Becoming an accountable care organization (ACO) requires serious consideration of the impact it can have on a company’s operations. See which issues overlap in the for-profit and not-for-profit sectors.

1. 22nd Annual Health Sciences
Tax Conference
When for-profit and not-for-profit worlds collide
December 4, 2012

2. Disclaimer
► Any US tax advice contained herein was not intended or
written to be used, and cannot be used, for the purpose of
avoiding penalties that may be imposed under the Internal
Revenue Code or applicable state or local tax law
provisions.
Page 2 When for-profit and not-for-profit worlds collide

3. Disclaimer
Ernst & Young refers to the global organization of member firms of Ernst & Young
Global Limited, each of which is a separate legal entity. Ernst & Young LLP is a client-
serving member firm of Ernst & Young Global Limited operating in the US. For more
information about our organization, please visit www.ey.com.
This presentation is © 2012 Ernst & Young LLP. All rights reserved. No part of this
document may be reproduced, transmitted or otherwise distributed in any form or by
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transmission or distribution of this form or any of the material herein is prohibited and
is in violation of US and international law. Ernst & Young LLP expressly disclaims any
liability in connection with use of this presentation or its contents by any third party.
Views expressed in this presentation are not necessarily those of Ernst & Young LLP.
Page 3 When for-profit and not-for-profit worlds collide

4. Presenters
► Donna Borgese ► Jim Steen
UPMC Health System Ernst & Young LLP
Pittsburgh, PA Pittsburgh, PA
+1 412 644 7850
► Mark Rountree james.steen@ey.com
Ernst & Young LLP
Dallas, TX ► David Miller
+1 214 969 8607 Ernst & Young LLP
mark.rountree@ey.com Dallas, TX
+1 214 969 0636
► Chris Monte david.miller@ey.com
LifePoint Hospitals
Nashville, TN
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5. Agenda
► Current IRS perspective regarding for-profit/tax-exempt
joint ventures
► Practical considerations from the for-profit perspective
► Practical considerations from the tax-exempt perspective
► Partnership technical considerations and pitfalls
► Q&A
Page 5 When for-profit and not-for-profit worlds collide

6. Mark Rountree, Ernst & Young LLP, Dallas, TX
Current IRS perspective regarding
for-profit/tax-exempt joint ventures

7. Current IRS perspective regarding for-profit/
tax-exempt joint ventures
► Relevant authority
► In general
► Accountable care organizations
► Pending cases and rulings
► Current IRS perspective
► Ruling posture
► Audit activity
► Proceed with caution ... but proceed
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8. Chris Monte, LifePoint Hospitals, Nashville, TN
PRACTICAL CONSIDERATIONS
FROM THE FOR-PROFIT
PERSPECTIVE

9. Practical considerations from the for-profit
perspective
► Indirect tax implications for joint venture entity
► Sales tax
► Property tax
► Valuation of asset considerations
► Controversy activity
► Information reporting considerations for exempt partner
► For 990 reporting (e.g., Part VI, Schedules H and R)
► For UBI purposes
► For exempt bond/private use purposes
► Information gathering and tracking considerations
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10. Practical considerations from the for-profit
perspective (cont.)
► “Managing the tension”
► Protect tax-exempt status of exempt partner
► Preserve consolidated financial reporting and other preferred
methods
► Process considerations for resolving “tension” matters
► Issues for ventures with health plans
► Section 162(m)(6)
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11. Donna Borgese, UPMC Health System, Pittsburgh, PA
Jim Steen, Ernst & Young LLP, Pittsburgh, PA
PRACTICAL CONSIDERATIONS
FROM THE TAX-EXEMPT
PERSPECTIVE

12. Practical considerations from the
tax-exempt perspective
► Allocation and valuation of costs and charges
► Issues unique to internal allocations
► Issues unique to external allocations
► Educating internal and external parties regarding valuation issues
and requirements of tax-exempt partner
► Transfer pricing
► Regulatory criteria and methodology
► When to apply transfer pricing valuations
► Documentation and process considerations
► Pitfalls
► IRS audit experience
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13. Practical considerations from the
tax-exempt perspective (cont.)
► Choice of entity and structuring considerations
► Dynamic environment results in numerous forms and structures
► No “one size fits all” structure in light of market pressures,
competing priorities of partners and need for creativity and
innovation
► Key non-tax considerations:
► Respective contributions of venture partners
► Optimizing economies of scale
► Optimizing leverage of partner resources and expertise
► Ongoing flexibility and adaptability of structure
► Exit strategy considerations
► Ongoing 990 reporting implications for exempt partner
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14. David Miller, Ernst & Young LLP, Dallas, TX
Partnership technical considerations
and pitfalls

15. Partnership technical considerations
and pitfalls
► Disguised sale implications upon formation of venture
► Section 704(c) considerations
► At formation
► Ongoing
► Section 168(h)(6)
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16. Disguised sales – basic rules
► General rules
► The transfer of property to a partnership in exchange for an interest
therein is not taxable to the contributing partner or the partnership.
► The distribution of money from a partnership to a partner is not taxable
to the extent of the partner’s basis in its partnership interest.
► Exception – disguised sale rule
► Transfer of property from a partner to a partnership is presumed to be
a sale of the property to the extent partnership makes a distribution
(whether actual or “deemed”) to partner within two years.
► A reduction in a contributing partner’s share of a “nonqualified” liability
is treated as a distribution of money and, as a result, part of a
disguised sale.
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17. Disguised sale of property
Disguised sale
Third 1. Target transfers Target
Target assets to JV for cash
party
and units.
2. Transaction is treated
as if Target sold 80%
of the Target assets
FMV $1B $200m units
AB $0 $800m cash
(and Target will
recognize 80% of its
gain in the property).
JV
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18. Impact of liabilities
► A reduction in a partner’s share of a nonqualified liability is treated as
a distribution of money.
► Nonqualified liabilities
► All liabilities other than qualified liabilities
► Qualified liabilities
► A liability is a qualified liability if, and only if:
► It was incurred more than two years prior to the contribution or was not incurred
in anticipation of the transfer and has been secured by the property during
those two years.
► It was incurred to acquire the property being contributed.
► It was incurred in the ordinary course of the trade or business and all assets
associated with the business are being transferred.
► If the transferor receives any consideration in the transfer other than
equity and the assumption of qualified liabilities, a portion of the qualified
liability will be reclassified as a nonqualified liability.
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19. Disguised sale planning — basic strategies
► Goal: front load basis recovery
► Deferral only
► Strategies
► Assumption of qualified liabilities
► Reimbursement of capital expenditures
► Mixing and matching disguised sale exceptions
► Debt financed distribution rule
► Avoiding distributions through borrowings
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20. Disguised sale reporting obligations
► Taxpayers must disclose:
► Any distribution within two years of a property contribution that the
parties do not treat as part of a disguised sale
► Exceptions for certain preferred returns, guaranteed payments and
operating cash flow distributions
► Any liability treated as a qualified liability under the “not in
anticipation” rule
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21. Section 704(c) — contributions of built-in
gain or built-in loss property
► General rules
► Built-in gain (BIG) and built-in loss (BIL)
► Difference between Section 704(b) book basis (FMV) and tax basis of
property at contribution date
► Partnership must allocate tax items of income, gain, loss or deduction
related to built-in gain or loss to the contributing partner
► Affects only tax basis, not book basis
► Applied on a property-by-property basis
► De minimis rule applies for small disparities between FMV
and basis
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22. Section 704(c) — impact of the method
chosen
► Method more important if property’s depreciable tax basis
is less than noncontributing partner’s aggregate share of
book value (i.e., ceiling rule)
► Method affects taxable income — negotiate method
up front
► If parties are in different tax positions, choice of method
may result in aggregate tax savings to parties (that may
be shared subject to anti-abuse rule)
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23. Section 704(c) allocation methods
► Treas. Reg. §1.704-3 — specified methods
► Traditional allocation method
► Traditional method with curative allocations
► Remedial allocation method
► Different methods may be used for each property, but the
method or combination of methods must be reasonable.
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24. Traditional allocation method — example
with ceiling rule limitation
► Assume A and B form a partnership with each owning a
50% interest
► A contributes depreciable property with a tax basis of $3,000 and
FMV of $10,000, and B contributes $10,000 of cash
► The property has a remaining depreciation period of 10 years and
the property is depreciated on a straight-line basis
► Step 1 – calculate and allocate annual book depreciation –
$500 ($10,000/10 years = $1,000 shared 50%/50%)
► Step 2 – calculate annual tax depreciation – $300
($3,000/10 years) and allocate all available tax depreciation
from the Section 704(c) property to the non-contributor (B)
to the extent of its book depreciation – $300
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25. Traditional allocation method — example
with ceiling rule limitation (cont.)
► Step 3 – allocate the remaining tax depreciation to the
contributor – $0
► Note: In this example, B is allocated $500 of book
depreciation and only receives $300 of tax depreciation.
This problem is known as the “ceiling rule” and causes B
to bear the burden of the built-in gain in the section 704(c)
property.
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26. Section 704(c) alternative methods
► Traditional method with curatives
► Attempts to correct distortions created by the ceiling rule by allocating other
partnership tax items of income, gain, deduction or loss to the noncontributing
partner
► Must be of the same character (i.e., same tax attributes)
► Remedial method
► Corrects distortions created by the ceiling rule by allocating notional items of
expense to the non-contributing partner and income to the contributing partner
► Book basis of asset is split into two components
► Amount of book basis equal to tax basis is recovered over remaining tax
recovery period
► Excess of book basis over tax basis is treated as new asset and depreciated
over applicable tax recovery period
► Has the effect of lengthening the recovery period as compared to curative or
traditional method
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27. Section 704(c) — other items to consider
► Anti-abuse rule if partners have different tax profiles –
impact on joint ventures with tax-exempt partners
► “Reverse” Section 704(c) items
► “Opposite sign” layers (arises in the case of multiple
revaluations where the property has fluctuated in value)
► Netting approach
► Layering approach
► Applying Section 704(c) when the contributed property is
an interest in a lower-tier partnership
► Section 704(c)(1)(C) trap
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28. Section 168(h)(6)
► General rule
► Implications for depreciation method
► Implications for recovery period
► Implications for joint ventures, including tax-exempt
partners
► Qualified allocations
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29. Q&A