2016-11-02T14:05:18-05:00 2015-12-31 390758449 Wipfli LLP PO Box 12237 Green Bay WI 543072237 990 2015-01-01 390806359 ThedaCare Medical Center - Berlin Inc THED 9203611313 225 MEMORIAL DR BERLIN WI 54923 tom KRYSTOWIAK CHIEF FINANCIAL OFFICER 9203611313 2016-10-19 1 Terri Rexrode CPA MST P00096513 9206620016 2016-10-18 2015 2017-02-10 21:41:12Z TIM A OLSON 225 MEMORIAL DR BERLIN WI 54923 80799494 0 X www.thedacare.org X 1910 WI Improving the Health of our Community. 12 7 0 60 2235654 0 0 219584 18469671 79175209 5138 98565 6472692 1178260 24947501 80671618 27967 212601 0 0 12661822 47134373 0 0 0 8249712 34702045 20939501 82049019 4008000 -1377401 56601513 51908036 26653586 24504228 29947927 27403808 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 81017786 212601 77773326 25-bed critical access hospital serving Green Lake, Marquette, and Waushara counties. Thedacare Medical Center - Berlin, 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. 81017786 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 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 12 7 1 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 GALATOWITSCH KRISTIN BOARD CHAIR 1.00 3.00 X X 0 0 0 KUEHN RUSSELL BOARD VICE CHAIR 1.00 1.00 X X 0 0 0 WISE LARRY BOARD TREASURER 1.00 X X 0 0 0 WILLETT THOMAS DO BOARD SECRETARY 1.00 X X 0 0 0 BUDDE DAVID DO BOARD MEMBER/PHYSICIAN 41.00 X 449750 0 27361 BURMEISTERBRIAN BOARD MEMBER/VP SR AMC & TC 5.00 38.00 X 47560 428044 61298 FEENEY JOHN BOARD MEMBER/CEO 41.00 X X 384226 0 24377 HOSTAK JOLENE BOARD MEMBER 1.00 X 0 0 0 KUJAWA PAUL BOARD MEMBER 1.00 X 0 0 0 LONGGREGORY MD BOARD MEMBER/CMO 5.00 37.00 X 61539 553851 99179 SHATTUCK P MICHAEL MD BOARD MEMBER/PHYSICIAN 41.00 X 230479 0 25924 WHITE KELLY DDS BOARD MEMBER 1.00 X 0 0 0 GRUNER DEAN CEO - SYSTEM 4.00 39.00 X 125990 1133910 214531 OLSON TIM VP CFO SYSTEM 4.00 37.00 X 53683 483143 28004 LIVINGSTON KEITH VP SR CIO 4.00 36.00 X 51346 462104 108486 PISTONE MAUREEN VP SR HR SERVICES 4.00 36.00 X 47096 423867 99911 ALVORD BRICE MD PHYSICIAN 40.00 X 796259 0 32771 KEITH PHILIP MD PHYSICIAN 40.00 X 858055 0 32627 LO HORACE MD PHYSICIAN 40.00 X 660696 0 33581 NELSON DARREN MD PHYSICIAN 40.00 X 568083 0 28892 VAISMAN URI MD PHYSICIAN 40.00 X 930405 0 32503 5265167 3484919 849445 38 0 1 0 DELL MARKETING LP PO BOX 802816 CHICAGO IL 606802816 TECHNOLOGY SERVICES 197595 1 32627 186957 219584 OUTPATIENT SERVICE REVENUE 624100 52144350 52144350 INPATIENT SERVICE REVENUE 624100 24563775 24563775 OTHER REVENUE 624100 2367334 131680 2235654 CAFETERIA REVENUE 900099 99750 99750 79175209 226441 226441 244739 0 244739 244739 244739 127876 -127876 -127876 -127876 EHR INCENTIVE 909999 933521 933521 933521 80671618 77773326 2235654 443054 212601 212601 1590471 1142117 448354 36339760 36220958 118802 890196 890196 6149696 6117298 32398 2164250 2164250 3761 3761 6027141 5618067 409074 179775 179775 505285 486829 18456 3169249 3165100 4149 329319 329319 150079 150079 145676 145676 3615094 3615094 439406 439406 CLINIC & PATIENT SERVIC 12173874 12173874 PROVISION FOR BAD DEBTS 5479151 5479151 Equipment Rental and Ma 2484235 2484235 82049019 81017786 1031233 0 15347 10816298 6189334 13934097 9150809 75000 1443326 763497 6147783 5345969 58809186 38557805 23251853 20251381 5453535 5580082 91238 56601513 51908036 4163366 540499 4116 0 22486104 23963729 26653586 24504228 X 29947927 27403808 29947927 27403808 56601513 51908036 X -1377401 -359409 -807309 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 3486 3486 0 Part II-B, Line 1: A portion of the WHA dues represent lobbying performed in regard to healthcare issues. The amount for 2015 was $3,486. 897714 897714 32182715 21499677 10683038 25728757 17058128 8670629 20251381 Deferred Employee benefits 6545655 DUE TO AFFLILIATES 17418074 23963729 Part XII, Line 2d - Other Adjustments: RENTAL EXPENSES Part XII, Line 4b - Other Adjustments: Provision for bad debt 1 1 1 X 1 X 1 0 1 1 359875 359875 0.00470 6794795 4464175 2330620 0.03040 7154670 4464175 2690495 0.03510 24 109198 247708 247708 0.00320 2 58 41194 41194 0.00050 2 369098 369098 0.00480 3 204090 255399 255399 0.00330 31 313346 913399 913399 0.01180 31 313346 8068069 4464175 3603894 0.04690 1 14382 1753 1753 0.00000 1 25 902 902 0.00000 1 2 429 429 0.00000 1 139 139 0.00000 1 26 26 0.00000 5 14409 3249 3249 0 2188921 348111 13678266 17590796 -3912530 X 1 1 1 1 thedacare medical center - berlin inc 225 Memorial Drive Berlin WI 54923 https://www.thedacare.org 1060 X X X X thedacare medical center - berlin inc 1 0 0 1 X X X X X X X X X X 13 1 1 0 1 X see 7d X X 1 13 1 see 7d 1 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X X X 1 X www.thedacare.org/~/link.aspx?_id=206478F0E2874D2EAD353B71BC978623& X www.thedacare.org/~/link.aspx?_id=206478F0E2874D2EAD353B71BC978623& X WWW.THEDACARE.ORG/~/LINK.ASPX?_ID=206478F0E2874D2EAD353B71BC978623& X X X X X X 1 X 0 X X X X 1 X 0 0 thedacare medical center - berlin, inc. Part V, Section B, Line 3j: ThedaCare Medical Center - Berlin's CHNA also identified owner expectations, mission/values, key components of our commitment, organizational support, advisory team guidance and the Health Improvement Model. thedacare medical center - berlin, inc. Part V, Section B, Line 5: Public HealthCommunity Health Center-Berlin worked closely with 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. A CHAT team will be implemented in Berlin in August 2015.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. thedacare medical center - berlin, inc. Part V, Section B, Line 6a: Affinity Health System thedacare medical center - berlin, 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-medical-center-berlin.aspx thedacare medical center - berlin, inc. Part V, Section B, Line 11: Identified and working on:Obesity:-In 2015, ThedaCare continued Good to Go Week, an employee led initiative that takes place in 6 school districts throughout the ThedaCare system. Activities include healthy snacks, build a school garden, fats in foods, measure your drink, leading gym classes.-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.-Provides funding to local Farmer's Markets to provide healthy food to the community -ThedaCare partners with local Boy's and Girl's Club 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.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 textingAccess 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 door thedacare medical center - berlin, inc. Part V, Section B, Line 15e: Contracted with 2 agencies to assist patients. First, Partnership Community Education Center - they provide the patient with free assistance with completing the financial assistance application and also assist patients in finding community funding that may be avaialable. Second, Cardon works directly with the uninsured patient to assist them with insurance enrollment and education. thedacare medical center - berlin, inc. Part V, Section B, Line 16i: The FAP and application were available at hospital cashier offices, on web site and offered to all patients that expressed a financial hardship when calling the billing office. The PLS was printed on every statement and a footer was added to the front of the statement advising patient to see reserve side of statement for financial assistance and payment options. Notification of financial assistance availability was added to the initial letter sent by the third party collection agency. thedacare medical center - berlin, inc. Part V, Section B, Line 20e: ThedaCare and/or third party collection agency are placing a minimum of one outbound call to advise customer of payment options including FA prior to credit bureau reporting or legal judgement. Process adjusted to ensure no ECA until customer receives at least 4 billing statements after date of discharge. No ECA until at least 120 days after discharge. thedacare medical center - berlin, inc. Part V, Section B, Line 22d: Lookback Method: For ER patients, take the 3 largest commercial insurers plus Medicare. Add all payments and all charges to arrive at a deduction percentage. Reduce the patient's bill by this percentage. For non-ER patients, take the 3 largest commercial insurers. Add all payments and all charges to arrive at a deduction percentage. Part V, Line 13: Patients are sent an overview letter explaining the process for applying for our assistance program or our staff walks them through the process. They are asked to complete an application that includes requests for information. This information is needed in order to make a decision as to whether the patient meets the criteria for acceptance, and if accepted, what level of assistance will be provided. Once the decision is made, we will notify the patient and if acceptable, write off the balance as determined. Part I, Line 3c: It is the organization's policy that no patient should be denied appropriate and necessary care on the basis of income. In response to this policy, the Caring Hearts Financial Assistance Program was set up to provide shelter to those patients who are unable to pay for their medical services. Medical service fees are written off under the financial assistance program that would otherwise have been sent to a collection agency. Part I, Line 7: The costing methodology used to calculate the amounts in the table is a combination of average costs and actual costs pertaining to supplies, wages, and benefits. For supplies, the actual cost of items used for each event is applied. If no actual cost is available, we then use an estimate. Wages are calculated by multiplying the average wage rate times actual hours worked. The benefit rate used includes a fringe ratio of all benefits related to the above wage calculation. The cost accounting system does not differentiate between different payer types and no cost-to-charge ratio is used. Part I, Line 7g: No physician clinics are included in subsidized health services. Part I, Ln 7 Col(f): The bad debt expense included on form 990 (Part IX, Line 25, Column A) but subtracted for purposes of calculating the percentage in this column is $5,479,151. Part II, Community Building Activities: THE HEALTH OF THE COMMUNITY THEDACARE MEDICAL CENTER - Berlin 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.Community Sharps Collection - reducing the risks of infectious waste.Community Garden - development of community gardens to provide fresh produce to community members and food pantry patrons.Farmer's Markets - provides fresh produce to area food pantries and community.United Way - working every day to improve the communitySexual Assault Nurse Examiner - working to end sexual and domestic violence.Emerging Leaders - making an impact in our community through dedication to service and philanthropy.Electronic Recycling Event - working to treat the Earth with the respect that it deserves.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.Rural Health Initiative - addressing growing concerns regarding the health and safety issues facing today's farm families. Health and Economic Summit - wellness with health in mind.Working with local schools and business - to provide wellness activities.Green Lake Greenways - promoting safe pedestrian/bike pathways.Green Lake County Wellness CoalitionAnnual Women's Night Out Part III, Line 4: A cost-to-charge ratio was used to determine the amounts reported in Part III lines 2 and 3. Patient payments or discounts are applied prior to determining bad debt expense and are not included in the bad debt write-off reported on the audited financial statements. Deductibles and coinsurance amounts that are deemed uncollectible are written off either to bad debt expense or, if applicable, to charity care if the patient so qualifies for financial assistance. The financial statements do not contain a footnote but they account for bad debts based on gross charges to patients after reflecting any payments or discounts, or amounts determined to be eligible for charity care/financial assistance. Part III, Line 8: Hospitals must accept Medicare patients regardless of whether they make a surplus or deficit from providing services to those patients. We did not report any shortfall as a community benefit. The costing methodology used to determine the Medicare allowable costs reported in the organizations Medicare cost report is step down. Part III, Line 9b: Our policy is not to pursue patient accounts to the extent any charges are eligible and written off through our charity care/financial assistance program. If only a portion of the charges are eligible and written off through our charity care/financial assistance program, the remaining balance will be billed to the patient and collected in accordance with our normal collection policy. Part VI, Line 2: ThedaCare serves a 9 county primary service area. Seven ThedaCare hospitals provide service in this area. ThedaCare conducts a Community Needs Assessment every 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 community leaders in business, non-profit, clergy, education, diverse population groups, 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: Community Health Center-Berlin service area consists of Green Lake County, population 18,959 and is located in east-central Wisconsin. 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.-Fourteen 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 Medical Center - Berlin'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 2015, Waupaca took a Plunge into Obesity. ThedaCare provides funding and staff support to make CHAT and these community health efforts possible. A CHAT is prepared to be implemented in Berlin in August 2015.Other ways that ThedaCare hospitals improve the health of the community include:-In 2015, ThedaCare shared its cutting edge application of Lean Production improvements with hundreds of healthcare and non-healthcare visitors from around the world. Most were visitors were from hospitals and health systems in the United States looking to improve quality and reduce costs.-ThedaCare hospitals provided support to the ThedaCare Center for Healthcare Value which is coordinating efforts across the country to share quality improvement and cost reduction learnings. -All ThedaCare hospitals provide health education programming for their respective communities focusing on such critical topics as proper nutrition, diabetes identification, and cancer prevention.-ThedaCare partners with Affinity Health System to sponsor Mosiac Health, providing hands on experience for medical students.-ThedaCare also partners with area nursing schools such as UW Oshkosh and Fox Valley Technical College to provide professional mentors for their nursing programs and venues for nursing students to practice their skills.-ThedaCare hospitals 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 $1,707,00 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 while driving. Hosted at Appleton 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 medical center - Berlin staff work with the area Chamber of Commerce and local high schools and colleges to inform youth about medical career opportunities and to help prepare our educational facilities to meet the healthcare staffing needs for the communities we serve.-Thedacare medical center - Berlin supports the American Cancer Society's Sole Burner Run and the American Heart Association Heart Walk events to help raise funds for the non-profit organizations.-Thedacare medical center - Berlin supplies Athletic Training Services to area high schools at reduced cost.-Thedacare medical center - Berlin organizes support groups for cancer and diabetes and provides a telephone hotline for nutrition counseling.-Thedacare medical center - Berlin makes financial and in-kind donations to non-profit organizations including United Way, area schools, American Heart Association, American Cancer Society. -Theda Care 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 medical center - berlin 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 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 1 BOYS AND GIRLS CLUB 501 E PARKWAY AVE PO BOX 411 OSHKOSH WI 54903 396120658 501(c)(3) 73900 GENERAL OPERATIONS CITY OF BERLIN 108 N CAPRON ST BERLIN WI 54923 396005398 government 115039 ambulance 2 Part I, Line 2: In order for grant requests to be considered they must meet the following guidelines: 1) Directed toward projects that support ThedaCare's mission and values 2) Benefit the communites served by ThedaCare, Inc. 3) Benefit a 501 (c)(3) not-for-profit organization Conversely, requests must NOT be for: 1) The sole benefit of an individual 2) Political organizations or campaign committees 3) Religious organizations (for strictly religious purposes) 4) Organizations in conflict with ThedaCare's mission and values 5) State or national campaigns All organizations requesting grant funds must apply through the ThedaCare website. Requests are screened, reviewed, and approved by committee six times throughout the fiscal year. A letter of restriction is issued by ThedaCare in conjunction with all grant checks. This letter of restriction states that all grant funds received from ThedaCare must be used strictly for the purposes for which they were applied. X X 1 1 X X X X 0 1 0 0 0 0 0 1 0 BUDDE DAVID DO BOARD MEMBER/PHYSICIAN 209415 0 239936 0 399 0 9149 0 18212 0 477111 0 0 0 BURMEISTERBRIAN BOARD MEMBER/VP SR AMC & TC 37577 338195 4468 40213 5515 49636 4209 37885 1920 17284 53689 483213 0 0 FEENEY JOHN BOARD MEMBER/CEO 316038 0 50216 0 17972 0 2701 0 21676 0 408603 0 0 0 LONGGREGORY MD BOARD MEMBER/CMO 45761 411847 5628 50652 10150 91352 7679 69114 2239 20147 71457 643112 0 0 SHATTUCK P MICHAEL MD BOARD MEMBER/PHYSICIAN 204206 0 0 0 26273 0 7618 0 18306 0 256403 0 0 0 GRUNER DEAN CEO - SYSTEM 83135 748215 21061 189553 21794 196142 19316 173848 2137 19230 147443 1326988 0 0 OLSON TIM VP CFO SYSTEM 45333 407997 5630 50670 2720 24476 795 7155 2005 18049 56483 508347 0 0 LIVINGSTON KEITH VP SR CIO 37782 340035 4656 41900 8908 80169 8892 80025 1957 17612 62195 559741 0 0 PISTONE MAUREEN VP SR HR SERVICES 32446 292018 4049 36438 10601 95411 8018 72164 1973 17756 57087 513787 0 0 ALVORD BRICE MD PHYSICIAN 596881 0 0 0 199378 0 9950 0 22821 0 829030 0 0 0 KEITH PHILIP MD PHYSICIAN 586496 0 0 0 271559 0 9950 0 22677 0 890682 0 0 0 LO HORACE MD PHYSICIAN 419044 0 53000 0 188652 0 9950 0 23631 0 694277 0 0 0 NELSON DARREN MD PHYSICIAN 432750 0 60000 0 75333 0 9950 0 18942 0 596975 0 0 0 VAISMAN URI MD PHYSICIAN 622538 0 152790 0 155077 0 9950 0 22553 0 962908 0 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 Employees received taxable medical expense reimbursements. Part I, Line 4b Senior level executives of the company are entitled to an annual flexible benefit equal to 20% of the midpoint of their salary range. This 457(f) supplemental benefit plan complies with the final regulations under Section 409A and 457(f) of the Internal Revenue Code. Participants may elect the benefit to be used to purchase particular insurance benefits, invest in a capital accumulation account, or a combination of the two. Benefits are accrued on a monthly basis and are subject to the Substantial Risk of Forfeiture Agreement signed by the participants. Plan contributions are made on a quarterly basis. Part I, Line 7 Executive At Risk Compensation Plan The plan objectives are to enhance ThedaCare Inc's ability to achieve its goals by providing a tool for stimulating and rewarding superior levels of performance among key executives, improve ThedaCare Inc's ability to compete with other employers for high talent executives and to encourage top-level executives to work together as a cohesive group toward common goals. The president of ThedaCare Inc. develops a list of senior level executives who are eligible to participate in this plan, as well as the performance levels the senior executives must achieve and the bonus amounts that the executives will receive. The president then submits this list to the executive committee of the board of trustees for final approval. These executives must be in active regular service of ThedaCare Inc. for the entire plan year (January 1, 2014 to December 31, 2014) to receive their 2015 bonuses. If the employee retires, becomes disabled, moves to a position that is eligible under the bonus plan or moves to a position that is no longer eligible for the bonus plan or dies, the plan will be prorated for the amount of time they served the company. If an eligible employee is fired or leaves the company for any other reason the plan bonus earned will be forfeited. Caring for Success The plan objectives are to provide incentive to focus the organization's resources, energy and attention on the fulfillment of ThedaCare's mission. Employee eligibility is based on the number of hours worked, and all eligible employees share in the payout. The payout amount is determined based on both financial and employee health and safety thresholds. The amount per employee is determined by dividing the total gain realized (the employee share) by hours paid to all eligible employees. The resulting dollar unit payout is multiplied by an individual employee's number of hours paid. This plan is overseen by an administrative committee. The ThedaCare Board of Trustees must approve the plan. Form 990, Part I, Line 5 ThedaCare Inc. centralizes payroll and tax withholding functions for a number of affiliated entities, while all filing under ThedaCare's federal identification number. thedacare medical center - berlin,inc. (Berlin) reports "0" employees because employees are paid by ThedaCare, Inc., therefore, Berlin does not file any W-2 forms. ThedaCare Inc. is reimbursed by Berlin for salary expenses for the employees who are permanently assigned to Berlin. Form 990, Part VI, Section A, line 2 Russell Kuehn and Thomas Willett are members of the Board of Directors of 1st National Bank. Form 990, Part VI, Section A, line 6 thedacare medical center - berlin, 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. Merge, consolidate, or change control of the organization 2. Sell, lease, transfer, or dispose of material assets 3. Enter joint ventures or affiliations 4. Amend bylaws and articles of incorporation 5. Develop and approve capital and operating budgets 6. Authorize and make capital expenditures 7. Approve strategic plans, with management and board oversight 8. Approve the safety and quality plan 9. Approve the dissolution or liquidation 10. Appoint auditors and legal counsel 11. Retain investment advisors and establish investment policies Form 990, Part VI, Section B, line 11 A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. Form 990, Part VI, Section B, line 12c QUESTIONNAIRES ARE SENT TO ALL MANAGERS, TRUSTEES, AND OFFICERS ANNUALLY. COMPLETED FORMS ARE RETURNED TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFIcER REVIEWS THE QUESTIONNAIRES AND FOLLOWS UP WITH ANY QUESTIONS ABOUT THE MANAGERS' ANSWERS ON THE CONFLICT OF INTEREST FORMS. ALL EMPLOYEES AND BOARD MEMBERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE CORPORATE COMPLIANCE COMMITTEE REVIEWS THE POTENTIAL CONFLICT AND THE CFO/BOARD OF TRUSTEES REVIEW ALL CONFLICTS. AFTER DISCLOSURE OF THE CONFLICT, THE EMPLOYEE SHALL NOT PARTCIPATE IN THE DECISION WHETHER TO ENGAGE IN THE TRANSACTION IN WHICH THE EMPLOYEE HAS AN INTEREST. Form 990, Part VI, Section B, line 15 THEDACARE HIRES AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMS THE COMPENSATION POLICY, REVIEWS DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SENIOR VICE PRESIDENT OF HUMAN RESOURCES, ADVISES, VALIDATES, AND APPROVES A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIES THE AT-RISK COMPENSATION PLAN. Form 990, Part VI, Section C, line 19 The organization believes its governing documents, conflict of interest policy, and financial statements are the property of the organization and does not make them available to the public. Form 990, Part XI, line 9: FUNDS RELEASED FROM RESTRICTIONS -205,306. Equity recLass -602,003. Form 990, Part XII, line 2c Management provides oversight of the audit. The audit is presented to the Finance Committee of the Board of Directors. Form 990, Part XI, line 2c The process has not changed from the prior year. COMMUNITY MEDICAL CENTER OF GREEN LAKE LLC 670 COUNTY HWY A GREEN LAKE WI 54941 261424367 CLINIC WI 0 0 THEDACARE MEDICAL CENTER - BERLIN INC THEDACARE INC 122 EAST COLLEGE AVENUE APPLETON WI 54911 391509362 HEALTHCARE WI 501(c)(3) Line 11b, II N/A 0 ThedaCare Regional Medical Center - Neenah INC PO BOX 8025 APPLETON WI 54912 390830664 HOSPITAL WI 501(c)(3) Line 3 THEDACARE INC 1 ThedaCare Medical Center - New London INC 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(c)(3) Line 3 THEDACARE INC 1 ThedaCare Medical Center - Waupaca INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 390871113 HOSPITAL WI 501(c)(3) Line 3 THEDACARE INC 1 ThedaCare Regional Medical Center - Appleton INC PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(c)(3) Line 3 THEDACARE INC 1 ThedaCare Medical Center - Shawano INC 100 COUNTY ROAD B SHAWANO WI 54166 390807068 HOSPITAL WI 501(c)(3) Line 3 THEDACARE INC 1 ThedaCare Medical Center - Wild Rose INC PO BOX 243 WILD ROSE WI 54984 396089134 HOSPITAL WI 501(c)(3) Line 3 THEDACARE INC 1 THEDACARE FAMILY OF FOUNDATIONS INC 1818 NORTH MEADE STREET APPLETON WI 54912 464112255 FOUNDATION WI 501(c)(3) Line 7 THEDACARE INC 1 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 1 1 1 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 thedacare family of foundations inc C 32627 actual