2017-11-14T16:53:54-06:00 2016-12-31 KPMG LLP 4200 WELLS FARGO CTR 90 S 7TH ST MINNEAPOLIS MN 55402 990 2016-01-01 390813416 Gundersen Lutheran Medical Center Inc % DARA BARTELS GUND 6087827300 1910 SOUTH AVE LA CROSSE WI 54601 DARA BARTELS CFO 2017-11-15 true Monroe J Gierl P01413237 6123055000 2017-11-15 167.68.102.5 41438720173185000007 2017-11-14 P CBDCF8A62BCD6705D428F3975F29828786D22771 30031D5E7EADAC179FA13A5C3B90D0218042D0DA 2016 2017-02-10 21:41:12Z SCOTT RATHGABER MD 1910 SOUTH AVE LA CROSSE WI 54601 997078418 false X WWW.GUNDERSENHEALTH.ORG X 1899 WI See Schedule O 13 4 0 0 470010 90953 4218247 3585230 928711210 992124966 29290 156193 435764 463419 933394511 996329808 20050652 16941409 0 0 372340882 385543211 0 0 0 466510131 506404412 858901665 908889032 74492846 87440776 1129322051 1215243277 5638642 4119092 1123683409 1211124185 X See Schedule O. false false 767557232 16941409 992124966 See Schedule O. 767557232 true true false true false false false false false false true false false true true true false true false false false false false false false false true true true true true false false false false false false false false false false false false false true false true false true 0 0 0 true true false false false false false false false false false X 13 4 true false false false true true true true true false false true true true true true true true true false MN WI X DARA BARTELS 6087759487 1900 S AVE LA CROSSE WI 54601 X Scott Rathgaber MD Chief Executive Officer 2.0 46.0 X X 0 849051 65310 Greg Prairie Board of Trustees - 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At December 31, 2016 and 2015, net deferred tax assets of $3,493 and $3,083, respectively, which primarily are related to net operating loss carryforwards, have valuation allowances of $2,766 and $2,205, respectively, recorded against them due to the uncertainty of realizing those benefits in the future. At December 31, 2016, the System's federal net operating loss carryforwards were approximately $27,109, and the state net operating loss carryforwards were approximately $22,902, which will expire between 2025 and 2034. The System has reviewed its tax positions for all open years and has concluded that no liabilities exist for uncertain tax positions. The System's income tax returns are no longer subject to examination for 2012 and prior years. true true true X true X true true false true true 2104642 2104642 0.00240 96113207 49999778 46113429 0.05170 298175 157587 140588 0.00020 98516024 50157365 48358659 0.05420 666372 38719 627653 0.00070 12039550 4845047 7194503 0.00810 582914 582914 0.00070 13288836 4883766 8405070 0.00940 111804860 55041131 56763729 0.06360 414 414 11960 11960 4590 4590 32038 32038 3476491 3476491 3525493 3525493 true 7308137 2828350 119685603 185708707 -66023104 X true true 1 1 GUNDERSEN LUTHERAN MED CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 WWW.GUNDERSENHEALTH.ORG X X X X X GUNDERSEN LUTHERAN MEDICAL CENTERINC 1 false false true X X X X X X X X X X 15 true true true true X REFER TO SECTION C X REFER TO SECTION C X X true 16 true Refer to Section C false false true X 200. 400. X X X true true X X X X true X Refer to Section C X Refer to Section C X Refer to Section C X X X X X X true X false X X X X X true X false false Schedule H, Part V, Line 3j: THE COMPASS NOW 2015 PROCESS USED A VARIETY OF DATA COLLECTION METHODS TO CREATE AN OVERALL DEPICTION OF THE ISSUES FACING OUR COMMUNITIES. THESE METHODS INCLUDED A RANDOM HOUSEHOLD SURVEY, CONVENIENCE SURVEY, COMMUNITY CONVERSATIONS, AND AN EXTENSIVE REVIEW OF SOCIOECONOMIC INDICATORS, WHICH PROVIDES AN INVENTORY OF COMMUNITY RESOURCES. THE DATA COLLECTED DURING COMPASS NOW 2015 GUIDE FOUR PILLAR PROFILES. THESE ARE REFERRED TO AS PILLARS BECAUSE THEY CREATE THE BUILDING BLOCKS FOR A BETTER LIFE. THE PILLARS OF COMPASS NOW 2015 ARE COMMUNITY, EDUCATION, INCOME/ECONOMIC, AND HEALTH. THE PROFILES DESCRIBE OUR COMMUNITY WITH REGARDS TO THE KEY ISSUES OF EACH AREA. EACH PROFILE PULLS KEY INDICATOR DATA AND COMPASS SURVEY RESULTS INTO A NARRATIVE FORMAT THAT IS INTENDED TO PROVIDE A CONTEXT TO THE DATA FOUND IN THE INDICATOR REPORT, MAKING THE DATA EASY TO NAVIGATE. COMPASS COUNCILS WERE ADVISORY GROUPS OF LOCAL EXPERTS IN THE FIELDS OF EDUCATION, INCOME, HEALTH, AND A VARIETY OF COMMUNITY ISSUES. THESE MEMBERS COLLECTED AND REVIEWED DATA, ANALYZED THE SURVEY RESULTS, AND OFFERED PROFESSIONAL INSIGHTS ABOUT TOPIC-SPECIFIC ISSUES IN THE GREAT RIVERS REGION. AFTER SIGNIFICANT REVIEW OF THE DATA AND SURVEY RESULTS, PRIORITY ISSUES WERE IDENTIFIED BY COMPASS COUNCIL MEMBERS. THESE ISSUES WERE THEN RANKED BY COUNCIL MEMBERS USING THE CRITERIA BELOW: 1. HOW WIDESPREAD IS THE ISSUE IN OUR COMMUNITY? 2. HOW SERIOUS ARE THE EFFECTS OF THE ISSUE IN OUR COMMUNITY? 3. HOW IMPORTANT IS THE ISSUE TO THE COMMUNITY? THE COMPASS NOW STEERING COMMITTEE THEN APPLIED ITS KNOWLEDGE OF THE ISSUES. THE COMBINATION OF COMPASS COUNCIL RECOMMENDATIONS AND THE INSIGHTS FROM THE COMPASS NOW STEERING COMMITTEE RESULTED IN THE IDENTIFICATION OF THREE TOP AREAS OF NEED FOR EACH OF THE FOUR GREAT RIVERS UNITED WAY PILLARS. Schedule H, Part V, Line 5: IN ADDITION TO THE RANDOM HOUSEHOLD SURVEY, THE COMPASS NOW 2015 COMMUNITY NEEDS ASSESSMENT ALSO INCLUDED A CONVENIENCE SAMPLE THAT FOCUSED ON SPECIFIC SUBGROUPS IN THE GREAT RIVERS REGION. THE OVERALL OBJECTIVE OF THIS SAMPLING WAS TO COLLECT FEEDBACK FROM POPULATIONS WITHIN THE COMMUNITY THAT WERE POTENTIALLY UNDERREPRESENTED IN THE RANDOM HOUSEHOLD SURVEY DUE TO THE SMALL NUMBER IN WHICH THEY EXIST IN THE COMMUNITY. THESE SMALLER POPULATIONS INCLUDED, BUT WERE NOT LIMITED TO, AFRICAN AMERICANS, HISPANICS, LGBT YOUTH, YOUTH AT-RISK, LOW-INCOME ADULTS, AND SENIOR CITIZENS. RESULTS FROM THIS SURVEY WERE COMPARED TO THE RESPONSES OF THE RANDOM HOUSEHOLD SURVEY RESPONDENTS IN AN ATTEMPT TO DETERMINE ANY SIGNIFICANT DIFFERENCES THAT EXISTED BETWEEN THE GENERAL POPULATION AND THOSE IN SMALLER SUBGROUPS WITHIN THE COMMUNITY. IN TOTAL, 753 COMMUNITY MEMBERS SHARED FEEDBACK THROUGH THE CONVENIENCE SAMPLE PROCESS. (OF THE 5,000 HOUSEHOLDS THAT RECEIVED THE RANDOM HOUSEHOLD SURVEY, 791 WERE RETURNED WITH RESPONSES ANALYZED.) ANOTHER WAY IN WHICH COMMUNITY FEEDBACK WAS GATHERED WAS THROUGH COMMUNITY CONVERSATIONS. THESE CONVERSATIONS WERE CONDUCTED IN LIEU OF THE FOCUS GROUPS THAT WERE CONDUCTED IN THE COMPASS NOW 2012 COMMUNITY NEEDS ASSESSMENT. THESE SMALL GROUP GATHERINGS WERE A SAFE SPACE IN WHICH COMMUNITY MEMBERS COULD COME TOGETHER AND SHARE THEIR THOUGHTS AND EXPERIENCES ABOUT LIVING IN THE GREAT RIVERS REGION. INDIVIDUALS CONSULTED: ANN KAPPAUF, NEW HORIZONS SHELTER & OUTREACH CENTERS; ANNA CARDARELLA, WESTERN DAIRYLAND; ASHLEY FOREMAN, MARINE CREDIT UNION; AUDRA MARTINE, AGING & DISABILITY RESOURCE CENTER OF WESTERN WISCONSIN; AUDRA WIESER, THE PARENTING PLACE; BEN CRENSHAW, MAYO CLINIC HEALTH SYSTEM; BETH HARTUNG, CONSULTANT, WFPRHA; BETH JOHNSON, VERNON COUNTY HEALTH DEPARTMENT; BETH THEEDE, LA CRESCENT-HOKAH PUBLIC SCHOOLS; BETTY JOREGENSON, MAYO CLINIC HEALTH SYSTEM; BRENDA ROONEY, GUNDERSEN HEALTH SYSTEM; BRIAN THEILER, GUNDERSEN TRI-COUNTY HOSPITAL & CLINICS; CAROL ABRAHAMZON, MISSISSIPPI VALLEY CONSERVANCY; CAROLINE NEILSEN, CITY OF LA CROSSE COMMUNITY DEVELOPMENT; CATHERINE EMMANUELLE, TREMPEALEAU COUNTY UW- EXTENSION; CATHERINE KOLKMEIER, LA CROSSE MEDICAL HEALTH SCIENCE CONSORTIUM; CECIL ADAMS, AFRICAN AMERICAN MUTUAL ASSISTANCE NETWORK; CHARLIE HANDY, LA CROSSE COUNTY PLANNING/COMMUNITY DEVELOPMENT; CHERYL RHODA, TREMPEALEAU COUNTY HEALTH DEPARTMENT; CHRISTINE DEAN, GUNDERSEN ST. JOSEPH'S HOSPITAL & CLINICS; ERIC PRISE, TOMAH MEMORIAL HOSPITAL; ERIN WALDHART, WAFER FOOD PANTRY; FAI DEMARK, CONSUMER CREDIT COUNSELING SERVICE OF LA CROSSE; GINA MERRELL, WORKFORCE CONNECTIONS; GREG FLOGSTAD, MISSISSIPPI RIVER REGIONAL PLANNING COMMISSION; GREG STANGL, LA CROSSE COUNTY LAND CONSERVATION; HEATHER MYHRE, HOUSTON COUNTY HEALTH DEPARTMENT; HEATHER QUACKENBOSS, LA CROSSE COMMUNITY FOUNDATION; JACKIE EASTWOOD, LA CROSSE COUNTY AREA PLANNING COMMITTEE; JAMIE SCHLOEGEL, FAMILY & CHILDREN'S CENTER; JASON LARSEN, LA CROSSE AREA FAMILY COLLABORATIVE; JASON WITT, LA CROSSE COUNTY HUMAN SERVICES DEPARTMENT; JENNIFER SLABAUGH, SEMCAC OUTREACH & EMERGENCY SERVICES PROGRAM; JENNY KUDERER, WISCONSIN ECONOMIC DEVELOPMENT CORPORATION; JERILYN DINSMOOR, LA CROSSE PROMISE; JESSIE CUNNINGHAM, VERNON MEMORIAL HEALTHCARE; JOAN MUELLER, MAYO CLINIC HEALTH SYSTEM; JOHN HENDRICKS, SPARTA AREA SCHOOL DISTRICT; JOSHUA WALDEN, CROSSFIRE; JULIE NELSON, THE SALVATION ARMY OF LA CROSSE; KAREN EHLE-TRAASTAD, VERNON COUNTY UW-EXTENSION; KAREN JOOS, COMMUNITY VOLUNTEER; KARI REYBURN, WESTERN TECHNICAL COLLEGE; KATE NOELKE, UNIVERSITY OF WISCONSIN-LA CROSSE; KAYLEIGH DAY, MONROE COUNTY HEALTH DEPARTMENT; KEITH LEASE, WESTERN TECHNICAL COLLEGE; KIM CABLE, COULEECAP; LAURA PETTERSEN, SCENIC BLUFFS AREA HEALTH EDUCATION CENTER; LAURIE STRANGMAN, UNIVERSITY OF WISCONSIN-LA CROSSE; LINDSEY MENARD, LA CROSSE COUNTY HUMAN SERVICES DEPARTMENT; LISA LUCKEY, LA CROSSE AREA FAMILY YMCA; LORI DUBCZAK, INDEPENDENT LIVING RESOURCES; LORI FREIT-HAMMES, MAYO CLINIC HEALTH SYSTEM; LORIE GRAFF, WESTERN REGION FOR ECONOMIC ASSISTANCE IM CONSORTIUM; MARI FREIBERG, SCENIC BLUFFS COMMUNITY HEALTH CENTER; MARY JACOBSON, CATHOLIC CHARITIES; MARY KAY WOLF, GREAT RIVERS UNITED WAY; MARY KOENIG, VERNON MEMORIAL HEALTHCARE; MARY MEEHAN-STRUB, LA CROSSE COUNTY UW-EXTENSION; MIKE DESMOND, BOYS & GIRLS CLUBS OF GREATER LA CROSSE; PAT KERRIGAN, VITERBO UNIVERSITY; PATRICIA MALONE, TREMPEALEAU COUNTY UW-EXTENSION; PAULINE BYOM, MAYO CLINIC HEALTH SYSTEM; ROBERT LYNN, GUNDERSEN HEALTH SYSTEM; SANDRA BREKKE, ST. CLARE HEALTH MISSION; SANDY GRAVES, LA CRESCENT AREA HEALTHY COMMUNITY PARTNERSHIP; SARA WROBEL, CAUSEWAY CAREGIVERS; SARAH HAVENS, GUNDERSEN HEALTH SYSTEM; SARAH SPAH, MAYO CLINIC HEALTH SYSTEM; SHARON NELSON, MONROE COUNTY HEALTH DEPARTMENT; SHELLY TEADT, COULEECAP; STEVE SALERNO, SCHOOL DISTRICT OF LA CROSSE; TERESA PIERCE, WORKFORCE CONNECTIONS; TJ BROOKS, UNIVERSITY OF WISCONSIN-LA CROSSE; TODD MANDEL, COULEECAP; TOM FAELLA, LA CROSSE COUNTY ADMINISTRATIVE CENTER; TONI ASHER, PUMP HOUSE REGIONAL ARTS CENTER; TRACY CRAKER, WESTERN TECHNICAL COLLEGE; TRACY HERLITZKE, COOPERATIVE EDUCATIONAL SERVICE AGENCY (CESA) #4; TRICIA WAVRA, WESTERN REGION FOR ECONOMIC ASSISTANCE IM CONSORTIUM; VALJEAN ADAMS, CLARA FIELDS MULTICULTURAL LITERACY PROGRAM; WES REVELS, GREAT RIVERS UNITED WAY BOARD OF DIRECTORS; WILLIAM COLCLOUGH, UNIVERSITY OF WISCONSIN-LA CROSSE. Schedule H, Part V, Line 6a: HOSPITALS INCLUDED ARE GUNDERSEN HEALTH SYSTEM, GUNDERSEN ST. JOSEPH'S HOSPITAL & CLINICS, GUNDERSEN TRI-COUNTY HOSPITAL & CLINICS, MAYO CLINIC HEALTH SYSTEM-LA CROSSE, MAYO CLINIC HEALTH SYSTEM-SPARTA, TOMAH MEMORIAL HOSPITAL, VERNON MEMORIAL HOSPITAL. Schedule H, Part V, Line 6b: OTHER ORGANIZATIONS INCLUDE GREAT RIVERS UNITED WAY, HOUSTON COUNTY (MN) HEALTH DEPARTMENT, LA CROSSE COMMUNITY FOUNDATION, LA CROSSE COUNTY (WI) HEALTH DEPARTMENT, MONROE COUNTY (WI) HEALTH DEPARTMENT, TREMPEALEAU COUNTY (WI) HEALTH DEPARTMENT, VERNON COUNTY (WI) HEALTH DEPARTMENT. Schedule H, Part V, Line 7A: http://www.gundersenhealth.org/community-assessment/ 7B: OTHER WEB SITE HTTP://WWW.GREATRIVERSUNITEDWAY.ORG/OUR-WORK/COMMUNITY-NEEDS-ASSESSMENT/ 7C: PAPER COPY: AVAILABLE IN 5 MOONEY LIBRARIES LOCATED AT OUR LA CROSSE AND ONALASKA CAMPUS AND UPON REQUEST 7D: AVAILABLE BY CONTACTING SARAH HAVENS, PHONE (608) 775-6580 OR (800) 362-9567, EXT. 56580 OR EMAIL SJHAVENS@GUNDERSENHEALTH.ORG. PART V, SECTION B, 10A: IMPLEMENTATION STRATEGY URL: http://www.gundersenhealth.org/community-assessment/ Schedule H, Part V, Line 11: THE GUNDERSEN COMMUNITY HEALTH NEEDS ASSESSMENT UTILIZES THE COMPASS NOW COLLABORATIVE ASSESSMENT THAT INCLUDES 5 COUNTIES IN OUR SERVICE AREA REPRESENTING 77.6% OF OUR HOSPITAL SERVICE PATIENT POPULATION. THE COMPASS NOW ASSESSMENT HAS BEEN AN ONGOING COMMUNITY NEEDS ASSESSMENT IN COLLABORATION WITH THE UNITED WAY AND OTHER COMMUNITY PARTNERS SINCE 1995, WITH UPDATES EVERY THREE TO FIVE YEARS. TO EXPAND THE COMPASS NOW ASSESSMENT AND REPRESENTED POPULATION, WE HAVE ALSO COMPLETED A COMMUNITY HEALTH ASSESSMENT FOR THE 19-COUNTY SERVICE AREA AS A WHOLE, UTILIZING TOOLS GENERATED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION COMMUNITY HEALTH STATUS INDICATORS- 2015 CHSI 2015 AND COMMUNITY COMMONS. THE FIVE COUNTIES REPRESENTED IN COMPASS REFLECT 42% THE OVERALL POPULATION OF OUR 19 COUNTY SERVICE REGION. REVIEWING THE BROADER 19-COUNTY REGION NEEDS REVEALED NO SIGNIFICANT DIFFERENCES FOR THE TOP TWO CONCERNS MENTAL HEALTH AND/OR SUBSTANCE ABUSE (ADULT BINGE DRINKING, OLDER AND DEPRESSION) AND CHRONIC DISEASE AND CONTRIBUTING FACTORS (OBESITY, PHYSICAL INACTIVITY, SMOKING, DIABETES, STROKE, OVERALL HEALTH STATUS). THE NEED THAT WAS IDENTIFIED IN COMPASS NOW NOTED IN OUR BROADER SERVICE REGION ASSESSMENT IS ORAL HEALTH AND ALTERNATIVELY FEMALE PAP TESTS ARE INDICATED AS A NEED FOR THE BROADER 19-COUNTY SERVICE REGION BUT NOT IN COMPASS. SOCIAL FACTORS AND THE PHYSICAL ENVIRONMENT ARE ESPECIALLY IMPORTANT BECAUSE THEY REPRESENT THE CONDITIONS IN WHICH PEOPLE ARE BORN, WORK, AND PLAY. NEIGHBORHOODS WITH AFFORDABLE HEALTHY FOOD, SAFE AND ACCESSIBLE HOUSING, AND QUALITY EMPLOYMENT OPPORTUNITIES CAN POSITIVELY INFLUENCE BEHAVIORS AND HELP TO CREATE HEALTHY LIFESTYLES. THE WORLD HEALTH ORGANIZATION AND OTHERS CALL THE LIVING CONDITIONS THAT CAN AFFECT HEALTH AND QUALITY OF LIFE THE "SOCIAL DETERMINANTS OF HEALTH". GUNDERSEN LUTHERAN MEDICAL CENTER'S 2016-2018 IMPLEMENTATION PLAN ADDRESSES THE IDENTIFIED NEEDS FROM COMPASS AND THE ADDITIONAL ISSUE REVEALED FROM THE GREATER 19-COUNTY ASSESSMENT. WE USED THE FOLLOWING PROCESS TO DETERMINE OUR IMPLEMENTATION STRATEGY: 1. CREATED SELECTION CRITERIA TO SELECT AREAS OF CONCERN FROM COMPASS (CHNA) THAT WE WOULD ADDRESS. THESE CRITERIA INCLUDE: a. MAGNITUDE - HOW WIDESPREAD IS THE ISSUE IN OUR COMMUNITY? b. SERIOUSNESS - HOW SERIOUS ARE THE EFFECTS OF THE ISSUE IN OUR COMMUNITY? c. IMPACT - HOW IMPORTANT IS THE ISSUE TO THE COMMUNITY? d. FEASIBILITY - DO WE HAVE THE ABILITY TO REASONABLY IMPACT THE ISSUE WITH AVAILABLE RESOURCES? NOTE: RESOURCES AVAILABLE TO ADDRESS THESE IDENTIFIED NEEDS VARY FROM COMMUNITY TO COMMUNITY, AND COUNTY TO COUNTY. AS A COMPONENT OF OUR IMPLEMENTATION PLAN, A GOAL WILL BE TO IDENTIFY RESOURCES ACROSS OUR SERVICE AREA. THIS WORK WILL INVOLVE OUR NETWORK OF REGIONAL PARTNERS (HOSPITAL AFFILIATES). e. CONSEQUENCES OF INACTION: WHAT IS THE RISK BY NOT ADDRESSING THE ISSUE? f. CURRENT SOLUTIONS: WHAT IS THE DEGREE TO WHICH OUR ACTIONS WILL ENHANCE CURRENT LEVELS OF INTERVENTIONS BY OTHERS? 2. INVENTORIED THE GUNDERSEN HEALTH SYSTEM FOR EXISTING PROGRAMS AND PROCESSES THAT ADDRESS THE IDENTIFIED NEED. 3. INCORPORATED FEEDBACK FROM COMMUNITY CONVERSATIONS AND SURVEY COMMENTS (FROM COMPASS PROCESS) 4. DETERMINED OPPORTUNITIES FOR NEW PROGRAMMING OR PARTNERSHIPS THAT COULD IMPACT AREAS NOT BEING ADDRESSED. 5. FORMALIZED GOALS AND ACTIVITIES THAT WILL DIRECTLY IMPACT IDENTIFIED PRIORITIES. 6. IDENTIFIED THOSE PRIORITIES NOT ADDRESSED IN OUR PLAN, BUT NOTE WE WILL MAINTAIN ACTIVE PARTNERSHIPS WITH AND REMAIN SUPPORTIVE OF THE LEAD ORGANIZATIONS ADDRESSING THOSE PRIORITIES. OUR IMPLEMENTATION PLAN, INCLUDING GOALS AND ACTION STEPS, HAS BEEN ESTABLISHED FOR THE THREE KEY ISSUES DETERMINED IN THE HEALTH CATEGORY (CHRONIC DISEASE AND CONTRIBUTING FACTORS, MENTAL HEALTH AND/OR SUBSTANCE ABUSE, ORAL HEALTH) AND ONE KEY ISSUE IN EACH OF THE OTHER CATEGORIES: INCOME- QUALITY HOUSING; EDUCATION- YOUTH RESILIENCE; AND COMMUNITY- ADVERSE CHILDHOOD EXPERIENCES. THE SIX REMAINING ISSUES WILL BE ADDRESSED BY OUR COMMUNITY PARTNERS. ENGAGEMENT WITH KEY PARTNERS WILL ULTIMATELY LEAD TO COMMUNITY HEALTH IMPROVEMENT. Schedule H, Part V, Line 13c: GHS patients not meeting financial assistance eligibility thresholds may be eligible for assistance under circumstances when GHS medical bills would result in severe financial hardship. Patients, or their guarantors, may be eligible for catastrophic care assistance if they have incurred out-of-pocket obligations resulting from medical services provided by GHS that exceed 25% of family income and have assets below the equivalent of 600% of the Federal Poverty Level threshold. Patients, or patient guarantors, meeting eligibility criteria for catastrophic care will have their GHS charges discounted to an amount not to exceed 25% of family income. Schedule H, Part V, Line 13h: GHS PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN GHS MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY HAVE INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GHS THAT EXCEED 25% OF FAMILY INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE Federal Poverty Level THRESHOLD. PRESUMPTIVE ELIGIBILITY: GHS UNDERSTANDS THAT NOT ALL PATIENTS ARE ABLE TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION OR COMPLY WITH REQUESTS FOR DOCUMENTATION. THERE MAY BE INSTANCES UNDER WHICH A PATIENT'S QUALIFICATION FOR FINANCIAL ASSISTANCE IS ESTABLISHED WITHOUT COMPLETING THE FORMAL FINANCIAL ASSISTANCE APPLICATION. OTHER INFORMATION MAY BE UTILIZED BY GHS TO DETERMINE WHETHER A PATIENT'S ACCOUNT IS UNCOLLECTIBLE AND THIS INFORMATION WILL BE USED TO DETERMINE PRESUMPTIVE ELIGIBILITY. PRESUMPTIVE ELIGIBILITY MAY BE GRANTED TO PATIENTS BASED ON THEIR ELIGIBILITY FOR OTHER PROGRAMS OR LIFE CIRCUMSTANCES SUCH AS: 1. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY. IN CASES INVOLVING BANKRUPTCY, ONLY THE ACCOUNT BALANCE AS OF THE DATE THE BANKRUPTCY IS DISCHARGED WILL BE WRITTEN OFF. 2. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE. 3. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS. 4. ACCOUNTS RETURNED BY THE COLLECTION AGENCY AS UNCOLLECTIBLE DUE TO ANY OF THE ABOVE REASONS. 5. PATIENTS OR GUARANTORS WHO QUALIFY FOR STATE MEDICAID PROGRAMS, WILL BE ELIGIBLE FOR ASSISTANCE FOR ANY COST-SHARING OBLIGATIONS ASSOCIATED WITH THE PROGRAM OR UNCOVERED SERVICES. GHS UNDERSTANDS THAT CERTAIN PATIENTS MAY BE NON-RESPONSIVE TO GHS'S APPLICATION PROCESS. UNDER THESE CIRCUMSTANCES, GHS MAY UTILIZE OTHER SOURCES OF INFORMATION TO MAKE AN INDIVIDUAL ASSESSMENT OF FINANCIAL NEED. THIS INFORMATION WILL ENABLE GHS TO MAKE AN INFORMED DECISION ON THE FINANCIAL NEED OF NON- RESPONSIVE PATIENTS UTILIZING THE BEST ESTIMATES AVAILABLE IN THE ABSENCE OF INFORMATION PROVIDED DIRECTLY BY THE PATIENT. GHS MAY UTILIZE A THIRD-PARTY TO CONDUCT AN ELECTRONIC REVIEW OF PATIENT INFORMATION TO ASSESS FINANCIAL NEED. THIS REVIEW UTILIZES A HEALTHCARE INDUSTRY-RECOGNIZED MODEL THAT IS BASED ON PUBLIC RECORD DATABASES. THIS PREDICTIVE MODEL INCORPORATES PUBLIC RECORD DATA TO CALCULATE A SOCIO-ECONOMIC AND FINANCIAL CAPACITY SCORE THAT INCLUDES ESTIMATES FOR INCOME, ASSETS AND LIQUIDITY. THE ELECTRONIC TECHNOLOGY IS DESIGNED TO ASSESS EACH PATIENT TO THE SAME STANDARDS AND IS CALIBRATED AGAINST HISTORICAL APPROVALS FOR GHS FINANCIAL ASSISTANCE UNDER THE TRADITIONAL APPLICATION PROCESS. THE ELECTRONIC TECHNOLOGY, WHEN UTILIZED, WILL BE DEPLOYED PRIOR TO BAD DEBT ASSIGNMENT AFTER ALL OTHER ELIGIBILITY AND PAYMENT SOURCES HAVE BEEN EXHAUSTED. THIS ALLOWS GHS TO SCREEN ALL PATIENTS FOR FINANCIAL ASSISTANCE PRIOR TO PURSUING ANY EXTRAORDINARY COLLECTION ACTIONS. THE DATA RETURNED FROM THIS ELECTRONIC ELIGIBILITY REVIEW WILL CONSTITUTE ADEQUATE DOCUMENTATION OF FINANCIAL NEED UNDER THIS POLICY. WHEN ELECTRONIC ENROLLMENT IS USED AS THE BASIS FOR PRESUMPTIVE ELIGIBILITY, THE HIGHEST DISCOUNT LEVELS WILL BE GRANTED FOR ELIGIBLE SERVICES FOR RETROSPECTIVE DATES OF SERVICE ONLY. IF A PATIENT DOES NOT QUALIFY UNDER THE ELECTRONIC ENROLLMENT PROCESS, THE PATIENT MAY STILL BE CONSIDERED UNDER THE TRADITIONAL FINANCIAL ASSISTANCE APPLICATION PROCESS. GHS WILL PROVIDE PATIENTS NOT QUALIFYING FOR FINANCIAL ASSISTANCE THROUGH THIS PROCESS WITH A WRITTEN NOTICE INFORMING THEM THAT FINANCIAL ASSISTANCE IS AVAILABLE. THIS NOTICE WILL INCLUDE A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY AND ACTIONS TO BE TAKEN IF AN APPLICATION IS NOT SUBMITTED OR THE OUTSTANDING BALANCE PAID. PATIENT ACCOUNTS GRANTED PRESUMPTIVE ELIGIBILITY WILL BE RECLASSIFIED UNDER THE FINANCIAL ASSISTANCE POLICY. THEY WILL NOT BE SENT TO COLLECTION, WILL NOT BE SUBJECT TO FURTHER COLLECTION ACTIONS, WILL NOT BE SENT A WRITTEN NOTIFICATION OF THEIR ELECTRONIC ELIGIBILITY QUALIFICATION, AND WILL NOT BE INCLUDED IN THE HOSPITAL'S BAD DEBT EXPENSE. Schedule H, Part V, Line 15c: Contact info detailing phone number, physical location of financial counselors, and mailing address are included in the financial assistance policy, the financial assistance application, on the financial assistance website(http://www.gundersenhealth.org/pay-your-bill/financial-assistance) on every patient statement, and on brochures at all registration desks. Schedule H, Part V, Line 15e: APPLICATION REQUIREMENTS: ELIGIBILITY FOR FINANCIAL ASSISTANCE WILL BE BASED ON FINANCIAL NEED AT THE TIME OF APPLICATION. IN GENERAL, DOCUMENTATION IS REQUIRED TO SUPPORT AN APPLICATION FOR FINANCIAL ASSISTANCE. IF ADEQUATE DOCUMENTATION IS NOT PROVIDED, GHS MAY SEEK ADDITIONAL INFORMATION. RELIABLE EVIDENCE TO SUPPORT THE NEED FOR FINANCIAL ASSISTANCE IS REQUIRED. THE FOLLOWING INCOME DOCUMENTATION IS REQUIRED FROM PATIENTS, OR THEIR GUARANTORS, TO DETERMINE ELIGIBILITY: 1. COPY OF THE FEDERAL TAX RETURN, AND ALL ATTACHED SCHEDULES, FROM THE MOST RECENT TAX YEAR 2. CURRENT PROOF OF INCOME (COPY OF MOST RECENT PAY STUBS OR OTHER DOCUMENTATION) 3. PROOF OF OTHER INCOME, INCLUDING UNEMPLOYMENT, WORKERS' COMPENSATION, ALIMONY, TRUST INCOME, VETERAN'S BENEFITS 4. CURRENT BANK STATEMENTS THE FOLLOWING ASSET DOCUMENTATION IS REQUIRED FROM PATIENTS, OR THEIR GUARANTORS, TO DETERMINE ELIGIBILITY: 1. CHECKING ACCOUNTS 2. SAVINGS ACCOUNTS 3. MONEY MARKET ACCOUNTS 4. CERTIFICATES OF DEPOSIT 5. ANNUITIES 6. NON-RETIREMENT INVESTMENT ACCOUNTS 7. RETIREMENT ACCOUNTS, INCLUDING PENSIONS 8. REAL ESTATE 9. OTHER ASSETS Schedule H, Part V, Line 16A, 16B, and 16C: THE FAP, FAP APPLICATION AND PLAIN LANGUAGE SUMMARY OF THE FAP WERE AVAILABLE ON A WEBSITE: WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE Schedule H, Part V, Line 20e: NOTIFICATION OF FINANCIAL ASSISTANCE: NOTIFICATIONS OF AVAILABILITY OF FINANCIAL ASSISTANCE ARE INCLUDED ON EVERY PATIENT STATEMENT, PROVIDED AT ADMISSION/CHECK-IN, ARE ANNOUNCED ON SIGNS AT EACH CHECK-IN AREA, AT BEDSIDE FOR PATIENTS DIRECTLY ADMITTED WHO MAY NOT HAVE MET WITH ADMISSIONS STAFF. Schedule H, Part V, Line 22B: AMOUNT GENERALLY BILLED (AGB): THE AMOUNT GENERALLY BILLED IS THE EXPECTED PAYMENT FOR EMERGENCY OR MEDICALLY NECESSARY SERVICES FROM PATIENTS, AND/OR A PATIENT'S GUARANTOR. FOR QUALIFYING PATIENTS, THIS AMOUNT WILL NOT EXCEED A RATE THAT WILL BE DETERMINED UTILIZING A LOOK BACK METHOD DESCRIBED IN 1.501(R)-5(B)(3) OF THE INTERNAL REVENUE CODE. THE LOOK BACK METHOD WILL BE BASED ON ACTUAL PAST CLAIMS PAID TO GUNDERSEN BY MEDICARE FEE-FOR-SERVICE TOGETHER WITH ALL PRIVATE HEALTH INSURERS PAYING CLAIMS. THE CLAIMS TO BE INCLUDED IN THE AGB CALCULATION WILL BE CLAIMS ALLOWED DURING THE PRIOR CALENDAR YEAR. THE AMOUNTS FOR CO-INSURANCE, CO-PAYMENTS AND DEDUCTIBLES WILL BE INCLUDED IN THE NUMERATOR ALONG WITH THE MEDICARE FEE-FOR-SERVICE TOGETHER WITH ALL ALLOWED CLAIMS FROM PRIVATE HEALTH INSURERS. THE GROSS CHARGES FOR SAID CLAIMS WILL BE INCLUDED IN THE DENOMINATOR. THE AGB WILL BE CALCULATED ANNUALLY BY THE 45TH DAY FOLLOWING THE CLOSE OF THE PRIOR CALENDAR YEAR, AND IMPLEMENTED BY THE 120TH DAY FOLLOWING THE CLOSE OF THE CALENDAR YEAR. 10 GL HOSPICE INDUSTRIAL REHAB BUILDING 1843 SIMS PL LA CROSSE WI 54601 HOSPICE SERVICES GL SATELLITE DIALYSIS-ONALASKA 3075 S KINNEY COULEE RD ONALASKA WI 54650 RENAL DIALYSIS CENTER UNITY HOUSE FOR WOMEN 1312 5TH AVE LA CROSSE WI 54601 ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES UNITY HOUSE FOR MEN 1918-1924 MILLER ST LA CROSSE WI 54601 ALCOHOL AND OTHER DRUG ABUSE (AODA) SERVICES GL SATELLITE DIALYSIS-VIROQUA 407 S MAIN ST VIROQUA WI 54665 RENAL DIALYSIS CENTER GL SATELLITE DIALYSIS-TOMAH 321 BUTTS AVE TOMAH WI 54660 RENAL DIALYSIS CENTER GL SATELLITE DIALYSIS-BLACK RVR FALLS 711 W ADAMS ST BLACK RIVER FALLS WI 54615 RENAL DIALYSIS CENTER GL SATELLITE DIALYSIS-PRAIRIE DU CHIEN 610 E TAYLOR ST PRAIRIE DU CHIEN WI 53821 RENAL DIALYSIS CENTER GL SATELLITE DIALYSIS-RICHLAND CENTER 1313 W SEMINARY ST RICHLAND CENTER WI 53581 RENAL DIALYSIS CENTER GL MENTAL HEALTH DAY TREAT BEHAV HLTH 123 16TH AVE S ONALASKA WI 54656 OUTPATIENT PSYCHOLOGICAL SERVICES Schedule H, Part I, Line 6a: GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. (EIN: 39-1866425) Schedule H, Part I, Line 6b: THE COMMUNITY BENEFIT DATA IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE WHA MAKES A COMBINED SUMMARY AVAILABLE THAT INCLUDES ALL WISCONSIN HOSPITALS. Schedule H, Part I, Line 7: COST TO CHARGE RATIO, AS CALCULATED USING WORKSHEET 2 METHODOLOGY TO DETERMINE THE COST OF SERVICES PROVIDED TO PATIENTS. MEDICAID AND OTHER MEANS TESTED PROGRAM COMMUNITY BENEFIT EXPENSES FOLLOWED THE CALCULATION METHODOLOGY ON WORKSHEET 3. SCHEDULE H, PART I, LINE 7 COLUMN (F): THE PERCENT OF TOTAL EXPENSE WAS CALCULATED BY DIVIDING THE COMMUNITY BENEFIT COST BY TOTAL HOSPITAL EXPENSES OF $892,007,104. Schedule H, Part II: THE GUNDERSEN HEALTH SYSTEM, WHICH INCLUDES GUNDERSEN LUTHERAN MEDICAL CENTER, IS COMMITTED TO OUR COMMUNITIES AS EXPRESSED IN OUR MISSION: WE DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. THE COMMUNITY BUILDING ACTIVITIES ARE INCLUDED IN COMMUNITY SERVICE REPORTING WHICH ARE PROGRAMS OR SERVICES SUPPORT THAT OUR POPULATION HEALTH INITIATIVE, BENEFITING COMMUNITIES BY ADDRESSING IDENTIFIED NEED THROUGH EFFECTIVE HEALTH IMPROVEMENT PROGRAMMING, ECONOMIC CONTRIBUTION, CORPORATE CITIZENSHIP AND VOLUNTEERISM. SUPPORT IS PROVIDED THROUGH CONTRIBUTION TO OTHER ORGANIZATIONS, OR THROUGH PROGRAMMING DELIVERED BY GUNDERSEN. WHENEVER POSSIBLE, THIS TYPE OF PROGRAMMING IS EVALUATED TO IDENTIFY THE IMPACT ON POPULATION HEALTH AND QUALITY OF LIFE. VERIFICATION OF ADDRESSING COMMUNITY NEEDS IS DOCUMENTED IN THE IMPLEMENTATION PLAN. AS A LARGER SYSTEM, COMMUNITY BUILDING ACTIVITIES ENCOMPASS ALL CORPORATIONS. LEADERSHIP IN COMMUNITY HEALTH IMPROVEMENT IS EVIDENCED BY OUR ACTIVITY WITH SEVERAL COMMUNITY COALITIONS AND INITIATIVES. AS WE CONSIDER OUR COMMUNITY NEEDS IDENTIFIED IN THE COMPASS REPORT, IT IS EVIDENT THAT HEALTH IS IMPACTED BY NOT ONLY THE TRADITIONAL SENSE OF PROVISION OF QUALITY MEDICAL SERVICES, BUT THE ENVIRONMENT IN WHICH WE LIVE, THE ECONOMIC CONDITION OF OUR PERSON AND FAMILY AND OVERALL QUALITY OF LIFE OFFERED IN THE COMMUNITIES WHERE WE LIVE. Schedule H, Part III, Line 2: COST TO CHARGE RATIO WAS OUR STARTING POINT FOR DETERMINING THE COST OF BAD DEBTS. THE COST TO CHARGE RATIO WAS CALCULATED FOLLOWING THE METHODOLOGY ON WORKSHEET 2. BAD DEBT EXPENSE IS THE PRODUCT OF THE COST TO CHARGE RATIO AND THE NET PROVISION FOR BAD DEBTS FROM THE FINANCIAL STATEMENTS. Schedule H, Part III, Line 3: GUNDERSEN LUTHERAN'S FINANCIAL ASSISTANCE POLICY (FAP) PROVIDES FREE AND DISCOUNTED CARE UP TO 400% OF THE FEDERAL POVERTY GUIDELINES (FPG). SOME PATIENTS MAY EXCEED THE 400% FPG WHEN ADDITIONAL CRITERIA SUCH AS CATASTROPHIC MEDICAL COSTS ARE CONSIDERED. THE DATA USED IS FROM THE US CENSUS BUREAU, 2008-2010 AMERICAN COMMUNITY SURVEY (ACS) 3-YEAR DATA SET FOR THE WISCONSIN COUNTIES AND ACS 5-YEAR DATA SET FOR HOUSTON COUNTY. FOR HOUSTON COUNTY, WE USED THE MINNESOTA STATE AVERAGE BECAUSE 200% VALUE WAS SO HIGH FOR HOUSTON COUNTY. WE OBTAINED THE AVERAGE OF THE FIVE COUNTIES BY USING THE INFORMATION AT THE 3.00-3.99 (399%) OF FEDERAL POVERTY LEVEL (FPL) AND BELOW. THE NEXT RANGE WAS 4.00-4.99 RATIO OF INCOME TO POVERTY IN THE LAST 12 MONTHS. WE MULTIPLIED THE FIVE COUNTY AVERAGE AT 399% OF FPL TO THE BAD DEBT AT COST. WE DEDUCTED THE AMOUNT OF CHARITY CARE AT COST TO OBTAIN THE AMOUNT OF BAD DEBT AT COST TO PATIENTS ELIGIBLE UNDER FAP(BUT FOR WHOM INSUFFICIENT INFORMATION WAS OBTAINED TO DETERMINE THEIR ELIGIBILITY). Schedule H, Part III, Line 4: THE COLLECTION OF RECEIVABLES FROM THIRD-PARTY PAYORS AND PATIENTS IS THE System'S PRIMARY SOURCE OF CASH FOR OPERATIONS. THE PRIMARY COLLECTION RISKS RELATE TO UNINSURED PATIENT ACCOUNTS AND PATIENT DEDUCTIBLES AND COINSURANCE ON INSURERS' ACCOUNTS. PATIENT RECEIVABLES, INCLUDING THE PORTION FOR WHICH A THIRD-PARTY PAYOR IS RESPONSIBLE, ARE CARRIED AT NET REALIZABLE VALUE, DETERMINED BY THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AN ESTIMATE MADE FOR CONTRACTUAL ADJUSTMENTS OR DISCOUNTS PROVIDED TO THIRD-PARTY PAYORS. PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED ON THE ACCOMPANYING consolidated BALANCE SHEETS AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS, ALLOWANCES FOR OTHER DISCOUNTS, AND AN ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. THE system DOES NOT CHARGE INTEREST ON PAST-DUE RECEIVABLES. RECEIVABLES ARE WRITTEN OFF AFTER COLLECTION EFFORTS HAVE BEEN FOLLOWED IN ACCORDANCE WITH THE system'S POLICIES. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE system ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. THE ANALYSIS IS PERFORMED USING A HINDSIGHT CALCULATION THAT UTILIZES WRITE-OFF DATA FOR ALL PAYOR CLASSES DURING A DETERMINED TIME PERIOD TO CALCULATE THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AT A POINT IN TIME. Accounts receivable balances, without payment arrangements, over 365 days are fully allowed for. The system grants credit without collateral to patients, most of whom are local residents and are insured under third-party payor agreements. AT DECEMBER 31, 2016 AND 2015, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS WAS $30,083 AND $28,955 (Dollars in thousands), RESPECTIVELY. The allowance for uncollectible accounts as a PERCENTAGE OF ACCOUNTS RECEIVABLE has remained consistent between December 31, 2015 (16%) and December 31, 2016 (17%). At December 31, 2016 and 2015, amounts due from Medicare represented 23% and 14% respectively, of the System's net patient accounts receivable. Schedule H, Part III, Line 8: THE MEDICARE COST REPORT IS USED TO DETERMINE ALLOWABLE COSTS. THE UNREIMBURSED MEDICARE COSTS ON PART III, SECTION B OF SCHEDULE H ARE ALLOWABLE COSTS PER THE MEDICARE COST REPORT. THIS CALCULATION IS LIMITED TO PATIENTS WHO ARE COVERED UNDER THE MEDICARE FEE FOR SERVICE PLAN AND DOES NOT INCLUDE THOSE COVERED BY THE MEDICARE ADVANTAGE PLANS. IT ALSO DOES NOT INCLUDE ALL SERVICES PROVIDED BY THE HOSPITAL TO PATIENTS COVERED UNDER THE MEDICARE FEE FOR SERVICE PLAN. IT EXCLUDES HOSPICE SERVICES, AMBULANCE SERVICES, CLINICAL LABORATORY SERVICES, AND A FEW OTHER MISCELLANEOUS SERVICES. INCORPORATING ALL SERVICES TO ALL MEDICARE BENEFICIARIES, THE UNREIMBURSED COST FOR MEDICARE IS $68,280,762. Medicare shortfall should be considered a community benefit because our mission is to promote health in the community and we do not limit the care available to any patients, including those covered by Medicare. We are relieving a government burden by providing care to Medicare patients even though reimbursements exceed cost by $66 million. Tax-exempt hospitals are expected to participate in the Medicare program. Schedule H, Part III, Line 9b: PURSUANT TO SELF-PAY BILLING & COLLECTION POLICY, NO EXTRAORDINARY COLLECTION ACTIONS WILL BE PURSUED AGAINST A PATIENT, OR PATIENT GUARANTOR, BEFORE REASONABLE EFFORTS HAVE BEEN MADE TO DETERMINE WHETHER THE PATIENT OR GUARANTOR IS ELIGIBLE FOR ASSISTANCE UNDER THE GHS FINANCIAL ASSISTANCE POLICY (FAP). NO ACCOUNT WILL BE SUBJECT TO BAD DEBT COLLECTION ACTIONS, OR ECA, WITHIN 120 DAYS OF THE FIRST POST-DISCHARGE STATEMENT BEFORE GHS HAS MADE REASONABLE EFFORTS TO DETERMINE WHETHER THAT PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE. THIS 120 DAY TIMEFRAME MAY BE ABBREVIATED IF A DETERMINATION HAS BEEN MADE ON FINANCIAL ASSISTANCE, A PAYMENT PLAN HAS BEEN ESTABLISHED AND AGREED TO BY THE PATIENT OR GUARANTOR, AND THE PATIENT OR GUARANTOR IS NO LONGER COMPLYING WITH THE PAYMENT PLAN. NO COLLECTION ACTIONS WILL BE PURSUED AGAINST A PATIENT IF THE PATIENT, OR GUARANTOR, HAS PROVIDED DOCUMENTATION SHOWING THAT HE OR SHE HAS APPLIED FOR COVERAGE UNDER MEDICAID, OR OTHER PUBLICLY SPONSORED HEALTH PROGRAMS, THAT MAY PAY THE OUTSTANDING CLAIM AND FOR WHICH AN ELIGIBILITY DETERMINATION IS STILL PENDING. PRIOR TO SENDING A PATIENT'S ACCOUNT TO A COLLECTION AGENCY GHS WILL MAKE REASONABLE EFFORTS TO PROVIDE INFORMATION ON FINANCIAL ASSISTANCE AND WILL MAIL A MINIMUM OF THREE (3) WRITTEN STATEMENTS TO THE PATIENT OR GUARANTOR. EACH STATEMENT WILL INCLUDE CONSPICUOUS NOTICE OF THE GHS FINANCIAL ASSISTANCE POLICY, TELEPHONE NUMBER TO CALL FOR HELP, AND DIRECT WEBSITE ADDRESS. IF ALL EFFORTS TO COMMUNICATE WITH THE PATIENT, OR PATIENT GUARANTOR, ARE UNSUCCESSFUL, AND A CORRECT ADDRESS FOR UNDELIVERABLE MAIL IS NOT FOUND, ACCOUNTS WILL BE SENT TO A COLLECTION AGENCY. WITHIN 240 DAYS FROM THE FIRST POST-DISCHARGE STATEMENT, IF A PATIENT, OR GUARANTOR, APPLIES FOR FINANCIAL ASSISTANCE, THE APPLICATION WILL BE ACCEPTED AND COLLECTION ACTIONS WILL CEASE WHILE AN ELIGIBILITY DETERMINATION IS BEING MADE. IF THE APPLICANT IS APPROVED FOR FREE CARE, NO FURTHER ACTIONS WILL BE TAKEN TO COLLECT ON THE AMOUNT. IF THE APPLICANT IS DENIED FINANCIAL ASSISTANCE OR IS APPROVED FOR DISCOUNTED CARE, STEPS WILL BE TAKEN TO RESOLVE THE OUTSTANDING OBLIGATION. IF THE ACCOUNT IS NOT RESOLVED OR ARRANGEMENTS TO RESOLVE THE ACCOUNT ARE NOT MADE, ADDITIONAL COLLECTION ACTIONS WILL BE PURSUED. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE APPLICATION DURING THE APPLICATION PERIOD, GHS MUST (I) SUSPEND ALL COLLECTION ACTIONS, (II) PROVIDE THE INDIVIDUAL WITH A WRITTEN NOTICE THAT DESCRIBES THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION REQUIRED UNDER THE FAP OR APPLICATION FORM THAT MUST BE SUBMITTED TO COMPLETE THE FAP APPLICATION AND (III) PROVIDE GHS'S CONTACT INFORMATION. THE APPLICATION WILL REMAIN ACTIVE FOR 30 DAYS FROM THE DATE THE LETTER WAS MAILED TO THE APPLICANT REQUESTING THIS INFORMATION. IF THE APPLICANT HAS NOT RESPONDED WITHIN THE 30 DAY TIMEFRAME, THE APPLICATION WILL BE DENIED. APPLICANTS APPROVED FOR FINANCIAL ASSISTANCE WILL BE REFUNDED PAYMENTS IN EXCESS OF THE AMOUNT DETERMINED OWED BY THE PATIENT OR PATIENT'S GUARANTOR ON ACCOUNTS FOR WHICH THEY HAVE BEEN GRANTED ASSISTANCE UNDER THE GHS FAP. REFUNDS APPLY TO EXCESS PAYMENTS OF $5.00 OR MORE. IN ACCORDANCE WITH THIS POLICY, FINANCIAL ASSISTANCE IS GENERALLY NOT EXTENDED FOR CO-PAYMENTS OR A BALANCE REMAINING AFTER THE INSURANCE COMPANY HAS PAID IF A PATIENT FAILS TO OBTAIN PROPER REFERRALS OR AUTHORIZATIONS, OR IF SUCH ASSISTANCE IS NOT IN ACCORDANCE WITH INSURER'S CONTRACTUAL AGREEMENT THEREFORE SUCH PAYMENTS RECEIVED WILL NOT BE REFUNDED. COLLECTION ACTIONS MAY BE UTILIZED BY GHS WHEN PURSUING PAYMENT FROM PATIENTS OR GUARANTORS (I) WITH BALANCES DUE THAT GO UNPAID FOR MORE THAN 120 DAYS WHO DO NOT APPLY FOR FINANCIAL ASSISTANCE, (II) PATIENTS OR GUARANTORS NOT IN CONFORMANCE WITH AN AGREED UPON PAYMENT PLAN, OR (III) PATIENTS OR GUARANTORS WHO ARE NO LONGER COOPERATING IN GOOD FAITH TO PAY OFF THE REMAINING BALANCE. AT LEAST 30 DAYS BEFORE INITIATING ONE OR MORE ECAS TO OBTAIN PAYMENT FOR THE CARE PROVIDED, GHS WILL PROVIDE A PATIENT OR PATIENT'S GUARANTOR WITH A WRITTEN NOTICE THAT INDICATES FINANCIAL ASSISTANCE IS AVAILABLE FOR ELIGIBLE INDIVIDUALS, HOW AN INDIVIDUAL CAN APPLY FOR FINANCIAL ASSISTANCE, AND WHERE THE FAP CAN BE OBTAINED. SUCH WRITTEN NOTICE WILL IDENTIFY THE ECAS THAT GHS OR OTHER AUTHORIZED PARTY INTENDS TO INITIATE TO OBTAIN PAYMENT FOR THE CARE, AND INDICATE THE DEADLINE AFTER WHICH SUCH ECAS MAY BE INITIATED. THE DEADLINE WILL BE NO EARLIER THAN THIRTY (30) DAYS AFTER THE DATE THAT THE WRITTEN NOTICE IS PROVIDED TO THE PATIENT OR PATIENT'S GUARANTOR. A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WILL BE INCLUDED WITH THE NOTICE GHS WILL ALSO MAKE REASONABLE EFFORTS TO ORALLY NOTIFY THE INDIVIDUAL ABOUT GHS FAP AND HOW THE PATIENT CAN OBTAIN ASSISTANCE WITH THE FAP PROCESS. Schedule H, Part VI, Line 2: IT IS THE POLICY OF GUNDERSEN HEALTH SYSTEM TO ENGAGE IN PRACTICES WHICH PROVIDE A BENEFIT TO THE COMMUNITY (GL-1820). THIS IS IN ACCORDANCE WITH OUR COMMUNITY SERVICE STATEMENT WHICH READS "WE SUPPORT AND STRENGTHEN THE COMMUNITIES WE SERVE WITH PARTNERSHIPS AND INVESTMENTS THROUGH EFFECTIVE HEALTH IMPROVEMENT PROGRAMMING, CORPORATE CITIZENSHIP, VOLUNTEERISM AND ECONOMIC CONTRIBUTIONS". COMMUNITY BENEFIT PROGRAMS ARE THOSE PROGRAMS OR ACTIVITIES THAT PROVIDE TREATMENT AND /OR PROMOTE HEALTH AND HEALING AS A RESPONSE TO IDENTIFIED COMMUNITY NEEDS (I.E. CHNA, WORKSITE HEALTH RISK ASSESSMENTS, HEALTH SCORECARD, PATIENT AGGREGATE DATA, OTHER LOCAL, STATE, NATIONAL DATA SOURCES) REGARDLESS OF SOURCE OR AVAILABILITY OF PAYMENT. COMMUNITY SERVICE ACTIVITIES PROVIDE A MEASURABLE IMPROVEMENT IN POPULATION HEALTH. THE ACTIVITIES PROVIDED IN OUR COMMUNITIES INCLUDE HEALTH IMPROVEMENT, ADVOCACY FOR PEOPLE WITH DISABILITIES, RECOGNITION OF DIVERSITY AND INCLUSION, MENTAL HEALTH, DOMESTIC VIOLENCE, WORKFORCE DEVELOPMENT, EDUCATION AND SAFETY. ACTIVITIES ARE GUIDED BY COMMUNITY NEEDS ASSESSMENT AND AS APPROPRIATE, INCLUDED IN OUR IMPLEMENTATION PLAN. LEADERSHIP IN COMMUNITY HEALTH IMPROVEMENT IS EVIDENCED BY OUR ACTIVITY WITH SEVERAL COALITIONS AND INITIATIVES. GUNDERSEN HEALTH SYSTEM COMMUNITY SERVICES SUPPORT ONE OR MORE OF THE FOLLOWING ESTABLISHED CRITERIA: - SUPPORT GUNDERSEN HEALTH SYSTEM COMMUNITY-BASED MISSION THROUGH STRATEGIC COMMITMENT - TARGET POOR, MEDICALLY UNDERSERVED OR SPECIAL NEEDS POPULATION - IMPACT HEALTH STATUS - SUPPLY OR SUPPORT A SERVICE THAT WOULD BE DISCONTINUED IF DECISION MADE ON PURE FINANCIAL BASIS - ACCESSIBLE TO THE ENTIRE COMMUNITY REGARDLESS OF ABILITY TO PAY - STIMULATES EXTERNAL COMMUNITY PARTNERSHIPS, INCLUDING EMPLOYEE PARTICIPATION (VOLUNTEERISM) - CAN BE MEASURED IN TERMS OF FINANCIAL VALUE, EMPLOYEE CONTRIBUTIONS, THE NUMBER OF PEOPLE SERVED, AND IF THE GIVEN COMMUNITY BENEFITS ADDRESSES A HEALTH DISPARITY IN THE COMMUNITY. GUNDERSEN HEALTH SYSTEM FURTHER REFINES COMMUNITY SERVICE INTO THE FOLLOWING CATEGORIES: - ACCESS AND COVERAGE - HEALTH PROMOTION - SOCIAL AND BASIC NEEDS - CORPORATE CITIZENSHIP - ACTIVITIES 1. FINANCIAL CONTRIBUTIONS 2. DONATION OF MATERIALS AND EQUIPMENT 3. EMPLOYEE VOLUNTEERISM IN THE COMMUNITY Schedule H, Part VI, Line 3: EVERY PATIENT IS MADE AWARE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE UPON CHECK-IN. SIGNS THAT ARE OF NOTICEABLE SIZE AND PLACEMENT ARE DISPLAYED IN EACH CHECK-IN AREA. PATIENTS ARE OFFERED A BROCHURE EXPLAINING THE FINANCIAL ASSISTANCE PROGRAM. PATIENTS THAT MEET WITH FINANCIAL COUNSELORS EITHER BY REFERRAL FROM A DEPARTMENT, OR SELF-REFERRAL ARE INFORMED OF THE FINANCIAL ASSISTANCE PROGRAM. FINANCIAL ASSISTANCE INFORMATION IS POSTED ON GLMC WEBSITE. INFORMATION IS ALSO POSTED IN NOT-FOR-PROFIT ORGANIZATIONS WHERE PATIENTS MIGHT SEEK ASSISTANCE FOR NON-MEDICAL FINANCIAL OBLIGATIONS. Schedule H, Part VI, Line 4: GUNDERSEN LUTHERAN MEDICAL CENTER INC. IS A MAJOR TERTIARY TEACHING HOSPITAL IN THE GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. LOCATED IN LA CROSSE, WI, THE HOSPITAL SERVES PATIENTS FROM THE LA CROSSE AND SURROUNDING AREAS INCLUDING THE 19 COUNTIES IN WESTERN WISCONSIN, SOUTHEASTERN MINNESOTA AND NORTHEASTERN IOWA. LA CROSSE COUNTY, WITH A POPULATION OF APPROXIMATELY 117,800 PEOPLE, IS THE LARGEST COMMUNITY IN OUR SERVICE REGION. TOTAL 19 COUNTY SERVICE POPULATION IS APPROXIMATELY 570,700 WITH AN AVERAGE HOUSEHOLD INCOME OF $64,373. 11.8% OF THE 19 COUNTY SERVICE AREA POPULATION IS COVERED BY MEDICAID (ACCORDING TO WI AND IA DATA). PROJECTED POPULATION GROWTH IS MUCH SLOWER AT 1.0% COMPARED TO THE NATIONAL POPULATION GROWTH PROJECTION OF 3.7%. 21.7% OF THE POPULATION ARE AGE 17 OR UNDER COMPARED TO 23.0% NATIONALLY. THE SERVICE AREA POPULATION OF 65 AND OLDER ADULTS IS 18.0% COMPARED TO 15.1% NATIONALLY. 7.3% OF THE POPULATION IS NON-WHITE. SEVERAL SMALLER RURAL COMMUNITY HOSPITALS ARE LOCATED THROUGHOUT THE REGION. GUNDERSEN TRI-COUNTY HOSPITAL IN WHITEHALL, WI, GUNDERSEN ST. JOSEPH'S HOSPITAL IN HILLSBORO, WI, PALMER LUTHERAN HEALTH CENTER IN WEST UNION, IA, AND GUNDERSEN BOSCOBEL AREA HOSPITAL IN BOSCOBEL, WI ARE PARTNERS/AFFILIATES OF THE GUNDERSEN HEALTH SYSTEM. SPECIALIZED SERVICES PERFORMED AT THE GUNDERSEN LUTHERAN MEDICAL CENTER AND IN MANY CASES, OUTREACH AT OUR REGIONAL CLINIC/HOSPITAL PARTNERS LOCATIONS INCLUDE ALLERGY, AUDIOLOGY, BEHAVIORAL MEDICINE, CARDIOLOGY, CARDIO TESTING LAB, CATH LAB, DERMATOLOGY, ECHOCARDIOGRAPHY, ENDOCRINOLOGY, ENDODONTICS, EXERCISE PHYSIOLOGY, GASTROENTEROLOGY, HEMATOLOGY, HOSPITALIST, INFECTIOUS DISEASE, NEPHROLOGY, NEUROLOGY, NEUROPSYCHOLOGY, NUTRITION THERAPY, OB/GYN, OCCUPATIONAL SERVICES, ONCOLOGY, OPHTHALMOLOGY, OTOLARYNGOLOGY, PATHOLOGY, PEDIATRICS, PERIODONTICS, PHYSICAL MEDICINE AND REHAB, PHYSICAL THERAPY, PLASTIC SURGERY, PODIATRY, PROSTHODONTICS, PSYCHIATRIC, PULMONARY, RENAL DIALYSIS, RHEUMATOLOGY, SPEECH PATHOLOGY, SPORTS MEDICINE, SURGERY, AND UROLOGY. GUNDERSEN PROVIDED SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT, MUCH OF WHICH IS NOT QUALIFIED. OUR HOSPITAL, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY, CARE THAT WITHOUT OUR HOSPITAL MAY NOT BE AVAILABLE. Schedule H, Part VI, Line 5: GUNDERSEN'S BOARD OF TRUSTEES IS COMPRISED OF INDIVIDUALS FROM THE COMMUNITY WHO RESIDE HERE. THESE INDIVIDUALS ARE NOT EMPLOYEES OF THE HEALTH SYSTEM. THIS GROUP WORKS WITH THE BOARD OF GOVERNORS, MAKING DECISIONS THAT SUPPORT THE COMMUNITY-BASED MISSION AND VISION OF OUR ORGANIZATION. MANY OTHER EXAMPLES EXIST REFLECTING THE HEALTH SYSTEM'S SUPPORT AND PROMOTION OF THE HEALTH OF THE COMMUNITY. MANY PROGRAMS FOR THE COMMUNITY ARE PROVIDED AT NO COST SUCH AS A PHYSICAL ACTIVITY CHALLENGE, HEALTHY MENU PLANNING AT LOCAL RESTAURANTS, CHILD RESILIENCE TRAINING FOR PARENTS, AND HEALTH SCREENINGS AT LOCAL EVENTS. A FREE NURSE ADVISOR LINE IS AVAILABLE FOR ALL TO ASSIST CALLERS. PRIORITY ONE DESIGNATION ASSURES HEART ATTACK PATIENTS SEEN IN HOSPITALS THROUGHOUT THE REGION ARE CARED FOR WITH PROVEN PROTOCOLS AND TIMELY PROCEDURES. GUNDERSEN STAFF ARE ENCOURAGED TO PARTICIPATE IN THEIR LOCAL COMMUNITY ORGANIZATIONS. STAFF LEND THEIR EXPERTISE IN LEADERSHIP POSITIONS TO ORGANIZATIONS SUCH AS UNITED WAY, HEALTH MISSION, CHAMBER OF COMMERCE, HUMAN SERVICE ORGANIZATIONS, HEALTH IMPROVEMENT INITIATIVES, and homelessness initiatives. STAFF FROM GUNDERSEN HAVE BEEN INSTRUMENTAL IN ACCOMPLISHING COMMUNITY NEEDS ASSESSMENTS AND IMPLEMENTATION OF COMMUNITY INITIATIVES IN AREAS OF OBESITY, ALCOHOL USE, CHILD SAFETY, MENTAL HEALTH, DOMESTIC VIOLENCE, CHILD ABUSE AND ENVIRONMENTAL HEALTH. PATIENT ADVISORY GROUPS FROM VARIOUS SECTORS OF OUR COMMUNITY ARE COORDINATED IN ORDER FOR US TO BETTER MEET THE NEEDS OF OUR PATIENTS. Schedule H, Part VI, Line 6: ALL AFFILIATES OF THE HEALTH SYSTEM HAVE A RESPONSIBILITY TO PROMOTE THE HEALTH OF THE COMMUNITIES WE SERVE. THE MAJORITY OF EMPLOYEES, BASED IN THE ADMINISTRATIVE CORPORATION, ARE ACTIVELY INVOLVED IN PROGRAMS AND SERVICES FOR THE COMMUNITY AS WELL AS MAINTAINING PARTNERSHIPS WITH A VARIETY OF ORGANIZATIONS, COALITIONS, INITIATIVES AND AGENCIES IN OUR COMMUNITIES THAT PROMOTE HEALTH. THE ADMINISTRATIVE CORPORATION ALSO PROVIDES THE FINANCIAL CORPORATE CONTRIBUTIONS TO VARIOUS ORGANIZATIONS AND COMMUNITY ACTIVITIES. OUR FOUNDATION PROVIDES SUPPORT FOR some COMMUNITY HEALTH PROMOTION PROGRAMS AS WELL, PROVIDED BY THE HEALTH SYSTEM OR OTHER ORGANIZATIONS IN OUR COMMUNITY. CLINICAL STAFF SUPPORT SCREENINGS AND THE HEALTH MISSION. OUR LOCAL RURAL HOSPITAL AFFILIATES PROVIDE SUPPORT TO THEIR RESPECTIVE COMMUNITIES. OUR CLINICS, LOCATED IN OVER 20 COMMUNITIES in 3 states PROVIDE SUPPORT UNIQUE TO THE NEEDS OF THAT COMMUNITY. THE MEDICAL CENTER, AS PART OF AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, WORKS WITH AND IS RELATED TO GUNDERSEN CLINIC, LTD. WHICH PROVIDED UNCOMPENSATED CARE IN THE AMOUNT OF APPROXIMATELY $46,259,342. BASED ON POLICIES AND CONTRACTS ARRANGED TO HELP SUPPORT THE COMMUNITY'S NEEDS RELATED TO HEALTH CARE SERVICES, THE $46,259,342 IS THE SUM OF UNREIMBURSED MEDICARE & MEDICAID COST PLUS CHARITY AT COST. ALL OF THESE ARE CALCULATED USING THE SAME METHOD UTILIZED FOR THE HOSPITAL CALCULATION OF CHARITY COST AND UNREIMBURSED MEDICARE AND MEDICAID COSTS. THE COST OF CHARITY IS CALCULATED BY FOLLOWING THE METHODOLOGY ON WORKSHEET 1. THE COST TO CHARGE RATIO IS CALCULATED FOLLOWING THE METHODOLOGY ON WORKSHEET 2. THE UNREIMBURSED MEDICARE AND MEDICAID COSTS ARE CALCULATED BY COMPARING THE COST OF SERVICES TO MEDICARE AND MEDICAID PATIENTS TO THE NET REVENUE FOR THOSE SAME PATIENTS. UNREIMBURSED COST IS THE AMOUNT THE COST EXCEEDS THE NET REVENUE. AMOUNTS ARE REPORTED IN THE SEPARATE 990 FOR GUNDERSEN CLINIC, LTD. AFFILIATED ENTITY CHARITY CARE AN AFFILIATE OF GUNDERSEN LUTHERAN MEDICAL CENTER, INC., GUNDERSEN CLINIC LTD., IS NOT REQUIRED TO FILE SCHEDULE H OF FORM 990. GUNDERSEN CLINIC, LTD. PROVIDED COMMUNITY BENEFIT OF: CHARITY AT COST $1,104,804 MEDICARE UNREIMBURSED COST $32,792,397 MEDICAID UNREIMBURSED COST $12,362,141. Schedule H, Part VI, Line 7: List of states receiving community benefit report: WI true GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 501(C)(3) 11089953 SUPPORT OF GLMF CHARITY CARE FOR 3793 RECIPIENTS 1 CHARITY CARE 6195 5851456 Book CHARITY CARE Schedule I, Part I, Line 2: ASSISTANCE WAS MADE TO A RELATED ORGANIZATION. THE FUNDS ARE MONITORED BY MANAGEMENT AND THE BOARD OF TRUSTEES. true false false false false false false false false Scott Rathgaber MD Chief Executive Officer 794496 50000 4555 0 39750 0 25614 0 914415 0 0 Stephen Shapiro MD Board of Trustees - Member 442396 5000 373 0 39750 0 30296 0 517815 0 0 Brian Sieck MD Board of Trustees - Member 391446 5000 333 0 39750 0 30346 0 466875 0 0 Kelley Bahr MD Board of Trustees - Member 355000 4195 0 36250 0 54 0 395499 0 0 Jonathan Zlabek MD Board of Trustees - Member 296496 7500 4093 0 29150 0 26114 0 363353 0 0 Greg Thompson MD BOT - Member, CMO 429880 4555 0 39938 0 24614 0 498987 0 0 P Michael Jacobs DPM Medical Vice President 348996 3000 7455 0 39750 0 26114 0 425315 0 0 Mary Kuffel MD Medical Vice President 461912 4195 0 39750 0 1318 0 507175 0 0 Stephanie Carroll MD Medical Vice President 297744 7000 13 0 39750 0 18868 0 363375 0 0 Todd Kowalski MD Medical Vice President 308995 7500 13 0 33916 0 28915 0 379339 0 0 Lisa Wied Vice President 117528 8799 0 18488 0 54 0 144869 0 0 Mike McKee Vice President 116812 23552 0 21901 0 26961 0 189226 0 0 Kraig Schuster Vice President 200584 360 0 30033 0 26372 0 257349 0 0 Elizabeth Smith-Houskamp Vice President, Admin COO 365917 13435 0 39750 0 54 0 419156 0 0 Bryan Erdmann Vice President 231686 1501 0 35625 0 28845 0 297657 0 0 Kelly Barton Vice President 121266 1579 0 4908 0 1850 0 129603 0 0 Michael Dolan MD EXEC VP, MEDICAL COO 589058 5000 13 0 39750 0 27796 0 661617 0 0 Marilu Bintz MD Senior Vice President, Med VP 572848 4542 0 39750 0 10156 0 627296 0 0 Kathleen Klock Senior Vice President 427000 120 0 39750 0 4236 0 471106 0 0 Mark Platt Senior Vice President 373996 4182 0 39750 0 23614 0 441542 0 0 Debra Rislow SVP, Admin COO 158366 231506 0 23925 0 14945 0 428742 0 0 Rose Ann-Laureto Chief Information Officer 197938 345 0 21827 0 5906 0 226016 0 0 Dara Bartels Chief Financial Officer 305237 25010 3686 0 39750 0 23614 0 397297 0 0 Mary Jafari Senior Physicist 225504 0 34314 0 16178 0 275996 0 0 John Wochos Senior Physicist 204573 3917 0 32120 0 26114 0 266724 0 0 Alan Daus Senior Physicist 210939 360 0 29347 0 23614 0 264260 0 0 Kimberly Schmidt Senior Physicist 188533 360 0 28843 0 16678 0 234414 0 0 Ryan Holte Administrative Director 170236 1206 0 26211 0 24614 0 222267 0 0 Mary Lu Gerke Former Nurse Executive 198836 0 30000 0 11616 0 240452 0 0 Jeffrey Thompson MD Former CEO 243996 3448 0 37500 0 26114 0 311058 0 0 Schedule J, Part I, Line 1a and Line 3: ALL PERSONNEL SERVICES FOR GUNDERSEN LUTHERAN MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICE, INC. AND ALL PAYMENTS TO VENDORS ARE MADE BY GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. Schedule J, Part I, Line 4A: 2016 SEVERANCE PAYMENTS: DEBRA RISLOW $230,500 Form 990, Part I, Line 1: GUNDERSEN LUTHERAN MEDICAL CENTER (GLMC) ESTABLISHED IN 1899, PROVIDES ACUTE AND TERTIARY CARE FOR 19 COUNTIES LOCATED THROUGHOUT WESTERN WISCONSIN, NORTHEASTERN IOWA AND SOUTHEASTERN MINNESOTA. GLMC IS A TEACHING HOSPITAL WITH 325 LICENSED BEDS AND A LEVEL II TRAUMA AND EMERGENCY CENTER. OUR MISSION IS TO DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH AND THROUGH IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. WE WILL WORK AS A TEAM TO DEMONSTRATE OUR VALUES: INTEGRITY-PERFORM WITH HONESTY, RESPONSIBILITY AND TRANSPARENCY, EXCELLENCE-ACHIEVE EXCELLENCE IN ALL ASPECTS OF DELIVERING HEALTHCARE, RESPECT-TREAT PATIENTS, FAMILIES AND COWORKERS WITH DIGNITY, INNOVATION-EMBRACE CHANGE AND NEW IDEAS, COMPASSION-PROVIDE COMPASSIONATE CARE TO PATIENTS AND FAMILIES. Form 990, Part III, Line 1: GUNDERSEN LUTHERAN MEDICAL CENTER (GLMC) A PHYSICIAN-LED, NOT-FOR-PROFIT HEALTHCARE SYSTEM, ESTABLISHED IN 1899, PROVIDES ACUTE AND TERTIARY CARE FOR 19 COUNTIES LOCATED THROUGHOUT WESTERN WISCONSIN, NORTHEASTERN IOWA AND SOUTHEASTERN MINNESOTA. WE SERVE AS A REGIONAL REFERRAL CENTER. GLMC IS A TEACHING HOSPITAL WITH 325 LICENSED BEDS AND A LEVEL II TRAUMA AND EMERGENCY CENTER. OUR MISSION IS TO DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH AND THROUGH IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. WE WILL WORK AS A TEAM TO DEMONSTRATE OUR VALUES: INTEGRITY-PERFORM WITH HONESTY, RESPONSIBILITY AND TRANSPARENCY, EXCELLENCE -ACHIEVE EXCELLENCE IN ALL ASPECTS OF DELIVERING HEALTHCARE, RESPECT-TREAT PATIENTS, FAMILIES AND COWORKERS WITH DIGNITY, INNOVATION-EMBRACE CHANGE AND NEW IDEAS, COMPASSION-PROVIDE COMPASSIONATE CARE TO PATIENTS AND FAMILIES. OUR CURRENT VISION IS TO ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES, AND STAFF. Form 990, Part III, Line 4a: GLMC PROVIDES A COMPREHENSIVE RANGE OF INPATIENT, CLINICAL AND DIAGNOSTIC SERVICES IN NUMEROUS MEDICAL SPECIALTIES AND SUBSPECIALTIES. GLMC IS A TEACHING HOSPITAL WITH 325 LICENSED BEDS WITH SPECIALTY SERVICES INCLUDING RENAL DIALYSIS, CANCER CARE, REHABILITATION SERVICES, AND CARDIAC SERVICES. IN 2013, GLMC OPENED A NEW INPATIENT BEHAVIORAL HEALTH BUILDING, MEETING A TREMENDOUS NEED IN OUR REGION FOR ADDITIONAL BEDS AND SERVICES. WE ARE ABLE TO PROVIDE CARE LOCALLY FOR PATIENTS OF ALL AGES. THE FACILITY IS THE ONLY PLACE IN THE REGION OFFERING INPATIENT CARE FOR ADOLESCENTS AND TEENAGERS WITH BEHAVIORAL HEALTH NEEDS. GLMC HAS REPEATEDLY BEEN NAMED ONE OF THE TOP 50 HOSPITALS IN THE NATION, PLACING US IN THE TOP ONE PERCENT. GLMC VOLUNTARILY PROVIDES MEDICALLY NECESSARY PATIENT CARE SERVICE THAT IS DISCOUNTED OR FREE OF CHARGE TO PERSONS WHO HAVE INSUFFICIENT RESOURCES AND/OR WHO ARE UNINSURED. DURING 2016, GLMC PROVIDED FINANCIAL ASSISTANCE ON APPROXIMATELY 6,195 PATIENTS THAT RESULTED IN GLMC INCURRING ROUGHLY $5,581,133 IN UNCOMPENSATED COST ASSOCIATED WITH THIS PROGRAM. Form 990, Part IV, Line 24a: GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. IS A PART OF GUNDERSEN LUTHERAN'S OBLIGATED GROUP (GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC., GUNDERSEN LUTHERAN MEDICAL CENTER, INC., GUNDERSEN CLINIC, LTD., AND GUNDERSEN LUTHERAN MEDICAL FOUNDATION, INC.) AND TAX-EXEMPT DEBT RESIDES ON THE BALANCE SHEET OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. FEIN 39-1606449. Form 990, Part VI, Line 2: Mark Glendenning, Gerald Arndt and Greg Prairie - Business Relationship Form 990, Part VI, Line 6: GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. IS THE SOLE MEMBER OF THIS ORGANIZATION. Form 990, Part VI, Line 7a: GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. Form 990, Part VI, Line 7b: GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE PARENT CORPORATION AND SOLE MEMBER OF THE CORPORATION, SHALL HAVE THE POWER TO RECOMMEND AND REVIEW, AS APPROPRIATE, AND APPROVE CERTAIN MATTERS. ARTICLES OF INCORPORATION MAY BE AMENDED BY VOTE OF THE SOLE MEMBER OF THE CORPORATION. Form 990, Part VI, Line 11b: THE FORM 990 WILL BE AVAILABLE FOR ALL BOARD MEMBERS AT A BOARD MEETING AND THE GUNDERSEN LUTHERAN HEALTH SYSTEM FINANCE COMMITTEE RECEIVES A COPY OF THE 990 BEFORE FILING AND UPON FURTHER REVIEW FROM THE CFO THE 990S ARE APPROVED AND FILED. Form 990, Part VI, Line 12c: GUNDERSEN LUTHERAN MEDICAL CENTER, INC. MONITORS CONFLICTS ON AN ANNUAL BASIS BY REVIEWING DISCLOSURES ON COMPLETED CONFLICT OF INTEREST STATEMENTS. Form 990, Part VI, Line 15a: ALL PERSONNEL SERVICES FOR GUNDERSEN LUTHERAN MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. THE COMPENSATION OF THE CEO IS DETERMINED ANNUALLY BY A COMMITTEE MADE UP OF THE COMMUNITY MEMBERS OF THE BOARD OF TRUSTEES. THEIR DETERMINATION IS MADE AFTER A REVIEW OF MARKET DATA OBTAINED FROM SEVERAL ORGANIZATIONS AND CEO PERFORMANCE. MEETING MINUTES ARE TAKEN AND KEPT AT THE MEETINGS WHERE SUCH DISCUSSIONS TAKE PLACE. RECOMMENDATIONS FOR COMPENSATION FOR THE ORGANIZATIONS' KEY MANAGEMENT EMPLOYEES ARE DEVELOPED ANNUALLY BY THE CEO, AFTER A REVIEW OF PERFORMANCE AND COMPARABLE MARKET DATA. THE PROPOSED SALARIES ARE INDEPENDENTLY REVIEWED BY AN OUTSIDE AUDITING FIRM. THE COMPENSATION RECOMMENDATIONS, AUDIT REPORTS, ALONG WITH THE MARKET DATA, ARE PRESENTED TO A COMMITTEE MADE UP OF THE COMMUNITY MEMBERS OF THE BOARD OF TRUSTEES. THE COMPENSATION AMOUNTS ARE NOT EFFECTIVE UNTIL THE BOARD COMMITTEE APPROVES THEM. MEETING MINUTES ARE TAKEN AND KEPT AT THE MEETINGS WHERE THE BOARD REVIEWS AND APPROVES THE COMPENSATION OF THE KEY EMPLOYEES. Form 990, Part VI, Line 19: REQUESTS FOR ALL DOCUMENTS ARE MADE THROUGH THE LEGAL DEPARTMENT AND THE APPROPRIATE DOCUMENTS ARE MADE AVAILABLE FOR INSPECTION IN THE LEGAL DEPARTMENT. Form 990, Part VII, Section A, Line 1: ALL PERSONNEL SERVICES FOR GUNDERSEN LUTHERAN MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. Form 990, Part VII, Section B, Line 1: ALL PAYMENTS TO VENDORS ARE MADE BY GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. Form 990, Part XII, Line 2c: THE PROCESS ALLOWS THE AUDIT COMMITTEE OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. TO INDEPENDENTLY COMMUNICATE WITH THE EXTERNAL AUDIT FIRM THROUGHOUT THE YEAR, BUT FORMAL COMMUNICATION OCCURS BEFORE THE ENGAGEMENT AND UPON CONCLUSION. THE AUDIT COMMITTEE MEETS WITH THE AUDIT FIRM FOR PRESENTATION OF THE STATEMENTS. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. Form 990, Part XII, Line 3a: The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. FORM 990 PART IX LINE 11G DESCRIPTION:Purchased Health Services TOTAL FEES:93481048 FORM 990 PART IX LINE 11G DESCRIPTION:Purchased Program Services TOTAL FEES:9225786 FORM 990 PART IX LINE 11G DESCRIPTION:Consulting TOTAL FEES:338631 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPTNG. 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