2017-11-14T08:45:11-06:00 2016-12-31 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2016-01-01 390824015 ThedaCare Regional Medical Center - Appleton Inc THED 9207355560 PO Box 8025 Appleton WI 54912 Tim A Olson Chief Financial Officer 9207355560 2017-10-24 1 Terri Rexrode CPA MST P00096513 9206620016 2017-10-24 74.87.127.142 2017-10-24 07:49:42 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2016 2017-02-10 21:41:12Z Tim A Olson PO Box 8025 Appleton WI 54912 274425953 0 X www.thedacare.org X 1958 WI TO IMPROVE THE HEALTH OF OUR COMMUNITY. 18 14 0 362 0 0 2312632 993435 264095582 273377538 21375 4845 150405 50135 266579994 274425953 0 0 0 0 107357991 109352789 0 0 0 115879569 123881663 223237560 233234452 43342434 41191501 408349943 449668392 0 126948 408349943 449541444 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 219399436 272034023 160-BED ACUTE CARE HOSPITAL, HEART, CANCER, AND OUTPATIENT SURGERY CENTERS, AND WELLNESS PROGRAMS. WITH CORPORATE PARENT THEDACARE, WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. 219399436 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 0 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 18 14 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 DAVIS JOHN board chair 1.00 2.00 X X 0 0 0 TIMM TERRY board vice-chair 1.00 2.00 X X 0 0 0 KOTEK JIM board secretary 1.00 2.00 X X 0 0 0 GRUNER DEAN BOARD MEMBER/CEO - SYSTEM 5.00 38.00 X X 129688 1167188 215288 BERGSTROM TIM BOARD MEMBER 1.00 2.00 X 0 0 0 BRENNAN PATRICK MD BOARD MEMBER 1.00 2.00 X 0 0 0 BURSTEIN MARK BOARD MEMBER 1.00 2.00 X 0 0 0 EDELMAN GARY MD BOARD MEMBER/PHYSICIAN 1.00 42.00 X 0 395249 29831 KLISTER PAUL BOARD MEMBER 1.00 2.00 X 0 0 0 LaMONTAGNE GRANT BOARD MEMBER 1.00 2.00 X 0 0 0 MEYER JIM BOARD MEMBER 1.00 3.00 X 0 0 0 MOARD DOUGLAS MD BOARD MEMBER/PHYSICIAN 1.00 42.00 X 0 296517 34118 TIMBERLAKEKAREN BOARD MEMBER 1.00 2.00 X 0 0 0 TURK NORMA MD BOARD MEMBER/PHYSICIAN 41.00 2.00 X 389176 0 21276 VAN LAANEN MARIA BOARD MEMBER 1.00 2.00 X 0 0 0 WALSH CYRIL P MD BOARD MEMBER 1.00 2.00 X 0 0 0 KOEPER DAVID MD BOARD MEMBER 1.00 2.00 X 0 0 0 HENSON PAM BOARD MEMBER 1.00 2.00 X 0 0 0 OLSON TIM VP CFO SYSTEM 4.00 37.00 X 55627 500638 29143 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 BURMEISTER BRIAN VP SR AMC & TC 8.00 35.00 X 148296 346026 63644 laura reed coo/cne 4.00 37.00 X 33754 303788 29981 FERRANTE ROBERT MD PHYSICIAN 40.00 X 738007 0 31797 AUGELLI NICHOLAS MD PHYSICIAN 40.00 X 715771 0 34168 SIDHU JASDEEP MD PHYSICIAN 40.00 X 594049 0 33283 WILSON ROBERT MD PHYSICIAN 40.00 X 594131 0 33459 LONG GREGORY MD CMO 4.00 37.00 X 61960 557641 103740 3560449 4466959 871215 76 0 1 0 SPECIALTY CARE INC DEPT 1614 BIRMINGHAM AL 352461614 MEDICAL SERVICES 966434 DAILY CARE HOSPITALIST LLC 2919 SHELTER CREEK GREEN BAY WI 54313 MEDICAL SERVICES 307089 Aureus Radiology LLC PO Box 3037 GOmaha NE 68103 mediCAL SERVICES 272424 Being Human Inc 2040 E Plank Rd Appleton WI 54915 meDICAL SERVICES 261168 RADIOLOGY ASSOCIATES OF APPLETON PO Box 117 Appleton WI 54912 MEDICAL SERVICES 228164 11 848120 145315 993435 OUTPATIENT REVENUE 621400 170414265 170414265 INPATIENT REVENUE 621990 101619758 101619758 Cafeteria Revenue 900099 877691 877691 OTHER MISC REVENUE 900099 465824 465824 273377538 4845 4845 50135 0 50135 50135 50135 274425953 272034023 0 1398495 945490 410452 535038 86183475 78090336 8093139 1901280 1901280 14850779 13380141 1470638 5471765 5471765 18599936 15121926 3478010 199597 199597 1372339 1155528 216811 5952915 5911535 41380 83178 83178 303550 303550 4910194 4910194 14294692 14294692 590302 590302 CLIENT & PATIENT SERVIC 68387165 68387165 Bad debt expense 5001000 5001000 Equipment Maintenance 4186795 4186795 233234452 219399436 13835016 0 28374098 35797693 2459185 3083067 254060334 150025645 101449303 104034689 276067357 306752943 408349943 449668392 0 126948 0 126948 X 408349943 449541444 408349943 449541444 408349943 449668392 41191501 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 6911 6911 0 Part II-B, Line 1: Lobbying = $6,911 2384215 2384215 152479766 75598617 76881149 1185024 760458 424566 98011329 73666570 24344759 104034689 Due from Affiliates 306752943 306752943 Other Liabilities 126948 126948 1 1 X 1 X 1 X 1 0 1 1 956522 956522 0.00420 21008268 16765522 4242746 0.01860 21964790 16765522 5199268 0.02280 19 336536 965735 965735 0.00420 3 1485 917573 917573 0.00400 4 1662956 1662956 0.00730 2 22 158978 158978 0.00070 6 1097039 761271 761271 0.00330 34 1435082 4466513 4466513 0.01950 34 1435082 26431303 16765522 9665781 0.04230 17920 17920 0.00010 1 2000 2464 2464 0.00000 1 250 14767 14767 0.00010 1 19 2529 2529 0.00000 1 446 183219 183219 0.00080 4 2715 220899 220899 0.00100 0 1950320 932576 42245664 41125341 1120323 X 1 1 1 1 thedacare regional medical center - appleton inc PO BOX 8025 APPLETON WI 54912 https://www.thedacare.org 169 X X X thedacare regional medical center - appl 1 0 0 1 X X X X X X X X X 16 1 1 1 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 regional medical center - appleton, 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, veterans, Hispanics/Latino's, LGBT, Hmong and African American. Input was collected by representatives of:- Rural Health Initiative- Casa Hispana- Aging and disability Resource Center of Outagamie County- Hmong-American Partnership- Outagamie County Veterans' Service - African Heritage, Inc.- LGBT Partnership thedacare regional medical center - appleton, inc. Part V, Section B, Line 6a: Affinity Health System & Aurora Health thedacare regional medical center - appleton, inc. Part V, Section B, Line 6b: ThedaCare Regional Medical Center-Appleton is a member of the Fox Valley Community Health Coalition whose members include the Public Health Departments of Calumet, Outagamie and Winnebago Counties and the Health Departments of the City of Appleton and City of Menasha. Member also includes representatives from Aurora Health in Oshkosh and Affinity Health in Appleton. This coalition was part of a joint CHNA during 2015/2016. thedacare regional medical center - appleton, inc. Part V, Section B, Line 7d: Hospital facility website: https://www.thedacare.org/full CHNA and implementation strategy website: https://www.thedacare.org/Getting-Involved/Improving-Community-Health.aspx thedacare regional medical center - appleton, inc. Part V, Section B, Line 11: The ThedaCare Community Health Implementation Strategy was approved by 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- ThedaCare supports Weight of the Fox Valley - a four healthcare system approach to tackling obesity in Calumet, Outagamie and Winnegaco Counties, with financial contributions and participation on the leadership and core teams. Using the collective impact approach, Weight of the Fox Valley workgroups include Active Communities, Worksite, Early Care and Education, Food System, Healthcare and school. - Provides funding to local Farmer's Markets including the Downtown Appleton Farmers' Market.- ThedaCare partners with local YMCA's 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.Mental 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. - ThedaCare annually sponsors Party at the PAC for thousands of area youth to educate on the perils of risky behavior while texting/drinking and driving. Early Childhood/Youth- ThedaCare is a supporter of the Reach out and Read Program.Poverty- ThedaCare is a partner with The Poverty Outcomes & Improvement Team (POINT), an 18 month initiative equipping the region with continuous improvement methodologies focused on poverty. POINT is using these processes to strengthen existing poverty reduction efforts, address service gaps, and measure progress on reducing poverty in Northeast Wisconsin.Health Disparities:- Opportunity Gap working to close the graduation gap between Black and White students in the Appleton and Menasha school districts.- Diversity and Inclusion working to establish a Diverse and Inclusive Business Council through the Fox Cities Chamber. Also, working to establish a more welcoming downtown Appleton for people of color. End of Life:- ThedaCare is part of the Fox Valley Advanced Care Planning Coalition, a partnership of Mosiac Family Health, Ascension Medical System and ThedaCare Medical System.Identified but not addressed:- Asthma: Beyond scope of resources- E-cigarettes/tobacco: Existing efforts are under way- Dental: Existing efforts are under way- Alzheimer's Disease: Existing efforts are under way- Domestic Violence: Existing efforts are under way thedacare regional medical center - appleton, 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 regional medical center - appleton, 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 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. 1 1 - GROTH SURGERY CENTER PO BOX 8025 APPLETON WI 54912 OUTPATIENT SURGERY CENTER 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 $5,001,000. Part II, Community Building Activities: Obesity- ThedaCare supports Weight of the Fox Valley - a four healthcare system approach to tackling obesity in Calumet, Outagamie and Winnegaco Counties, with financial contributions and participation on the leadership and core teams. Using the collective impact approach, Weight of the Fox Valley workgroups include Active Communities, Worksite, Early Care and Education, Food System, Healthcare and school. - Provides funding to local Farmer's Markets including the Downtown Appleton Farmers' Market.- ThedaCare partners with local YMCA's 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. Mental 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. - ThedaCare annually sponsors Party at the PAC for thousands of area youth to educate on the perils of risky behavior while texting/drinking and driving. Early Childhood/Youth- ThedaCare is a supporter of the Reach out and Read Program.Poverty- ThedaCare is a partner with The Poverty Outcomes & Improvement Team (POINT), an 18 month initiative equipping the region with continuous improvement methodologies focused on poverty. POINT is using these processes to strengthen existing poverty reduction efforts, address service gaps, and measure progress on reducing poverty in Northeast Wisconsin.Health Disparities:- Opportunity Gap working to close the graduation gap between Black and White students in the Appleton and Menasha school districts.- Diversity and Inclusion working to establish a Diverse and Inclusive Business Council through the Fox Cities Chamber. Also, working to establish a more welcoming downtown Appleton for people of color. End of Life:- ThedaCare is part of the Fox Valley Advanced Care Planning Coalition, a partnership of Mosiac Family Health, Ascension Medical System and ThedaCare Medical System. 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 Regional Medical Center-Appleton service area consists of Outagamie and Calumet Counties and is located in east-central Wisconsin. The two-county area hosts a population of over 225,000 combined with concentration in the Fox Cities urban area.Outagamie County: Over the last decade, Outagamie County population has grown by 9.77%. This will make Outagamie the 5th most populous county in Wisconsin by 2035. Outagamie County high school graduation rate is 90%. 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. In comparison to more rural counties in the ThedaCare service area, Outagamie and Calumet Counties continue to have a higher percentage of children. In Outagamie County 9% of the population live below 100% of the Federal Poverty Level and 9% of the population is uninsured. The percentage of non-Caucasian population has grown from 9.3% to 10.7%. Ninety one percent of the service area is Caucasian with Hispanic population of 4.1%. The largest minority populations are Latino (4.1%) and Asian (3.5%). Native Americans account for approximately 1.8% of the population and African-Americans represent 1.8%. Calumet County: Over the past decade, Calumet County has grown in population by 20.53%. The Calumet County high school graduation rate is 94% 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. In comparison to more rural counties in the ThedaCare service area, Outagamie and Calumet Counties continue to have a higher percentage of children. Six percent of the Calumet County population live below 100% of the Federal Poverty Level, 9% of Calumet County is uninsured. The percentage of non-Caucasian population has grown from 6.5% to 7.9%. Ninety five percent of service area is Caucasian with Hispanic population of 4.3% seeing the fastest growth. Native Americans account for approximately 0.5% of the population and African-Americans represent less than 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. 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 0 1 0 0 0 0 0 1 0 GRUNER DEAN BOARD MEMBER/CEO - SYSTEM 84854 763682 25281 227533 19553 175973 19316 173842 2213 19917 151217 1360947 0 0 EDELMAN GARY MD BOARD MEMBER/PHYSICIAN 0 358282 0 4429 0 32538 0 9950 0 19881 0 425080 0 0 MOARD DOUGLAS MD BOARD MEMBER/PHYSICIAN 0 252785 0 41606 0 2126 0 9950 0 24168 0 330635 0 0 TURK NORMA MD BOARD MEMBER/PHYSICIAN 314186 0 70312 0 4678 0 9950 0 11326 0 410452 0 0 0 OLSON TIM VP CFO SYSTEM 46522 418697 6918 62261 2187 19680 795 7155 2119 19074 58541 526867 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 BURMEISTER BRIAN VP SR AMC & TC 114619 267445 17206 40148 16471 38433 12628 29465 6465 15086 167389 390577 0 0 laura reed coo/cne 32993 296938 0 0 761 6850 740 6658 2258 20325 36752 330771 0 0 FERRANTE ROBERT MD PHYSICIAN 735799 0 414 0 1794 0 9950 0 21847 0 769804 0 0 0 AUGELLI NICHOLAS MD PHYSICIAN 695258 0 414 0 20099 0 9950 0 24218 0 749939 0 0 0 SIDHU JASDEEP MD PHYSICIAN 555739 0 24164 0 14146 0 9950 0 23333 0 627332 0 0 0 WILSON ROBERT MD PHYSICIAN 564819 0 24164 0 5148 0 9950 0 23509 0 627590 0 0 0 LONG GREGORY MD CMO 47651 428856 7013 63117 7296 65668 7679 69112 2695 24254 72334 651007 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. 8 Employees received taxable medical expense reimbursements and 5 employees received club dues reimbursements. Part I, Line 3 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, invested 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 4b 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 regional medical center - appleton,inc. (Appleton) reports "0" employees because employees are paid by ThedaCare, Inc., therefore, Appleton does not file any W-2 forms. ThedaCare Inc. is reimbursed by Appleton for salary expenses for the employees who are permanently assigned to Appleton. Form 990, Part VI, Section A, line 6 thedacare regional medical center - appleton, 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. 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 participate 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 SR VP of human resources, advises, validates, and approves a range for CEO compensation. The committee also ratifies the bonus plan. Form 990, Part VI, Section C, line 19 thedacare regional medical center - appleton, Inc. does not make its governing documents, conflict of interest policy and internal financial statements available to the public. FORM 990, Part XII, Line 2c THIS PROCESS DID NOT CHANGE DURING THE 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 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 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 thedacare family of foundations inc C 848120 actual