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HCA’s 15 Commitments To WNC: Looking Forward

Lilly Knoepp
North Carolina Attorney General Josh Stein visited Transylvania Regional Hospital six months after Mission Health's sale to HCA in 2019.

In this week’s BPR Presents “The Porch,” news director Matt Bush talks with our regional report Lilly Knoepp about her recent reporting on HCA Healthcare’s commitment to the Mission Health System.

For-profit HCA purchased Mission Health in 2019. Here’s a transcript of the conversation along with links to resources: 

Matt Bush: So you have been doing some new reporting on the independent monitor that is insuring that the stipulations in the Mission Health sale agreement that happened with HCA a couple years ago. This independent monitor makes sure these agreements are followed. Before we get into their latest meeting which took place earlier this month. Let’s go back and remind everybody, who is the independent monitor?

Lilly Knoepp: Gibbins Advisors is the independent monitor. The independent monitor is an independent firm that was chosen in part by Dogwood Heath Trust and approved by the attorney general. This firms who mission is to make sure that HCA is following through on 15 commitments that HCA made when it purchased Mission Health System in 2019. So whenever there is something seems like it might not be in compliance with that asset purchase agreement. It’s the job of the independent monitor to advise Dogwood Health Trust – which is the foundation that was formed from the profits of that sale – so that they can call out HCA and say, ‘Hey. You aren’t following this deal that you made with the North Carolina Attorney General you need to change and provide these services for people in Western North Carolina.’

Matt Bush: And among those stipulations in the sale this includes service, keeping the hospitals open and many others. The independent monitor did hold meetings last year. They were right before the pandemic. People might be forgetting them in the haze that is last year so remind us what took place. You were at some of the meetings, I was at one of the meetings.

Lilly Knoepp: Absolutely. So the independent monitor, part of their work is that they were supposed to be able to go out into the community and hear about the services that HCA is providing.  So as you mentioned, that has been really hard to do this year during the pandemic. So they held seven meetings at the five regional hospitals as well as Mission Health in Asheville. The meetings that I attended – the independent monitor at this month’s virtual meeting, he described those public meetings as “spirited.” Because people had a lot to say – they had a lot of questions and some of those have been addressed and some are still waiting for answers.

The independent monitor breaks down the 15 commitments into four areas.  

  1. Retaining service and hospitals. This includes keep all facilities open for at least 10 years.
  2.  Invest in facilities. This includes completing the Mission Health North Tower and building the new Angel Medical Center.
  3. Invest in community health. This includes maintaining the charity care policy.
  4. Other. This catch-all includes commitments such as HCA’s annual report to the independent monitor.

Matt Bush: A lot has happened since then with the pandemic, the nurses in Asheville unionizing so the independent monitor is going to be doing a second round of meetings. You attended virtually. Tell us what happened.  

Lilly Knoepp: The independent monitor went through a refresh to remind everyone what their role is. To make sure that it’s clear that they are being paid by Dogwood not by HCA.

They really want it to be clear what those commitments are in the asset purchase agreement. There are only 15 commitments. So, a lot of people’s questions don’t necessarily fall under the purview of the independent monitor. It was an entire meeting of answering questions and reminding folks what they had done of the last year.

HCA is responsible for putting out an annual reporting each year so that came out in April 2020. They also released an amended report in July 2020.

Credit Lilly Knoepp
Timeline of HCA and independent monitor actions in 2020 from independent monitor virtual presentation April 7, 2021.

It is the independent monitor’s job to go through that report to see how it stacks up with the requirements that are in that asset purchase agreement. Then they advise Dogwood Health Trust on the report.

Matt Bush: You mentioned the first report came out to explain if HCA has been compliant or noncompliant in all of the things. Have they been found in noncompliance in anything?

Lilly Knoepp: Not at this time. In October 2020, Dogwood Health Trust in their end of year report said that they didn’t find HCA noncompliant in 2019. HCA’s 2020 annual report will come out in May at the latest. But there were a few things that came up during the virtual meeting that I found really interesting. There were some times that the independent monitor said that HCA wasn’t noncompliant but that they did have discussions with HCA about some of the issues that were happening in Western North Carolina. The independent monitor wanted to be really clear that these weren’t noncompliance issues but they were times that policies changed.

There have also been so other issues that they have gone back and forth on. In February 2020, Attorney General Stein sent HCA a letter with a number of questions.

HCA has sent responses directly to the AG on those issues. Here’s HCA’s response on SANE nurses.  Here’s HCA’s 54-page response on charity care from April 2020.

One of the ways that the independent monitor answered questions about charity care is they explained that when Mission was being purchased by HCA they had the option to move forward with Mission’s charity care policy. And instead, the board at Mission felt that HCA’s policy was actually going to cover patients better. And so they did make changes to that charity care policy to go with HCA’s policy instead.

Here’s how Ron Winters, principal of Gibbins Advisors, talked about charity care at the virtual meeting:

“It is difficult to qualify for charity care, and until you qualify, they have the right to ask you to pay a deposit and you don’t have the right to get it back,” said Winters.

The other dispute that the independent monitor mentioned that was a “non-dispute” was when the Transitional Care Unit at Transylvania Regional Hospital closed. HCA said it wasn’t getting rid of this service because it was still available at other parts of the hospital. So that is the line that is in question for noncompliance: if the service is less, is it still available or is that when HCA is in noncompliance with the asset purchase agreement?

So in that case, at Transylvania Regional Hospital, the community brought forward this concern and HCA reopened the unit. The independent monitor said that they didn’t see this as an official dispute or being in noncompliance, but it was definitely a time that the independent monitor brought up an issue to HCA and then policy drastically changed.

Matt Bush: Transylvania is one of 18 counties in the Mission Health System service area. All counties have been bringing things up. There are few things that people in this region care more about than how this sale is going to impact their healthcare. But we bring up Transylvania because as you just mentioned this particular unit being restored. Does that mean all questions that have been asked by people in Transylvania County have been answers?

Lilly Knoepp: The short answer is no. The Brevard City Council recently wrote a letter to Attorney General Stein in February about what is happening in the county. They have seen a real loss in primary care physicians. 

Here’s the link to the letter.

I spoke with City Councilwoman Maureen Copelof and she said the county has lost 14 healthcare providers recently. She added that one physician has signed on with HCA since the letter was sent, it says 15 in the letter.  But this is something that we have seen throughout the region – local physicians, surgeons and other have not been signing updated contracts with HCA. For example, in Brevard, 14 people have left, so Copelof explains that this as a significant loss of access to care.

Copelof, said she is the liaison to Dogwood and HCA for the city council and that they meet quarterly.

Copelof explained the issue of primary care access very clearly here. While primary care isn’t on the list in of the asset purchase agreement, it is something that is really important in their community:

“Primary care is so important to our community and making sure that we have easy local access to primary care is a critical community concern,” said Copelof in an interview.

And this is something that has come up across the region. Copelof explained the gist of the entire meeting with the independent monitor: 

“We don’t have a good mechanism in the agreement with the independent monitor for really enforcing or tracking or holding HCA accountable that we thought we did when the sale went through,” said Copelof in an interview.

Matt Bush: This is going to be a continuing issue and a continuing major topic of conversation throughout Western North Carolina in years and decades to come. What’s next for the independent monitor? Will they have more meetings? Will they be in-person once it’s safe to do so?

Lilly Knoepp: So there are a number of things coming up pretty quickly.  

Credit Lilly Knoepp/BPR News
Timeline of 2021 activities for HCA and the independent monitor as presented at independent monitor virtual meeting on April 7, 2021.

Brevard has called on other towns and counties to write their own letters to Attorney General Josh Stein. So we are looking to see what the Attorney General has to say about these questions. The annual report from HCA this month or next. So that will answer some of these questions and give an overview of what HCA has been doing this year. And then the independent monitor will start to have meetings again in the region once it is safe to do so with the pandemic so hopefully we will see them pretty soon.

Matt Bush: Lastly a lot of your reporting has been focused on Macon County and what is happening there. Macon County is where we originally heard a lot of pushback about the sale and concerns. Have they had anything addressed within this too?

Lilly Knoepp: Mayor Bob Scott in Franklin still has a lot of questions about the sale. He released a letter last week to Attorney General Josh Stein, echoing a lot of these issues that we are seeing across the region: seeing physicians leaving, and surgeons. Angel Medical Center is the hospital in Franklin. HCA is building a new hospital to replace it. There is no word on what will happen to the old hospital. The groundbreaking at new hospital will take place at the end of this month.

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.
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