IN FREE OR REDUCED LUNCH PROGRAMS AT SCHOOL APPROACHES 50% FOR ALL COUNTIES AND EXCEEDS 70% IN FOUR COUNTIES. POVERTY AND FOOD INSECURITY ARE GROWING CONCERNS BECAUSE OF THE LINKAGES BETWEEN THESE SOCIAL DETERMINANTS AND POOR HEALTH OUTCOMES.

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ETCH'S PHILOSOPHY IS THAT, BECAUSE CHILDREN ARE SPECIAL, THEY DESERVE THE BEST POSSIBLE HEALTH CARE GIVEN IN A POSITIVE, CHILD/FAMILY CENTERED ATMOSPHERE OF FRIENDLINESS AND COOPERATION REGARDLESS OF RACE, RELIGION, OR ABILITY TO PAY. ETCH IS COMMITTED TO CARING FOR VULNERABLE POPULATIONS SUCH AS CHILDREN WITH SPECIAL MEDICAL NEEDS, ADVOCATING FOR THE HEALTH AND SAFETY OF CHILDREN AS PART OF THE COMMON GOOD AND EFFECTIVELY STEWARDING COMMUNITY RESOURCES. ETCH OPERATES AN EMERGENCY ROOM OPEN TO ALL PERSONS, WITHOUT REGARD TO THE ABILITY TO PAY. ETCH USES ANY SURPLUS FUNDS TO IMPROVE THE QUALITY OF PATIENT CARE, EXPAND, OR IMPROVE ITS FACILITIES, AND ADVANCE ITS MEDICAL TRAINING, EDUCATION AND RESEARCH PROGRAMS. ETCH'S BOARD OF DIRECTORS CONSISTS PRIMARILY OF INDIVIDUALS REPRESENTING THE COMMUNITY. ETCH MAINTAINS AN OPEN MEDICAL STAFF, WITH MEMBERSHIP AND PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS AND HEALTH CARE PROFESSIONALS. IN THESE AND OTHER RESPECTS, ETCH IS ORGANIZED AND OPERATED IN A MANNER THAT PROMOTES THE HEALTH OF THE COMMUNITY AND, THEREFORE, FULFILLS CHARITABLE PURPOSES WITHIN THE MEANING OF INTERNAL REVENUE CODE SECTION 501(C)(3).ADDITIONALLY, PLEASE REFER TO THE STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS AS PROVIDED IN SCHEDULE O FOR FURTHER DOCUMENTATION REGARDING ETCH'S COMMITMENT WITHIN ITS COMMUNITY.