2017-11-14T08:45:11-06:00 2016-12-31 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2016-01-01 390871113 ThedaCare Medical Center - Waupaca Inc THED 7152581000 800 Riverside Dr Waupaca WI 54981 TIM A OLSON Chief Financial Officer 7152581000 2017-10-24 1 Terri Rexrode CPA MST P00096513 9206620016 2017-10-24 74.87.127.142 2017-10-24 09:55:05 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2016 2017-02-10 21:41:12Z Tim A Olson 800 Riverside Dr Waupaca WI 54981 35768084 0 X www.thedacare.org X 1955 WI Improving the health of our community. 10 6 0 160 0 0 15164 254570 37749999 35003697 -124025 167523 285136 227868 37926274 35653658 1244 51080 0 0 18096884 18547669 0 0 0 12603336 12333583 30701464 30932332 7224810 4721326 85593758 90795812 2877503 2598379 82716255 88197433 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 30348274 51080 34913356 25-bed critical access hospital serving Waupaca and nearby communities. Thedacare Medical Center - Waupaca, Inc. provides patient care and support services including ER, diagnostic, lab, radiology, surgery, and therapy care and treatment to persons in need of medical attention. With corporate parent ThedaCare, Inc. we offer public awareness campaigns, charity care, support groups, and education programs targeted to local community needs. 30348274 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 10 6 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 POESCHL DAVID PHD BOARD CHAIR 1.00 X X 0 0 0 ZIMMERMAN WILLIAM BOARD VICE CHAIR 1.00 X X 0 0 0 ANTHONY CHRIS BOARD SECRETARY 1.00 X X 0 0 0 LAZERS LAINE BOARD TREASURER 1.00 X X 0 0 0 BURMEISTERBRIAN BOARD MEMBER/VP SR AMC & TC 5.00 38.00 X 49431 444891 63643 FAULKS RANDY BOARD MEMBER 1.00 X 0 0 0 HALLETT MARK BOARD MEMBER/PHYSICIAN 1.00 40.00 X 0 436943 31363 HANSEN KENLEY BOARD MEMBER 1.00 X 0 0 0 REED LAURA BOARD MEMBER 5.00 36.00 X 33754 303788 29981 WENBERG ELLEN MD BOARD MEMBER/PHYSICIAN 41.00 X 227834 0 30284 KANTOS CRAIG CEO - Waupaca 35.00 5.00 X 272480 0 27429 OLSON TIM VP CFO SYSTEM 4.00 37.00 X 55627 500638 29143 GRUNER DEAN CEO - SYSTEM 4.00 39.00 X 129688 1167188 215288 LIVINGSTON KEITH VP SR CIO 4.00 37.00 X 53701 483310 109713 PISTONE MAUREEN VP SR HR SERVICES 4.00 36.00 X 46289 416602 101774 LONG GREGORY MD CMO 4.00 37.00 X 61960 557641 103740 REDMAN-SCHELL JENNIFER VP SR PHYS, BEHAV,TRANS 2.00 38.00 X 16960 322236 31512 MATHESON JAMES VP SR STRATEGY & MARKETING 4.00 37.00 X 29838 268536 32055 MANN WILLIAM VP SR STRATEGY 4.00 36.00 X 45690 411221 74697 PETERSON ROBERT MD PHYSICIAN 40.00 X 379560 0 44616 1402812 5312994 925238 20 0 1 0 SHARED MEDICAL SERVICES 209 limestone pass COTTAGE GROVE WI 53527 MEDICAL SERVICES 118455 1 236454 18116 254570 OUTPATIENT REVENUE 621400 26775221 26775221 INPATIENT REVENUE 621990 7768768 7768768 OTHER MISC REVENUE 621990 369367 369367 Cafeteria Revenue 722210 90341 90341 35003697 281824 281824 227868 0 227868 227868 227868 125 114426 0 -114426 125 -114301 -114301 35653658 34913356 0 485732 51080 51080 623021 258118 364903 14201675 14201675 262132 262132 2504980 2459831 45149 955861 955861 2212684 2047395 165289 5298 5298 383781 376880 6901 860086 858270 1816 58338 58338 100034 100034 155100 155100 1920301 1920301 108756 108756 CLIENT & PATIENT SERVIC 4497478 4497478 Equipment Maintenance 1240700 1240700 Bad Debt Expense 791027 791027 30932332 30348274 584058 0 2000000 1000000 4706600 4215996 426353 544202 58856088 34049721 25548519 24806367 9888664 11776751 43023622 48452496 85593758 90795812 2877503 2598379 2877503 2598379 X 82716255 88197433 82716255 88197433 85593758 90795812 4721326 759852 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2262 2262 0 Part II-B, Line 1: A portion of the WHA dues represent lobbying performed in regard to healthcare issues. The amount for 2016 was $2,262. 2102028 2102028 39561908 19738272 19823636 1025200 842538 182662 16166952 13468911 2698041 24806367 Due From Affiliate 48452496 48452496 Allocable portion of tax-exempt bonds due to Affiliate 2598379 2598379 1 1 X 1 X 1 X 1 0 1 1 114066 114066 0.00380 3769518 3466802 302716 0.01000 3883584 3466802 416782 0.01380 19 39682 303332 14430 288902 0.00960 3 219 141631 141631 0.00470 3 2676821 2676821 0.08880 1 936 936 0.00000 6 83756 210679 210679 0.00700 32 123657 3333399 14430 3318969 0.11010 32 123657 7216983 3481232 3735751 0.12390 1 1001 10012 10012 0.00030 1 39 2280 2280 0.00010 1 183 1853 1853 0.00010 1 30 2857 2857 0.00010 4 1253 17002 17002 0.00060 0 667760 117384 8197249 8126853 70396 X 1 1 1 1 thedacare medical center - waupaca INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 https://www.thedacare.org 1038 X X X X thedacare medical center - waupaca INC 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 300.000000000000 X X X X X 1 1 X X X X X 1 X https://www.thedacare.org/Policies-and-Legal-Forms/payment-options.aspx X https://www.thedacare.org/Policies-and-Legal-Forms/payment-options.aspx X https://www.thedacare.org/Policies-and-Legal-Forms/payment-options.aspx X X X X X X X 1 X 0 X X X 1 X 0 0 thedacare medical center - waupaca, INC. 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, grandparents as caretakers, single-parents, homeless, veterans and HeadStart population. Input was collected by representatives of:- Rural Health Initiative- Waupaca County Aging and Disability Resource Center- Waupaca County Public Health- HeadStart- Waupaca County WIC- Waupaca County Veteran's Service Officer- Waupaca County Economic Support- Waupaca School District- Waupaca County UW-Extension thedacare medical center - waupaca, INC. Part V, Section B, Line 7d: Hospital facility website: https://www.thedacare.org/FULL WEBSITE FOR CHNA & implementation strategy: https://www.thedacare.org/Getting-Involved/Improving-Community-Health.aspx thedacare medical center - waupaca, INC. Part V, Section B, Line 11: The ThedaCare Community Health Implementation Strategy was approved by the ThedaCare Medical Center-Waupaca Board of Directors in October 2016 and the ThedaCare Board of Trustees in December of 2016.- ThedaCare provides support to the Center for Healthcare Value which is coordinating efforts across the country to share quality improvement and cost reduction learnings. - ThedaCare partners with Affinity Health System to sponsor Mosiac Health, providing hands on experience for medical students.- 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 clinics providing medical and dental care to the underserved in our service area.- ThedaCare supports the End of Life Coalition- ThedaCare employees take part in Helping Hearts, an employee volunteerism program encouraging staff to give of their time in the community. ThedaCare provides paid staff to coordinate the program and identify and promote volunteerism opportunities. Obesity:- Provides funding to local Farmer's Markets including Waupaca.- ThedaCare partners with local area events to educate children about eating healthy and the benefits of being active.- Good to Go Week is an annual employee led initiative that takes place in 6 school districts throughout the ThedaCare system. Activities include healthy snacks, build a school garden, fats in foods, measure your drink, leading gym classes.- A Waupaca CHAT Plunge initiative created Living the Waupaca Way (merging with NuAct). Living the Waupaca Way focuses on physical and mental health, spiritual and social health. In 2016, the first Farm to Table Dinner was held.- Contribute to Project Backpack supplying food to children during weekendsMental Health/AODA: - ThedaCare financially supports the New Mental Health Connection which connects stakeholders and resources to improve the mental health of our community- Provides leadership and financial support for Catalpa Health, dedicated to pediatric mental health. - Provides leadership and funding for the Fox Valley Partnership Community Health Center working to improve the health status of the medically underserved by providing comprehensive primary care services.- Provided over $2,000,000 in subsidized mental health services. - Developed a protocol for screening patients for substance abuse and a policy for those on long-term opiate use. - Have gone live with the Wisconsin Prescription Drug Monitoring Program.- Have developed a policy for medical assisted treatment including Vivitrol. - A CHAT/Heroin AODA Task Force addresses local AODA issues to include a recovery coach program.- Working to become a Trauma Sensitive Community.Early childhood/Family Support- ThedaCare is a supporter of the Reach out and Read Program.Identified but not working on:- Homelessness: Beyond scope of resources- Transportation: Beyond scope of resources- Youth Pregnancy: Resources exist- Veteran's Justice: Beyond scope of resources- Dental Care: Resources exist thedacare medical center - waupaca, INC. Part V, Section B, Line 15e: Contracted with 2 agencies to assist patients. First, Partnership Community Education Center - they provide the patient with free assistance with completing the financial assistance application and also assist patients in finding community funding that may be avaialable. Second, Cardon works directly with the uninsured patient to assist them with insurance enrollment and education. thedacare medical center - waupaca, INC. 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 reserve 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 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 $791,027. Part II, Community Building Activities: Obesity:- Provides funding to local Farmer's Markets including Waupaca.- ThedaCare partners with local area events to educate children about eating healthy and the benefits of being active.- Good to Go Week is an annual employee led initiative that takes place in 6 school districts throughout the ThedaCare system. Activities include healthy snacks, build a school garden, fats in foods, measure your drink, leading gym classes.- A Waupaca CHAT Plunge initiative created Living the Waupaca Way (merging with NuAct). Living the Waupaca Way focuses on physical and mental health, spiritual and social health. In 2016, the first Farm to Table Dinner was held.- Contribute to Project Backpack supplying food to children during weekendsMental Health/AODA: - ThedaCare financially supports the New Mental Health Connection which connects stakeholders and resources to improve the mental health of our community- Provides leadership and financial support for Catalpa Health, dedicated to pediatric mental health. - Provides leadership and funding for the Fox Valley Partnership Community Health Center working to improve the health status of the medically underserved by providing comprehensive primary care services.- Provided over $2,000,000 in subsidized mental health services. - Developed a protocol for screening patients for substance abuse and a policy for those on long-term opiate use. - Have gone live with the Wisconsin Prescription Drug Monitoring Program.- Have developed a policy for medical assisted treatment including Vivitrol. - A CHAT/Heroin AODA Task Force addresses local AODA issues to include a recovery coach program.- Working to become a Trauma Sensitive Community.Early childhood/Family Support- ThedaCare is a supporter of the Reach out and Read Program. 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: ThedaCare covers a 9 county primary service area served by 7 hospitals. ThedaCare conducts a Community Needs Assessment every three years for each hospital gathering data pertinent to that community and the surrounding areas. Information collected includes data from the Wisconsin County Health Rankings, Fox Cities LIFE Study (Local Indicators for Excellence), the Behavioral Risk Factor Surveillance Survey, insights from interviews of Public Health Officials, insights from interviews with representatives of vulnerable populations, emergency department patient data and insights gathered from monthly meetings of the ThedaCare-led CHAT Team (Community Health Action Team) comprised of community leaders in business, non-profit, clergy, education, diverse population groups, healthcare, United Way, Public Health and the local Community Foundations. 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: ThedaCare Medical Center-Waupaca provides services primarily to people in Waupaca County. County population is concentrated in the western portion of the City of New London and City of Waupaca. Waupaca County is mostly rural with a large farming population in the northeast region. Waupaca County:- Waupaca County high school graduation rate is 91%. - Top industries in Waupaca County include Nursing/Residential Facilities, Food/Beverage Services, Education, Metal Fabrication and Social Assistance. The area has a strong industrial base and stable government. - The median age of Waupaca County residents is 43 years.- Twelve percent of Waupaca County population lives below 100% of the Federal Poverty Level, the uninsured rate is10%.- In Waupaca County, the largest minority population is Hispanic/Latino at 3%. Native American, Asian, multi-racial and African-American account for less than 1% each. 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. ThedaCare provides funding and staff support to make CHAT and these community health efforts possible. ThedaCare Medical Center-Waupaca has held a Plunge into AODA, a Plunge into Mental Health and a Plunge into Obesity. 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 1 thedacare family of foundations 1818 north meade street appleton WI 54912 464112255 501(c)(3) 51080 General 1 0 Part I, Line 2: In order for grant requests to be considered they must meet the following guidelines: 1) Directed toward projects that support ThedaCare's mission and values 2) Benefit the communites served by ThedaCare, Inc. 3) Benefit a 501 (c)(3) not-for-profit organization Conversely, requests must NOT be for: 1) The sole benefit of an individual 2) Political organizations or campaign committees 3) Religious organizations (for strictly religious purposes) 4) Organizations in conflict with ThedaCare's mission and values 5) State or national campaigns All organizations requesting grant funds must apply through the ThedaCare website. Requests are screened, reviewed, and approved by committee six times throughout the fiscal year. A letter of restriction is issued by ThedaCare in conjunction with all grant checks. This letter of restriction states that all grant funds received from ThedaCare must be used strictly for the purposes for which they were applied. X X 1 1 X X X X 0 1 0 0 0 0 0 1 0 BURMEISTERBRIAN BOARD MEMBER/VP SR AMC & TC 38206 343858 5735 51619 5490 49414 4209 37883 2155 19396 55795 502170 0 0 HALLETT MARK BOARD MEMBER/PHYSICIAN 0 373207 0 43351 0 20385 0 7950 0 23413 0 468306 0 0 REED LAURA BOARD MEMBER 32993 296938 0 0 761 6850 740 6658 2258 20325 36752 330771 0 0 WENBERG ELLEN MD BOARD MEMBER/PHYSICIAN 219797 0 3314 0 4723 0 8926 0 21358 0 258118 0 0 0 KANTOS CRAIG CEO - Waupaca 240686 0 18634 0 13160 0 7950 0 19479 0 299909 0 0 0 OLSON TIM VP CFO SYSTEM 46522 418697 6918 62261 2187 19680 795 7155 2119 19074 58541 526867 0 0 GRUNER DEAN CEO - SYSTEM 84854 763682 25281 227533 19553 175973 19316 173842 2213 19917 151217 1360947 0 0 LIVINGSTON KEITH VP SR CIO 37839 340554 5774 51968 10088 90788 8892 80025 2080 18716 64673 582051 0 0 PISTONE MAUREEN VP SR HR SERVICES 32468 292209 4970 44731 8851 79662 8018 72163 2159 19434 56466 508199 0 0 LONG GREGORY MD CMO 47651 428856 7013 63117 7296 65668 7679 69112 2695 24254 72334 651007 0 0 REDMAN-SCHELL JENNIFER VP SR PHYS, BEHAV,TRANS 14667 278668 2170 41239 123 2329 421 7994 1155 21942 18536 352172 0 0 MATHESON JAMES VP SR STRATEGY & MARKETING 25784 232056 3449 31039 605 5441 547 4926 2658 23924 33043 297386 0 0 MANN WILLIAM VP SR STRATEGY 34460 310144 5237 47137 5993 53940 6459 58127 1011 9100 53160 478448 0 0 PETERSON ROBERT MD PHYSICIAN 313368 0 46873 0 19319 0 9950 0 34666 0 424176 0 0 0 Part I, Line 1a Executives receive reimbursement for personal medical expenses at an amount grossed-up for taxes. All executives in the senior management benefit category are eligible to have health or fitness club fees paid directly to the club, or reimbursed to them on evidence of payment. Senior executives whose duties include meeting with people outside the company for purposed of developing business relationships have company paid memberships at a local country club. 9 Employees received taxable medical expense reimbursements and 5 employees received club dues reimbursements. Part I, Line 4b 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, 2015 TO DECEMBER 31, 2015) TO RECEIVE THEIR 2016 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 MULTIPLIE 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 - Waupaca,inc. (Waupaca) reports "0" employees because employees are paid by ThedaCare, Inc., therefore, Waupaca does not file any W-2 forms. ThedaCare Inc. is reimbursed by Waupaca for salary expenses for the employees who are permanently assigned to Waupaca. Form 990, Part VI, Section A, line 6 Thedacare medical center - waupaca, inc.'s sole corporate member 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. Amendment of the articles of incorporation 2. Adoption and amendment of bylaws of the corporation 3. Consolidation, merger and dissolution of the corporation 4. Monitoring compliance with laws and regulations 5. Selection, appointment, and removal of a Chief Operating Officer 6. Provision for long-range financial stability of the hospital and provision for the control and use of the physical and financial resources of the hospital 7. Establishment of a long-range planning mechanism 8. Approval of a hospital organization and major authority delegation patterns 9. Approval of financial, capital, and other items 10. Approval of debt or leases 11. Consideration and action upon policies concerning relations with external groups and organizations 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 HIRES AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMS THE COMPENSATION POLICY, REVIEWS DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SENIOR VICE PRESIDENT OF HUMAN RESOURCES, ADVISES, VALIDATES, AND APPROVES A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIES THE AT-RISK COMPENSATION PLAN. Form 990, Part VI, Section C, line 19 thedacare medical center - waupaca, inc. does not make its governing documents, conflict of interest policy and internal financial statements available to the public. FORM 990, PART XI, LINE 2C: Oversight of audit and selection process: 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 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 Medical Center - Wild Rose INC PO BOX 243 WILD ROSE WI 54984 396089134 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 THE AUXILIARY OF RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 900328881 FOUNDATION WI 501(c)(3) Line 12a, I 0 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 thedacare family of foundations C 236454 actual thedacare family of foundations B 51080 actual