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‘Quality does matter,’ new HCA monitor says as Mission emerges from federal oversight

Highlands Cashiers Hospital is part of the Mission Health System.
Lilly Knoepp
Highlands Cashiers Hospital is part of the Mission Health System.

As Mission Health moves out of “immediate jeopardy” federal status, a new group will monitor the company as part of the agreement made when HCA Healthcare purchased the health care system, which includes six hospitals across Western North Carolina.

The new system monitor will have an expanded scope, including evaluating the quality of care across HCA’s operations in 18 counties and holding more community meetings.

About 20 people sat in the meeting room at Hudson Library in Highlands on Tuesday evening to discuss Highlands-Cashiers Hospital and meet the new independent monitor.

Dr. Susan Mims is CEO of Dogwood Health Trust, the nonprofit foundation that was created when Mission Health was purchased by for-profit hospital system HCA in 2019.

Mims introduced Boston-based Affiliated Monitors, which will now oversee HCA’s compliance with the asset purchase agreement. The agreement requires an independent monitor role, previously held by Gibbins Advisors. Mims explained that Dogwood saw a need for the monitor to engage more with the community and work with the state attorney general’s office.

“Dogwood is a relatively young organization. We have many decades of work ahead of us and we are here for the long haul,” Mims said. 

Each year the independent monitor puts together a compliance report based on data, community input and facility visits. That report is then submitted to the Attorney General’s office, Mims explained.

During the event, independent monitor team leader Gerald Coyne outlined where HCA stands within the asset purchase agreement. Out of the 15 commitments, about 10 are focused on fulfilling capital spending goals and completing specific projects like the new Angel Medical Center in Franklin.

The other five are the “heart and soul,” Coyne said, and focus on charitable care, continuing to participate in Medicaid and Medicare Services, maintaining hospital service levels, and other items that aren’t so easily checked off a list.

Coyne says these items are where two main issues have arisen for the community.

“If services are diminished but not eliminated, at what point does the reduction of a service become so reduced that it really shouldn't be considered activity anymore,” Coyne said. “Please don't ask for a specific number, I can't give you one because we have to look at each one individually.”

The new monitor, Coyne and Mims say, will also consider the quality of care at HCA facilities.

The previous independent monitor had not included quality of care in its scope, to the chagrin of many community members. Coyne explained that while “quality” isn’t mentioned in the agreement it is an important part of health care.

“Quality does matter. You can't talk about the delivery of medicine without quality. It's inherent,” Coyne said.

Gerald Coyne, independent monitor team leader with Boston-based Affiliated Monitors, speaks in Highlands on June 18, 2024. The monitor group is assigned to HCA Healthcare as Mission Health moves out of “immediate jeopardy” federal status.
Lilly Knoepp
Gerald Coyne, independent monitor team leader with Boston-based Affiliated Monitors, speaks in Highlands on June 18, 2024. The monitor group is assigned to HCA Healthcare as Mission Health moves out of “immediate jeopardy” federal status.

Coyne was previously the chief deputy attorney general in Rhode Island for 20 years. He said that despite the fact that the independent monitor’s review process is annual, the group plans to be in the community more often.

“Our engagement will continue and be more of a year-round process. We plan on being back at some time in the fall to do another sort of round of community engagements,” Coyne said.

The HCA/Mission Hospital faced several serious allegations in a 384-page report issued by CMS last year. HCA then submitted a plan of correction that CMS accepted. The report detailed nine incidents that took place between April 2022 to November 2023. Under the corrective plan, HCA had until June 5 to remedy the issues and satisfy state surveyors at an unannounced visit. Last week, CMS lifted HCA’s “immediate jeopardy” status, which previously put Mission Hospital at risk of losing Medicaid/Medicare funding.

However, nurses and community members have continued to question the quality of care across the Mission Health System.

About 1,600 Mission nurses are represented by National Nurses Organizing Committee/National Nurses United (NNOC/NNU) in negotiations. The group held another rally Wednesday morning to call attention to the working conditions at the facility and the impact on patients.

“Nurses at Mission have been consistent and clear about how HCA is failing the people of Asheville and Western North Carolina with the cuts it’s made at our hospital,” Kol Wilds, RN in the general surgical unit said in a press release. “The entire world has taken notice. This contract fight is about fixing what HCA has broken at our hospital, and ensuring a better future for nurses and all our patients.”

Keri Wilson, a registered nurse on the medical cardiology step-down unit at Mission Hospital, is on the bargaining team and has been at Mission for eight years. At a National Nurses United rally on June 5, Wilson addressed the contract negotiations.

"Our current contract expires on July 2nd. We have received a few more bargaining dates from the hospital that extend into August. We have not heard anything back from the hospital on our key issues, including staffing and workplace violence. It doesn't seem as though they're bargaining in good faith, but we're going to keep going back to the table and pushing for a good contract,” Wilson told BPR on the phone after the rally.

Attorney General and Democratic nominee for North Carolina governor Josh Stein spoke at the June 5 rally. Stein filed a lawsuit at the end of last year, claiming HCA hasn't lived up to the purchase agreement when it bought Mission Hospital in 2019.

Stein told the crowd he would stand with health care providers and patients in North Carolina, emphasizing that competition helps drive down costs. He also highlighted payment and staffing – key points in their contract negotiations.

"You deserve to be respected at your place of work. You deserve to not be understaffed and overworked. You deserve to be paid fairly. These are not things that are too great to ask,” said Stein.

The National Nurses Organizing Committee endorsed him for governor during the event.

Stein didn’t comment on CMS removing Mission’s immediate jeopardy status but has stated in the past that his lawsuit will stand – regardless of the federal agency’s decision
Nancy Lindell, spokesperson for Mission Health, provided the following statement following the June 5 rally.

“It is important for our nurses and community to know the facts. We are always working to innovate and improve, and Mission Hospital continues to be recognized as one of the top hospitals in the country in third-party quality and patient safety ratings,” Lindell said in an email.

“Nurses are an important part of our care team, and we remain committed to reaching a contract agreement that is fair and equitable and allows us to continue providing the excellent care our community deserves."

HCA has sought the dismissal of Stein’s lawsuit, arguing that it did not breach the terms of the purchase agreement because emergency and oncology services have not been discontinued at Mission Hospital. Buncombe County has also sought to join the lawsuit, alleging that understaffing by HCA forced paramedics to remain in the emergency room with patients long after their arrival, costing taxpayers millions.

“Buncombe County is here because it is concerned about the welfare of all the citizens as well as its own employees who are going in and out of the emergency room every day, and the back-up of its ambulances,” attorney Mona Lisa Wallace, who is representing the county, said during a hearing last week.

North Carolina Business Court Judge Julianna T. Earp has not yet issued a ruling.

Community members at the listening session in Highlands called for further investigation into Mission and HCA.

Messino Cancer Center founder Michael Messino spoke about the loss of regional cancer care over the last few years, as reported by theAsheville Watchdog.

“We had to reduce our ability to take care of the leukemic patients because we lost support from the hospital administration,” Messino said in Highlands, referring to the relationship between his business and Mission Health.

“...We could not negotiate a contract because they wanted to employ us to the point where we were not going to be able to be as independent as we've been. And since that time we've had to struggle.”

Highlands Mayor Pat Taylor attributed Tuesday’s small crowd to the frustration the community feels from the previous independent monitor.

“A concerned resident would make a comment and usually they would be stopped and (told) ‘Well this isn't a part of the 15 points on the APA and it became very frustrating,” said Taylor. “People just got to a point where they were so frustrated that they thought the meetings were useless, so I want to thank you for what you're doing with opening up the process.”

Previously quality of care wasn’t a part of the independent monitor’s role. Mims, CEO of Dogwood, explained that the previous independent monitor was chosen before the creation of Dogwood and that quality is a crucial part of a hospital system’s accreditation.

“While the asset purchase agreement doesn't specifically call out quality …participation with Centers for Medicare and Medicaid is a requirement,” Mims said. The monitor, she said, will look “at the quality and safety metrics that are part of that participation.”

In 2020, community members attending the Highlands/Cashiers Hospital meeting complained that services - including access to a primary care doctor - had been cut after HCA purchased the hospital in 2019.

A number of board members from the hospital praised HCA and Highlands/Cashiers CEO Tom Neal for improving care at the hospital.

“I’m real proud of what has been accomplished here,” said Jimmy Maurin, board member and past board chair. “People complain about health care, but all of those that have been in the business for a long time know that health care has been under attack nationally in this country for a long time and it gets harder every day to do the same job you did yesterday.”

Taylor agreed that Highlands/Cashiers Hospital has improved since 2019 but pointed out that the outlying hospitals all funnel to Mission Health in Asheville.

“We were sold an understanding that [our] hospital would be kind of an intake area. And then if you had a major problem you have to go to the main center, which is in Asheville,” Taylor said. “That’s the real concern now … People are proud of their local hospitals. But when they go to Asheville, they're worried about everything they've heard such as price increases and hidden fees, understaffing.”

The independent monitor has already held fivelistening sessions across the region.

There is a listening session scheduled in Franklin to discuss Angel Medical Center at the Macon County Community Building on June 20.

Affiliated Monitors is already working on the required 2023 annual review of HCA. Through 2022, HCA has been in compliance every year. The report is expected in July.

Lilly Knoepp is Senior Regional Reporter for Blue Ridge Public Radio. She has served as BPR’s first fulltime reporter covering Western North Carolina since 2018. She is from Franklin, NC. She returns to WNC after serving as the assistant editor of Women@Forbes and digital producer of the Forbes podcast network. She holds a master’s degree in international journalism from the City University of New York and earned a double major from UNC-Chapel Hill in religious studies and political science.
Felicia Sonmez is a reporter covering growth and development for Blue Ridge Public Radio.
Helen Chickering is a host and reporter on Blue Ridge Public Radio. She joined the station in November 2014.
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