2014-11-10T15:30:30-06:00 2013-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2013-01-01 390871113 RIVERSIDE MEDICAL CENTER INC RIVE 7152581000 800 RIVERSIDE DR WAUPACA WI 54981 TIM A OLSON CHIEF FINANCIAL OFFICER 7152581000 2014-10-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-10-06 2013 2015-11-30 17:44:51Z TIM A OLSON 800 RIVERSIDE DR WAUPACA WI 54981 38569634 0 X WWW.THEDACARE.ORG X 1955 WI IMPROVING THE HEALTH OF OUR COMMUNITY. 9 6 0 80 45 0 40572 59212 38142742 37474070 1002959 941178 3849 90629 39190122 38565089 0 0 0 0 19396133 18775876 0 0 0 13924122 14004526 33320255 32780402 5869867 5784687 67717234 75434716 5691606 4765360 62025628 70669356 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 31423876 37397544 25-BED CRITICAL ACCESS HOSPITAL SERVING WAUPACA AND NEARBY COMMUNITIES. RIVERSIDE MEDICAL CENTER, 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. 31423876 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 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 9 6 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 ANTHONY CHRIS BOARD SECRETARY 1.00 0.00 X X 0 0 0 BURMEISTER BRIAN BOARD MEMBER 9.00 33.00 X 72498 289991 80071 DENT ROBERT MD BOARD MEMBER/PHYSICIAN 1.00 40.00 X 0 195634 23142 LONG GREGORY MD BOARD MEMBER/CHIEF MEDICAL OFFICER 7.00 34.00 X 70252 398096 89753 RHODES JACK BOARD MEMBER 1.00 0.00 X 0 0 0 POESCHL DAVID PHD BOARD VICE CHAIRMAN 1.00 0.00 X X 0 0 0 JANSSEN GARY BOARD TREASURER 1.00 0.00 X X 0 0 0 JOHNSON TOM BOARD MEMBER 1.00 0.00 X 0 0 0 LARSON JIM BOARD CHAIRMAN 1.00 3.00 X X 0 0 0 KANTOS CRAIG CEO - RMC 40.00 0.00 X 261795 0 24408 OLSON TIM VP CFO - SYSTEM 6.00 35.00 X 72973 413510 104930 GRUNER DEAN CFO - SYSTEM 6.00 37.00 X 155912 883497 175678 LIVINGSTON KEITH VP SR CIO 6.00 34.00 X 61563 348846 86106 PISTONE MAUREEN VP SR TALENT MANAGEMENT 6.00 34.00 X 52659 298403 80998 BARNAS KIM VP SR AMC & THEDA CLARK HOSPITAL 4.00 36.00 X 41544 373898 99279 DEVINE GREGORY VP SR PROVIDER STRATEGY & SYSTEMS OF CARE 6.00 34.00 X 73066 414039 78875 HUNTER WILLIAM VP SR PLANNING & MARKETING 6.00 36.00 X 62951 356722 76222 PETERSON ROBERT MD PHYSICIAN 40.00 0.00 X 288158 0 18489 POOLE JOHN VP SR THEDACARE IMPROVEMENT SYSTEM (TIS) 6.00 34.00 X 58296 330348 83963 1271667 4302984 1021914 16 0 1 0 RICHARD VEIGA MD SC E2409 PEBBLE RUN RD WAUPACA WI 54981 MEDICAL SERVICES 394599 AMER DIAGNOSTIC MEDICINE INC PO BOX 4210 LISLE IL 60532 MEDICAL SERVICES 214415 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MEDICAL SERVICES 132142 3 59212 59212 OUTPATIENT REVENUE 621400 26852689 26852689 INPATIENT REVENUE 621990 9110699 9110699 OTHER MISC REVENUE 621990 1432693 1432693 CAFETERIA REVENUE 722210 76481 76481 AFFILIATE RENTAL REVENUE 900099 1463 1463 45 45 37474070 945723 945723 90629 0 90629 90629 90629 4545 -4545 -4545 -4545 38565089 37397544 45 1108288 1282982 1282982 13738243 13693447 44796 456746 456746 2405249 2405249 892656 892656 129493 100965 28528 3191743 3191743 4229759 4229539 220 476607 476607 55318 55318 81931 81931 244020 244020 2777771 2777771 120546 120546 BAD DEBT EXPENSE 2066768 2066768 EQUIPMENT MAINTENANCE 603707 603707 MEANINGFUL USE OVERPAYM 26863 26863 32780402 31423876 1356526 0 1295 1295 3459873 2756454 4033953 4219158 190488 229797 55063856 27799467 29070300 27264389 30031892 39825624 929433 1137999 67717234 75434716 155267 180262 5536339 4585098 5691606 4765360 X 62005584 70661170 20044 8186 62025628 70669356 67717234 75434716 X 5784687 2870899 -11858 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 4467 4467 0 PART II-B, LINE 1: PORTION OF WHA DUES = $4,467. 2102028 2102028 38183978 16105292 22078686 1025200 714545 310655 13752650 10979630 2773020 27264389 ALLOCABLE PORTION OF TAX-EXEMPT BONDS DUE TO AFFILIATE 4585098 4585098 X PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THEDACARE DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THEDACARE RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2013 AND 2012. TAX RETURNS FOR THE YEARS ENDED 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 1 X 1 0 1 1 268197 268197 0.00870 3291014 3032831 258183 0.00840 3559211 3032831 526380 0.01710 26 173082 287450 21954 265496 0.00860 4 533 43786 43786 0.00140 5 1559285 1559285 0.05080 2 482 36170 36170 0.00120 6 317898 223485 223485 0.00730 43 491995 2150176 21954 2128222 0.06930 43 491995 5709387 3054785 2654602 0.08640 1 1 336 336 0.00000 1 4819 2948 2948 0.00010 1 100000 7821 7821 0.00030 1 647 4202 4202 0.00010 1 2 118 118 0.00000 1 26886 798 798 0.00000 6 132355 16223 16223 0.00050 0 1128735 263913 6099167 5827135 272032 X 1 1 1 1 RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 X X X X RIVERSIDE MEDICAL CENTER INC 1 1 X X X X X X X X X X 13 1 1 1 X WWW.THEDACARE.ORG/HOSPITALS-AND-CLINICS/R X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 1 X 0 0 RIVERSIDE MEDICAL CENTER, INC. PART V, SECTION B, LINE 1J: RIVERSIDE MEDICAL CENTER - WAUPACA CHNA ALSO IDENTIFIED OWNER EXPECTATIONS, MISSION/VALUES, KEY COMPONENTS OF OUR COMMITMENT, ORGANIZATIONAL SUPPORT, ADVISORY TEAM GUIDANCE AND THE HEALTH IMPROVEMENT MODEL. RIVERSIDE MEDICAL CENTER, INC. PART V, SECTION B, LINE 3: 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 THEDACARES 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. RIVERSIDE MEDICAL CENTER 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. 2013 WAUPACA COMMUNITY HEALTH ACTION TEAM ROSTERCRAIG KANTOS, CEO RIVERSIDE MEDICAL CENTER THEDACARECINDY OERTER, OWNER GREEN FOUNTAIN INN AND GARDEN PARK CBRFLINDA BEHM, PUBLIC HEALTH SUPERVISOR WAUPACA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICESCHUCK TEWS, PASTOR TRINITY LUTHERAN CHURCHSTEVE HUHTA, REALTOR SHAMBEAU REALTYJAY KRCMAR, FINANCIAL MANAGER FARMERS STATE BANKANGIE LANDSVERK, REPORTER WAUPACA COUNTY POSTRHONDA HARE, DIRECTOR OF INSTRUCTION WAUPACA SCHOOL DISTRICTBETTY JO BALZAR, DIRECTOR OF NURSING RIVERSIDE MEDICAL CENTER WAUPACAPAULA MORGEN, COMMUNITY HEALTH THEDACAREKAYE THOMPSON, COMMUNITY HEALTH THEDACAREKEY 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. RIVERSIDE MEDICAL CENTER, INC. PART V, SECTION B, LINE 4: AFFINITY HEALTH SYSTEM RIVERSIDE MEDICAL CENTER, INC. PART V, SECTION B, LINE 5D: THE CHNA WAS MADE AVAILABLE TO LOCAL CHAT, THEDACARE BOARDS AND LEADERSHIP TEAMS. RIVERSIDE MEDICAL CENTER, INC. PART V, SECTION B, LINE 6I: THEDACARE ADDRESSES COMMUNITY HEALTH IMPROVEMENT IN THE ANNUAL STRATEGIC PLANNING PROCESS, AND REPORTS PROGRESS ANNUALLY TO THE THEDACARE BOARD OF TRUSTEES. RIVERSIDE MEDICAL CENTER, INC. PART V, SECTION B, LINE 7: POVERTY - BEYOND THE SCOPE OF OUR RESOURCES AT THIS TIMEMOTOR VEHICLE CRASH RATE - BEYOND THE SCOPE OF OUR RESOURCES AT THIS TIMEACCESS TO DENTISTS - BEYOND THE SCOPE OF OUR RESOURCES AT THIS TIMESOME COLLEGE EDUCATION - BEYOND THE SCOPE OF OUR RESOURCES AT THIS TIMEINDEPENDENT LIVING SUPPORT - BEYOND THE SCOPE OF OUR RESOURCES AT THIS TIMEACCESS TO RECREATIONAL FACILITIES - MAY BE INCLUDED AS PART OF THE OBESITY PRIORITYCHRONIC DISEASE PREVENTION - SIGNIFICANT EXISTING EFFORTS 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 $2,066,768. PART II, COMMUNITY BUILDING ACTIVITIES: THE HEALTH OF THE COMMUNITY SHAWANO MEDICAL CENTER 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/FARMERS 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. PART III, LINE 2: OVERDUE PATIENT ACCOUNTS ARE SENT THREE STATEMENTS BEGINNING THE MONTH AFTER THE ACCOUNT BECOMES OVERDUE. IF NO PAYMENT IS MADE DURING THIS PERIOD A FINAL LETTER IS SENT GIVING NOTICE OF THE OVERDUE ACCOUNT AND NOTIFYING THE INDIVIDUAL THAT THE AMOUNT WILL GO INTO COLLECTIONS. AT THIS POINT, THE AMOUNT IS MARKED AS BAD DEBT. PART III, LINE 3: 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: 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 8 COUNTY PRIMARY SERVICE AREA. FIVE 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: RIVERSIDE MEDICAL CENTER 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 90%. - 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, RIVERSIDE MEDICAL CENTER'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 2013, WAUPACA TOOK A PLUNGE INTO ALCOHOL AND DRUGS. 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 2013, 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 $1,434,000 IN UNPAID VOLUNTEER HOURS TO LOCAL NON-PROFITS IN 2013. - RIVERSIDE MEDICAL CENTER STAFF ARE ENGAGED IN WAUPACA COUNTY NUACT COALITION, A COMMUNITY-WIDE MULTI-DISCIPLINARY TEAM ADDRESSING COMMUNITY HEALTH AND WELLNESS NEEDS- RIVERSIDE MEDICAL CENTER HOSTS SUPPORT GROUPS FOR DIABETES, LIVING WITH LOSS AND NEW BABY.- RIVERSIDE MEDICAL CENTER 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.- RIVERSIDE MEDICAL CENTER REACHES OUT TO THE COMMUNITY TO HOST SCREENINGS AND HEALTH FAIRS.- RIVERSIDE MEDICAL CENTER HOSTS AN ANNUAL FUN RUN FOR THE COMMUNITY AND ALSO SPONSORS AN ANNUAL AREA TRIATHLON TO ENCOURAGE FITNESS AND ACTIVITY.- RIVERSIDE MEDICAL CENTER STAFF PROVIDE FREE ATHLETIC TRAINING SERVICES TO AREA HIGH SCHOOL ATHLETIC EVENTS.- RIVERSIDE MEDICAL CENTER STAFF SUPPORT THE AMERICAN HEART ASSOCIATIONS GO RED FOR WOMEN EVENT.- RIVERSIDE MEDICAL CENTER STAFF ARE INVOLVED IN STATEWIDE AND REGIONAL DISASTER READINESS PLANNING TO PREPARE OUR COMMUNITY FOR TIMES OF CRISIS.- THEDA CARE PRESIDENT AND CEO IS ENGAGED IN STATEWIDE WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY MAKING QUALITY HEALTHCARE DATA TRANSPARENT. 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 BURMEISTER BRIAN BOARD MEMBER 57911 231642 11552 46209 3035 12140 12488 49953 3526 14104 88512 354048 0 0 DENT ROBERT MD BOARD MEMBER/PHYSICIAN 0 172045 0 18621 0 4968 0 6250 0 16892 0 218776 0 0 LONG GREGORY MD BOARD MEMBER/CHIEF MEDICAL OFFICER 57496 325811 11574 65588 1182 6697 10417 59030 3046 17260 83715 474386 0 0 KANTOS CRAIG CEO - RMC 227161 0 22757 0 11877 0 7337 0 17071 0 286203 0 0 0 OLSON TIM VP CFO - SYSTEM 58093 329193 11277 63901 3603 20416 13133 74418 2607 14772 88713 502700 0 0 GRUNER DEAN CFO - SYSTEM 112054 634967 42854 242840 1004 5690 23426 132745 2926 16581 182264 1032823 0 0 LIVINGSTON KEITH VP SR CIO 48788 276459 9487 53757 3288 18630 10257 58122 2659 15068 74479 422036 0 0 PISTONE MAUREEN VP SR TALENT MANAGEMENT 41635 235936 7972 45174 3052 17293 9508 53881 2641 14968 64808 367252 0 0 BARNAS KIM VP SR AMC & THEDA CLARK HOSPITAL 32953 296577 6610 59490 1981 17831 7895 71055 2033 18296 51472 463249 0 0 DEVINE GREGORY VP SR PROVIDER STRATEGY & SYSTEMS OF 58156 329552 13581 76957 1329 7530 9051 51288 2780 15756 84897 481083 0 0 HUNTER WILLIAM VP SR PLANNING & MARKETING 49628 281223 11593 65695 1730 9804 8762 49653 2671 15136 74384 421511 0 0 PETERSON ROBERT MD PHYSICIAN 276804 0 1358 0 9996 0 7350 0 11139 0 306647 0 0 0 POOLE JOHN VP SR THEDACARE IMPROVEMENT SYSTEM ( 47514 269250 9565 54203 1217 6895 9833 55718 2762 15650 70891 401716 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 AND 1 EMPLOYEE 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, 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, 2012 TO DECEMBER 31, 2012) TO RECEIVE THEIR 2013 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: NUMBER OF EMPLOYEES: THEDACARE INC., A RELATED ORGANIZATION, CENTRALIZES PAYROLL AND TAX WITHHOLDING FUNCTIONS FOR A NUMBER OF AFFILIATED ENTITIES, WHILE ALL FILING UNDER THEDACARE'S FEDERAL IDENTIFICATION NUMBER. RIVERSIDE MEDICAL CENTER (RMC) REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE PAID BY THEDACARE, INC., THEREFORE, RMC DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY RMC FOR SALARY EXPENSES FOR THE EMPLOYEES WHO ARE PERMANENTLY ASSIGNED TO RMC. FORM 990, PART VI, SECTION A, LINE 6 RIVERSIDE MEDICAL CENTER, 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 ON AN ANNUAL BASIS, ALL EMPLOYEES WHO MAKE PURCHASES ON BEHALF OF THE COMPANY REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A FORM TO DISCLOSE PERSONAL INTEREST AS STATED IN THE POLICY. 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 THE PROCESS FOR DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, OFFICERS AND KEY EMPLOYEES INVOLVES A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 RIVERSIDE MEDICAL CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: RELEASED FROM RESTRICTIONS -11,858. FORM 990, PART XI, LINE 2C: OVERSIGHT OF AUDIT AND SELECTION PROCESS: THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR. 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