2014-11-10T15:30:01-06:00 2013-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2013-01-01 390824015 APPLETON MEDICAL CENTER INC APPL 9207355560 PO BOX 8025 APPLETON WI 54912 TIM A OLSON CHIEF FINANCIAL OFFICER 9207355560 2014-10-20 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-10-20 2013 2015-11-30 17:44:51Z TIM A OLSON PO BOX 8025 APPLETON WI 54912 237413215 0 X WWW.THEDACARE.ORG X 1958 WI TO IMPROVE THE HEALTH OF OUR COMMUNITY. 15 11 0 463 716353 -78171 72824 470238 229158631 236362664 421053 198132 156791 382181 229809299 237413215 8000 0 0 0 107238432 113055200 0 0 0 108919506 110374179 216165938 223429379 13643361 13983836 326853142 340798306 1611587 1572915 325241555 339225391 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 181381109 235116357 160-BED ACUTE CARE HOSPITAL, HEART, CANCER, AND OUTPATIENT SURGERY CENTERS, AND WELLNESS PROGRAMS. WITH CORPORATE PARENT THEDACARE, WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. 181381109 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 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 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 ANDERLA DAVID MD BOARD MEMBER 1.00 41.00 X 0 317508 28818 ATTASSI OMAR MD BOARD MEMBER 1.00 3.00 X 0 0 0 DALEY-ULLEM BETH BOARD MEMBER 1.00 2.00 X 0 0 0 DAVIS JOHN BOARD MEMBER 1.00 2.00 X 0 0 0 EDELMAN GARY MD BOARD MEMBER 1.00 42.00 X 0 432258 31028 JONES GINGER BOARD MEMBER 1.00 2.00 X 0 0 0 LARSON JIM BOARD MEMBER 1.00 3.00 X 0 0 0 MOARD DOUGLAS MD BOARD MEMBER 1.00 42.00 X 0 289271 27239 TIMBERLAKE KAREN BOARD MEMBER 1.00 2.00 X 0 0 0 WALSH CYRIL P BOARD MEMBER 1.00 3.00 X 0 0 0 STELLMACHER JON BOARD CHAIRMAN 1.00 2.00 X X 0 0 0 MALANOWSKI JOHN BOARD VICE-CHAIRMAN 1.00 2.00 X X 0 0 0 WELLER MIKE BOARD TREASURER 1.00 2.00 X X 0 0 0 WHITESIDE JEFFREY MD BOARD SECRETARY 1.00 2.00 X X 0 0 0 GRUNER DEAN CEO-SYSTEM 7.00 36.00 X X 155912 883497 175678 OLSON TIM VP, CFO-SYSTEM 7.00 34.00 X 72973 413510 104930 BARNAS KIM VP SR AMC & THEDA CLARK HOSPITAL 10.00 30.00 X 103860 311582 99280 LIVINGSTON KEITH VP SR CIO 6.00 34.00 X 61562 348846 86106 PISTONE MAUREEN VP SR TALENT MANAGEMENT 6.00 34.00 X 52659 298403 80998 FERRANTE ROBERT MD PHYSICIAN 40.00 0.00 X 739467 0 29661 GITTER MICHAEL MD PHYSICIAN 40.00 0.00 X 607957 0 39428 MIELKE DOUGLAS MD PHYSICIAN 40.00 0.00 X 607126 0 28801 WILSON ROBERT MD PHYSICIAN 40.00 0.00 X 612251 0 36651 ZHOU LI MD PHYSICIAN 40.00 0.00 X 607204 0 38733 3620971 3294875 807351 67 0 1 0 RADIOLOGY ASSOCIATES OF APPLETON PO BOX 117 APPLETON WI 54912 MEDICAL SERVICES 507751 GROWTH GROUP LLC 200 E WASHINGTON ST APPLETON WI 54912 MANAGEMENT SERVICES 312500 FRESENIUS MANAGEMENT SVCS INC 16343 COLLECTION CENTER DR CHICAGO IL 60693 MANAGEMENT SERVICES 290800 FOX VALLEY PATHOLOGISTS SC 325 N COMMERCIAL STREET NEENAH WI 54956 MEDICAL SERVICES 157793 4 450925 19313 470238 OUTPATIENT REVENUE 621400 133438010 133438010 INPATIENT REVENUE 621990 99688497 99688497 OTHER MISC REVENUE 900099 1758074 1758074 CAFETERIA REVENUE 900099 761730 761730 LAB REFERRAL REVENUE 621500 716353 716353 236362664 20908 20908 150405 0 150405 150405 150405 177224 0 177224 177224 177224 EQUITY GAIN IN AFFILIATE 900099 231776 231776 231776 237413215 235116357 716353 1110267 X 3650016 3650016 84506719 64330759 20175960 3291379 3291379 16409620 12883122 3526498 5197466 5197466 312500 312500 26982070 15155728 11826342 203446 203446 48453624 46294180 2159444 3869438 3471928 397510 92413 92413 300054 300054 5392847 5392847 14075140 14075140 640810 640810 BAD DEBT EXPENSE 6481994 6481994 EQUIPMENT MAINTENANCE 3569843 3569843 223429379 181381109 42048270 0 3500 3500 25957519 29048936 1061453 1306927 223982410 120810301 107421684 103172109 192408986 207266834 326853142 340798306 1577821 1572915 33766 0 1611587 1572915 X 325240507 339225391 1048 0 325241555 339225391 326853142 340798306 13983836 0 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 13397 13397 0 PART II-B, LINE 1: PORTION OF WHA DUES = $13,397 2384215 2384215 144341884 61625714 82716170 1088660 606222 482438 76167651 58578365 17589286 103172109 DUE FROM AFFILIATES 207266834 207266834 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 2012 AND 2011. TAX RETURNS FOR THE YEARS ENDED 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 X 1 X 1 X 1 0 1 1 2738937 2738937 0.01260 18318997 12637515 5681482 0.02620 21057934 12637515 8420419 0.03880 27 929857 1577610 1577610 0.00730 3 1234 322702 322702 0.00150 4 5102699 5102699 0.02350 2 2778 219660 219660 0.00100 6 2505938 538271 538271 0.00250 42 3439807 7760942 7760942 0.03580 42 3439807 28818876 12637515 16181361 0.07460 1 1406 2646 2646 0.00000 1 266271 2284 2284 0.00000 1 16 53 53 0.00000 1 60 705 705 0.00000 1 39746 1356 1356 0.00000 1 3000 20928 5672 15256 0.00010 6 310499 27972 5672 22300 0.00010 0 2970104 2734213 42232124 49017493 -6785369 X 1 1 1 1 APPLETON MEDICAL CENTER PO BOX 8025 APPLETON WI 54912 X X X APPLETON MEDICAL CENTER 1 1 X X X X X X X X X X 13 1 1 1 X WWW.THEDACARE.ORG/HOSPITALS-AND-CLINICS/A 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 APPLETON MEDICAL CENTER PART V, SECTION B, LINE 1J: APPLETON MEDICAL CENTER'S CHNA ALSO IDENTIFIED OWNER EXPECTATIONS, MISSION/VALUES, KEY COMPONENTS OF OUR COMMITMENT, ORGANIZATIONAL SUPPORT, ADVISORY TEAM GUIDANCE AND THE HEALTH IMPROVEMENT MODEL. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 3: PUBLIC HEALTH:THEDACARE WORKED CLOSELY WITH LOCAL OUTAGAMIE AND CALUMET 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. 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: MARY DORN, OUTAGAMIE COUNTY PUBLIC HEALTH MANAGER; KURT EGGEBRECHT, CITY OF APPLETON PUBLIC HEALTH OFFICER; BONNIE KOLBE, CALUMET COUNTY PUBLIC HEALTH OFFICER.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. APPLETON MEDICAL CENTER PROVIDERS AND STAFF ARE INTEGRATED INTO A WIDE VARIETY OF THESE INITIATIVES. THE FOX CITIES CHAT INCLUDES LEADERS FROM PUBLIC HEALTH, UNITED WAY, COMMUNITY FOUNDATION, NON-PROFITS, EDUCATION, AND HEALTH ORGANIZATIONS WHICH COLLECTIVELY REPRESENT THE BROAD INTERESTS OF THE COMMUNITY. 2013 FOX CITIES COMMUNITY HEALTH ACTION TEAM ROSTER:ROGER BERTSCHAUSEN, MINISTERFOX VALLEY UNITAVERSALIST FELLOWSHIPWILL BLOEDOW, RETIRED PASTORRAY DURKEE, APPLETON MEDICAL CENTER FOUNDATION, BOARD MEMBERKURT EGGEBRECHT, PUBLIC HEALTH OFFICER, APPLE HEALTH DEPARTMENTMICHAEL FROHNA, EXECUTIVE DIRECTOR, THEDACARE FOUNDATIONSTIM GALLOWAY, PRESIDENT GALLOWAY COMPANYERNESTO GONZALES, PRESIDENT CASA HISPANADEAN GRUNER, CEO THEDACAREMARTI HEMWALL, VP OF DONOR ENGAGEMENT COMMUNITY FOUNDATION FOR THE FOX VALLEY REGIONPETER KELLY, PRESIDENT UNITED WAY OF THE FOX CITIESSHANNON KENEVAN, DIVERSITY DIRECTOR HARMONY CAF-GOODWILL INDUSTRIESGREG LEMKE ROCHON, CPO BOYS & GIRLS CLUB OF THE FOX VALLEYCHRIS MATHENY, VP FOX VALLEY TECHNICAL COLLEGEJOHN MIELKE, MD, RETIRED CARDIOLOGIST THEDACAREPAULA MORGEN, COMMUNITY HEALTH THEDACARECATHY MUTSCHLER, DIRECTOR U.S. VENTUREAMY PUTZER, DIRECTOR OSHKOSH AREA COMMUNITY FOUNDATIONCAROLYN SLAVIK, COORDINATOR MISSION SERVICES MINISTRY HEALTH SYSTEMROLLIE STEPHENSON, CEO FAITH TECHNOLOGIESDAVE VANDER ZANDEN, RETIRED SCHOOL SPECIALITIESBEN VOGEL, ASSISTANT SUPERINTENDENT APPLETON AREA SCHOOL DISTRICTDEBORAH WETTER, GENERAL MANAGER VALLEY TRANSITKEY INFORMANT INTERVIEWS WERE CONDUCTED WITH EXPERTS REPRESENTING VULNERABLE OR MARGINALIZED POPULATIONS IN OUR COMMUNITY INCLUDING FARM FAMILIES, LATINO POPULATION, LESBIAN, GAY, BISEXUAL TRANSGENDER (LGBT), LOW INCOME, HMONG. SOURCES: RHONDA STREBEL, RURAL HEALTH INITIATIVE; ERNESTO GONZALES, CASA HISPANA; DR. IRIS TORRES AND PATRICIA SARVALA, FOX CITIES COMMUNITY HEALTH CENTER; TONY GONZALES, THOMPSON COMMUNITY CENTER; TRICIA NELSON, THEDACARE MEDICAL HOME; LO LEE AND JENNIFER GAINES BATES, HMONG AMERICAN PARTNERSHIP; CHAT INCLUDE BREAKFAST, JAN & MAY 2013. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 4: AFFINITY HEALTH SYSTEM APPLETON MEDICAL CENTER PART V, SECTION B, LINE 5D: THE CHNA WAS MADE AVAILABLE TO LOCAL CHAT, THEDACARE BOARDS AND LEADERSHIP TEAMS. APPLETON MEDICAL CENTER 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. APPLETON MEDICAL CENTER PART V, SECTION B, LINE 7: NUMBER OF PRIMARY CARE PROVIDERS: LIMITED TO EASTERN CALUMET COUNTY, SERVED BY OTHER AREA HEALTH SYSTEMS.POVERTY: ISSUE IS BEYOND WHAT OUR RESOURCES CAN SUPPORT AT THIS TIME.SMOKING: SIGNIFICANT PROGRESS HAS ALREADY BEEN MADE ON THIS ISSUE.DIABETES: WILL BE ADDRESSED THROUGH THE OBESITY PRIORITY. 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. 1 GROTH SURGERY CENTER PO BOX 8025 APPLETON WI 54912 OUTPATIENT SURGERY CENTER PART I, LINE 3C: IT IS THE ORGANIZATION'S POLICY THAT NO PATIENT SHOULD BE DENIED APPROPRIATE AND NECESSARY CARE ON THE BASIS OF INCOME. IN RESPONSE TO THIS POLICY, THE CARING HEARTS FINANCIAL ASSISTANCE PROGRAM WAS SET UP TO PROVIDE SHELTER TO THOSE PATIENTS WHO ARE UNABLE TO PAY FOR THEIR MEDICAL SERVICES. MEDICAL SERVICE FEES ARE WRITTEN OFF UNDER THE FINANCIAL ASSISTANCE PROGRAM THAT WOULD OTHERWISE HAVE BEEN SENT TO A COLLECTION AGENCY. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COMBINATION OF AVERAGE COSTS AND ACTUAL COSTS PERTAINING TO SUPPLIES, WAGES, AND BENEFITS. FOR SUPPLIES, THE ACTUAL COST OF ITEMS USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A FRINGE RATIO OF ALL BENEFITS RELATED TO THE ABOVE WAGE CALCULATION. THE COST ACCOUNTING SYSTEM DOES NOT DIFFERENTIATE BETWEEN DIFFERENT PAYER TYPES AND NO COST-TO-CHARGE RATIO IS USED. PART I, LINE 7G: NO PHYSICIAN CLINICS ARE INCLUDED IN SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990 (PART IX, LINE 25, COLUMN A) BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $6,481,994. PART II, COMMUNITY BUILDING ACTIVITIES: THE HEALTH OF THE COMMUNITY SHAWANO MEDICAL CENTER SERVES IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW:WELL CITY INITIATIVE PROMOTES DEVELOPMENT OF A HEALTHY WORKPLACE THROUGHOUT THE FOX CITIES.NEW MENTAL HEALTH CONNECTION COALITION OF MENTAL HEALTH PROVIDERS MEETING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES THROUGHOUT FOX CITIES.CHAMBER OF COMMERCE SUPPORT ENCOURAGES ECONOMIC DEVELOPMENT WHICH IN TURN PROVIDES JOBS AND INCOME, BOTH CONTRIBUTORS TO HEALTH.VOICES OF MEN WORKS TO ADDRESS THE ROOT CAUSE OF VIOLENCE AGAINST WOMEN AND GIRLS WHICH INCLUDES DEVALUING AND OBJECTIFYING WOMEN AND TREATING WOMEN AS PROPERTY. NO WRONG DOOR EFFORT TO DEVELOP COMMUNITY WIDE MENTAL HEALTH SAFETY NET.DISASTER READINESS HELPS ENSURE THE ENTIRE COMMUNITY IS READY FOR POTENTIAL EMERGENCIES. PSYCHIATRIST RECRUITMENT IMPROVES MENTAL HEALTH OF COMMUNITY. COMMUNITY ACTION FOR HEALTHY LIVING COALITION THAT ADVOCATES FOR HEALTHY LIFESTYLE CHANGE. THEDACARE NEIGHBORHOOD GARDEN/FARMER'S MARKETS PROVIDES FRESH PRODUCE TO AREA FOOD PANTRIES AND THE COMMUNITY.FOX VALLEY END OF LIFE COALITION - A GRASSROOTS CONSORTIUM WITH A MISSION TO IMPROVE END-OF-LIFE CARE AND CHOICES FOR ALL PEOPLE, THEIR FAMILIES, AND THEIR PHYSICIANS IN THE FOX CITIES.EMERGING LEADERS - MAKING AN IMPACT IN OUR COMMUNITY THROUGH DEDICATION TO SERVICE AND PHILANTHROPY.SUMMIT FOR HOPE - AIMS TO RAISE AWARENESS ABOUT SUBSTANCE ABUSE AND THE GROWING HEROIN ISSUE. PARTY AT THE PAC - PUTS TEEN SAFETY INTO FOCUS.ELECTRONIC RECYCLING EVENT WORKING TO TREAT THE EARTH WITH THE RESPECT THAT IT DESERVES.COMMUNITY SHARPS COLLECTION REDUCING THE RISKS OF INFECTIOUS WASTE.WISCONSIN SUSTAINABLE BUSINESS COUNCIL - TAKING AN ACTIVE POSITION ON THE ROLE OF CLIMATE CHANGE AND BUILDING HEALTHY COMMUNITIES BY REDUCING OR ELIMINATING OUR ENERGY WASTE AND WATER FOOTPRINT. ORGAN/TISSUE DONATION ADVANCING ORGAN DONATION EDUCATION.RURAL HEALTH INITIATIVE - ADDRESSING GROWING CONCERNS REGARDING THE HEALTH AND SAFETY ISSUES FACING TODAY'S FARM FAMILIES. YMCA STRONG KIDS PROVIDING KIDS THE OPPORTUNITIES THEY NEED TO REACH THEIR FULL POTENTIAL, LIVE HEALTHIER, HAPPIER LIVES TODAY, AND GROW INTO PRODUCTIVE ADULTS IN THE FUTURE. FOX VALLEY FAMILY MEDICINE RESIDENCY PROGRAM TEACHING THE ART AND HEART OF CARE.BUILDING FOR KIDS BUILDING KIDS IMAGINATION, CREATIVITY AND CONFIDENCE.CHAT - COMMUNITY LEADERS WORKING TOGETHER TO EXPLORE LOCAL AND REGIONAL HEALTH ISSUES. THEDACARE CENTER FOR HEALTHCARE VALUE - OFFERS LEARNING EXPERIENCES THAT DEVELOP HEALTHCARE LEADERS WHO ARE CAPABLE OF CONFIDENTLY DRIVING THE LEAN TRANSFORMATION OF THEIR ORGANIZATIONS TO DELIVER MEASURABLY BETTER VALUE TO THE PATIENTS, FAMILIES AND COMMUNITIES THEY SERVE.TRAUMA SYMPOSIUM FOCUSING ON EMERGENCY PREPAREDNESS. SEXUAL ASSAULT NURSE EXAMINER WORKING TO END SEXUAL AND DOMESTIC VIOLENCE.UNITED WAY WORKING EVERY DAY TO IMPROVE THE COMMUNITY. 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: HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SERVICES TO THOSE PATIENTS. WE DID NOT REPORT ANY SHORTFALL AS A COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: OUR POLICY IS NOT TO PURSUE PATIENT ACCOUNTS TO THE EXTENT ANY CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM. IF ONLY A PORTION OF THE CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM, THE REMAINING BALANCE WILL BE BILLED TO THE PATIENT AND COLLECTED IN ACCORDANCE WITH OUR NORMAL COLLECTION POLICY. PART VI, LINE 2: THEDACARE SERVES AN 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, INSIGHTS FROM INTERVIEWS OF PUBLIC HEALTH OFFICIALS, INSIGHTS FROM INTERVIEWS WITH REPRESENTATIVES OF VULNERABLE POPULATIONS, EMERGENCY DEPARTMENT PATIENT DATA AND INSIGHTS GATHERED FROM MONTHLY MEETINGS OF THE THEDACARE-LED CHAT TEAM (COMMUNITY HEALTH ACTION TEAM) COMPRISED OF 25 COMMUNITY LEADERS IN BUSINESS, NON-PROFIT, CLERGY, HEALTHCARE, UNITED WAY, PUBLIC HEALTH AND THE LOCAL COMMUNITY FOUNDATION. PART VI, LINE 3: PATIENT EDUCATION BEGINS WHEN A PATIENT IS ADMITTED TO A THEDACARE HOSPITAL. ADMISSION SPECIALISTS MEET WITH EACH PERSON INDIVIDUALLY TO ASSESS INSURANCE STATUS AND FINANCIAL NEED. IF NECESSARY, SPECIALISTS REFER PATIENTS TO CARE MANAGEMENT SPECIALISTS WHO ASSIST WITH THE ENROLLMENT OF PATIENTS IN AN APPLICABLE PROGRAM. THE HOSPITAL PATIENT HANDBOOK IS PROVIDED TO ALL IN-PATIENTS. INTERNAL POLICIES SUCH AS DISCOUNTED SERVICES POLICY, CARING HEARTS POLICY AND PAYMENT FOR SERVICE POLICY FOR SELF-PAY BALANCES PROVIDE GUIDANCE.THE THEDACARE WEBSITE, WWW.THEDACARE.ORG, PROVIDES EDUCATION REGARDING THE AFFORDABLE CARE ACT IN EASY TO UNDERSTAND LANGUAGE. IT DISCUSSES OPTIONS AND WHERE TO GO FOR ASSISTANCE. PART VI, LINE 4: APPLETON MEDICAL CENTER'S SERVICE AREA CONSISTS OF OUTAGAMIE AND CALUMET COUNTIES AND IS LOCATED EAST-CENTRAL WISCONSIN. THE TWO-COUNTY AREA HOSTS A POPULATION OF 225,666 COMBINED WITH CONCENTRATION IN THE FOX CITIES URBAN AREA.OUTAGAMIE COUNTY:- OVER THE LAST DECADE, OUTAGAMIE COUNTY POPULATION HAS GROWN BY 9.77%. THIS WILL MAKE OUTAGAMIE THE 5TH MOST POPULOUS COUNTY IN WISCONSIN BY 2035. - OUTAGAMIE COUNTY HIGH SCHOOL GRADUATION RATE IS 87%.- TRADE/TRANSPORTATION/UTILITIES, ALONG WITH MANUFACTURING EMPLOY THE MOST PEOPLE IN THE TWO-COUNTY REGION FOLLOWED BY EDUCATION/HEALTH. THESE THREE SECTORS EMPLOY 40% OF THE AREA'S WORKFORCE.- IN COMPARISON TO MORE RURAL COUNTIES IN THE THEDACARE SERVICE AREA, OUTAGAMIE AND CALUMET COUNTIES CONTINUE TO HAVE A HIGHER PERCENTAGE OF CHILDREN.- IN OUTAGAMIE COUNTY 8% OF THE POPULATION LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL AND 10% OF THE POPULATION IS UNINSURED.- THE PERCENTAGE OF NON-CAUCASIAN POPULATION HAS GROWN FROM 6.2% TO 8.8%. NINETY SIX PERCENT OF THE SERVICE AREA IS CAUCASIAN WITH HISPANIC POPULATION OF 2% SEEING THE FASTEST GROWTH. HMONG ARE ARRIVING AS REFUGEES FOR SIMULATION. THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENT LESS THAN 1%. THE MOST SIGNIFICANT GROWTH AMONG MINORITY POPULATIONS FROM 2000 TO 2010 OCCURRED AMONG LATINOS.CALUMET COUNTY:- OVER THE PAST DECADE, CALUMET COUNTY HAS GROWN IN POPULATION BY 20.53%.- THE CALUMET COUNTY HIGH SCHOOL GRADUATION RATE IS 93%- TRADE/TRANSPORTATION/UTILITIES ALONG WITH MANUFACTURING EMPLOY THE MOST PEOPLE IN THE TWO-COUNTY REGION FOLLOWED BY EDUCATION/HEALTH. THESE THREE SECTORS EMPLOY 40% OF THE AREA'S WORKFORCE.- IN COMPARISON TO MORE RURAL COUNTIES IN THE THEDACARE SERVICE AREA, OUTAGAMIE AND CALUMET COUNTIES CONTINUE TO HAVE A HIGHER PERCENTAGE OF CHILDREN- SIX PERCENT OF THE CALUMET COUNTY POPULATION LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL, 8% OF CALUMET COUNTY POPULATION ARE UNINSURED.- THE PERCENTAGE OF NON-CAUCASIAN POPULATION HAS GROWN FROM 6.2% TO 8.8%. NINETY SIX PERCENT OF SERVICE AREA IS CAUCASIAN WITH HISPANIC POPULATION OF 2% SEEING THE FASTEST GROWTH. HMONG ARE ARRIVING AS REFUGEES FOR SIMULATION. THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENT LESS THAN 1%. THE MOST SIGNIFICANT GROWTH AMONG MINORITY POPULATIONS FROM 2000 TO 2010 OCCURRED AMONG LATINOS PART VI, LINE 5: EACH YEAR, APPLETON 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 25 COMMUNITY LEADERS WHO STUDY SYSTEMIC HEALTH ISSUES OUTSIDE THE WALLS OF OUR HOSPITALS AND CLINICS AND WORK TO IDENTIFY INNOVATIVE, COLLABORATIVE SOLUTIONS THAT DRAW UPON THE WIDE ARRAY OF RESOURCES AND STRENGTHS OF OUR COMMUNITY. THROUGH CHAT, SUCH EFFORTS AS THE SHAWANO COUNTY RURAL HEALTH INITIATIVE HAVE BEEN DEVELOPED. THIS INITIATIVE TAKES BASIC HEALTH CARE AND SCREENING SERVICES TO THE FARM. EACH YEAR HUNDREDS OF FARM FAMILIES LIVING WITHOUT INSURANCE OR ONLY CATASTROPHIC COVERAGE RECEIVE CRITICAL ASSISTANCE. THIS INITIATIVE HAS NOW SPREAD TO OUTAGAMIE, WINNEBAGO AND WAUPACA COUNTIES. ANOTHER INITIATIVE IS THE THE NEW MENTAL HEALTH CONNECTION WHICH IS WORKING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES IN THE AREA. HIGH LATINO TEEN PREGNANCY RATES INSPIRED CHAT TO LAUNCH CUIDATE!, A CULTURALLY BASED TEEN PREGNANCY PREVENTION PROGRAM IN PARTNERSHIP WITH THE PARTNERSHIP COMMUNITY HEALTH CENTER. MAKING THE RIDE HAPPEN IS ANOTHER CHAT EFFORT THAT PROVIDES TRANSPORTATION TO OLDER ADULTS WHO OTHERWISE WOULD STAY COOPED UP IN APARTMENTS AND FIGHT DEPRESSION AND ISOLATION. PROJECT PROMISE IS A POVERTY INITIATIVE DEVELOPED THROUGH CHAT THAT BROUGHT TOGETHER MANY LOCAL AGENCIES AND BUSINESSES TO WORK TO ADDRESS POVERTY IN A COLLABORATIVE FASHION. VOICES OF MEN WAS LAUNCHED WITH SUPPORT FROM CHAT TO RAISE AWARENESS OF EVERYDAY BEHAVIORS OF MEN THAT CAN LEAD TO AN ACCEPTANCE OF VIOLENCE TOWARD WOMEN. ANOTHER RECENT INITIATIVE IS INCLUDE WHICH FOCUSES ON BUILDING INCLUSIVENESS AND TOLERANCE TO PREVENT SUICIDE AMONG THE GAY, LESBIAN, BISEXUAL, TRANSGENDER POPULATION. THEDACARE PROVIDES FUNDING AND STAFF SUPPORT TO MAKE CHAT AND 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. - 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 THE FOX CITIES/UW RESIDENCY CENTER TO PROVIDE HANDS ON EXPERIENCE FOR MEDICAL STUDENTS.- THEDACARE ALSO PARTNERS WITH AREA NURSING SCHOOLS SUCH AS UW OSHKOSH AND FOX VALLEY TECHNICAL COLLEGE TO PROVIDE PROFESSIONAL MENTORS FOR THEIR NURSING PROGRAMS AND VENUES FOR NURSING STUDENTS TO PRACTICE THEIR SKILLS.- THEDACARE HOSPITALS PROVIDED FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO TWO AREA CLINICS PROVIDING MEDICAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA.- THEDACARE HOSPITAL EMPLOYEES TAKE PART IN HELPING HEARTS, AN EMPLOYEE VOLUNTEERISM PROGRAM ENCOURAGING STAFF TO GIVE OF THEIR TIME IN THE COMMUNITY. THEDACARE PROVIDES PAID STAFF TO COORDINATE THE PROGRAM AND IDENTIFY AND PROMOTE VOLUNTEERISM OPPORTUNITIES. THEDACARE EMPLOYEES DONATED MORE THAN $1,434,000 IN UNPAID VOLUNTEER HOURS TO LOCAL NON-PROFITS IN 2013. - THEDACARE SPONSORS PARTY AT THE PAC FOR THOUSANDS OF AREA YOUTH TO EDUCATE YOUTH ON THE PERILS OF RISKY BEHAVIOR AND DRIVING. HOSTED AT OUR PERFORMING ARTS CENTER, LIVE DRAMATIZATIONS ALONG WITH STORIES OF YOUTH DISABLED DUE TO DRIVING AND RISKY BEHAVIOR ENCOURAGE TEENS TO THINK TWICE BEFORE DRINKING OR TEXTING AND DRIVING. - APPLETON 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.- APPLETON MEDICAL CENTER 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.- APPLETON MEDICAL CENTER STAFF SUPPORT THE THEDACARE NEIGHBORHOOD GARDEN WHICH SUPPLIES PRODUCE TO THE LOCAL EMERGENCY SHELTER. - APPLETON MEDICAL CENTER SUPPLIES ATHLETIC TRAINING SERVICES TO AREA HIGH SCHOOLS AT REDUCED COST.- APPLETON MEDICAL CENTER ORGANIZES SUPPORT GROUPS FOR CANCER AND DIABETES AND PROVIDES A TELEPHONE HOTLINE FOR NUTRITION COUNSELING.- APPLETON MEDICAL CENTER 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. - APPLETON 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 ANDERLA DAVID MD BOARD MEMBER 0 273016 0 43387 0 1105 0 9064 0 19754 0 346326 0 0 EDELMAN GARY MD BOARD MEMBER 0 55507 0 60349 0 316402 0 12000 0 19028 0 463286 0 0 MOARD DOUGLAS MD BOARD MEMBER 0 272885 0 15907 0 479 0 9350 0 17889 0 316510 0 0 GRUNER DEAN CEO-SYSTEM 112054 634967 42854 242840 1004 5690 23426 132745 2926 16581 182264 1032823 0 0 OLSON TIM VP, CFO-SYSTEM 58093 329193 11277 63901 3603 20416 13133 74418 2607 14772 88713 502700 0 0 BARNAS KIM VP SR AMC & THEDA CLARK HOSPITAL 82382 247148 16525 49575 4953 14859 19738 59213 5082 15247 128680 386042 0 0 LIVINGSTON KEITH VP SR CIO 48787 276459 9487 53757 3288 18630 10257 58122 2659 15068 74478 422036 0 0 PISTONE MAUREEN VP SR TALENT MANAGEMENT 41635 235936 7972 45174 3052 17293 9508 53881 2641 14968 64808 367252 0 0 FERRANTE ROBERT MD PHYSICIAN 736218 0 374 0 2875 0 9350 0 20311 0 769128 0 0 0 GITTER MICHAEL MD PHYSICIAN 579211 0 23662 0 5084 0 15500 0 23928 0 647385 0 0 0 MIELKE DOUGLAS MD PHYSICIAN 581670 0 23662 0 1794 0 7350 0 21451 0 635927 0 0 0 WILSON ROBERT MD PHYSICIAN 581820 0 23662 0 6769 0 15350 0 21301 0 648902 0 0 0 ZHOU LI MD PHYSICIAN 579115 0 23662 0 4427 0 15350 0 23383 0 645937 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. 4 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 2 EMPLOYEES 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, INVESTED 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 4B 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 THEDACARE INC. CENTRALIZES PAYROLL AND TAX WITHHOLDING FUNCTIONS FOR A NUMBER OF AFFILIATED ENTITIES, WHILE ALL FILING UNDER THEDACARE'S FEDERAL IDENTIFICATION NUMBER. APPLETON MEDICAL CENTER (AMC) REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE PAID BY THEDACARE, INC., THEREFORE, AMC DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY AMC FOR SALARY EXPENSES FOR THE EMPLOYEES WHO ARE PERMANENTLY ASSIGNED TO AMC. FORM 990, PART VI, SECTION A, LINE 6 APPLETON MEDICAL CENTER, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THEDACARE, INC. HAS SOLE AUTHORITY IN THE CORPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION A, LINE 7B THEDACARE, INC. HAS THE SOLE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. AMENDMENT OF THE ARTICLES OF INCORPORATION 2. ADOPTION AND AMENDMENT OF BYLAWS OF THE CORPORATION 3. CONSOLIDATION, MERGER AND DISSOLUTION OF THE CORPORATION 4. MONITORING COMPLIANCE WITH LAWS AND REGULATIONS 5. SELECTION, APPOINTMENT, AND REMOVAL OF A CHIEF OPERATING OFFICER 6. PROVISION FOR LONG-RANGE FINANCIAL STABILITY OF THE HOSPITAL AND PROVISION FOR THE CONTROL AND USE OF THE PHYSICAL AND FINANCIAL RESOURCES OF THE HOSPITAL 7. ESTABLISHMENT OF A LONG-RANGE PLANNING MECHANISM 8. APPROVAL OF A HOSPITAL ORGANIZATION AND MAJOR AUTHORITY DELEGATION PATTERNS 9. APPROVAL OF FINANCIAL, CAPITAL, AND OTHER ITEMS 10. APPROVAL OF DEBT OR LEASES 11. CONSIDERATION AND ACTION UPON POLICIES CONCERNING RELATIONS WITH EXTERNAL GROUPS AND ORGANIZATIONS FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C QUESTIONNAIRES ARE SENT TO ALL MANAGERS, TRUSTEES AND OFFICERS ANNUALLY. COMPLETED FORMS ARE RETURNED TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER REVIEWS THE QUESTIONNAIRES AND FOLLOWS UP WITH ANY QUESTIONS ABOUT THE MANAGERS' ANSWERS ON THE CONFLICT OF INTEREST FORMS. ALL EMPLOYEES AND BOARD MEMBERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE CORPORATE COMPLIANCE COMMITTEE REVIEWS THE POTENTIAL CONFLICT AND THE CFO/BOARD OF TRUSTEES REVIEW ALL CONFLICTS. AFTER DISCLOSURE OF THE CONFLICT, THE EMPLOYEE SHALL NOT PARTICIPATE IN THE DECISION WHETHER TO ENGAGE IN THE TRANSACTION IN WHICH THE EMPLOYEE HAS AN INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THEDACARE HIRES AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMS THE COMPENSATION POLICY, REVIEWS DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SR VP OF HUMAN RESOURCES, ADVISES, VALIDATES, AND APPROVES A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIES THE BONUS PLAN. FORM 990, PART VI, SECTION C, LINE 19 APPLETON MEDICAL CENTER INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 12,861,728. MANAGEMENT AND GENERAL EXPENSES 11,826,342. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 24,688,070. CONTRACT LABOR SERVICES: PROGRAM SERVICE EXPENSES 1,815,197. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,815,197. RECRUITING: PROGRAM SERVICE EXPENSES 10,493. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,493. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 468,310. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 468,310. FORM 990, PART XII, LINE 2C THIS PROCESS DID NOT CHANGE DURING THE YEAR. 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