SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Go to www.irs.gov/form990 for instructions and the latest informtion.
OMB No. 1545-0047
2017
Open to Public Inspection
Name of the organization
AGNESIAN HEALTHCARE INC
 
Employer identification number

39-0807236
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . . 		    1,126,944   1,126,944 0.300 %
b Medicaid (from Worksheet 3, column a) . . . . .     22,920,434   22,920,434 6.060 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     24,047,378   24,047,378 6.360 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     1,613,592 238,615 1,374,977 0.360 %
f Health professions education (from Worksheet 5) . . .     732,968   732,968 0.190 %
g Subsidized health services (from Worksheet 6) . . . .     845,520 23,650 821,870 0.220 %
h Research (from Worksheet 7) .     5,387   5,387 0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     193,620   193,620 0.050 %
j Total. Other Benefits . .     3,391,087 262,265 3,128,822 0.820 %
k Total. Add lines 7d and 7j .     27,438,465 262,265 27,176,200 7.180 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2017
Schedule H (Form 990) 2017
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support     15,570   15,570 0 %
4 Environmental improvements            
5 Leadership development and
training for community members		            
6 Coalition building     4,249   4,249 0 %
7 Community health improvement advocacy            
8 Workforce development     115,239   115,239 0.030 %
9 Other            
10 Total     135,058   135,058 0.030 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
13,504,473
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
 
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
123,744,927
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
186,521,599
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-62,776,672
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2017
Schedule H (Form 990) 2017
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 ST AGNES HOSPITAL
430 E DIVISION STREET
FOND DU LAC,WI54935 		X X         X      
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
ST AGNES HOSPITAL
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 17
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 17
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): WWW.FDLCO.WI.GOV/HOME/SHOWDOCUMENT?ID=20012
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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Part VFacility Information (continued)

Financial Assistance Policy (FAP)
ST AGNES HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
WWW.AGNESIAN.COM/PAGE/FINANCIAL-ASSISTANCE
b
WWW.AGNESIAN.COM/PAGE/FINANCIAL-ASSISTANCE
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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Part VFacility Information (continued)

Billing and Collections
ST AGNES HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
ST AGNES HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
ST. AGNES HOSPITAL PART V, SECTION B, LINE 5: THE CHNA WAS COMMISSIONED BY AGNESIAN HEALTHCARE (ST. AGNES HOSPITAL, WAUPUN MEMORIAL HOSPITAL, AND RIPON MEDICAL CENTER), AURORA HEALTHCARE, FOND DU LAC AREA UNITED WAY, FOND DU LAC COUNTY HEALTH DEPARTMENT, FOND DU LAC FAMILY YMCA, AND FOND DU LAC SCHOOL DISTRICT. THE TASK FORCE REVIEWED COUNTY AND STATE DISEASE INCIDENCE AND DEATH DATA, AS WELL AS ECONOMIC, DEMOGRAPHIC, AND HEALTH STATUS DATA. TO SUPPLEMENT THIS DATA, COMMUNITY AND STAKEHOLDER OPINION SURVEYS WERE CONDUCTED TO DETERMINE WHAT PEOPLE IN FDL COUNTY PERCEIVED AS THE MAJOR HEALTH PROBLEMS IN THE COUNTY. COMMUNITY MEMBERS WERE SCIENTIFICALLY SELECTED SO THAT THE SURVEY WOULD BE REPRESENTATIVE OF ALL ADULTS 18 YEARS OLD AND OLDER. A TOTAL OF 400 TELEPHONE INTERVIEWS WERE COMPLETED WITH COMMUNITY MEMBERS. THE FOND DU LAC HEALTH 2020 COALITION, WHICH WAS FORMED AFTER THE 2014 SURVEY, RESPONDED TO THE NEEDS IDENTIFIED IN THE CHNA. THE HEALTHY 2020 STEERING COMMITTEE INCLUDES THE FOLLOWING MEMBERS: MICHAEL DEGERE, DPM, AGNESIAN HEALTHCARE/SSM HEALTH; ERIN GERRED, FOND DU LAC COUNTY, GREG GILES, FOND DU LAC YMCA, SARA HATHAWAY, RIPON COLLEGE, AMBER KILAWEE, FOND DU LAC AREA UNITED WAY; BILL LAMB, FOND DU LAC CITY POLICE DEPARTMENT; KIM MUELLER, FOND DU LAC COUNTY HEALTH DEPARTMENT, KELLY NORTON, ST. MARY'S SPRINGS ACADEMY; LALITHA RAMAMOORTHY, PH. D, MARION UNIVERSITY; LARRY RICHARDSON, FABOH; JACKIE RUNGE, FOND DU LAC AREA FOUNDATION; MARTY RYAN, ROTARY; JIM SALASEK, PH.D., COMMUNITY MEMBER; HEATHER SCHMIDT, DO, AGNESIAN HEALTHCARE/SSM HEALTH; LORI SCHRAGE, MORAINE PARK TECHNICAL COLLEGE; MARIAN SHERIDAN, FOND DU LAC SCHOOL DISTRICT; MICHELLE TIDEMANN, UW- EXTENSION FOND DU LAC; ERIC TONEY, FOND DU LAC COUNTY; JENNIFER WALTERS, AURORA HEALTH CARE; MELISSA WORTHINGTON, ENVISION GREATER FOND DU LAC. THE HEALTHY 2020 COALITION HAS TAKEN THE LEAD ON DISTRIBUTION OF INFORMATION TO THE PUBLIC, AS WELL AS CONTINUING COMMUNITY UPDATES AND ASSESSMENT OF PROGRESS.
ST. AGNES HOSPITAL PART V, SECTION B, LINE 6A: HOSPITALS INCLUDED IN THE CHNA WERE AGNESIAN HEALTHCARE (ST. AGNES HOSPITAL), WAUPUN MEMORIAL HOSPITAL AND RIPON MEDICAL CENTER.
ST. AGNES HOSPITAL PART V, SECTION B, LINE 6B: THE CHNA WAS CONDUCTED BY AGNESIAN HEALTHCARE (ST. AGNES HOSPITAL, WAUPON MEMORIAL HOSPITAL, AND RIPON MEDICAL CENTER), AURORA HEALTHCARE, FOND DU LAC AREA UNITED WAY, FOND DU LAC COUNTY HEALTH DEPARTMENT, FOND DU LAC FAMILY YMCA, AND FOND DU LAC SCHOOL DISTRICT.
ST. AGNES HOSPITAL PART V, SECTION B, LINE 7D: IN ADDITION TO THE HOSPITAL'S WEBSITE, THE HEALTHY 2020 COALITION MADE THE RESULTS OF THE CHNA WIDELY AVAILABLE THROUGH A SERIES OF COMMUNITY MEETINGS, DISTRIBUTION OF COMMUNITY HEALTH IMPROVEMENT PLAN FLYERS, NEWSPAPER ARTICLES, AND THE HEALTHY 2020 WEBSITE, WWW.LIVINGWELLFDL.ORG. THE FULL REPORT IS AVAILABLE ON THE FOND DU LAC COUNTY WEBSITE.PART V, LINE 7A HOSPITAL FACILITY'S WEBSITE: WWW.AGNESIAN.COM - AT BOTTOM OF HOME PAGE LABELED: "COMMUNITY HEALTH NEEDS ASSESSMENT."
ST. AGNES HOSPITAL PART V, SECTION B, LINE 11: AS A RESULT OF THE CHNA CONDUCTED IN 2012, 2014 AND 2017, THREE MAJOR AREAS OF FOCUS WERE DETERMINED, AND TWO OVERARCHING PRIORITIES SPANNING THE THREE AREAS OF FOCUS WERE AGREED UPON. A STRATEGIC ACTION PLAN HAS BEEN DEVELOPED FOR EACH FOCUS AREA.1) PRIORITY: NUTRITION AND PHYSICAL ACTIVITY - INCREASE THE NUMBER OF FOND DU LAC COUNTY RESIDENTS LIVING AT HEALTHY WEIGHT FOR THEIR HEIGHT THROUGH EATING HEALTHIER AND BEING MORE ACTIVE. HEALTHYOUTH IS A 4TH GRADE PROGRAM DONE AT 3 DIFFERENT ELEMENTARY SCHOOLS WITH THE HIGHEST PERCENTAGE OF FREE/REDUCED LUNCH RECIPIENTS. THE PROGRAM FOCUSES ON NUTRITION, SAFETY, PHYSICAL ACTIVITY AND EMOTIONAL WELL-BEING. EACH SESSION RUNS 5 WEEKS AND IS STAFFED BY MULTIPLE VOLUNTEERS FROM AGNESIAN HEALTHCARE MINISTRIES. THIS PARTNERSHIP WAS RECENTLY EXPANDED TO INCLUDE THE UNIVERSITY OF WISCONSIN EXTENSION. AGNESIAN HEALTHCARE PARTICIPATES IN LOCAL MIDDLE SCHOOL WELLNESS INSTRUCTION AND PROGRAMMING (PRIORITY-SPECIFIC: "FUEL FOR PERFORMANCE," TWICE WEEKLY) COMMUNITY PARTNERSHIPS TO PROVIDE ELDER COMMUNITY PROGRAMMING (PRIORITY-SPECIFIC: "SENIOR CENTER AGING MASTERY PROGRAM,") FOOD FOREST- AGNESIAN HEALTHCARE AND COMMUNITY PARTNERS FOCUSING ON ACCESS TO FRESH FRUITS AND VEGETABLES AND COLLABORATION WITH MULTIPLE STAKEHOLDERS TO PLANT AND MAINTAIN FREE COMMUNITY FRUIT GROVES AND VEGETABLE GARDENS. WALK WITH A DOC PROGRAM: AGNESIAN HEALTHCARE CLINICIANS MEET WITH COMMUNITY MEMBERS TO PROVIDE A BRIEF MEDICAL TOPIC REVIEW BEFORE AND DURING A WALK TOGETHER IN A MALL SETTING. 2) PRIORITY; MENTAL HEALTH - DECREASE THE NUMBER OF DEATHS BY SUICIDE IN FOND DU LAC COUNTY AND REDUCE STIGMA SURROUNDING MENTAL HEALTH. AGNESIAN HEALTHCARE: PARTICIPATES IN LOCAL MIDDLE SCHOOL WELLNESS INSTRUCTION AND PROGRAMMING (PRIORITY SPECIFIC: "BRAIN HEALTH," TWICE WEEKLY), HAS PARTNERED WITH COMMUNITY STAKEHOLDERS TO FORM TRAUMA-INFORMED CARE COMMITTEE AND PROMOTING A STIGMA-FREE APPROACH TO MENTAL/BEHAVIORAL WELLNESS, IS AN ACTIVE PARTICIPANT IN THE SUICIDE PREVENTION INITIATIVE: DESTINATION ZERO SUICIDE. 3) PRIORITY: ALCOHOL AND OTHER DRUG USE - DECREASE UNDERAGE DRINKING, ADULT BINGE DRINKING, AND THE MISUSE AND ABUSE OF DRUGS, PARTICULARLY OPIODS. AGNESIAN HEALTHCARE HAS REPRESENTATION ON DRUG-FREE COMMUNITIES, WITH FULL INTEGRATION OF A FOUR-PILLAR APPROACH TO FORM THE OPIOD INITATIVE. ACTION PLAN, GOALS AND INITIATIVES, BUILDING CAPACITY, AND DATA COLLECTION REFINEMENT HAVE ALL BEEN COMPLETED. AGNESIAN HEALTHCARE IS ACTIVELY INVOLVED IN PROVIDING DRUG DROP BOXES IN ALL FACILITIES, PARTICIPATING IN COMMUNITY NARCAN TRAINING, COMMUNITY AWARENESS, EDUCATION AND ENGAGEMENT CAMPAIGNS. ITS STRATEGIES INCLUDE IMPLEMENTING AN APPROACH TO ADDRESS HERION/OPIOD ABUSE AND IS ALSO UTILIZING A MEDIA/MARKETING CAMPAIGN TO RAISE AWARENESS AND ACTIVELY DISCOURAGE BINGE DRINKING AND OVER-CONSUMPTION. TWO OVERARCHING PRIORITIES:1) SOCIAL DETERMINANTS OF HEALTH - THE SOCIAL DETERMINANTS OF HEALTH ARE THE CONDITIONS IN WHICH PEOPLE ARE BORN, WORK AND AGE. WE RECOGNIZE THAT HEALTH BEGINS IN THESE ENVIRONMENTS WHERE WE SPEND THE MAJORITY OF OUR TIME. RESEARCH SHOWS THAT INDIVIDUAL HEALTH BEHAVIORS AND ACCESS TO CLINICAL CARE ONLY MAKE UP ABOUT HALF OF WHAT PREDICTS HEALTH. SOCIAL, ECONOMIC, AND PHYSICAL ENVIRONMENTS (OFTEN REFERRED TO AS THE SOCIAL DETERMINANTS OF HEALTH) MAKE UP THE OTHER 50% OF WHAT PREDICTS HEALTH OUTCOMES. EXAMPLES OF SOCIAL DETERMINANTS INCLUDE: AVAILABILITY OF COMMUNITY-BASED RESOURCES TO MEET DAILY NEEDS (E.G. ACCESS TO HEALTHY FOODS, SAFE HOUSING), TRANSPORTATION OPTIONS, EDUCATION, LANGUAGE, AND LITERACY, ACCESS TO HEALTH CARE, SOCIAL COHESION AND SOCIAL SUPPORT, SOCIOECONOMIC CONDITIONS, AND NEIGHBORHOOD AND BUILT ENVIRONMENT OUR GOALS: 1) INCREASE AWARENESS OF THE INFLUENCE SOCIAL DETERMINANTS HAVE IN SHAPING HEALTHY OUTCOMES. 2) IMPROVE HEALTH CONSIDERATIONS IN DECISION-MAKING.2) TRAUMA- INFORMED CARE - TRAUMAIES ON TRAUMA-INFORMED CARE IN FOND DU LAC COUNTY. 3). IMPLEMENT A TRAMA-INFORMED CARE ASSESSMENT AMONG A VARIETY OF COMMUNITY ORGANIZATIONS.THE HOSPITAL IS PARTICIPATING IN THE INITIATIVES NOTED ABOVE TO ADDRESS THE NEEDS IDENTIFIED IN CHNA. OUR INITIATIVES ARE ALREADY SHOWING POSITIVE RESULTS. THE UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE PRODUCES A WELL-KNOWN DOCUMENT TITLED "COUNTY HEALTH RANDINGS AND ROADMAPS". THE MOST CURRENT REPORT SHOWS THAT FOND DU LAC COUNTY HAS IMPROVED FROM THE HEALTH FACTORS RANK OF 20 RANK OF 16 IN THE STATE. IN ORDER TO FURTHER HELP COMMUNITY MEMBERS TAKE POSITIVE STEPS IN IMPROVING THEIR HEALTH, AGNESIAN HEALTHCARE DISTRIBUTED 2018 WELLNESS CALENDARS TO 75,000 RESIDENTS.
ST. AGNES HOSPITAL PART V, SECTION B, LINE 13B: PATIENTS AND THEIR GUARANTOR'S INCOME IS USED IN DETERMINING INCOME LEVEL FOR FREE OR DISCOUNTED CARE.
ST. AGNES HOSPITAL PART V, SECTION B, LINE 18E: COLLECTION AGENCIES ARE ENGAGED TO COLLECT UNPAID BALANCES. THESE AGENCIES ARE AUTHORIZED TO REPORT TO CREDIT AGENCIES. COLLECTION AGENCIES ARE AUTHORIZED BY THE HOSPITAL TO ESTABLISH GARNISHMENT AGAINST WAGES ON UNPAID BALANCES THEY ARE ATTEMPTING TO COLLECT. THESE ACTIONS ARE NOT UNDERTAKEN UNTIL REASONABLE EFFORTS TO DETERMINE THE PATIENT'S ELIGIBILITY UNDER THE FAP HAVE BEEN MADE.AGNESIAN HEALTHCARE DOES NOT TAKE ANY OF THE ACTIONS AGAINST AN INDIVIDUAL THAT ARE LISTED IN 18A - 18D.
PART V, LINE 22 UNINSURED PATIENTS RECEIVE A DISCOUNT AT THE TIME THE UNDISCOUNTED CHARGES ARE RENDERED. THIS APPLIES TO PATIENTS WITH NO COVERAGE FOR PAYMENT FROM HEALTH CARE INSURANCE AND/OR OTHER THIRD PARTY PAYORS.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2017
Page 9
Schedule H (Form 990) 2017
Page 9
Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?3
Name and address Type of Facility (describe)
1 1 - AGNESIAN HEALTHCARE ENTERPRISES LLC
430 E DIVISION STREET
FOND DU LAC,WI54935 		PHARMACEUTICALS, HOME HEALTH, MEDICAL SUPPLIES
2 2 - CONSULTANTS LAB OF WISCONSIN LLC
430 E DIVISION STREET
FOND DU LAC,WI54935 		LABORATORY AND TESTING
3 3 - FOND DU LAC REGIONAL CLINIC
420 E DIVISION STREET
FOND DU LAC,WI54935 		OUTPATIENT PHYSICIAN CLINIC
4
5
6
7
8
9
10
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Form and Line Reference Explanation
PART I, LINE 3C: AGNESIAN HEALTHCARE DOES NOT USE ANY OTHER FACTORS THAN FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY.
PART I, LINE 6A: THE CHNA WAS COMMISSIONED BY AGNESIAN HEALTHCARE, COUNTY HEALTH DEPARTMENT, FOND DU LAC COUNTY YMCA, AND FOND DU LAC SCHOOL DISTRICT. AN ANNUAL COMMUNITY BENEFIT REPORT IS COMPLETED BY THE FINANCE DEPARTMENT AND DISTRIBUTED TO THE PUBLIC THROUGH THE PUBLIC RELATIONS OFFICE OF AGNESIAN HEALTHCARE, INC.
PART I, LINE 7: A COST-TO-CHARGE RATIO WAS USED TO COMPUTE COST OF COMMUNITY BENEFIT SERVICES. OVERALL COSTS LESS TAXES WERE DIVISIBLE BY TOTAL CHARGES.
PART I, LINE 7G: AGNESIAN HEALTHCARE SUBSIDIZES A SAMARITAN CLINC AND PALLIATIVE CARE FOR THOSE THAT QUALIFY.
PART I, LN 7 COL(F): THE BAD DEBT EXPENSE THAT WAS INCLUDED ON FORM 990, PART VIII AND THEREFORE NOT CONSIDERED IN THE PERCENTAGE CALCULATION FOR PURPOSES OF PART I, LINE 7, COL(F) IS 13,504,473.
PART II, COMMUNITY BUILDING ACTIVITIES: AGNESIAN HEALTHCARE PROVIDES COMMUNITY SUPPORT, LEADERSHIP DEVELOPMENT AND TRAINING FOR COMMUNITY MEMBERS, COALITION BUILDING AND WORKFORCE DEVELOPMENT THROUGH THEIR COMMUNITY BENEFIT ACTIVITIES.
PART III, LINE 4: THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A CHARGE TO CONTRACTUAL ADJUSTMENTS AND A CREDIT TO THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. THE COSTING METHODOLOGY FOR DETERMINING BAD DEBTS IS A COST TO CHARGE RATIO.
PART III, LINE 8: MEDICARE SHORTFALL IS NOT TREATED AS A COMMUNITY BENEFIT. TO ARRIVE AT COST OF MEDICARE SERVICES, THE TOTAL EXPENSE LESS OTHER OPERATING REVENUE IS MULTIPLIED BY THE RATIO OF MEDICARE REVENUE TO TOTAL REVENUE.ALTHOUGH MEDICARE SHORTFALL HAS NOT BEEN REPORTED AS A COMMUNITY BENEFIT, IT SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE IT PROMOTES ACCESS TO HEALTHCARE TO THE UNDERSERVED ELDERLY POPULATION, WHO WOULD NOT HAVE ACCESS TO LOCAL CARE IF WE WERE NOT ABLE TO SERVE THEM. ALTHOUGH OUR HOSPITAL IS EFFICIENTLY OPERATED, THE CALCULATIONS USED FOR MEDICARE REIMBURSEMENT DO NOT ALLOW FOR PAYMENTS THAT COVER COSTS OF NECESSARY SERVICES.
PART III, LINE 9B ST. AGNES HOSPITAL HAS A WRITTEN DEBT COLLECTION POLICY. PAYMENT IS DUE WITHIN 30 DAYS OF RECEIPT OF A STATEMENT. IF PATIENTS DO NOT SET UP ACCEPTABLE PAYMENT ARRANGEMENTS, BILLS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. FINANCIAL COUNSELORS WORK WITH ALL PATIENTS ON AN INDIVIDUAL BASIS AND MAY OFFER EXTENDED MONTHLY PAYMENTS WITHOUT INTEREST BASED ON DOLLAR AMOUNT, PRIVATE PAY DISCOUNTS (INDIVIDUALS WHO DO NOT HAVE INSURANCE COVERING EMERGENCY OR OTHER MEDICALLY NECESSARY CARE ARE BILLED AT A REDUCED RATE), OR GUARANTEED BANK LOANS.A ZERO DOLLAR AMOUNT WAS ESTIMATED FOR THE AMOUNT OF BAD DEBTS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE. IF PATIENTS QUALIFY, THEIR EXPENSES ARE RECLASSIFIED AS CHARITY CARE. PATIENTS WHO RECEIVED A COLLECTION NOTICE COULD APPLY FOR CHARITY CARE. IF THEIR APPLICATION IS APPROVED, THIS WOULD TRIGGER A TRANSFER OF EXPENSES FROM BAD DEBT TO CHARITY CARE.
PART VI, LINE 2: IN ADDITION TO THE CHNA NOTED ABOVE, THE HOSPITAL'S SENIOR LEADERS MEET REGULARLY WITH COMMUNITY LEADERS TO GATHER INPUT FROM AND RESPOND TO PATIENT AND CUSTOMER NEEDS. SENIOR LEADERS AND MEMBERS OF THE WORKFORCE PARTICIPATE IN A VARIETY OF ORGANIZATIONS IN SUPPORT OF ST. AGNES HOSPITAL'S KEY COMMUNITIES. THROUGH THE HOSPITAL'S PARTICIPATION IN THESE ACTIVITIES, COMMUNITY MEMBERS LEARN OF THE HOSPITAL'S COMMITTMENT TO COMMUNITY-WIDE HEALTHCARE AND PROVIDE AGNESIAN HEALTHCARE (ST. AGNES HOSPITAL, WAUPUN MEMORIAL HOSPITAL, AND RIPON MEDICAL CENTER), WITH INSIGHTS INTO COMMMUNITY HEALTH NEEDS AND DESIRES.
PART VI, LINE 3: FINANCIAL COUNSELORS AT ST. AGNES HOSPITAL ASSIST PATIENTS WITH APPLICATION FOR COMMUNITY CARE. PATIENTS CAN BE REFERRED TO COMMUNITY CARE BY CLERGY, DEPARTMENTS OF ST. AGNES HOSPITAL, SISTERS OF ST. AGNES, PHYSICIANS, AREA SOCIAL AND HEALTH AGENCIES, FAMILY OR SELF. THE APPLICATION IS COMPLETED BY THE PATIENT WITH ASSISTANCE FROM THE FINANCIAL COUNSELOR IF NEEDED. THE FINANCIAL COUNSELOR WILL COMMUNICATE TO THE PATIENT WHAT PROGRAMS THEY WILL BE ELIGIBLE FOR, AS WELL AS PROVIDE NOTIFICATION OF APPROVAL OR DENIAL OF THEIR APPLICATION IN A TIMELY MANNER.
PART VI, LINE 4: COMMUNITY CARE APPLICATIONS ARE ACCEPTED ONLY FROM PATIENTS OF ST. AGNES HOSPITAL WHO RESIDE IN THE COUNTIES OF DODGE, FOND DU LAC OR GREEN LAKE IN THE STATE OF WISCONSIN. INDIVIDUALS MUST BE A RESIDENT OF ONE OF THESE AREAS FOR A MINIMUM OF THREE MONTHS AND PROVIDE SUPPORTING DOCUMENTATION. ON OCCASION, INDIVIDUALS WHO ARE NOT COMMUNITY MEMBERS BUT MAY NEED ASSISTANCE; THOSE APPLICATIONS ARE CONSIDERED ON A CASE-BY-CASE BASIS.
PART VI, LINE 5: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT", THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFIT AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY - CARE THAT, WITHOUT OUR HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY, BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: DIALYSIS CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, EXTENDED CARE, INFUSION SERVICES, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMEN'S SERVICES.
PART VI, LINE 6: ST. AGNES HOSPITAL IS PART OF SSM HEALTH, AN INTEGRATED, COMPREHENSIVE NOT-FOR-PROFIT HEALTHCARE DELIVERY SYSTEM COMPRISED OF NUMEROUS MINISTRIES LISTED ON SCHEDULE R. SSM HEALTH PROVIDES A CONTINUUM OF HEALTHCARE FROM BIRTH TO END OF LIFE, PREVENTATIVE CARE, DIAGNOSIS, TREATMENT AND FOLLOWUP, ASSISTED LIVING, AND INDEPENDENT AND SKILLED CARE SERVICES. AGNESIAN HEALTHCARE IS COMMITTED TO ENSURING THAT INDIVIDUALS NEEDING VITAL HEALTHCARE SERVICES GET THE HELP THEY NEED AND DESERVE.
PART VI, LINE 7, REPORTS FILED WITH STATES WI
Schedule H (Form 990) 2017
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