2018-11-12T11:33:04-06:00 2017-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-01-01 396089134 THEDACARE MEDICAL CENTER - WILD ROSE INC THED 9206223257 PO BOX 243 WILD ROSE WI 549840243 MARK THOMPSON CFO & COO 9206223257 2018-10-22 1 TERRI REXRODE CPA MST P00096513 9206620016 2018-10-22 74.87.127.216 2018-10-22 15:13:18 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2017 2019-02-21 02:37:17Z MARK THOMPSON PO BOX 243 WILD ROSE WI 549840243 7737855 0 X WWW.THEDACARE.ORG X 1956 WI IMPROVING THE HEALTH OF OUR COMMUNITY. 12 9 0 50 0 0 10649 85 13776455 7737770 -273 0 0 0 13786831 7737855 93150 0 0 0 7713132 6706154 0 0 0 4025018 3714817 11831300 10420971 1955531 -2683116 4318037 5036987 2396662 5798728 1921375 -761741 X TO PROVIDE THE HIGHEST QUALITY HEALTH CARE, DELIVERED IN THE MOST EFFICIENT AND COST-EFFECTIVE WAYS, AND ACCESSIBLE TO ALL MEMBERS OF THE COMMUNITY. 0 0 9405755 0 7737770 THEDACARE IS A TAX-EXEMPT, NON-PROFIT CORPORATION, AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE.THEDACARE MEDICAL CENTER-WILD ROSE IS A 25-BED CRITICAL ACCESS HOSPITAL SERVING WILD ROSE AND NEARBY COMMUNITIES. THEDACARE REGIONAL MEDICAL CENTER- WILD ROSE PROVIDES PATIENT CARE AND SUPPORT SERVICES INCLUDING DIAGNOSTIC SERVICES SUCH AS X-RAY, ULTRASOUND, MRI, CT SCAN, MAMMOGRAPHY AND MEDICAL LABORATORY TESTING AND SPECIALTY SERVICES SUCH AS CANCER CARE, CARDIOVASCULAR CARE, ORTHOPEDIC CARE, SPINE, NEUROLOGY, FAMILY BIRTH CARE, INTERNAL MEDICINE, EMERGENCY, OCCUPATIONAL HEALTH, PULMONOLOGY, UROLOGY, WOMEN'S CARE, OUTPATIENT SURGERY, AND THERAPY SERVICES.NEARLY 4,900 UNIQUE PATIENTS ACCOUNT FOR MORE THAN 13,700 VISITS ANNUALLY.WITH CORPORATE PARENT THEDACARE, INC. WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. THEDACARE IS COMMITTED TO COMMUNITY FOCUSED EFFORTS IDENTIFIED IN THE COMMUNITY NEEDS HEALTH ASSESSMENT IN COUNTIES (WAUSHARA) WHERE SERVICES ARE PROVIDED. EFFORTS INCLUDE PARTNERSHIPS WITH WAUSHARA COUNTY EMS SERVICES, WILD ROSE AND WAUTOMA SCHOOL DISTRICTS, FOX VALLEY TECHNICAL COLLEGE WAUTOMA, WAUSHARA COUNTY PUBLIC HEALTH. THE TOP PRIORITY IS MENTAL HEALTH AND WORKING ON A MENTORING PROJECT WHICH INVOLVES TARGETING K THROUGH 5TH GRADERS WITH SENIOR MENTORS/PARTNERS. NEXT UP WILL BE WORK ON ALCOHOL RELATED ISSUES.THEDACARE OPERATES ON A NON-DISCRIMINATORY BASIS REGARDLESS OF RACE, COLOR, SEX, RELIGION, OR NATIONAL ORIGIN. THEDACARE PROVIDES A VARIETY OF FINANCIAL ASSISTANCE OPTIONS TO PATIENTS WHO MEET ESTABLISHED CRITERIA. SERVICES ARE ALSO PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES.HOSPITAL INPATIENT DAYS TOTALED 1,889. THE COST OF UNCOMPENSATED MEDICAID FOR 2017 WAS APPROXIMATELY $135,673. THE UNREIMBURSED COST OF MEDICARE WAS APPROXIMATELY $15,216. THE COST OF CHARITY CARE PROVIDED DURING 2017 WAS APPROXIMATELY $69,938. 9405755 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 WILLIAMS ROGER CHAIR 1.00 0.00 X X 0 0 0 STEA ALLEN VICE CHAIR 1.00 0.00 X X 0 0 0 WILLIAMS CAROL SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 BENDING TAMMY BOARD MEMBER/VP OF CAH OPERATIONS 1.00 41.00 X 0 181672 15555 BROTEN WILLIAM BOARD MEMBER 1.00 0.00 X 0 0 0 CAVES CHANDLER MD BOARD MEMBER/PHYSICIAN 41.00 0.00 X 419129 0 31429 ERDMAN JAMES BOARD MEMBER 1.00 0.00 X 0 0 0 KJENTVET MARK BOARD MEMBER 1.00 0.00 X 0 0 0 MCGOVERN JAMES MD BOARD MEMBER/PHYSICIAN 41.00 0.00 X 353615 0 29167 MIELKE DAN BOARD MEMBER 1.00 0.00 X 0 0 0 THURLEY DARLENE BOARD MEMBER 1.00 0.00 X 0 0 0 WEST KAREN BOARD MEMBER 1.00 0.00 X 0 0 0 KANTOS CRAIG FORMER BOARD MEMBER, CEO-WILD ROSE 1.00 40.00 X X 0 345309 32296 STAUDINGER MICHAEL MD FORMER BOARD MEMBER/PHYSICIAN 41.00 0.00 X 386646 0 31415 BURMEISTER BRIAN FORMER BOARD MEMBER/VP SR AMC & TC 5.00 37.00 X 43612 392507 30773 ANDRABI IMRAN MD PRESIDENT AND CEO - SYSTEM 4.00 39.00 X 61065 549582 14340 THOMPSON MARK CFO & COO - SYSTEM 4.00 36.00 X 26286 236565 4928 GRUNER DEAN FORMER PRESIDENT AND CEO 4.00 39.00 X 82012 738103 21472 OLSON TIM FORMER CFO - SYSTEM 4.00 36.00 X 72249 650240 31903 AUSLOOS JODI INTERIM CIO 4.00 36.00 X 27625 248619 26502 PISTONE MAUREEN VP SR HR SERVICES 4.00 36.00 X 42720 384476 30869 REED LAURA FORMER COO/CHIEF NURSING EXEC 4.00 37.00 X 27727 249541 22139 REDMAN-SCHELL JENNIFER VP SR PHYS, BEHAV, TRANS 2.00 39.00 X 18146 344777 38719 LONG GREGORY MD CMO 4.00 37.00 X 58979 530809 33161 MANN WILLIAM VP SR STRATEGY 4.00 36.00 X 47758 429825 18883 MATHESON JAMES FORMER VP SR STRATEGY 4.00 38.00 X 29418 264766 37890 VOSKUIL CHAD MD PHYSICIAN 40.00 0.00 X 295214 0 29674 1992201 5546791 481115 6 0 1 0 SHARED MEDICAL SERVICES 209 LIMESTONE PASS COTTAGE GROVE WI 53527 MEDICAL SERVICES 133010 1 85 85 OUTPATIENT REVENUE 621990 4523303 4523303 INPATIENT REVENUE 621990 3162312 3162312 CAFETERIA REVENUE 621990 31377 31377 ALL OTHER PROGRAM SERV 621990 20778 20778 7737770 7737855 7737770 0 0 X 1664272 1251401 412871 3560649 3377936 182713 134993 134993 1046049 898393 147656 300191 300191 1058683 802666 256017 1549 1549 92436 78396 14040 308775 306856 1919 26014 26014 27120 27120 675 675 682444 682444 50605 50605 CLIENT/PATIENT SERVICE 918455 918455 BAD DEBT EXPENSE 548061 548061 10420971 9405755 1015216 0 157252 996377 1895572 242576 142103 7346181 4346869 2921832 2999312 4318037 5036987 2396662 5798728 2396662 5798728 X 1921375 -761741 1921375 -761741 4318037 5036987 -2683116 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 1499 1499 0 PART II-B, LINE 1: A PORTION OF THE WHA DUES REPRESENT LOBBYING PERFORMED IN REGARD TO HEALTHCARE ISSUES. THE AMOUNT FOR 2017 WAS $6,524 X 22.98% = $1,499. 167668 167668 2489910 1290469 1199441 44199 38048 6151 4644404 3018352 1626052 2999312 DUE TO AFFILIATES 5798728 5798728 1 1 X 1 X 1 X 1 0 1 1 87 69938 69938 0.00710 2251 1518098 1382425 135673 0.01370 2338 1588036 1382425 205611 0.02080 21 77696 210060 210060 0.02130 2 5524 154055 154055 0.01560 1 4003 1928416 1928416 0.19530 3 54873 215360 215360 0.02180 27 142096 2507891 2507891 0.25400 27 144434 4095927 1382425 2713502 0.27480 1 24723 817 817 0.00010 1 121 6172 6172 0.00060 1 8 65 65 0.00000 3 24852 7054 7054 0.00070 0 289775 72223 2807458 2822674 -15216 X 1 1 1 1 THEDACARE MEDICAL CENTER - WILD ROSE INC 601 GROVE AVE WILD ROSE WI 54984 HTTPS://WWW.THEDACARE.ORG 1004 X X X X THEDACARE MEDICAL CENTER - WILD ROSE 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X SEE 7D X X 1 16 1 SEE 7D 0 1 X 200.000000000000 350.000000000000 X X X X 1 1 X X X X X 1 X HTTPS://WWW.THEDACARE.ORG/POLICIES-AND-LEGAL-FORMS/PAYMENT-OPTIONS X HTTPS://WWW.THEDACARE.ORG/POLICIES-AND-LEGAL-FORMS/PAYMENT-OPTIONS X HTTPS://WWW.THEDACARE.ORG/POLICIES-AND-LEGAL-FORMS/PAYMENT-OPTIONS X X X X X X X 1 X 0 X X X 1 X 0 0 THEDACARE MEDICAL CENTER - WILD ROSE PART V, SECTION B, LINE 5: THEDACARE UTILIZES MODELS CREATED BY THE UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE AND THE ROBERT WOOD JOHNSON FOUNDATION AS THE FRAMEWORK FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT. OVER THE COURSE OF A ONE YEAR PERIOD, SECONDARY DATA WAS COLLECTED, PUBLIC HEALTH AND KEY INFORMANT INTERVIEWS WERE CONDUCTED, THEDACARE CHAT (COMMUNITY HEALTH ACTION TEAM) PROVIDED INPUT AND PATIENT HEALTH DATA WAS STUDIED. VULNERABLE POPULATIONS INCLUDED THOSE LIVING IN POVERTY, RURAL FARM FAMILIES, THE ELDERLY AND MIGRANT HISPANIC. INPUT WAS COLLECTED BY REPRESENTATIVES OF:- WAUSHARA DEPARTMENT OF HEALTH AND HUMAN SERVICES- WILD ROSE AND WAUTOMA SCHOOL DISTRICTS- WAUSHARA COUNTY UW-EXTENSION- WAUSHARA COUNTY FAMILY LIVING EDUCATOR- WAUSHARA COUNTY AGING AND DISABILITY RESOURCE CENTER- FAMILY HEALTH/LA CLINICA- WAUSHARA FOOD PANTRY THEDACARE MEDICAL CENTER - WILD ROSE PART V, SECTION B, LINE 7D: HOSPITAL FACILITY WEBSITE: HTTPS://WWW.THEDACARE.ORG/FULL CHNA & IMPLEMENTATION STRATEGY WEBSITE: HTTPS://WWW.THEDACARE.ORG/GETTING-INVOLVED/IMPROVING-COMMUNITY-HEALTH THEDACARE MEDICAL CENTER - WILD ROSE PART V, SECTION B, LINE 11: THE THEDACARE COMMUNITY HEALTH IMPLEMENTATION STRATEGY WAS APPROVED BY THE THEDACARE MEDICAL CENTER-WILD ROSE BOARD OF DIRECTORS IN OCTOBER 2016 AND THE THEDACARE BOARD OF TRUSTEES IN DECEMBER OF 2016.- THEDACARE PARTNERS WITH ASCENSION HEALTH SYSTEM TO SPONSOR MOSAIC FAMILY HEALTH RESIDENCY PROGRAM PROVIDING HANDS ON EXPERIENCE FOR MEDICAL STUDENTS AND ACCESS TO PRIMARY CARE AND MENTAL HEALTH SERVICES.- THEDACARE ALSO PARTNERS WITH AREA NURSING SCHOOLS SUCH AS UW OSHKOSH AND FOX VALLEY TECHNICAL COLLEGE TO PROVIDE PROFESSIONAL MENTORS FOR THEIR NURSING PROGRAMS AND VENUES FOR NURSING STUDENTS TO PRACTICE THEIR SKILLS.- THEDACARE HOSPITALS PROVIDE FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO TWO AREA FQHC CLINICS PROVIDING MEDICAL, BEHAVIORAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA.OBESITY:- PROVIDES FUNDING TO LOCAL FARMER'S MARKETS.- THEDACARE PARTNERS WITH LOCAL AREA EVENTS TO EDUCATE CHILDREN ABOUT EATING HEALTHY AND THE BENEFITS OF BEING ACTIVE.- HOSTED GOOD TO GO TC EMPLOYEE VOLUNTEERISM EVENT IN SCHOOL FOR 1 WEEK. BUILT SCHOOL GARDEN, EDUCATED ON FATS IN FOODS AND SUGARY BEVERAGES, LEAD GYM CLASSES.MENTAL HEALTH/AODA:- FOLLOWED CHAT PLUNGE ON DRUG USE, LAUNCHED HEROIN TASK FORCE IN WAUPACA IN 2016. 150 ATTENDED. IDENTIFIED DRUG COURT AS PRIORITY. TC LED PROCESS TO LAUNCH DRUG COURT IN 2017. - DOJ GRANTS FOR TRAINING AND START UP. WAUPACA TRAINING JUNE 2017. - PROVIDED $25,000 TO WAUPACA FOR 6 MOS COORDINATOR START UP - INTRODUCED RECOVERY COACHING PROVIDED $3,000; STARTED SUPPORT GROUP; 60+ ATTEND REGULARLY - TCP PROVIDED MEDICAL ADVISOR TO WAUPACA DRUG COURT - WAUPACA LAUNCHED OCTOBER 2017; SHAWANO HIRED DC COORD IN JANURAY 2018 TO LAUNCH SUMMER 2018 - ENGAGED PROVIDERS IN USING VIVITROL; DEVELOPED POLICY WITH TCP WAUPACA AND PROBATION PAROLE FOLLOWING INCARCERATION. - PROVIDING UA'S FOR FEMALE DC PARTICIPANTS THROUGH WAUPACA TC- CATALPA OPENED CLINIC IN WAUPACA (SUPPORTED BY TC)- OPIOID ABUSE PREVENTION: INTERNAL TEAMS ARE WORKING TO ADDRESS PAIN MANAGEMENT AGREEMENTS, PAIN ASSESSMENT STANDARDIZATION, PRESCRIPTION PATHWAYS, USE OF EPDMP, OPIOID RISK TOOL USE, USE OF EPDMP ANALGEIA, MAT AND EPDMP ANALGESIA.- BEHAVIORAL HEALTH OPERATIONS: INITIATED PRIMARY CARE CONSULT. DR. PANZER AND DR. BELD DO INITIAL REVIEW OF ALL REFERRALS AND IF URGENT, GET THEM INTO CARE EXPEDITED (PSYCH, MH OR AODA). OTHERWISE, CONSULT WITH PC. HELPS PCP MANAGE PATIENTS IF ON WAIT LIST. SIGNIFICANTLY DROPPED # ON WAIT LIST. - INPATIENT PSYCH WENT TO 7 DAYS ON/7 OFF FOR HOSPITALIST. FREES UP OUTPATIENT PSYCH TIME. - DEPRESSION SCREENING: AS OF 6/1/2017, DEPRESSION SCREENING IS TAKING PLACE IN 100% OF TC PEDS AND FP CLINICS FOR PEOPLE AGE 12+. (12-18 YR. OLD ARE ASKED 4 QUESTIONS; 18+ COMPLETE PHQ2) - 53.56% OF PATIENT BASE IN THOSE CLINICS HAVE BEEN SCREENED AS OF OCTOBER 2017; 60.54% SCREENED AS OF DEC 31 2017- IN ADDITION - CONDUCTING COLUMBIA SCREENING AT EVERY MENTAL HEALTH VISITEARLY CHILDHOOD/FAMILY SUPPORT- WAUTOMA SENIOR CENTER, WAUSHARA COUNTY OFFICE ON AGING AND WILD ROSE AND WAUTOMA SCHOOL DISTRICTS TO ENGAGE ABLE SENIORS AS MENTORS/COMPANIONS TO ELEMENTARY STUDENTS FOR VARIOUS SCHOOL ACTIVITIES. IN EXCHANGE HIGH SCHOOL STUDENTS/SENIORS IN WILD ROSE AND WAUTOMA SCHOOLS WILL PROVIDE CHORE ASSISTANCE TO HOME-BOUND SENIORS. TC PROVIDING $18,000/YEAR FOR 3 YEARS. - REACH OUT AND READ: CHI WORKED WITH PHYSICIAN SERVICES TO COMMIT TO EXPANDING ROAR THROUGHOUT TC WITH FUNDING COMING THROUGH OPERATIONS/FOUNDATION BY 2019. FOX CITIES LOCATIONS FUNDED THROUGH UNITED WAY GRANT THROUGH 2018. (A CHILD 1 YEAR BEHIND IN READING BY 3RD GRADE HAS 26% OF DROPPING OUT OF HIGH SCHOOL VS.10% OF STUDENTS READING AT GRADE LEVEL.)IDENTIFIED BUT NOT WORKING ON:- TRANSPORTATION: BEYOND SCOPE OF RESOURCES- DENTAL: RESOURCES EXIST IN REGION- SMOKING: BEING ADDRESSED BY OTHERS- HOUSING: BEYOND SCOPE OF RESOURCES THEDACARE MEDICAL CENTER - WILD ROSE PART V, SECTION B, LINE 15E: CONTRACTED WITH ELIGIBILITY VENDOR (CARDON) TO WORK DIRECTLY WITH THE UNINSURED PATIENT TO ASSIST THEM WITH INSURANCE ENROLLMENT AND EDUCATION. THEDACARE MEDICAL CENTER - WILD ROSE PART V, SECTION B, LINE 16J: THE FAP AND APPLICATION WERE AVAILABLE AT HOSPITAL CASHIER OFFICES, ON WEB SITE AND OFFERED TO ALL PATIENTS THAT EXPRESSED A FINANCIAL HARDSHIP WHEN CALLING THE BILLING OFFICE. THE PLS WAS PRINTED ON EVERY STATEMENT AND A FOOTER WAS ADDED TO THE FRONT OF THE STATEMENT ADVISING PATIENT TO SEE REVERSE SIDE OF STATEMENT FOR FINANCIAL ASSISTANCE AND PAYMENT OPTIONS. NOTIFICATION OF FINANCIAL ASSISTANCE AVAILABILITY WAS ADDED TO THE INITIAL LETTER SENT BY THE THIRD PARTY COLLECTION AGENCY. PART V, LINE 13 PATIENTS ARE SENT AN OVERVIEW LETTER EXPLAINING THE PROCESS FOR APPLYING FOR OUR ASSISTANCE PROGRAM OR OUR STAFF WALKS THEM THROUGH THE PROCESS. THEY ARE ASKED TO COMPLETE AN APPLICATION THAT INCLUDES REQUESTS FOR INFORMATION. THIS INFORMATION IS NEEDED IN ORDER TO MAKE A DECISION AS TO WHETHER THE PATIENT MEETS THE CRITERIA FOR ACCEPTANCE, AND IF ACCEPTED, WHAT LEVEL OF ASSISTANCE WILL BE PROVIDED. ONCE THE DECISION IS MADE, WE WILL NOTIFY THE PATIENT AND IF ACCEPTABLE, WRITE OFF THE BALANCE AS DETERMINED. PART I, LINE 3C: IT IS THE ORGANIZATION'S POLICY THAT NO PATIENT SHOULD BE DENIED APPROPRIATE AND NECESSARY CARE ON THE BASIS OF INCOME. IN RESPONSE TO THIS POLICY, THE CARING HEARTS FINANCIAL ASSISTANCE PROGRAM WAS SET UP TO PROVIDE SHELTER TO THOSE PATIENTS WHO ARE UNABLE TO PAY FOR THEIR MEDICAL SERVICES. MEDICAL SERVICE FEES ARE WRITTEN OFF UNDER THE FINANCIAL ASSISTANCE PROGRAM THAT WOULD OTHERWISE HAVE BEEN SENT TO A COLLECTION AGENCY. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COMBINATION OF AVERAGE COSTS AND ACTUAL COSTS PERTAINING TO SUPPLIES, WAGES, AND BENEFITS. FOR SUPPLIES, THE ACTUAL COST OF ITEMS USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A FRINGE RATIO OF ALL BENEFITS RELATED TO THE ABOVE WAGE CALCULATION. THE COST ACCOUNTING SYSTEM DOES NOT DIFFERENTIATE BETWEEN DIFFERENT PAYER TYPES AND NO COST-TO-CHARGE RATIO IS USED. PART I, LINE 7G: NO PHYSICIAN CLINICS ARE INCLUDED IN SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(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 $548,061. PART II, COMMUNITY BUILDING ACTIVITIES: ECONOMIC DEVELOPMENT: THE PRIMARY AIM OF THE CHAMBER IS TO PROTECT THE INTEREST OF THE BUSINESS COMMUNITY AS A WHOLE. STRONG EMPLOYMENT IS A SOCIAL DETERMINANT OF HEALTH, REDUCING POVERTY AND PROVIDING INDIVIDUAL AND FAMILY SUSTAINABILITY. THEDACARE WORKS TOGETHER WITH LOCAL CHAMBER OF COMMERCE AND ALL OF THE COMMUNITIES IT SERVES. PART III, LINE 4: A COST-TO-CHARGE RATIO WAS USED TO DETERMINE THE AMOUNTS REPORTED IN PART III LINES 2 AND 3. PATIENT PAYMENTS OR DISCOUNTS ARE APPLIED PRIOR TO DETERMINING BAD DEBT EXPENSE AND ARE NOT INCLUDED IN THE BAD DEBT WRITE-OFF REPORTED ON THE AUDITED FINANCIAL STATEMENTS. DEDUCTIBLES AND COINSURANCE AMOUNTS THAT ARE DEEMED UNCOLLECTIBLE ARE WRITTEN OFF EITHER TO BAD DEBT EXPENSE OR, IF APPLICABLE, TO CHARITY CARE IF THE PATIENT SO QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE BUT THEY ACCOUNT FOR BAD DEBTS BASED ON GROSS CHARGES TO PATIENTS AFTER REFLECTING ANY PAYMENTS OR DISCOUNTS, OR AMOUNTS DETERMINED TO BE ELIGIBLE FOR CHARITY CARE/FINANCIAL ASSISTANCE. PART III, LINE 8: HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SERVICES TO THOSE PATIENTS. WE DID NOT REPORT ANY SHORTFALL AS A COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: OUR POLICY IS NOT TO PURSUE PATIENT ACCOUNTS TO THE EXTENT ANY CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM. IF ONLY A PORTION OF THE CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM, THE REMAINING BALANCE WILL BE BILLED TO THE PATIENT AND COLLECTED IN ACCORDANCE WITH OUR NORMAL COLLECTION POLICY. PART VI, LINE 2: TO STAY GROUNDED IN THE NEEDS OF THE COMMUNITY IN THE TIMEFRAME BETWEEN OFFICIAL CHNA'S EVERY THREE YEARS, THEDACARE EMPLOYS SEVERAL STRATEGIES:1. COMMUNITY HEALTH ACTION TEAMS (CHAT TEAMS) - THEDACARE ORGANIZES AND LEADS CHAT TEAMS IN EACH HOSPITAL COMMUNITY. CHAT TEAMS ARE COMPRISED OF LEADERS FROM ALL SECTORS, INCLUDING EDUCATION, NON-PROFITS, BUSINESS, GOVERNMENT, HEALTHCARE, AND FAITH ORGANIZATIONS. THESE CHAT TEAMS MEET REGULARLY AND STAY ON TOP OF EMERGING TRENDS IN THE HEALTH OF THE COMMUNITY. 2. PUBLIC HEALTH RELATIONSHIPS THEDACARE COMMUNITY HEALTH STAFF MEET REGULARLY WITH PUBLIC HEALTH LEADERS IN EACH HOSPITAL MARKET. THE PUBLIC HEALTH OFFICIALS ALSO HAVE A THOROUGH UNDERSTANDING OF EMERGING HEALTH NEEDS AND WORK IN PARTNERSHIP WITH THEDACARE.3. IN COMMUNITIES THAT HAVE A UNITED WAY PRESENCE, THEDACARE MEETS REGULARLY WITH UNITED WAY OFFICIALS TO ALSO STAY ON TOP OF EMERGING NEEDS. THE NEEDS IDENTIFIED ABOVE ARE INCLUDED AS INPUTS TO THE ANNUAL STRATEGIC PLANNING WORK OF THE HEALTH SYSTEM. PART VI, LINE 3: PATIENT EDUCATION BEGINS WHEN A PATIENT IS ADMITTED TO A THEDACARE HOSPITAL. ADMISSION SPECIALISTS MEET WITH EACH PERSON INDIVIDUALLY TO ASSESS INSURANCE STATUS AND FINANCIAL NEED. IF NECESSARY, SPECIALISTS REFER PATIENTS TO CARE MANAGEMENT SPECIALISTS WHO ASSIST WITH THE ENROLLMENT OF PATIENTS IN AN APPLICABLE PROGRAM. THE HOSPITAL PATIENT HANDBOOK IS PROVIDED TO ALL IN-PATIENTS. INTERNAL POLICIES SUCH AS DISCOUNTED SERVICES POLICY, CARING HEARTS POLICY AND PAYMENT FOR SERVICE POLICY FOR SELF-PAY BALANCES PROVIDE GUIDANCE.THE THEDACARE WEBSITE, WWW.THEDACARE.ORG, PROVIDES EDUCATION REGARDING THE AFFORDABLE CARE ACT IN EASY TO UNDERSTAND LANGUAGE. IT DISCUSSES OPTIONS AND WHERE TO GO FOR ASSISTANCE. PART VI, LINE 4: WAUSHARA COUNTY:- THE WAUSHARA COUNTY HIGH SCHOOL GRADUATION RATE IS 91%- TRADE/TRANSPORTATION/UTILITIES ALONG WITH MANUFACTURING EMPLOY THE MOST PEOPLE IN THE TWO-COUNTY REGION FOLLOWED BY EDUCATION/HEALTH. THESE THREE SECTORS EMPLOY 40% OF THE AREA'S WORKFORCE.- TWENTY-FOUR PERCENT OF THE WAUSHARA COUNTY POPULATION LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL, 93% ARE UNINSURED.- NINETY FIVE PERCENT OF SERVICE AREA IS CAUCASIAN WITH HISPANIC/LATINO POPULATION OF 6.4% SEEING THE FASTEST GROWTH. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 0.8% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENT LESS THAN 2.1%. PART VI, LINE 5: EACH YEAR THEDACARE SETS ASIDE A PERCENTAGE OF ANY MARGIN AND DESIGNATES THESE FUNDS TO SUPPORT EFFORTS AND INITIATIVES COMING FROM CHAT (COMMUNITY HEALTH ACTION TEAM). CHAT IS A GROUP OF COMMUNITY LEADERS WHO STUDY SYSTEMIC HEALTH ISSUES OUTSIDE THE WALLS OF OUR HOSPITALS AND CLINICS AND WORK TO IDENTIFY INNOVATIVE, COLLABORATIVE SOLUTIONS THAT DRAW UPON THE WIDE ARRAY OF RESOURCES AND STRENGTHS OF OUR COMMUNITY. THERE ARE THEDACARE LED CHAT'S IN EACH HOSPITAL AREA WILD ROSE, WAUPACA, FOX CITIES, SHAWANO, BERLIN AND NEW LONDON. THEDACARE PROVIDES FUNDING AND DEDICATED STAFF TO MAKE CHAT COMMUNITY HEALTH EFFORTS POSSIBLE. A WILD ROSE CHAT WAS IMPLEMENTED IN APRIL 2016. PART VI, LINE 6: THEDACARE, THE PARENT ORGANIZATION, PROVIDES DIRECTION RELATED TO COMMUNITY HEALTH NEEDS ASSESSMENT FOR EACH HOSPITAL AND SURROUNDING COMMUNITIES WITHIN ITS SERVICE AREA. PLANS ARE APPROVED BY LOCAL HOSPITAL BOARDS. EACH THEDACARE HOSPITAL, ALONG WITH CHI STAFF AND COMMUNITY MEMBERS DETERMINE HOW BEST TO MEET LOCAL NEEDS. IMPLEMENTATION OF COMMUNITY PROGRAMMING OCCURS AT THE LOCAL LEVEL. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X 1 1 X X X X 1 1 0 0 0 0 0 1 0 BENDING TAMMY BOARD MEMBER/VP OF CAH OPERATIONS 0 180172 0 150 0 1350 0 5483 0 10072 0 197227 0 0 CAVES CHANDLER MD BOARD MEMBER/PHYSICIAN 324352 0 93750 0 1027 0 10100 0 21329 0 450558 0 0 0 MCGOVERN JAMES MD BOARD MEMBER/PHYSICIAN 340671 0 150 0 12794 0 8100 0 21067 0 382782 0 0 0 KANTOS CRAIG FORMER BOARD MEMBER, CEO-WILD ROSE 0 223322 0 12615 0 109372 0 8027 0 24269 0 377605 0 0 STAUDINGER MICHAEL MD FORMER BOARD MEMBER/PHYSICIAN 286287 0 96150 0 4209 0 10100 0 21315 0 418061 0 0 0 BURMEISTER BRIAN FORMER BOARD MEMBER/VP SR AMC & TC 39725 357522 15 135 3872 34850 810 7290 2267 20406 46689 420203 0 0 ANDRABI IMRAN MD PRESIDENT AND CEO - SYSTEM 43831 394482 17144 154293 90 807 0 0 1434 12906 62499 562488 0 0 THOMPSON MARK CFO & COO - SYSTEM 8903 80123 17331 155978 52 464 111 996 382 3439 26779 241000 0 0 GRUNER DEAN FORMER PRESIDENT AND CEO 46701 420307 15 135 35296 317661 609 5480 1538 13845 84159 757428 0 0 OLSON TIM FORMER CFO - SYSTEM 50525 454722 15 135 21709 195383 810 7290 2380 21423 75439 678953 0 0 AUSLOOS JODI INTERIM CIO 23829 214457 15 135 3781 34027 387 13483 1263 11369 29275 273471 0 0 PISTONE MAUREEN VP SR HR SERVICES 33415 300731 15 135 9290 83610 810 7290 2277 20492 45807 412258 0 0 REED LAURA FORMER COO/CHIEF NURSING EXEC 24736 222620 15 135 2976 26786 724 6517 1490 13408 29941 269466 0 0 REDMAN-SCHELL JENNIFER VP SR PHYS, BEHAV, TRANS 15802 300235 7 142 2337 44400 405 7695 1531 29088 20082 381560 0 0 LONG GREGORY MD CMO 49036 441324 15 135 9928 89350 810 7290 2506 22555 62295 560654 0 0 MANN WILLIAM VP SR STRATEGY 39210 352894 15 135 8533 76796 810 7290 1078 9705 49646 446820 0 0 MATHESON JAMES FORMER VP SR STRATEGY 27938 251445 15 135 1465 13186 546 4917 3243 29184 33207 298867 0 0 VOSKUIL CHAD MD PHYSICIAN 264564 0 30650 0 0 0 6623 0 23051 0 324888 0 0 0 PART I, LINE 1A ALL EXECUTIVES AT THE LEVEL OF VICE PRESIDENT OR ABOVE RECEIVE REIMBURSEMENT FOR PERSONAL MEDICAL EXPENSES AT A MAXIMUM AMOUNT OF $6,800, THAT IS TAXED UPON REIMBURSEMENT. ALL EXECUTIVES AT A LEVEL OF VICE PRESIDENT AND ABOVE ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES REIMBURSED TO THEM, AND TAXED UPON REIMBURSEMENT. ONE EXECUTIVE, NOT PART OF THE SENIOR LEADERSHIP TEAM, RECEIVED REIMBURSEMENT FOR A LOCAL COUNTRY CLUB MEMBERSHIP THAT ENDED 9/1/2017. 12 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 2 EMPLOYEES RECEIVED FITNESS CLUB DUES REIMBURSEMENTS. PART I, LINES 4A-B CRAIG KANTOS RECEIVED $10,966 OF SEVERANCE PAY FROM THE ORGANIZATION AND RELATED ORGANIZATIONS DURING 2017. NONQUALIFIED PLAN DESCRIPTION: SENIOR LEVEL EXECUTIVES OF THE COMPANY ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THE MIDPOINT OF THEIR SALARY RANGE. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTION 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVEST IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. PART I, LINE 7 EXECUTIVE AT RISK COMPENSATION PLAN: THE PLAN OBJECTIVES ARE TO ENHANCE THEDACARE INC'S ABILITY TO ACHIEVE ITS GOALS BY PROVIDING A TOOL FOR STIMULATING AND REWARDING SUPERIOR LEVELS OF PERFORMANCE AMONG KEY EXECUTIVES AND TO ENCOURAGE TOP-LEVEL EXECUTIVES TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. THE PRESIDENT OF THEDACARE INC. DEVELOPS A LIST OF SENIOR LEVEL EXECUTIVES WHO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN, AS WELL AS THE PERFORMANCE LEVELS THE SENIOR EXECUTIVES MUST ACHIEVE AND THE BONUS AMOUNTS THAT THE EXECUTIVE WILL RECEIVE. THE PRESIDENT THEN SUBMITS THIS LIST TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THESE EXECUTIVES MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2016 TO DECEMBER 31, 2016) TO RECEIVE THEIR 2017 BONUSES. IF THE EMPLOYEE RETIRES, BECOMES DISABLED, MOVES TO A POSITION THAT IS NO LONGER ELIGIBLE FOR THE BONUS PLAN OR DIES, THE PLAN WILL BE PRORATED FOR THE AMOUNT OF TIME THEY SERVED THE COMPANY. IF AN ELIGIBLE EMPLOYEE IS FIRED OR LEAVES THE COMPANY FOR ANY OTHER REASON THE PLAN BONUS WILL BE FORFEITED. CARING FOR SUCCESS THE PLAN OBJECTIVES ARE TO PROVIDE INCENTIVE TO FOCUS THE ORGANIZATION'S RESOURCES, ENERGY AND ATTENTION ON THE FUFILLMENT OF THEDACARE'S MISSION. EMPLOYEE ELIGIBILITY IS BASED ON THE NUMBER OF HOURS WORKED. AND ALL ELIGIBLE EMPLOYEES SHARE IN THE PAYOUT. THE PAYOUT AMOUNT IS DETERMINED BASED ON BOTH FINANCIAL AND EMPLOYEE HEALTH AND SAFETY THRESHOLDS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE RESULTING DOLLAR UNIT PAYOUT IS MULTIPLIED BY AN INDIVIDUAL EMPLOYEE'S NUMBER OF HOURS PAID. THIS PLAN IS OVERSEEN BY AN ADMINISTRATIVE COMMITTEE. THE THEDACARE BOARD OF TRUSTEES MUST APPROVE THE PLAN. FORM 990, PART I, LINE 5 THEDACARE INC. CENTRALIZES PAYROLL AND TAX WITHHOLDING FUNCTIONS FOR A NUMBER OF AFFILIATED ENTITIES, WHILE ALL FILING UNDER THEDACARE'S FEDERAL IDENTIFICATION NUMBER. THEDACARE MEDICAL CENTER - WILD ROSE,INC. (WILD ROSE) REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE PAID BY THEDACARE, INC., THEREFORE, WILD ROSE DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY WILD ROSE FOR SALARY EXPENSES FOR THE EMPLOYEES WHO ARE PERMANENTLY ASSIGNED TO WILD ROSE. FORM 990, PART VI, SECTION A, LINE 6 THEDACARE MEDICAL CENTER - WILD ROSE, INC., INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THEDACARE, INC. HAS SOLE AUTHORITY IN THE CORPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION A, LINE 7B THEDACARE, INC. HAS THE SOLE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. DEVELOP AND APPROVE ANNUAL CAPITAL AND OPERATING TARGETS 2. AUTHORIZE AND MAKE CAPITAL EXPENDITURES 3. APPROVE STRATEGIC PLANS, WITH MANAGEMENT AND BOARD OVERSIGHT 4. APPROVE THE SAFETY AND QUALITY PLAN 5. APPROVE THE DISSOLUTION OR LIQUIDATION 6. HIRE OR TERMINATE THE PRESIDENT AND CEO 7. BORROW OR INCUR DEBT 8. APPOINT AUDITORS AND LEGAL COUNSEL 9. RETAIN INVESTMENT ADVISORS AND ESTABLISH INVESTMENT POLICIES THE BOARD OF TRUSTEES MAY NOT DO THE FOLLOWING WITHOUT RECEIVING THE CONSENT OF THEDACARE,INC. 1. MERGE, CONSOLIDATE, OR CHANGE CONTROL OF THE ORGANIZATION 2. SELL, LEASE, OR TRANSFER MATERIAL ASSETS 3. ENTER JOINT VENTURES OR AFFILIATIONS 4. AMEND THE ARTICLES OF INCORPORATION OR BYLAWS FORM 990, PART VI, SECTION B, LINE 11B A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C QUESTIONNAIRES ARE SENT TO ALL MANAGERS, TRUSTEES, AND OFFICERS ANNUALLY. COMPLETED FORMS ARE RETURNED TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER REVIEWS THE QUESTIONNAIRES AND FOLLOWS UP WITH ANY QUESTIONS ABOUT THE MANAGERS' ANSWERS ON THE CONFLICT OF INTEREST FORMS. ALL EMPLOYEES AND BOARD MEMBERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE CORPORATE COMPLIANCE COMMITTEE REVIEWS THE POTENTIAL CONFLICT AND THE CFO/BOARD OF TRUSTEES REVIEW ALL CONFLICTS. AFTER DISCLOSURE OF THE CONFLICT, THE EMPLOYEE SHALL NOT PARTCIPATE IN THE DECISION WHETHER TO ENGAGE IN THE TRANSACTION IN WHICH THE EMPLOYEE HAS AN INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THEDACARE HIRED AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMED THE COMPENSATION POLICY, REVIEWED DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SR VP OF HUMAN RESOURCES, ADVISED, VALIDATED, AND APPROVED A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIED THE BONUS PLAN. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND DOES NOT MAKE THEM AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 343,483. MANAGEMENT AND GENERAL EXPENSES 256,017. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 599,500. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 12,868. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,868. MEDICAL CONTRACT LABOR: PROGRAM SERVICE EXPENSES 248,181. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 248,181. EQUIPMENT MAINTENANCE: PROGRAM SERVICE EXPENSES 197,734. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 197,734. RECRUITMENT: PROGRAM SERVICE EXPENSES 400. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 400. FORM 990, PART XI, LINE 2C THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR. THEDACARE INC 122 EAST COLLEGE AVENUE APPLETON WI 54911 391509362 HEALTHCARE WI 501(C)(3) LINE 10 N/A 0 THEDACARE REGIONAL MEDICAL CENTER - NEENAH INC PO BOX 8025 APPLETON WI 54912 390830664 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE MEDICAL CENTER - NEW LONDON INC 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE MEDICAL CENTER - WAUPACA INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 390871113 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE REGIONAL MEDICAL CENTER - APPLETON INC PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE MEDICAL CENTER - SHAWANO INC 100 COUNTY ROAD B SHAWANO WI 54166 390807068 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE MEDICAL CENTER - BERLIN INC 225 MEMORIAL DRIVE BERLIN WI 54923 390806359 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE FAMILY OF FOUNDATIONS INC 1818 NORTH MEADE STREET APPLETON WI 54912 464112255 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 1 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0