What happened in the last five years?
In 2019, HCA Healthcare, the country’s largest for-profit hospital company, bought Mission Health System, a nonprofit health organization based in Asheville. Mission Health’s facilities include six hospitals — the largest is the 815-bed Mission Hospital in Asheville — as well as other clinics and specialty facilities throughout the region.
As part of the 2019 deal, HCA agreed to a set of commitments regarding its facilities and the services they offer.
Since the $1.5 billion transaction involved the sale of a nonprofit to a for-profit company, there was also the question of how to handle the proceeds. That issue was addressed by the creation of the Dogwood Health Trust, a foundation that aims to “dramatically improve the health and wellbeing of all people and communities of Western North Carolina.”
What did the agreement require?
In the final agreement, which was approved by North Carolina Attorney General Josh Stein, HCA pledged not to discontinue a wide range of services for the 10 years following the sale.
The services include oncology, emergency, cardiac, general medicine, pediatric, obstetrical, surgical and many others.
Under the terms of the agreement, HCA may not close any of its facilities before 2029 unless a local advisory board and independent monitor agree.
The agreement also called for HCA to build a 120-bed behavioral health center in Asheville. The facility, the Sweeten Creek Mental Health and Wellness Center, opened its doors in August.
The agreement also required the construction of the new Angel Medical Center in Franklin, which opened in September 2022. The plans for the old facility have still not been announced.
Who was given oversight in the agreement?
After the sale of Mission Health, an independent monitor was chosen to oversee HCA's commitment to the agreement. New York-based consulting firm Gibbins Advisors shares a yearly update about compliance and has held community meetings. The firm is paid by Dogwood Health Trust, not HCA.
Community members — as well as a growing number of current and former hospital staff — have voiced concerns about a sharp drop in the quality of care at Mission Health locations ever since HCA took over. Some argued the company prioritized profits over patient well-being. Many have complained of inadequate staffing at Mission Health hospitals, leading to long wait times for medical appointments and at the emergency room.
HCA has also faced criticism for shuttering two primary care facilities in Biltmore Park and Candler in 2020 and, more recently, for the loss of all but one member of its medical oncology team at Mission Hospital.
Ron Winters of Gibbins Advisors explained compliance and the monitor’s role to BPR in 2021.
"I don’t want to sound overly narrow, but the thing that we can do something about — which is raise our hand and say that they are not in compliance — only arises when they are not providing the service,” Winters said.
In other words, the independent monitor may not have the authority to address concerns about the quality of services HCA is providing, so long as HCA is not cutting those services entirely.
Separately, Mission Health was fined almost $30,000 by the North Carolina Department of Labor last year for violating health and safety laws, including failing to report an employee’s COVID-19-related death. The North Carolina Department of Health and Human Services has also dispatched inspectors to Mission Hospital in recent weeks on behalf of the U.S. Centers for Medicare & Medicaid Services in response to concerns about its emergency department, the Asheville Watchdog reported.
In the years since the sale, HCA Healthcare has faced several lawsuits over its business practices. A group of Western North Carolina residents filed a class-action lawsuit in August 2021 in Buncombe County Superior Court, alleging that HCA was using a monopoly to provide a lower quality of care at higher cost for patients. In June 2022, the city of Brevard filed a federal lawsuit against HCA, accusing the health care system of “predatory monopolistic practices." A month later, the City of Asheville and Buncombe County filed a federal lawsuit of their own.
"The Asheville City Council and the Buncombe County Board of Commissioners felt it was necessary to take this step to bring an end to predatory practices that limit HCA Healthcare’s competition and clearly result in overpriced and limited choices in people’s healthcare," Asheville Mayor Esther Manheimer said in a statement at the time.
How and why did the attorney general get involved?
North Carolina Attorney General Josh Stein approved the terms of HCA’s deal, so he has been following the situation at HCA since before 2019.
Stein, who is running for governor in 2024, wrote letters to HCA and Dogwood Health Trust about alleged violations of the agreement since at least 2021.
Complaints continued to mount, and the DOJ’s involvement has begun heating up over the past few months as Stein started calling for an investigation in the summer.
In late October, Stein’s office sent a letter to Dogwood notifying the foundation of an alleged breach of the agreement. The letter gave HCA 40 days to fix the issues or face another lawsuit.
The attorney general alleges that HCA violated the contract by employing only one medical oncologist on staff and failing to address staffing shortages in its emergency room.
Stein’s position appears to be that a decrease in the level of services provided (such as employing only one oncology doctor) would constitute a discontinuation of services, thereby breaching the purchase agreement.
How has HCA responded?
Nancy Lindell, a spokeswoman for HCA, dismissed the alleged violations in an email to BPR on November 21.
“We are confident that we have and will continue to meet our commitments under the APA,” Lindell said, referring to the sale contract, known as the asset purchase agreement.
A lawyer for HCA issued a stern response earlier this month to an investigative demand from Stein’s office, accusing the attorney general of engaging in “a bald attempt to obtain prelitigation discovery, masquerading as a consumer protection ‘investigation.’”
“Mission is now, and always has been, in full compliance with that contract and often exceeds its obligations under the APA,” the lawyer, Alice Fisher of the law firm Latham & Watkins, said in a letter to Stein’s office.
Nazneen Ahmed, the attorney general’s press secretary, told BPR that Stein’s office “strongly disagrees with the assertion HCA has made in its letter and we will be responding appropriately.”
Dogwood Health Trust said in a statement that it is working with HCA and the attorney general’s office “with an eye toward the best resolution for the community.”
“We are grateful to community members who have taken the time to share their concerns and we encourage them to continue to do so,” the foundation’s CEO, Susan Mims, said. “It’s only through ongoing dialogue and exchange of information that all of us — the Attorney General, HCA and Dogwood — can move forward to address any issues of potential noncompliance.”
How have Mission employees responded?
Fifty current and former Mission doctors sent a letter last month to the independent monitor, denouncing “many of the for-profit-driven changes that HCA has wrought” as having “gutted the heart and soul of our community healthcare system.” More than 120 doctors have now signed onto the letter, according to the Asheville Citizen-Times.
The letter was soon followed by a rebuttal letter solicited by Mission Hospital leadership and signed by more than 80 medical practitioners. They defended the hospital’s services and argued that the original letter "does not tell the whole story, and there are many of us who do not feel that their voice represents us as a whole."
Dr. Michael Messino, founder of Messino Cancer Centers, was one of the signatories of the original letter. He has written to and met with local and state officials, including the attorney general’s office, sharing his concerns about conditions at Mission Hospital.
“HCA has sold the people of Western North Carolina a lemon and now the Department of Justice is stepping in,” Messino wrote in a recent letter to state and local officials.
Nurses and other staff at HCA-run hospitals have also been speaking out, including to local and national media. Some have spoken anonymously, citing a fear of retaliation for publicly voicing their concerns.
Most recently, doctors at Mission Hospital rejected by a single vote newly-proposed bylaws that critics argued would have had a chilling effect on employees’ ability to speak publicly about conditions at the hospital, the Citizen-Times reported.
Correction: This article has been updated to reflect that the AG 's letter indicated HCA (not Dogwood) faces a potential lawsuit after the 40 day deadline.
