2016-11-02T14:05:18-05:00 2015-12-31 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2015-01-01 390871113 ThedaCare Medical Center - Waupaca Inc THED 7152581000 800 Riverside Dr Waupaca WI 54981 Tim A Olson Chief Financial Officer 7152581000 2016-10-19 1 Terri Rexrode CPA MST P00096513 9206620016 2016-10-14 2015 2017-02-10 21:41:12Z Tim A Olson 800 Riverside Dr Waupaca WI 54981 38137925 0 X www.thedacare.org X 1955 WI Improving the health of our community. 10 6 0 155 0 0 28967 15164 36457206 37749999 468948 -124025 239417 285136 37194538 37926274 0 1244 0 0 20716059 18096884 0 0 0 10871391 12603336 31587450 30701464 5607088 7224810 79709092 85593758 3821081 2877503 75888011 82716255 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 30020000 1244 37680207 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. 30020000 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 0 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 LAZERS LAINE BOARD TREaSURER 1.00 X X 0 0 0 ANTHONY CHRIS BOARD SECRETARY 1.00 X X 0 0 0 BURMEISTERBRIAN BOARD MEMBER/VP SR AMC & TC 5.00 38.00 X 47560 428044 61298 FAULKS RANDY BOARD MEMBER 1.00 X 0 0 0 HALLETT MARK MD BOARD MEMBER/CHIEF CLINICAL OFFICER 1.00 40.00 X 446965 0 30123 HANSEN KENLEY BOARD MEMBER 1.00 X 0 0 0 LONGGREGORY MD BOARD MEMBER/CMO 5.00 37.00 X 61539 553851 99179 WENBERG ELLEN MD BOARD MEMBER/PHYSICIAN 41.00 X 195726 0 28748 KANTOS CRAIG CEO 40.00 X 274440 0 26888 GRUNER DEAN CEO - SYSTEM 4.00 39.00 X 125990 1133910 214531 OLSON TIM VP CFO SYSTEM 4.00 37.00 X 53683 483143 28004 LIVINGSTON KEITH VP SR CIO 4.00 36.00 X 51346 462104 108486 PISTONE MAUREEN VP SR HR SERVICES 4.00 36.00 X 47096 423867 99911 DEVINE GREGORY VP SR PROVIDER STRATEGY 4.00 36.00 X 71049 639437 82381 PETERSON ROBERT MD PHYSICIAN 40.00 X 324648 0 22873 HUNTER WILLIAM VP SR PLANNING & MARKETING 4.00 36.00 X 41500 373502 14764 POOLE JOHN VP SR THEDACARE IMPROVE SYS 4.00 36.00 X 40405 363648 25230 MANN WILLIAM VP SR STRATEGY 4.00 36.00 X 43983 395848 74173 1825930 5257354 916589 19 0 1 0 AMER DIAGNOSTIC MEDICINE INC PO BOX 4210 LISLE IL 60532 MEDICAL SERVICES 212506 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MEDICAL SERVICES 110712 2 5986 9178 15164 OUTPATIENT REVENUE 621400 26595417 26595417 INPATIENT REVENUE 621990 8755454 8755454 OTHER MISC REVENUE 621990 2326078 2326078 Cafeteria Revenue 722210 69792 69792 Affiliate Rental Revenue 900099 3258 3258 37749999 87626 87626 285136 0 285136 285136 285136 211651 -211651 -211651 -211651 37926274 37680207 0 230903 1244 1244 1451244 1002890 448354 13228166 13228166 466884 466884 2030103 2013829 16274 920487 920487 68557 68557 2583780 2378298 205482 4299 4299 398112 388842 9270 884620 882536 2084 50731 50731 104703 104703 168697 168697 2046780 2046780 123058 123058 CLIENT & PATIENT SERVIC 4169084 4169084 Bad Debt Expense 1240027 1240027 Equipment Maintenance 760888 760888 30701464 30020000 681464 0 2000000 2000000 4733477 4706600 325726 426353 57677938 32129419 25579076 25548519 10473275 9888664 36597538 43023622 79709092 85593758 221566 3599515 2877503 3821081 2877503 X 75886153 82716255 1858 0 75888011 82716255 79709092 85593758 X 7224810 -394708 -1858 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 2960 2960 0 Part II-B, Line 1: Portion of WHA DUES = $2,960. 2102028 2102028 39433730 18567863 20865867 1025200 801945 223255 15116980 12759611 2357369 25548519 Due From Affiliate 42896139 due from third party settlements 127483 43023622 Allocable portion of tax-exempt bonds due to Affiliate 2877503 2877503 1 1 1 X 1 X 1 0 1 1 115605 115605 0.00390 3864367 4425482 -561115 0.00000 3979972 4425482 -445510 0.00390 22 82417 247007 16720 230287 0.00780 3 94 53820 53820 0.00180 5 1920851 1920851 0.06520 6 216649 280275 280275 0.00950 36 299160 2501953 16720 2485233 0.08430 36 299160 6481925 4442202 2039723 0.08820 1 14383 11998 11998 0.00040 1 26 1160 1160 0.00000 1 602 4669 4669 0.00020 1 157 157 0.00000 1 30 30 0.00000 1 206 7001 7001 0.00020 6 15217 25015 25015 0.00080 0 689106 120038 8666067 8625494 40573 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 X 13 1 1 0 1 X see 7d X X 1 13 1 see 7d 1 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X X X 1 X www.thedacare.org/~/link.aspx?_id=206478F0E2874D2EAD353B71BC978623& X www.thedacare.org/~/link.aspx?_id=206478F0E2874D2EAD353B71BC978623& X WWW.THEDACARE.ORG/~/LINK.ASPX?_ID=206478F0E2874D2EAD353B71BC978623& X X X X X X 1 X 0 X X X X 1 X 0 0 thedacare medical center - waupaca, INC. Part V, Section B, Line 3j: ThedaCare Medical Center - Waupaca's CHNA also identified owner expectations, mission/values, key components of our commitment, organizational support, advisory team guidance and the Health Improvement Model. thedacare medical center - waupaca, INC. Part V, Section B, Line 5: Public HealthThedaCare worked closely with Waupaca County Public Health Department throughout the entire needs assessment process. ThedaCare has representation on the Fox Valley Community Health Improvement Coalition which meets monthly with local health system representatives and public health officials from the Counties of Outagamie, Calumet and Winnebago and Cities of Appleton and Menasha. Waupaca County public health is also invited to attend. Public Health is represented on ThedaCare's Needs Assessment Advisory Committee and also on the ThedaCare- led Waupaca Community Health Action Team. In addition to these formal meetings, one-on-one interviews with public health officials were conducted either over the phone or in person. Sources: Linda Behm, Waupaca County Public Health Nurse.Community Health Action Teams (CHAT) are the primary resources ThedaCare uses to engage the community in better understanding the local health needs and developing plans for action. ThedaCare's Community Health Specialists help facilitate the CHAT efforts for four CHAT teams in the Fox Cities, New London, Shawano and Waupaca areas. Each CHAT team is comprised of local community leaders from business, education, public health, area health systems, faith communities, non-profit organizations and government. These leaders select issues to study, organize "plunge" experiences (day-long field trips) to gain in-depth understanding and collaborate in problem-solving initiatives. This results in sustainable, effective community-based solutions to systemic health issues. ThedaCare Medical Center - Waupaca providers and staff are integrated into a wide variety of these initiatives. The Waupaca CHAT team includes leaders from public health, non-profits, education, ministry and health organizations which collectively represent the broad interests of the community. Key informant interviews were conducted with experts representing vulnerable or marginalized populations in our community including farm families, elderly, school counselors, police liaison officer, SADD director, social worker and psychologist. Sources: Pat Enright, Aging and Disability Resource Center Waupaca County; Kim Ebert, New London Senior Services Manager; Teri Moe, Waupaca Senior Center; Greg Blonde and Connie Abert, University of Wisconsin Extension-Waupaca County; Rhonda Strebel, Rural Health initiative; Pat Enright, ADRC Manager; Kim Ebert Waupaca County Senior Services, Brian Hoelzel, Waupaca City Police, Father Jim, Anne Collins-Reed, Jeff Dolski, Jesse Riegert, Denise Saffeidt, Shane Dornfeld; Waupaca Schools counseling group. thedacare medical center - waupaca, INC. Part V, Section B, Line 6a: Affinity Health System thedacare medical center - waupaca, INC. Part V, Section B, Line 7d: The CHNA was made available to local CHAT, ThedaCare boards and leadership teams.FULL WEBSITE FOR CHNA & implementation strategy: https://www.thedacare.org/Hospitals-and-Clinics/ThedaCare-Medical-center-waupaca.aspx thedacare medical center - waupaca, INC. Part V, Section B, Line 11: Obesity:-Supported the purchased of new refrigerators for Waupaca county Food Pantries which allowed for fresh food storage-Worked with the Waupaca County Nutrition and Activity Coalition on a restaurant healthy food initiative-contributed financial support to the local farmer's Market-contributed support to Project Backpack - supplying food to children during weekends-supported numerous youth sporting teams-Parks and Recreation is a member of the Waupaca community Health Action Team-Sponsored many family related activity events-In 2015, ThedaCare established Good to Go Week an employee led initiative that took place in 6 school districts throughout the ThedaCare system. Activities will include healthy snacks, build a school garden, fats in foods, measure your drink, leading gym classes-ThedaCare led Community Health Action Team - CHAT - took the community on a Plunge into ObesityMental Health: -ThedaCare held a day- long event that brought together 62 community members interested in learning more about issues of mental health. -ThedaCare provides financial and in-kind support for the Primary Care/Mental Health Initiative aimed at improving PCP's ability to treat basic mental health issues,-Provides leadership and financial support for Catalpa Health - helping children and families obtain mental health and wellness-Provides leadership and funding for the Fox Valley Community Clinic-Provided over $1,000,000 in subsidized mental health services, provided leadership and financial support for the NEW Mental Health Connection-Supports the New Mental Health Connection, a coalition of mental health providersSubstance Abuse:-With the thedaCare led Community Health Action Team, conducted two major drug take back day initiatives and doubles the amount of unused drugs collected-Provide leadership to the Waupaca County Criminal Justice CommitteeAccess to Primary Care:-Provide financial support to the Partnership Community Health Center-Provide 24/7 access to medical call advise via telephone-Provide leadership and financial support to the rural Health Initiative - an initiative that takes healthcare right to the farmer's doorIdentified but not working on:1.Poverty - beyond the scope of our resources at this time2.Motor vehicle crash rate - beyond the scope of our resources at this time3.Access to dentists - beyond the scope of our resources at this time4.Some college education - beyond the scope of our resources at this time5.Access to recreational facilities - may be included in the obesity priority6.Independent living support - beyond the scope of our resources at this time7.Chronic disease prevention - significant existing efforts 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 16i: 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. thedacare medical center - waupaca, INC. Part V, Section B, Line 20e: ThedaCare and/or third party collection agency are placing a minimum of one outbound call to advise customer of payment options including FA prior to credit bureau reporting or legal judgement. Process adjusted to ensure no ECA until customer receives at least 4 billing statements after date of discharge. No ECA until at least 120 days after discharge. thedacare medical center - waupaca, INC. Part V, Section B, Line 22d: Lookback Method: For ER patients, take the 3 largest commercial insurers plus Medicare. Add all payments and all charges to arrive at a deduction percentage. Reduce the patient's bill by this percentage. For non-ER patients, take the 3 largest commercial insurers. Add all payments and all charges to arrive at a deduction percentage. 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 $1,240,027. Part II, Community Building Activities: THE HEALTH OF THE COMMUNITY ThedaCare Medical Center - Waupaca SERVES IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW:Chamber of Commerce Support - encourages economic development which in turn provides jobs and income, both contributors to health.Disaster Readiness - helps ensure the entire community is ready for potential emergencies. Rural Provider Recruitment - ensures quality of healthcare services in rural markets.Teaming for Health & Resiliency Improvement Via Education and Support (THRIVES) - Assisting people with chronic illness.CHAT - community leaders working together to explore local and regional health issues.Sexual Assault Nurse Examiner - working to end sexual and domestic violence.Emerging Leaders - making an impact in our community through dedication to service/philanthropy.Electronic Recycling Event - working to treat the Earth with the respect that it deserves.Community Sharps Collection - reducing the risks of infectious waste.Community Garden/Farmer's Markets - provides fresh produce to area food pantries/community.Wisconsin Sustainable Business Council - taking an active position on the role of climate change and building healthy communities by reducing or eliminating our energy waste and water footprint.Fox Valley Family Medicine Residency Program - teaching the art and heart of care.ThedaCare Center for Healthcare Value - offers learning experiences that develop healthcare leaders who are capable of confidently driving the lean transformation of their organizations to deliver measurably better value to the patients, families and communities they serve.Community Chest - working every day to improve the community.Plunge into Alcohol/Drugs - a day-long education learning event about the effects of drugs and alcohol on local schools, law enforcement, legal system, healthcare and the community.Drug Take Back Collection Campaign - a campaign focused on the dangers of pharmaceutical drugs and how to safely dispose of them.Concussion Management Program - educating students, parents and coaches to recognize the value of reducing the risk of injury. Waupaca County Nutrition and Activity coalition (NUACT) - creating environments that promote healthy eating and physically active lifestyles. Rural Health Initiative - addressing growing concerns regarding the health and safety issues facing today's farm families.Plunge into Mental Health - a day-long education learning event about mental health issues and the effect on local schools, law enforcement, legal system, healthcare and the community.Mentoring Committee - a committee working on creating an on-site mentoring program for kids in the Waupaca area.Mission of Hope - providing basic services to community in need.Foundations for Living - teaching basic living skillsWaupaca Warming Shelter - offering shelter for those in need 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 serves a 9 county primary service area. Seven ThedaCare hospitals provide service in this area. ThedaCare conducts a Community Needs Assessment every two years for the entire system gathering data pertinent to each community. Information collected includes data from the Wisconsin County Health Rankings, Fox Cities LIFE Study (Local Indicators for Excellence), the Behavioral Risk Factor Surveillance Survey, and insights gathered from monthly meetings of the ThedaCare-led CHAT Team (Community Health Action Team) comprised of 14 community leaders in business, non-profit, clergy, healthcare, education, Public Health and the local Community Foundation. 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. The population of Waupaca County is 52,410. 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 population growth rate over the last decade is 5.5%.-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.-Twelve percent of Waupaca County population lives below 100% of the Federal Poverty Level. The uninsured rate is 10%.-In Waupaca County, the largest minority population is also Latino. Native American, Asian, multi-racial and African-American account for less than 1% each. Part VI, Line 5: Each year, ThedaCare Medical Center - Waupaca's parent organization ThedaCare sets aside a percentage of excess net budgeted income to fund an effort called CHAT (Community Health Action Team). CHAT is a group of 14 local 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. Through CHAT, such efforts as the Shawano County Rural Health Initiative have been developed. This Initiative takes basic health care and screening services to the farm. Each year hundreds of farm families living without insurance or only catastrophic coverage receive critical assistance. This initiative has now spread to Outagamie, Winnebago and Waupaca Counties. In 2014, Waupaca took a Plunge into Mental Health. ThedaCare provides funding and staff support to make CHAT and these community health efforts possible. Other ways that ThedaCare hospitals improve the health of the community include:-In 2015, ThedaCare shared its cutting edge application of Lean Production improvements with hundreds of healthcare and non-healthcare visitors from around the world. Most were visitors were from hospitals and health systems in the United States looking to improve quality and reduce costs.-ThedaCare hospitals provided support to the ThedaCare Center for Healthcare Value which is coordinating efforts across the country to share quality improvement and cost reduction learnings. -ThedaCare partners with the Fox Cities/UW Residency Center to provide hands on experience for medical students.-ThedaCare also partners with area nursing schools such as UW Steven's Point and Fox Valley Technical College to provide professional mentors for their nursing programs and venues for nursing students to practice their skills.-ThedaCare hospitals provided 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 hospital 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. ThedaCare employees donated more than $1,707,000 in unpaid volunteer hours to local non-profits in 2015.-ThedaCare Medical Center - Waupaca staff are engaged in Waupaca County NuAct Coalition, a community-wide multi-disciplinary team addressing community health and wellness needs-ThedaCare medical center - Waupaca hosts support groups for diabetes, living with loss and new baby.-ThedaCare medical center - waupaca staff work with the area Chamber of Commerce and local high schools and colleges to inform youth about medical career opportunities and to help prepare our educational facilities to meet the healthcare staffing needs for the communities we serve.-ThedaCare medical center - waupaca reaches out to the community to host screenings and health fairs.-ThedaCare medical center - waupaca hosts an annual Fun Run for the community and also sponsors an annual area Triathlon to encourage fitness and activity. ThedaCare Medical Center - Waupaca staff provide free athletic training services to area high school athletic events.-ThedaCare staff support the American Heart Association's Go Red for Women event.-ThedaCare medical center - waupaca staff are involved in statewide and regional disaster readiness planning to prepare our community for times of crisis.-ThedaCare President and CEO is engaged in statewide Wisconsin Collaborative for Healthcare Quality making quality healthcare data transparent. -A Plunge into Substance resulted with the Waupaca CHAT working with Waupaca County to partner on Drug Take Back Days. Collected drugs were doubled.-Because of A Plunge into Mental Health an on-site mentoring project was launched in 2015. Currently 18 children are matched.-A Plunge ino Obesity was taken in 2015. Part VI, Line 6: ThedaCare, the parent organization, provides direction related to community needs assessment for all hospitals and markets within its service area. 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 BURMEISTERBRIAN BOARD MEMBER/VP SR AMC & TC 37577 338195 4468 40213 5515 49636 4209 37885 1920 17284 53689 483213 0 0 HALLETT MARK MD BOARD MEMBER/CHIEF CLINICAL OFFICER 387534 0 29679 0 29752 0 7950 0 22173 0 477088 0 0 0 LONGGREGORY MD BOARD MEMBER/CMO 45761 411847 5628 50652 10150 91352 7679 69114 2239 20147 71457 643112 0 0 WENBERG ELLEN MD BOARD MEMBER/PHYSICIAN 190584 0 3410 0 1732 0 7994 0 20754 0 224474 0 0 0 KANTOS CRAIG CEO 242810 0 15680 0 15950 0 7810 0 19078 0 301328 0 0 0 GRUNER DEAN CEO - SYSTEM 83135 748215 21061 189553 21794 196142 19316 173848 2137 19230 147443 1326988 0 0 OLSON TIM VP CFO SYSTEM 45333 407997 5630 50670 2720 24476 795 7155 2005 18049 56483 508347 0 0 LIVINGSTON KEITH VP SR CIO 37782 340035 4656 41900 8908 80169 8892 80025 1957 17612 62195 559741 0 0 PISTONE MAUREEN VP SR HR SERVICES 32446 292018 4049 36438 10601 95411 8018 72164 1973 17756 57087 513787 0 0 DEVINE GREGORY VP SR PROVIDER STRATEGY 47894 431044 14711 132401 8444 75992 6243 56190 1995 17953 79287 713580 0 0 PETERSON ROBERT MD PHYSICIAN 303369 0 10620 0 10659 0 7950 0 14923 0 347521 0 0 0 HUNTER WILLIAM VP SR PLANNING & MARKETING 18622 167594 4553 40980 18325 164928 635 5713 841 7575 42976 386790 0 0 POOLE JOHN VP SR THEDACARE IMPROVE SYS 35105 315948 4526 40730 774 6970 564 5075 1959 17632 42928 386355 0 0 MANN WILLIAM VP SR STRATEGY 34416 309746 4199 37787 5368 48315 6459 58128 959 8627 51401 462603 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 purposes of developing business relationships have company paid memberships at a local country club. 1 Employee received taxable medical expense 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, improve ThedaCare Inc's ability to compete with other employers for high talent 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 executives 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, 2014 to December 31, 2014) to receive their 2015 bonuses. If the employee retires, becomes disabled, moves to a position that is eligible under the bonus plan or 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 earned will be forfeited. Caring for Success The plan objectives are to provide incentive to focus the organization's resources, energy and attention on the fulfillment 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 - 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 11 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 9: funds released from restriction -1,858. 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 11b, II 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 11a, I 0 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0