2016-11-02T14:05:18-05:00 2015-12-31 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2015-01-01 390830664 ThedaCare Regional Medical Center - Neenah Inc THED 9207355560 PO Box 8025 Appleton WI 549128025 TIM A OLSON Chief Financial Officer 9207355560 2016-10-19 1 Terri Rexrode CPA MST P00096513 9206620016 2016-10-19 2015 2017-02-10 21:41:12Z Tim A Olson PO Box 8025 Appleton WI 549128025 206185084 0 X www.thedacare.org X 1909 WI IMPROVING THE HEALTH OF OUR COMMUNITY. 19 15 0 433 2004344 0 821289 2701393 192548696 202977746 69154 -141951 68800 429600 193507939 205966788 0 0 0 0 84999021 81937697 0 0 0 89034348 94256581 174033369 176194278 19474570 29772510 293620221 322651661 723970 0 292896251 322651661 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 163228413 200336007 250-BED ACUTE CARE HOSPITAL, LEVEL II TRAUMA CENTER, NEUROLOGY, AND OUTPATIENT SURGERY CENTER. WITH CORPORATE PARENT THEDACARE, INC., WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. 163228413 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 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 1 1 0 0 0 0 0 0 0 0 0 X 19 15 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 DAVISJOHN 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 BERGSTROM TIM BOARD MEMBER 1.00 2.00 X 0 0 0 BRENNAN PAT BOARD MEMBER 1.00 2.00 X 0 0 0 BURSTEIN MARK BOARD MEMBER 1.00 2.00 X 0 0 0 EDELMANGARY MD BOARD MEMBER/PHYSICIAN 1.00 42.00 X 0 405505 29119 GALATOWITSCH KRISTIN BOARD MEMBER 1.00 3.00 X 0 0 0 GRUNERDEAN BOARD MEMBER/CEO - SYSTEM 4.00 39.00 X X 125990 1133910 214531 KLISTER PAUL BOARD MEMBER 1.00 2.00 X 0 0 0 LaMONTAGNE GRANT BOARD MEMBER 1.00 2.00 X 0 0 0 LARSONJIM 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 299614 33237 STELLMACHERJON BOARD MEMBER 1.00 2.00 X 0 0 0 TIMBERLAKEKAREN BOARD MEMBER 1.00 2.00 X 0 0 0 TURK NORMA MD BOARD MEMBER/PHYSICIAN 1.00 42.00 X 0 326042 33449 WALSH CYRIL P MD BOARD MEMBER 1.00 2.00 X 0 0 0 WHITESIDE JEFFREY MD BOARD MEMBER 1.00 2.00 X 0 0 0 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 BURMEISTER BRIAN VP SR AMC & TC 8.00 35.00 X 95120 380483 61298 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 LONG GREGORY MD CMO 4.00 38.00 X 61539 553851 99179 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 631711 6240954 903762 57 0 1 0 NEUROSCIENCE GROUP OF NE WI 1305 W American DRIVE NEENAH WI 54956 MEDICAL SERVICES 984425 SURGICAL ASSOCIATES NEENAH SC 100 THEDA CLARK MED PLAZA STE 400 NEENAH WI 54956 MEDICAL SERVICES 852096 PHYSICIANS REALTY LP 309 N WATER ST STE 500 MILWAUKEE WI 53202 MEDICAL SERVICES 702732 uspack logistics llc po box 123545 dallas TX 75312 mediCAL SERVICES 649637 DAILY CARE HOSPITALISTS LLC PO BOX 11934 GREEN BAY WI 543071934 MEDICAL SERVICES 589565 15 2695582 5811 2701393 OUTPATIENT REVENUE 621400 99165832 99165832 INPATIENT REVENUE 621990 98652944 98652944 LAB REFERRAL REVENUE 621500 1919666 1919666 Affiliate Rental Revenue 900099 1860724 1860724 OTHER REVENUE 621990 741185 656507 84678 637395 637395 202977746 76345 76345 429600 0 429600 429600 429600 218296 -218296 -218296 -218296 205966788 200336007 2004344 925044 X 430588 430588 63831827 55270090 8561737 2891468 2891468 10259637 10122376 137261 4524177 4524177 19187687 15725088 3462599 18263 18263 1496197 1158406 337791 5826148 5790259 35889 44850 44850 161431 161431 3483427 3483427 12457440 12457440 425522 425522 CLIENT & PATIENT SERVIC 41826165 41826165 Bad Debt Expense 6607350 6607350 Equipment Maintenance 2722101 2722101 176194278 163228413 12965865 0 27057920 27174283 1850927 1786431 226236196 137289849 88489801 88946347 176221573 204744600 293620221 322651661 723970 0 723970 0 X 292879151 322651661 17100 0 292896251 322651661 293620221 322651661 X 29772510 -17100 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 8879 8879 0 Part II-B, Line 1: WHA DUES of $8,879. 6175775 6175775 150192489 81274135 68918354 2674963 1621782 1053181 67192969 54393932 12799037 88946347 Due from Affiliates 204744600 204744600 1 1 1 X 1 X 1 0 1 1 1397704 1397704 0.00820 23779070 17751840 6027230 0.03550 25176774 17751840 7424934 0.04370 21 849042 1388411 1388411 0.00820 4 1845 714330 295600 418730 0.00250 4 1292219 1292219 0.00760 1 397 6 2947323 582007 582007 0.00340 36 3798607 3976967 295600 3681367 0.02170 36 3798607 29153741 18047440 11106301 0.06540 1 1 18400 6538 11862 0.00010 1 239048 7625 7625 0.00000 1 425 10669 10669 0.00010 1 20 4554 4554 0.00000 1 1477 1477 0.00000 1 1 283 283 0.00000 1 595 31364 31364 0.00020 7 240090 74372 6538 67834 0.00040 0 3001719 1374409 24420351 27945562 -3525211 X 1 1 1 1 THEDACARE REGIONAL MEDICAL CENTER - NEENAH INC 120 SECOND STREET NEENAH WI 54956 https://www.thedacare.org 32 X X X THEDACARE REGIONAL MEDICAL CENTER - NEEN 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/policies-and-legal-forms/payment-options X X X X X X 1 X 0 X X X X 1 X 0 0 THEDACARE REGIONAL MEDICAL CENTER - NEENAH, INC. Part V, Section B, Line 3j: ThedaCare Regional Medical Center - Neenah's CHNA also identified owner expectations, mission/values, key components of our commitment, organizational support, advisory team guidance and the Health Improvement Model. THEDACARE REGIONAL MEDICAL CENTER - NEENAH, INC. Part V, Section B, Line 5: Public HealthThedaCare worked closely with Outagamie, Winnebago, Waushara and Green Lake County Public Health Departments 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. Waushara and Green Lake public health officials are also invited to attend. Public Health is represented on ThedaCare's Needs Assessment Advisory Committee and also on the ThedaCare-led 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: Sources: Doug Gieryn, Winnebago County Public Health Director; Kathryn Munsey,Green Lake Public Health Officer; Patti Wohlfiel, Waushara County Public Health OfficerCommunity 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. Theda Clark Medical Center providers and staff are integrated into a wide variety of these initiatives. The Fox Cities CHAT includes leaders from public health, United Way, Community Foundation, non-profits, education, 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, Latino population, Lesbian, Gay, Bisexual, Transgender (LGBT) Population, low income and seniors. Sources: Leona Whittman, Living Healthy Community Clinic; Tony Beregzazzi, ADVOCAP; Rhonda Strebel, Rural Health Initiative; Ernesto Gonzales, Casa Hispana; Dr. Iris Torres and Patricia Sarvala, Partnership Community Health Clinic; Tony Gonzales, Thompson Senior Center; Tricia Nelson, ThedaCare Medical Home; Hispanic Latino Focus Group Project, 2011; CHAT Plunge on Hispanic Population, 2010; CHAT Plunge on GLBT Population, 2011; CHAT INCLUDE Breakfast, 2013. THEDACARE REGIONAL MEDICAL CENTER - NEENAH, INC. Part V, Section B, Line 6a: Affinity Health System THEDACARE REGIONAL MEDICAL CENTER - NEENAH, INC. Part V, Section B, Line 7d: The CHNA was made available to local CHAT, ThedaCare boards and leadership teams.full chna & implementation strategy website: https://www.thedacare.org/Hospitals-and-Clinics/ThedaCare-regional-medical-center-neenah.aspx THEDACARE REGIONAL MEDICAL CENTER - NEENAH, INC. Part V, Section B, Line 11: Identified and working on:Obesity:-Established Weight of the Fox Valley - a four healthcare system approach to tackling obesity, is in the process of forming work groups. ThedaCare supports this with financial contributions and participation on the leadership and core teams.-Established Eat Smart - a local restaurant initiative promoting healthy eating-Provides funding to local Farmer's Markets to provide healthy food to the community -Contributed financially to the construction of hoop houses at the community garden -ThedaCare partners with local YMCA's to educate children about eating healthy and the benefits of being active-ThedaCare sponsors multiple family events that contribute to exercise and family activity and supports the YMCA Healthy Kids Campaign.-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.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 providers-Established No Wrong Door, a safety net system to detect kids in crisis-Provides leadership to the Suicide Prevention Task ForceSubstance Abuse:-Legislative work on laws related to substance abuse is included in Substance Abuse coalition efforts-Supported ReTHINK! An initiative to deter kids from using drugs and alcohol-Continues to host annually Party at the Pac - educating teens about the dangers of driving while drinking or textingEnd of Life:-With the goal of increasing people who have written end of life directives, ThedaCare is working with other healthcare systems to develop a common system-ThedaCare provides financial and leadership support to the End of Life CoalitionTeen Pregnancy:-Provides financial and leadership support for Cuidate - a culturally sensitive delayed pregnancy prevention initiativeViolence:-Provides funding and leadership to INCLUDE - changing attitudes about the LGBT community in the Fox Valley by educating both youth & adults on the effects of bullying and other behaviors.-Provides funding and leadership to Voices of Men - making a powerful statement that committing, condoning or remaining silent about men's violence against women and children is not acceptable.Access to 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 doorPoverty:-Supported Bright futures Start Here teaching middle through high school students mentoring and life skills-Sponsored Backyard Buddies at a local school partnering ThedaCare employees as mentors for school aged childrenAfrican American Issues:-The Fox Cities ThedaCare ThedaCare led Community Health Action Team - CHAT - took a Plunge into the African American Experience in last October 2015 - initiatives are just getting startedIdentified but not working on:1.Access to mental health care - a variety of other organizations are working on this issue2.Tobacco and smoking - recent state laws and social norms have had a significant impact on the reduction of smoking3.Access to dental care - several recent initiatives have expanded dental capacity including the start-up of a mobile dental bus service4.Affordable medications - Beyond what our resources can support at this time5.Diabetes - significant efforts are underway within local healthcare organizations THEDACARE REGIONAL MEDICAL CENTER - NEENAH, 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 - NEENAH, 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 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. THEDACARE REGIONAL MEDICAL CENTER - NEENAH, 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 REGIONAL MEDICAL CENTER - NEENAH, 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. 2 1 - AYLWARD SURGERY CENTER 120 SECOND STREET NEENAH WI 54956 OUTPATIENT SURGERY CENTER 2 - RENAISSANCE SURGERY CENTER 2400 WITZEL AVENUE OSHKOSH WI 54904 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 $6,607,350. Part II, Community Building Activities: THE HEALTH OF THE COMMUNITY THEDACARE REGIONAL MEDICAL CENTER - NEENAH IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW:Self Sufficiency Project - coalition to end poverty in the Oshkosh area. Poverty is directly related to health. Poverty Simulation - activity to help community leaders understand what it's like to live in poverty and ultimately encourage policy and programs to help lift people out of poverty. Backyard Buddies - provides mentors to help youth from low-income families to be successful academically and socially. Education has direct impact on health. Well City Initiative - promotes development of a healthy workplace throughout the Fox Cities.NEW Mental Health Connection - coalition of mental health providers meeting to improve access to mental health services throughout the Fox Cities.Chamber of Commerce Support - encourages economic development which in turn provides jobs and income, both contributors to health.Voices of Men - works to address the root cause of violence against women and girls which includes devaluing and objectifying women and treating women as property. No Wrong Door - effort to develop community wide mental health safety net.Disaster Readiness - helps ensure the entire community is ready for potential emergencies. Psychiatrist Recruitment - improves mental health of community. Community Action for Healthy Living - coalition that advocates for healthy lifestyle change. ThedaCare Neighborhood Garden/Farmer's Markets - provides fresh produce to area food pantries and the community.Fox Valley End of Life Coalition - a grassroots consortium with a mission to improve end-of-life care and choices for all people, their families, and their physicians in the Fox Cities.Emerging Leaders - making an impact in our community through dedication to service and philanthropy.Party at the PAC - putting teen safety in focus.Electronic Recycling Event - working to treat the Earth with the respect that it deserves.Community Sharps Collection - reducing the risks of infectious waste.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. Organ and Tissue Organization - advancing organ donation education. Rural Health Initiative - addressing growing concerns regarding the health and safety issues facing today's farm families. YMCA Strong Kids - providing kids the opportunities they need to reach their full potential, live healthier, happier lives today, and grow into productive adults in the future. Mosiac Medicine Residency Program - teaching the art and heart of care.Building for Kids - building kids imagination, creativity and confidence. CHAT - community leaders working together to explore local and regional health issues. 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. Trauma Symposium - focusing on emergency preparedness. Sexual Assault Nurse Examiner - working to end sexual and domestic violence.United Way - working every day to improve the community.End of Life Coalition - working towards getting end of life decisions coordinated and documents so that people have their last wishes recognized.Institute for Health Care Improvement - support for community transformation efforts 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 an 9-county primary service area. Seven ThedaCare hospitals provide service in this area. ThedaCare conducts a Community Needs Assessment every three 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, 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 25 community leaders in business, non-profit, clergy, healthcare, United Way, 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 Regional Medical Center - Neenah's service area consists of Winnebago, Waushara, and Green Lake Counties located in east-central Wisconsin. The three county area hosts a combined population of 209,736. Winnebago County: -Since 2000, Winnebago County has experienced a 6.1% population growth, or a total of 9,500 residents. -Winnebago County high school graduation rate is 90%,-Has had a lower unemployment rate than the state or nation primarily due to a strong manufacturing base. Trade/Transportation/Utilities, Education/Health and Manufacturing employ the most people in the county. -The median age of Winnebago County residents is 37 years.-Thirteen percent of Winnebago County live below 100% of the Federal Poverty Level. 10% of the Winnebago County population is uninsured.-The largest minority populations are Latino and Asian. Native Americans account for approximately 1% of the population and African-Americans represents less than 1%. The Latino population has a significant and growing presence at 4.6%. Waushara County:-Over the course of the past decade, Waushara County has experienced a population growth of 10.7%. -Waushara County high school graduation rate is 93%-Has a more seasonal employment base than the state or nation. Education, Health, Trade, Transportation and Utilities and Public Administration are the largest employment sectors. Waushara County's average annual wage across all industry sectors is below the state average. -The median age of Waushara County's population is 46.2 years.-Thirteen percent of Waushara County lives below 100% of the Federal Poverty Level, 13% are uninsured.-The largest minority populations are Latino and Asian. Native Americans account for approximately 1% of the population and African-Americans represents less than 1%. The Latino population has a significant and growing presence at 4.6%. Green Lake County:-Has been among Wisconsin's slower growing counties. -Green Lake County graduation rate is 90%.-Green Lake's unemployment rate is significantly higher than the state. The top employers in Green Lake County are in Health, Education and Manufacturing. -The median age of Green lake County residents is 41 years.-Eleven percent of Green Lake County lives below 100% of the Federal Poverty Level, 12% are uninsured.-The largest minority populations are Latino and Asian. Native Americans account for approximately 1% of the population and African-Americans represents less than 1%. The Latino population has a significant and growing presence at 4.6%. Part VI, Line 5: Each year, ThedaCare Regional Medical Center - Neenah's parent organization ThedaCare sets aside a percentage of excess budgeted margin to fund an effort called CHAT (Community Health Action Team). CHAT is a group of 25 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. Another initiative is the NEW Mental Health Connection which is working to improve access to mental health services in the area. High Latino teen pregnancy rates inspired CHAT to launch Cuidate!, a culturally based teen pregnancy prevention program in partnership with the Fox Cities Community Health Center. Making the Ride Happen is another CHAT effort that provides transportation to older adults who otherwise would stay cooped up in apartments and fight depression and isolation. Project Promise is a poverty initiative developed through CHAT that brought together many local agencies and businesses to work to address poverty in a collaborative fashion. Voices of Men was launched with support from CHAT to raise awareness of everyday behaviors of men that can lead to an acceptance of violence toward women. Another recent initiative is INCLUDE which focuses on building inclusiveness and tolerance to prevent suicide among the Gay, Lesbian, Bisexual, Transgender population. ThedaCare provides funding and staff support to make CHAT community health efforts possible. -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 Affinity Health System to sponsor Mosaic Health, to provide 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 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 sponsors Party at the PAC for thousands of area youth to educate youth on the perils of risky behavior and driving. Hosted at our Performing Arts Center, live dramatizations along with stories of youth disabled due to driving and risky behavior encourage teens to think twice before drinking or texting and driving. -ThedaCare regional medical center - neenah provides helpful community education programming on such topics as asthma, heart disease, pain management, CPR, stroke risk and diabetes.-ThedaCare regional medical center - neenah hosts health and safety fairs in the community.-ThedaCare regional medical center - neenah hosts support groups for stoke victims, grief, diabetes, and infant loss. -ThedaCare regional medical center - neenah works 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 regional medical center - neenah operates a radiology school to prepare new technologists for careers in the field. -A partnership among ThedaCare Regional Medical Center - Neenah, Children's Hospital of Wisconsin and Roosevelt Elementary School provides one-on-one mentoring and health education to underserved children in the Neenah area. -ThedaCare regional medical center - neenah makes financial and in-kind donations to non-profit organizations including United Way, YMCA, Kiwanis, 4H, and Girl Scouts etc to support community initiatives that address health risk factors such as poverty, education, environment and more.-ThedaCare regional medical center - neenah staff support the ThedaCare Neighborhood Garden which supplies produce to the local emergency shelter. -ThedaCare regional medical center - neenah supplies Athletic Training Services to area high schools at reduced cost.-ThedaCare staff participates in Leadership Fox Cities to groom middle managers in the workings of the entire community, from education systems and recycling programs to government and justice systems. -ThedaCare regional medical center - neenah staff is 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.-With information gathers from A Plunge into the End of Life, ThedaCare is working in partnership with the Affinity and Ministry Health Systems to develop a common set of documents with will capture end of life wishes for people living in the Fox Valley and beyond. 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 Community Health Improvement (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 EDELMANGARY MD BOARD MEMBER/PHYSICIAN 0 359979 0 11851 0 33675 0 9950 0 19169 0 434624 0 0 GRUNERDEAN BOARD MEMBER/CEO - SYSTEM 83135 748215 21061 189553 21794 196142 19316 173848 2137 19230 147443 1326988 0 0 MOARD DOUGLAS MD BOARD MEMBER/PHYSICIAN 0 264975 0 31708 0 2931 0 9950 0 23287 0 332851 0 0 TURK NORMA MD BOARD MEMBER/PHYSICIAN 0 266016 0 33281 0 26745 0 9950 0 23499 0 359491 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 BURMEISTER BRIAN VP SR AMC & TC 75154 300617 8936 35745 11030 44121 8419 33675 3841 15363 107380 429521 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 LONG GREGORY MD CMO 45761 411847 5628 50652 10150 91352 7679 69114 2239 20147 71457 643112 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. 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 1, Line 5 Number of employees: 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 - NEENAH, INC. (NEENAH) reports "0" employees because employees are paid by ThedaCare, Inc., therefore, NEENAH does not file any W-2 forms. ThedaCare Inc. is reimbursed by NEENAH for salary expenses for the employees who are permanently assigned to TC. Form 990, Part VI, Section A, line 6 thedacare regional medical center - neenah, 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 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 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 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 THEDA CLARK MEDICAL CENTER INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. Form 990, Part IX, line 11g Purchased Services: Program service expenses 15,327,525. Management and general expenses 3,462,599. Fundraising expenses 0. Total expenses 18,790,124. PROFESSIONAL MEDICAL FEES: Program service expenses 397,563. Management and general expenses 0. Fundraising expenses 0. Total expenses 397,563. Form 990, Part XI, line 9: Net Assets released to or from Restriction -17,100. Form 990, Part XII, Line 2c: OVERSIGHT OF THE AUDIT: The process has not changed from the prior year. 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