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Attorney General wants answers from HCA

Macon County residents voice their concerns over Angel Medical Center’s new one HCA Healthcare during a public forum held by the independent monitor hired to oversee the transition from Mission to HCA. File photo Macon County residents voice their concerns over Angel Medical Center’s new one HCA Healthcare during a public forum held by the independent monitor hired to oversee the transition from Mission to HCA. File photo

North Carolina Attorney General Josh Stein issued a letter to HCA Healthcare’s president last week wanting answers to the many concerns his office has heard regarding the for-profit’s takeover of Mission Health System in Western North Carolina. 

Specifically, the letter named four issues — a surge in complaints about quality of care, the lack of a sexual assault nurse examiner at Angel Medical Center in Franklin, how Mission Health implements its charity care and uninsured patient policies and the way HCA discloses charges to patients. 

There’s little doubt that Stein has been paying attention to the complaints that have been made during recent public meetings hosted by Gibbins Advisors, the independent monitors hired to oversee compliance following HCA’s purchase of Mission Health. The meetings were held throughout the region and every community with a Mission-affiliated hospital had its share of complaints about changes in services, a lack of providers, billing and a lack of communication from the corporation now in charge of their health care needs.

While Gibbins representatives weren’t able to give people many answers, they promised to pass along the information to HCA leaders and look into any issues that may be in violation of HCA’s purchase agreement. 

“The meetings held by the Independent Monitor over the last month have been a constructive opportunity for HCA customers to publicly raise their concerns about Mission Health,” Stein’s letter stated. “We have received 30 written complaints about Mission since Jan. 1.”

Many of the complaints have been about the quality of care, including the impact of staffing cuts — especially for nurses. Stein said some of the complaints are “harrowing to read” and are being taken very seriously by his office. 

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“We have been told that Angel Hospital no longer has a sexual assault nurse examiner on staff. These nurses are trained to provide specialized support in emergency rooms to survivors of sexul assualt,” he said. 

Indeed, this concern came up at the public meeting held in Franklin when an employee with REACH of Macon County said she had to transport a rape victim over an hour to Mission Hospital in Asheville because a nurse wasn’t available to examine the patient at Angel Medical Center. 

When purchasing Mission, HCA committed to offering a more expansive charity care policy compared to what Mission had in place, but Stein’s letter stated that the policy was not clear on what services it covered and had caused confusion for patients. According to Stein, HCA has chosen to have the chief medical officer personally make the decision regarding whether someone will be covered under charity care, but “his busy schedule makes it impossible for physicians to easily contact him.” It seems HCA is only applying the charity policy to emergency care, which Stein said appears inconsistent with the Asset Purchase Agreement. 

Lastly, the charity policy on Mission’s website does not match the policy attached to the APA. 

Stein said the complaints also align with recent changes in patients’ satisfaction scores. 

“HCA facilities have generally maintained their star ratings from the U.S. Centers for Medicare & Medicaid Services, which measures patient care. However, the Mission Asheville hospital has declined in the Leapfrog Hospital Safety Grades,” he said. 

In Leapfrog’s fall 2019 scores, Mission was a ‘C’ while it had previously received a ‘B’ in the spring of 2019 and earned an ‘A’ in the spring of 2018, 2017 and 2016. 

Stein said he planned to respond to the complaints in three ways — by providing HCA with copies of the complaints and asking for HCA to respond to them; sharing the complaints with regulators at the Department of Health and Human Services who investigate hospital quality-of-care concerns; and by evaluating the complaints to determine whether HCA is failing to provide any services that it promised to provide under the Asset Purchase Agreement. Complaints will also be shared with Dogwood Health Trust and Gibbins Advisors. 

The AG office requested the following information for the 12 months before and after HCA’s acquisition of Mission:

• Utilization rates for financial assistance policies in the Mission Health System under Mission Health System Inc.’s ownership and under HCA’s ownership.

• Dollar value of financial assistance provided under Mission Health System Inc.’s ownership and under HCA’s ownership.

• Dollar value of all write-offs or write-downs of patient bills provided under Mission Health System Inc.’s ownership and under HCA’s ownership.

• The overall percentage increase or decrease in charges for medical services since the consummation of the sale of Mission Health System.

• The overall change in gross revenues from medical services since the consummation of the sale of Mission Health System.

• A list of every individual involved in making coverage decisions for HCA’s financial assistance policies at Mission Health System, by name and title.

• The average number of cases per week that are considered in the weekly charity care appeal process Dr. Hathaway described.

• Mission Health’s policies and practices with respect to requiring payment in advance for services delivered in the hospital as they existed before the transaction and as they exist today.

• A copy of the one-page description of HCA’s financial assistance policies that was distributed to doctors with admitting privileges in the 2019 third quarter meeting.

As for the billing issues, patients have complained about an “outpatient” fee HCA may be charging to patients at Mission-affiliated primary care providers even if the patient never sets foot in a Mission hospital. 

“We ask that Mission provide our office with all disclosures that it made to customers about this outpatient fee. Please respond to this portion of our letter by March 11, 2020,” the letter stated. 

Stein has asked the public to contact Gibbins Advisors and also file a complaint with his office by visiting



Mission Health’s former CEO Dr. Ron Paulus announced the nonprofit’s intention to sell to HCA in early 2018, claiming it was the best way to keep Mission Health’s vision of providing “word-class quality of care within a rapidly consolidating healthcare industry.”

Paulus said the decision came down to the rising costs of health care partnered with low reimbursement rates on Medicare, Medicaid and private insurers. With so much of WNC’s population being uninsured or underinsured, he said the current nonprofit model was no longer sustainable. 

At the time, Haywood Regional Medical Center, Harris Regional Hospital and Swain Community Hospital had already transitioned from nonprofit to for-profit ownership when they were purchased by Duke LifePoint in 2014. Mission’s sale to HCA meant no more nonprofit hospitals in the western counties, and that made communities uneasy about the future. 

Mission had already shut down the labor and delivery unit at Angel Medical Center in Franklin and other rural hospitals to cut costs. That move forced expecting mothers to travel over an hour to Asheville to deliver their baby. At the same time, Mission had also committed to constructing a new Angel Medical Center to replace the aging building in downtown Franklin. The new hospital, which will cost about $60 million, will be located along U.S. 441 and is still in the planning phase. 

HCA’s purchase agreement includes the plans to continue with the replacement hospital in Franklin, but residents are still concerned the new facility will be a “glorified emergency room” that will mostly be used to transport people to Mission Hospital in Asheville. Plans do include a helipad on site. 

Stein worked closely with the parties during the transaction and negotiated the purchase agreement to address community concerns before it was approved in January 2019. Stein said he did not oppose the negotiated asset purchase agreement of $1.5 billion but did get HCA to extend its promise to provide the current services offered at Mission hospitals from five years to 10 years. Stein also negotiated the hiring of the independent monitors and the creation of local advisory boards in each community to be the watchdogs of the transition. 

The entire purchase agreement that was made public can be viewed at

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