The transition from local nonprofit to profit-hungry behemoth has not gone smoothly, and not just because of the coronavirus. Now, as Mission Health begins to reopen for elective surgeries and procedures put on hold during the first wave of the ongoing pandemic, the unresolved question that roiled the community just three months ago remains: Was HCA’s purchase of Mission Health healthy for Asheville?

Three months now seems a very long time ago, but just before the pandemic arrived — before the lawns on Mission Health were decorated with “Heroes Work Here” signs and before citizens cheered the front-line health professionals risking everything on their behalf — hundreds of area residents and local officials said they did not think so.

HCA reported to attorney general that Mission Health provided more than $260 million in charity care in first year … and raised prices 10 percent. Read the letter here.

And while the pandemic may have brought a reprieve from widespread negative sentiment, HCA-Mission still faces a vote by nurses to unionize and continuing scrutiny by the attorney general.

“In some ways the concerns that we’ve had haven’t gone away, but they haven’t been the focus of our attention during this completely, historically unprecedented concern about the pandemic,” said Brownie Newman, chairman of the Buncombe County Commission. “Whatever issues we were talking about 90 days ago have been put on pause.”

“As we do get beyond this, there will be a return to the original underlying concerns,” Newman said.

Those underlying concerns run deep.

Cost-Cutting Efficiencies

In a scalding public letter presented Feb. 10 to the independent monitor appointed to make sure HCA complies with terms of the sale, local officials including Newman, Asheville Mayor Esther Manheimer, and nearly the entire delegation of Buncombe County’s elected officials in the North Carolina statehouse accused HCA of flat-out lying about its intentions in taking over the assets and healthcare operations of the Mission Health system.

Before the sale, Ronald A. Paulus, then president and chief executive officer of Mission Health, told a local business group in Asheville that under HCA management, Mission Health would still have "the exact same people and exact same doctors and exact same nurses” providing similar or even superior care for the people of western North Carolina.

Where Mission Health’s nonprofit finances were strained, Paulus said, Nashville-based HCA, with $51 billion in annual revenue, had the resources to invest in new technologies and research. HCA could make money where Mission could not, he said, by cost-cutting “efficiencies” in such back-office functions as billing and purchasing.

Two weeks after the sale, Paulus announced he was leaving Mission and joining HCA as a strategic advisor.

HCA declined to make Paulus available for an interview or respond to questions about him.

Screaming for Help

Complaints about quality of care and staffing shortages dogged Mission in the year after HCA took over. Compared to visits before HCA assumed management, Will Overfelt of Asheville said he observed a decline in all aspects of the hospital from cleanliness to care during his father’s eight-day stay in February, before the pandemic.

His father, who had terminal cancer, wasn’t bathed, Overfelt said. His room wasn’t cleaned, and nurses were so short-staffed that patients on the floor were screaming for help, he said.

“I’m having to chase people sometimes up to an hour to say it’s time for his pain medication,” Overfelt said.

Wondering if his experience was an anomaly, Overfelt started a Facebook page, Mission Maladies, in mid-February.

“I thought I’d get 10 or 15 people, and two or three stories, and they just started coming. It was an avalanche,” he said.

On Wednesday Mission Maladies had 8,689 members.

On April 9, a new Facebook group appeared, Mission Mighty, stating that “some groups have been created to only promote negative opinions,” while Mission Mighty was created to counter the “false perception of what it is like to work at Mission.” On Wednesday it had 1,037 members.

‘It Wasn’t the Deal We Made’

The growing chorus of complaints caught the attention of local officials, who said they felt betrayed.

“HCA has chosen to make its money by reducing charity care, eliminating medical and unit administrative staff to the detriment of patient care and safety, and sacrificing entire physician groups . . . by demanding significant reductions in pay,” the local officials wrote in the Feb. 10 open letter to Gibbins Advisors of White Plains, N.Y., the independent monitor. “That wasn’t the deal we were told about and it wasn’t the deal we made as a community.”

The letter was signed by State Sen. Terry Van Duyn and state Reps. John Ager, Susan Fisher, and Brian Turner, as well as Newman and Manheimer.

An HCA Mission spokesperson said Mission executives responded to the letter by meeting privately with local leaders to discuss their concerns.

Manheimer, the mayor, confirmed the meetings in an email to AVL Watchdog. “We were able to meet in person [with Mission executives] and then we moved to virtual meetings,” she wrote. “There has been some back and forth with HCA addressing the concerns raised in the letter. Some items have been addressed, others have not. Covid-19 has temporarily eliminated some of the complaints, such as staffing levels, for example. But concerns remain and we will continue to press HCA to address the concerns and complaints raised.”

Scrutiny by Attorney General

Because Mission was a tax-exempt nonprofit operating in the public interest, the sale to HCA had to be approved by North Carolina’s Attorney General, Josh Stein. Stein agreed to allow the deal only after setting specific, legally enforceable conditions to guarantee that HCA not diminish the quality of health care in western North Carolina.

The conditions included annual reviews of HCA’s performance. Based on public complaints raised in a series of “town hall” meetings organized by the independent monitor, and in complaints sent directly to the attorney general, the first year’s review raised concerns.

“I am deeply concerned about what I’ve been hearing about HCA – and I want answers,” the attorney general wrote on Feb. 25 to Greg Lowe, president of the North Carolina division of HCA Healthcare. Among the concerns cited by Stein were “a surge in complaints about quality of care” and about HCA’s transparency in billing patients.

In the letter, Stein wrote that some of the complaints his office received from the public about patient care at HCA-run Mission Health were “harrowing to read.” He said he was sharing the complaints with investigators at the North Carolina Department of Health and Human Services.

HCA’s responses to the attorney general’s questions, in a letter from Lowe dated April 30, were shared with local officials Monday.

Financial Aid, Prices Are Up

In its letter responding to the attorney general’s requests for information, HCA Healthcare reported that it collected an increase of more than a half-billion dollars in payments for patient services in the Mission Health System in its first year, compared to the year before, when Mission’s hospitals and clinics were run as nonprofits.

"For the 12-month period following the HCA acquisition, gross revenues for patient services across MHS were $5,851,812,451, a net increase of $548,679,541,” Lowe wrote to the attorney general.

HCA also reported that it provided more than a quarter-billion dollars in discounts from its standard rates to uninsured and low-income patients in the first year.

“Mission Health patients received more than $260 million in financial assistance from HCA during the 12-month period following its acquisition of Mission Health System,” Lowe wrote in the response to the attorney general. That total “amounts to just over $108 million more in financial assistance than MHS provided in the 12-month period prior to the HCA acquisition.”

Besides the charity care policy, Lowe’s response to Stein also addressed nine other questions posed by the attorney general. In one, Lowe said that charges for medical services at Mission Health increased approximately 10 percent after the sale. For each of the four years before HCA took over, the increases averaged 6.8 percent a year.

Lowe wrote that “the significant increase in financial assistance for Mission Health patients,” along with his answers to the other questions, “should reassure you that HCA and Mission Health are committed to upholding their obligations.”

HCA/Mission declined to make Lowe available for comment.

Staffing Shortages

Before the pandemic hit, complaints about a perceived decline in quality of care at Mission Health after the sale were invariably linked to staffing shortages.

"Every single department in that hospital designed to help the patient is critically and unethically, inhumanely understaffed," Jennifer Kirby, a registered nurse at Mission Hospital for 15 years, told the independent monitor during a public meeting in Asheville.

In a letter to Lowe on March 8, local officials requested exact numbers on staff at the time of purchase, turnover, new hires, and the net increase or decrease in the numbers of technicians, certified nursing assistants, unit secretaries, language and sign-language interpreters, social workers, security, and cleaning staff.

“We request the same information for physicians who are either employed directly by Mission or by private practice groups that contract to provide services at Mission (e.g. cancer specialists, pathologists, hospitalists, ER physicians, etc.),” the officials wrote.

As of Monday, they had not received a response. Mission did not respond to a similar question from AVL Watchdog.

Competition for Workers

Mission did, however, issue an “open letter to our community” from Lowe two days after the local officials requested staffing numbers, in which he said Mission Health had recruited more than 100 new physicians and advanced practice providers, and had hired “hundreds of RNs, as well as other bedside caregivers and support team members.”

Critics contend that any new hires by HCA in the first year were offset by the loss of many long-time Mission doctors and nurses who quit or took early retirement as a result of HCA’s policies, including demands that some doctors and practices accept a reduction in pay. Several doctors’ practices, some that had treated generations of Asheville patients, also severed ties with the new management over fee disputes.

At the same time, Lowe wrote, inpatient admissions and emergency room visits grew more than 10 percent in 2019, while intense competition for skilled nurses and other healthcare workers made it harder to fill hundreds of open positions.

Separately, Lowe told local officials in a meeting Feb. 21 that HCA had moved aggressively to recruit more nurses, technicians and other healthcare workers, and had, for example, raised the minimum wage throughout the system to $12.50 an hour, from $11, and raised minimum pay for some technicians to $15 an hour.

Nurses contacted by AVL Watchdog said policies put in place by HCA have made their jobs even more stressful during the pandemic.

Kerri Wilson, a cardiac nurse at Mission Hospital, said that staff reductions and restructurings made by HCA put nurses under stress and caused many veteran nurses to quit or take early retirement. HCA also reduced the number of certified nursing assistants and other support personnel, she said.

Now, after two months of pandemic, and three months after the public hearings, “We’re still facing staffing shortages, and increased staff ratios per the grids HCA put in place,” Wilson said last week. Higher nurse-to-patient ratios mean one nurse on duty has to care for more patients, resulting in a greater workload and less time per patient.

Four Covid-19 Deaths at Mission

Asheville appears — so far — largely to have been spared the overwhelming surge of Covid-19 infections and death that many feared, thanks to early action by local officials, widespread public support for a near-total shutdown of nonessential activities, and heroic work by healthcare workers, including those in the HCA-run Mission Health System.

As of May 13, Buncombe County officially had 105 lab-confirmed cases of Covid-19 and four deaths. There were two confirmed Covid-19 patients hospitalized at the flagship hospital in Asheville Monday afternoon, according to William Hathaway, Mission Health’s chief medical officer.

In a conference call April 20 to update the public on Mission’s Covid-19 response in western North Carolina, Hathaway, along with Mission Hospital’s chief medical officer, Anthony Spensieri, described how Mission was able to leverage HCA’s expansive supply chain to quickly obtain personal protective equipment for the staff, including doctors, nurses, and technicians, and to obtain ventilators and rapid-testing equipment for diagnosing the virus and resulting antibodies.

The officials also pointed to new management, training, safety, testing, and logistics systems that contributed to Asheville’s lower infection and death rates, compared to other North Carolina counties. They said the “best practices” and training developed during the first wave will put Mission in a better position if, as many medical experts believe, a second wave of Covid-19 spreads in the community this summer and fall as a result of relaxed stay-at-home orders.

Meanwhile, HCA, in its first-quarter financial report filed April 30 with the Securities and Exchange Commission, revealed that systemwide its emergency-room and inpatient-surgery traffic fell 50 percent so far this year because of the pandemic, with a 70 percent drop in hospital-based outpatient surgery. Both are major sources of the hospital system’s profits. Hospital admissions dropped 30 percent in April compared with a year ago, HCA said.

HCA’s top executives said the length and depth of the financial hit will depend on how quickly states reopen their communities. They said recovery will also depend on the broader economy, and how many households lose health insurance because of unemployment.

Battle Over Nurses’ Union

If the pandemic were not enough, there’s another new battle, and it too is vicious. Hundreds of nurses at Mission Health have petitioned the National Labor Relations Board asking for an election to join National Nurses United (NNU), with 150,000 members the country’s largest labor union for registered nurses. By affiliating with the union, the nurses hope to gain collective bargaining rights that they now lack.

Mission nurses have spoken publicly about seeing exhausted colleagues weeping in the hallways, and patients recount how it sometimes takes 45 minutes or more for nurses to respond to call buttons.

Several nurses told AVL Watchdog that although Mission officials publicly said there was no shortage of masks, gowns, gloves, and other personal protective equipment for Mission employees, the nurses were first prohibited from wearing masks because they were told it would alarm the patients, then that the hospital was following Centers for Disease Control guidelines for conserving mask supplies, then that respirator masks were unnecessary for most employees, before finally allowing them to bring their own masks from home.

In a letter to employees on March 23, Mission wrote: “To help ensure our caregivers and patients continue to have enough supplies and equipment, we are implementing steps recommended by the Centers for Disease Control to conserve PPE.”

But three days later, after widespread complaints from nurses, nursing assistants, technicians and city officials, Mission told employees and local officials it was changing its policies to allow universal masking.

“Responding to employee concerns, Mission Health will change its personal protective equipment policies to allow staff to wear masks in all areas of Mission facilities,” Lori Kroll, vice president for the North Carolina Division of HCA Healthcare, wrote in an email to Asheville City and Buncombe County officials on March 26. “Our nursing staff has expressed a significant increase in anxiety with regard to the inability to wear their own commercially purchased PPE in areas that do not come into contact with COVID-19 patients or those who have been tested and are awaiting results (aka PUIs).” PUI is persons under investigation for covid-19 infection.

Kroll’s email was first reported by the Asheville Citizen-Times.

‘Spreading Fear and Misinformation’

While HCA Mission was appealing to delay the union election because of the demands of the pandemic, it also scheduled a series of hour-long “informational meetings” and one-on-one meetings led by professional labor union opponents hired by HCA. A Mission spokesperson said the meetings were voluntary. Many Mission nurses said they were told by their supervisors they had to attend.

On April 2, Mission nurses delivered a petition to management calling for an end to the informational meetings during the pandemic. Mission responded the same day with a public statement.

“Mission Health has frequently stated our position on unions, but the union’s behavior during a crisis shows exactly why we believe a union is wrong for Mission Health and Asheville,” wrote Nancy Lindell, Mission Health spokeswoman. “It’s unfortunate that the union is attempting to turn a crisis into a publicity event designed to promote the union’s own agenda and spreading fear and misinformation.”

Mission officials say such stories are part of union propaganda, and only serve to demoralize the staff and worry the community.

“As a professional, a nurse for 40 years, it hurts my heart to hear things that I know are not true,” said Karen Olsen, chief nursing executive at Mission Health, referring to some of the nurses’ complaints.

Labor Hearings Delayed

The hospital successfully appealed to the National Labor Relations Board to have the union certification hearings delayed several weeks because of the pandemic. Those hearings, to determine which of Mission’s nurses are eligible to vote for union representation, concluded last week.

Both sides are required to present their position papers to the NLRB Wednesday, with a decision on who can vote expected by the end of the month. Mission is asking for in-person voting, while the nurses, citing concerns about Covid-19, are requesting voting by mail.

Now that hospital operations are gradually returning, the drive for unionization — and HCA’s attempts to discourage it — are going to intensify.

“The nurses being able to organize is one of the ways a community can have more of a voice in the care that is delivered there,” said Newman, the chairman of the Buncombe County Commission.

Reputation Lured Retirees

Mission Health was founded in 1885 by Asheville residents Anna Woodfin and Fanny Patton, who raised money for it by selling flowers. From the start, the desire for profit was always secondary to quality of care and a goal to care for all citizens regardless of their ability to pay. Supporters say the nonprofit status of Mission Health was of great importance in serving western North Carolina, a region older, poorer, sicker, and less likely to be insured than state and national averages.

Also, Mission’s strong reputation for high-quality healthcare through the system was a key driver of Asheville’s recent growth, especially in luring retirees and older residents who now make up more than 20 percent of the city’s population.

Just before the sale, the federal Centers for Medicare and Medicaid Services rated quality of care at Mission Health’s six hospitals an average of 4.33 stars, out of a possible 5. Nationwide, the average of all hospitals for quality of services was 3.15.

The average for HCA’s hospitals was 2.73.

In the latest federal ratings, based on data collected up until June 30, 2019 — five months after the change to HCA — Mission Hospital scored 5 out of 5 stars, scoring above the national average in safety of care, readmission rate, and efficient use of medical imaging. It scored below the national average in mortality and timeliness of care.

Mission Health's ratings have steadily declined in a hospital safety survey by The Leapfrog Group, a national nonprofit that monitors quality and safety of American hospitals.

Leapfrog’s Fall 2019 score for the Mission Asheville hospital was a “C.” In a trend of decline, the Asheville facility scored “B” grades in Spring 2019 and Fall 2018, after scoring “A” grades in Spring 2018, Spring 2017, Fall 2016, and Spring 2016.

A Mission spokesperson said the latest Leapfrog ratings were based on data gathered before the HCA takeover.

“I’ve lived in Asheville my whole life, and Mission Health always set the standard of care for the entire region,” said Wilson, the cardiac nurse who has been at Mission Hospital for four years. “In the last few years, we started to see a decline, but since HCA took over our community reputation has crumbled.”

Dogwood Health Trust

The net proceeds of the $1.5 billion sale of Mission Health to HCA Healthcare created the Dogwood Health Trust, an Asheville-based nonprofit whose goal is make charitable grants of as much as $75 million a year “to dramatically improve the health and well-being of all people and communities of western North Carolina.”

The Dogwood Health Trust made its first grants in February, distributing a total of $3.7 million to 259 nonprofit and government agencies in its 18-county region, for an average grant amount of $14,600.  

Dogwood’s board of directors originally consisted mainly of Buncombe County residents who either served on the Mission Health board of directors — and thus voted for the sale to HCA — or who had close ties to the hospital.

As one of the stipulations required by the attorney general as terms of the sale, Dogwood was told to expand the board to represent the full diversity of the region, geographic, ethnic, gender, and socioeconomic. The Dogwood board expanded last year to add more women, rural residents and people of color.

Ultimately, enforcement of HCA’s promises to the Asheville and western North Carolina communities falls to Dogwood and the attorney general. To date, the independent monitor has not indicated any noncompliance with terms of the sale. The monitor, Gibbins Advisors, plans to return to the area for site visits at HCA’s six Mission Health hospitals sometime this summer.

The story has been updated (5.18.20) to include information about the first distributions of grant money by Dogwood Health Trust.

AVL Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Peter H. Lewis is a former senior writer and editor at The New York Times. Contact us at This email address is being protected from spambots. You need JavaScript enabled to view it..