4A (Expenses $ 849186841 including grants of $ 0) (Revenue $ 1016427812)
See Schedule O for Program Services Statement

Lakeland Regional Medical Center
Part V, Section B, Line 3j: Since our last Community Health Needs Assessment (2018-2021), so much in our community, state, and world has changed. Between the COVID-19 pandemic that changed the way we sought, delivered, and advanced healthcare to the unrest that followed incidents of social injustice, we learned to face extraordinary challenges in new ways with the constant goal of building a stronger, healthier tomorrow for every Polk County resident.Upon review of our County's current health data and as a result of the CHNA process, Lakeland Regional Health has identified the following areas of need:1. Cultural Competency2. Access to Quality, Coordinated Care3. Cancer Screening and Prevention4. Diabetes5. Heart Disease and Stroke6. Injury Prevention7. Mental Healthcare8. Obesity, Nutrition, and Physical ActivityIn response to the identified areas of need, the following initiatives and anticipated outcomes were established:1. CULTURAL COMPETENCEInitiatives and Actions: - Recruit and retain top diverse talent.- Develop an intentional curriculum for team members that works to enhance cultural competency and awareness.- Launch a Diversity Advisory Council that works to advance commitment to eliminating bias, advocates for the underserved, and establishes processes and procedures to reinforce cultural competency in patient care.- Further develop community partnerships that work to foster health equity and improve pathways to care.Anticipated Impact:- Greater understanding of health equity in our community.- Creation of an environment where all people feel a sense of belonging, are valued and respected, and have access to the same opportunities.2. ACCESS TO QUALITY, COORDINATED CAREInitiatives and Actions:- Increase capacity by attracting and retaining diverse, adaptable and highly qualified providers and team members.- Establish a Graduate Medical Education program that will foster health and healing, engage a diverse community and work collaboratively for positive medical and social transformation.- Establish new locations and optimize existing sites of service to provide clinical services in convenient, easily accessible locations.- Collaborate with local, regional and national partner organizations and affiliates to continue to expand and strengthen healthcare services to provide convenient access and highest quality outcomes.- Engage community members in education regarding their access to primary care.Anticipated Impact:- Care that is convenient as well as culturally sensitive and appropriate.- Increased patient satisfaction.- Reduction of barriers that impact a patient's ability to achieve health and wellbeing.- Increased compliance with preventive care recommendations (screenings, immunizations, lifestyle changes).- Reduction in the percentage of community members who delay obtaining needed medical care.3. CANCER SCREENING AND PREVENTIONInitiatives and Actions:- Engage with community partners to improve cancer screening rates in order to facilitate early detection of cancer.- Empower community members to engage in cancer prevention and early detection through use of cancer screenings. - Provide resources for community providers and community members experiencing cancer-related illness.- Increase education outreach opportunities through programs such as ShopTalk and the Congregational Health Partnership program. - Increase participation in the tobacco cessation program held in collaboration with Tobacco Free Florida. The program encourages participants to work on the process and problems of quitting, both individually and as part of a group.- Increase the number of adolescents aged 9-14 years who are up to date with the HPV vaccine series. (In partnership with the American Cancer Society, Florida Department of Health in Polk, Central Florida Healthcare).Anticipated Impact:- Increased compliance with preventive care recommendations (screenings and lifestyle changes).- Decreased cancer incidence and/or rate of late-stage cancer diagnoses.- Increased public awareness of cancer prevention strategies.- Increased focus on barriers that prevent timely and equitable cancer prevention, early detection, and treatment.4. DIABETESInitiatives and Actions:- Increase knowledge of and access to diabetes education programs.- Increase access to the Diabetes Prevention Program (DPP) for high-risk community members.- Provide education outreach opportunities through programs such as ShopTalk and the Congregational Health Partnership Program.- Continue to offer glucose screenings throughout the community and provide education about diabetes, pre-diabetes, risk factors, and early intervention.- Explore ways to assist providers and team members in providing culturally appropriate education to diabetic patients.Anticipated Impact:- Increased knowledge of available resources.- Increased referrals to diabetes education classes and to the Diabetes Prevention Program (DPP).- Decrease new incidences of diabetes.- Reduction in hospitalization rates due to diabetes.5. HEART DISEASE AND STROKEInitiatives and Actions:- Provide health education through community health events and in the media to encourage healthy behaviors and recognition of signs and symptoms of heart disease and stroke.- Continue to provide blood pressure screenings at community events and in faith-based organizations through the Congregational Health Partnership program.- Increase the number of community residents who know how to perform CPR and use an automated external defibrillator or AED.- Provide support programs and education on cardiovascular health, stroke prevention and recovery.- Increase knowledge and awareness of self-monitoring practices and signs/symptoms.- Reduced mortality rates for cardiovascular disease.Anticipated Impact:- Increased knowledge and awareness of self-monitoring practices and signs/symptoms.- Reduced mortality rates for cardiovascular disease.6. INJURY PREVENTIONInitiatives and Actions:- Continue to participate in the Coalition on Injury Prevention. The Coalition provides injury prevention education and activities by leveraging partnerships, community effort, support networks and community events.- Increase the use of safety equipment and knowledge of preventing childhood injuries (i.e. helmet safety, car seat safety,drowning prevention) across the county.- Continue to provide Stop the Bleed education to community residents.- Provide resources for community providers and members experiencing cancer-related illness, asthma and diabetes.Anticipated Impact:- Increased awareness and knowledge of injury prevention activities.- Increased participation in education/prevention programs.7. MENTAL HEALTHCAREInitiatives and Actions: - Construct the new Center for Behavioral Health and Wellness by 2022.- Increase integration of physical and behavioral health services through streamlined access to behavioral health resources across organization service lines including primary care.- Reduce deaths by suicide by increasing ability for patients to get care before it reaches crisis in addition to education and advocacy in the community.- Coordinate and work collaboratively with community stakeholders to expand access to a continuum of behavioral health services.- Conduct community-wide awareness campaigns aimed at reducing stigma and enhancing access to community education programs.Anticipated Impact:- Increased capacity for inpatient services.- Creation of new and expanded outpatient services that support a more comprehensive care continuum.- Increased awareness of the treatment of mental health.- Improved coordination among healthcare providers, community resources and programs.- Reduction in the percentage of residents who delay obtaining needed behavioral health and substance abuse intervention and care.- Reduction in stigma surrounding mental illness.OBESITYInitiatives and Actions:- Create innovative prevention and wellness initiatives and outreach efforts to improve overall population health status in our community.- Promote weight management programs and services.- Partner with community organizations and surrounding neighborhoods to implement impactful community education that increases knowledge and skills that promote healthy lifestyles for community residents.- Reduce cancer risk and increase support for cancer survivors by providing free and low-cost physical activity opportunities that allow participants to maintain a healthy weight, eat a healthy diet, and be physically active.- Continue to implement the Congregational Health Partnership program and annual FitChurch Challenge program (with the addition of FitKids curriculum).- Develop interactive childhood obesity education that promotes healthy nutrition, increased physical activity, and decreased screen time.

Lakeland Regional Medical Center
Part V, Section B, Line 5: The health of Polk County residents is influenced by many factors. In order to gain a broad perspective of these factors, the potential barriers they may create and to determine the priorities for the 2022-2025 Community Health Needs Assessment, Lakeland Regional Health and AdventHealth utilized a process that included the review of existing secondary data and collection of primary data through a number of focus groups. During focus groups and a community dialogue session, we looked to our community residents and partners to represent their respective communities and provide feedback on how health systems could most effectively address specific areas of need.The assessment was performed by reviewing data from sources including:1. United States Census Bureau2. Centers for Disease Control and Prevention3. Florida Health Assessment Resource Tool Set (CHARTS)4. Florida Behavioral Risk Factor Surveillance System (BRFSS)5. Community Commons6. Robert Wood Johnson Foundation County Health RankingsOver 900 community members participated in the 2022-2025 Community Health Needs Assessment survey. The survey was available both online and in hard copy in the following languages: English, Spanish and Creole. The survey opened on March 17, 2021, and closed on June 30, 2021.

Part V, Section B, Line 22b:
To be eligible for a 100% Financial Assistance Adjustment (i.e., full write-off), the patient's Household Income must be less than or equal to 200% of the current FPG (adjusted for family size). If the patient's Household Income is greater than 200% and less than or equal to 400% of the current FPG (adjusted for family size), the patient will receive a Financial Assistance Adjustment that is based upon LRMC's Amounts Generally Billed (AGB) percentage. By January 28th of each year, the AGB percentage will calculated by dividing the sum of allowed amounts for claims for services allowed by Medicare Fee-For-Service and all private health insurers during the prior twelve-month period ended September 30 by the gross charges for such claims. No individual eligible under this Financial Assistance Policy will be given a Financial Assistance Adjustment which is less than amount calculated using the AGB percentage. The AGB percentage in effect is 20%, thus the Financial Assistance Adjustment based on the AGB percentage is 80%. In all situations described in this paragraph, the Financial Assistance Adjustment will be applied to the outstanding balance of an account after payments by third parties, if any.The Financial Assistance Adjustment based on the AGB percentage will also be applied to the outstanding balance, after payments by insurance, if any, of patients with Catastrophic Medical Expenses, as defined above, who are not eligible for financial assistance based on the other provisions of this policy. Uninsured patients of LRMC who are not eligible for financial assistance based on the other provisions of the policy will also receive an Uninsured Discount based on the AGB percentage.

Part I, Line 7:
Lakeland Regional Medical Center determines the cost of charity by calculating a ratio of cost to charges as derived from the Medicare Cost Report and then multiplying that ratio by the gross uncompensated charges associated with providing care to charity patients. Similarly, the cost of subsidized health services is based on the unreimbursed cost of caring for the patients' services less the cost associated with Bad Debt, Charity, Medicaid and other means-tested government programs. The actual expenses paid for providing community health improvements and community benefits operations less any payments received for those activities is reflected above.

Part I, Line 7g:
Subsidized health services are clinical services that are essential to meet the health care needs of the entire community and are provided with a financial loss to Lakeland Regional Medical Center (LRMC). The financial loss is measured after removing losses associated with Bad Debt, Charity, Medicaid and other means-tested government programs. LRMC operates one of the busiest Emergency Departments in the nation with over 200,000 emergency visits each year prior to the COVID-19 pandemic. We treat all patients regardless of their ability to pay for the care they receive. In addition, we staff a Level II Trauma Center to provide critical care access to residents of Lakeland and surrounding communities. The cost of providing emergency and trauma care 24 hours each day exceeds the payments LRMC receives for providing that care. LRMC also operates the only inpatient Behavioral Health Unit in Lakeland to provide care for the mentally ill population who have nowhere else to go for essential inpatient psychiatric care.

Part I, Ln 7 Col(f):
There is $70,550,427 of bad debt expense which is included in Form 990, Part IX, Line 24(b). This amount was removed in the calculation of the Percent of Total Expense on Schedule H Line 7f.

Part II, Community Building Activities:
Lakeland Regional Medical Center is the only hospital in Lakeland and serves as a tertiary referral hospital serving the broader Polk County, Florida. As the only state-designated trauma center for Polk, Highlands, and Hardee counties, we provide critical access and care to the area's most seriously injured residents. A shortage of primary care physicians and mental health services has resulted in our ER becoming the highest volume ER in the nation, offering essential medical care to many underserved residents in our community.Ongoing education programs for diabetes and cardiac rehab are designed to help patients with chronic conditions maintain their health and avoid repeated hospitalizations. Support groups assist those living with chronic and life-threatening illnesses to access resources and critical peer support. Education and screening programs have identified those at risk of various conditions, allowing them to seek treatment. Participation in and support of community events helps to ensure a vibrant community and a positive quality of life for our employees as well as our patient-base.

Part III, Line 2:
"LRMC follows the guidance provided in the Healthcare Financial Management Association Principles and Practices Board ""Statement 15: Valuation and Financial Statement Presentation of Charity Care and Bad Debts by Institutional Healthcare Providers"" in determining bad debt expenses. Bad debt expense results when a patient who does not meet the criteria for Charity Care and who has been determined to have the financial capacity to pay for healthcare services and is unwilling to settle the claim. The hospital utilizes an overall ratio of cost to charges from the applicable Medicare cost report and this is applied to the bad debt expense."

Part III, Line 4:
The consolidated, audited financial statements of Lakeland Regional Health Systems, Inc. and Subsidiaries are attached to this return and contain language addressing Bad Debts on pages 9 thru 11.

Part III, Line 8:
Medicare allowable costs are determined using the approved standardized Medicare Cost Report methodology. The Medicare cost is derived using the Medicare Cost-to-Charge ratio from the Medicare cost report times the Medicare charges for service.

Part III, Line 9b:
LRH will not engage in the following collection activities for any patients (even if they do not qualify for financial assistance): - Place a lien on an individual's property- Foreclose on an individual's real property- Attach or seize an individual's bank account or any other personal property- Commence a civil action against an individual- Cause an individual's arrest- Cause an individual to be subject to a writ of body attachment- Garnish an individual's wages- Demand payment for a prior bill as condition of receiving future services at LRMC. This prohibition does not apply to office-based services provided by LRHS.LRMC or its representatives (i.e., a collection agency) may report a patient to a credit bureau if the patient has received a written notice (and an attempt has been made to provide oral notification) specifying the date, which shall be not less than 30 days after the date of the notice, after which credit bureau reporting may occur. Credit Bureau reporting may not occur earlier than 240 days after the date the patient received the first billing statement for the care provided. These limitations do not apply to LRHS.

Part VI, Line 2:
Lakeland Regional Medical Center collaborates with medical staff, community leaders and the Polk County Health Department to determine the health needs of the citizens of Lakeland and Polk County, Florida. LRMC sponsors various Medical Staff Committees where community health needs are frequently discussed. Our senior management and staff identify unmet community health needs through participation in community coalitions, partnerships, boards, committees, and advisory groups. Using available data on the demographics and service utilization for our primary and secondary markets, the LRMC executive team and Board develop a comprehensive annual Strategic Plan to address the healthcare needs of the community. For the 2022-2025 CHNA, stakeholders representing broad interests of the community served by Lakeland Regional Health attended a dialogue session to discuss the overall health of the community, available health services, in addition to opportunities to bridge gaps and access to current services. Following the community dialogue session, the data review process involved the formal prioritization method known as the Prioritization Matrix, which included ranking health priorities based on the six primary criteria: alignment with the health system's mission; existing programs; ability to impact within three years; financial resources required; human resources required and the availability of measurable outcomes to assess effectiveness of the intervention/plan.In 2012, LRMC opened a primary health clinic to provide a medical home for the uninsured and underinsured population. This clinic is designed to both improve the quality of care for low income patients and also reduce visits to the emergency room. In the fall of 2012 and continuing through 2015, LRMC partnered with the Polk County Health Department, Peace River Center and the Polk Healthcare Plan as part of the state Low Income Pool for primary care to offer a patient-centered, primary care integrated medical home within the I-4 corridor of Polk County. Beginning in 2016 and through 2018, LRMC continued its partnership with the Polk HealthcarePlan and Peace River to provide primary care and mental health screenings to the indigent population of Polk County and members of the Polk Healthcare Plan which was partially subsidized by a grant funded by Polk County. In 2020, the Family Health Center had 7,061 visits in which patients and their families were able to receive primary care.

Part VI, Line 3:
For scheduled admissions, LRMC conducts a pre-admission interview to discuss the financial plan with the patient, the guarantor, and/or his or her legal representative. If a pre-admission interview is not possible, this interview is conducted upon admission. In the case of an emergency admission, LRMC's evaluation of payment alternatives does not take place until the required stabilizing medical care has been provided. Identification of patients eligible for assistance can take place at any time during the rendition of services or during the patient account collection process (including bad debt).Those patients who may qualify for financial assistance from a government program are referred to the appropriate program, such as Medicaid or the Polk Healthcare Plan. LRMC provides on-site access to Medicaid eligibility specialists to assist patients in qualifying for governmental medical assistance programs. All patients identified as potential financial assistance recipients are offered the opportunity to apply for financial assistance. If this evaluation is not conducted until after the patient leaves, or in the case of outpatients or emergency patients, an LRMC representative mails a financial assistance application to the patient. For the first 120 days after the date of service, the hospital will notify an individual about the Financial Assistance Policy. The patient will receive at least three billing statements that include language about applying for financial assistance. The hospital will accept and process any financial assistance applications submitted by an individual for up to 240 days after the patient received the first billing statement for the care.

Part VI, Line 4:
The Lakeland Urban Area is considered the primary service area and the remainder of Polk County is considered the secondary/extended service area. Polk County has a population of over 742,777 with 20.4% of residents being over the age of 65 and 14.4% of residents living below the Federal Poverty Level. Children under 18 years of age make up 22% of the population. Located between Orange and Hillsborough Counties, it is the fourth (4th) largest county in Florida consisting of 1,797.84 square miles. Lakeland is the largest city in Polk County and is located between Tampa and Orlando on Interstate 4. The unemployment rate for Polk County was 3.3% as of November 2019. Census data reflects a population that is 24.6% Hispanic or Latino, 16.2% Black and under 5% from other minorities.

Part VI, Line 5:
Lakeland Regional Medical Center's senior management, directors, managers, physicians and staff provide leadership and resources to equip local organizations with the skills needed to create a healthy community. Our staff participates on boards, advisory committees, and coalitions benefiting the community we serve without compensation for their time. Our leaders and physicians participate in educational programs, workshops and health fair events that are provided free to members of the community. We provide cancer screening services to the community for early detection of breast, skin and colon cancers. We participate and provide support for educational programs for healthcare workers in partnership with local colleges, universities and trade schools. Lakeland Regional Medical Center has a vibrant volunteer program, offering varied opportunities for service to the members of the community. The medical staff of Lakeland Regional Medical Center consists of over 600 physicians and is organized to promote the public interest of healthcare. No part of the income of LRMC inures to the benefit of any private individual, nor is any private interest being served. All surplus funds are reinvested into the facilities, equipment, programs and resources needed to continually improve the quality of patient care, expand our outreach, and advance the medical training and education of our staff. As noted above, the primary health clinic opened in 2012, and the Low Income Pool partnership clinic with Polk County located on the I-4 corridor are excellent examples of LRH's commitment to community health promotion.

Part VI, Line 6:
Lakeland Regional Medical Center is a subsidiary of Lakeland Regional Health Systems, Inc., a not-for-profit system that reinvests its profits back into the community through programs that benefit the residents of Lakeland and Polk County, Florida. The Health System facilities are leased from the City of Lakeland and the operations of the Hospital and Health System directly benefit the citizens of the community.Under the terms of the Agreement prior to fiscal year 2016, annual rent of $1.00 per operating year plus additional payments were made to the City of Lakeland (the City) based on a formula, which took into consideration the net revenues of the Medical Center, and net income of certain affiliated organizations, as defined in the Agreement.An amendment to the Agreement was reached and became effective October 1, 2015. The amendment provided a lump sum payment of $15,000,000 to the City on October 1, 2015, with fixed annual additional payments due beginning in fiscal year ending September 30, 2016 through fiscal year ending September 30, 2040. The additional payment for fiscal year ending September 30, 2021 was $14,379,000 with future scheduled payments per operating year through the duration of the Agreement ranging from $14,379,000 in fiscal year 2022 to $22,194,000 in fiscal year 2040 totaling approximately $335,100,000.In March 2021, the Agreement was amended whereby the Medical Center provided the City a $215,000,000 lump sum payment in lieu of the aforementioned remaining lease payments under the Agreement scheduled for fiscal years 2022 through 2040. In addition to the lump sum payment, the lease was extended in perpetuity with annual payments beginning in fiscal year 2041 and beyond at $10.00 per year. The $215,000,000 million lump sum payment was funded in part with proceeds from the Series 2021 Bonds. As part of the amendment, the Medical Center's total consideration of $235,000,000, inclusive of additional payments made to the City during 2021 and throughout the Agreement was recorded as property and equipment in the accompanying consolidated balance sheet as a land purchase due to the right to control the use on the property in perpetuity.In addition, the Health System provides for the health of the community by directly employing physicians in underserved medical specialties, such as orthopedics, trauma surgery, oncology and behavioral health. The Health System's medical clinics provide access to all residents, regardless of income, and many operate at a loss. Despite this, LRH believes that the role these clinics provide in the community, and in the promotion and maintenance of health, is part of our mission and our significant contribution to the community.