The grievous decline in the quality of care provided by Asheville’s Mission Hospital during the past five years incites outrage and frustration on multiple levels. Failed leadership and corporate shortsightedness and greed have turned one of the nation’s premier health systems into one where substandard care may have resulted in patient deaths.
There was a time, not so long ago, when Mission and its integrated region-wide network ranked as one of the nation’s Top 15 Health Systems. The rating meant Mission performed better on six measures - fewer deaths, fewer complications and infections, shorter length of stay, shorter emergency department wait times, lower costs and higher patient satisfaction - than hundreds of other health systems evaluated.
That was before, in a surprise announcement in March 2018, the not-for-profit Mission’s Board of Directors revealed its intent to sell Mission to HCA Healthcare, the nation’s largest hospital chain, for approximately $1.5 billion. The sale was completed in February 2019. The announcement shocked virtually everyone – local leaders, Mission employees, associated medical professionals, patients and the larger community.
Five years later, Mission is in “immediate jeopardy” of losing Medicare and Medicaid reimbursements as a result of nine deficiencies related to incidents that happened between April 2022 and November 2023. The U.S. Centers for Medicare & Medicaid Services (CMS) defines “Immediate jeopardy” as noncompliance that “has placed the health and safety of recipients … at risk for serious injury, serious harm, serious impairment or death….” In early February, CMS informed Mission that it has 23 days to fix the problems or risk losing Medicare and Medicaid funding, thereby threatening the financial viability of the hospital. CMS cited Mission’s failure to meet standards in six areas: governing body, emergency services, nursing services, patients’ rights, quality assurance and laboratory services.
Accountability for this precipitous decline in quality of care rests with multiple entities.
First, there’s North Carolina’s Republican-dominated legislature which, for a decade, refused to approve expansion of Medicaid to hundreds of thousands of uninsured North Carolinians under the Affordable Care Act. The fact that 90 percent of the expansion would be paid for by the Federal government failed to overcome their stubborn partisan opposition. Lawmakers finally approved the expansion in 2023, too late for a number of struggling rural hospitals, and too late to provide a critical income stream for Mission before it was sold.
After selling Mission Hospital to HCA, according to reporting by Asheville Watchdog, Mission board members acknowledged that Mission was profitable and financially strong, but they were concerned about falling reimbursements from Medicare and Medicaid. Given lawmakers' refusal to expand Medicaid, there was no reason for them to expect that to change. They worried that Mission would face a future of cost-cutting that would ultimately degrade the quality, access and affordability of care, a concern that turned out to be ironic.
Second, there’s the failure of Mission’s not-for-profit board and then-CEO Ronald Paulus to involve the community in the decision to sell one of its most valuable and essential assets, one critical not only to the health of Western North Carolinians but to the region’s economic strength. By failing to do so, they denied the community an opportunity to engage in a dialogue that might have changed the outcome.
Third, there’s a serious question about whether the board performed adequate due diligence before selling Mission. Because everyone involved had to sign non-disclosure agreements, much of the circumstances surrounding the sale remain a mystery. But public record documents obtained by Asheville Watchdog suggest that HCA courted Mission directors and executives months before Mission’s board authorized CEO Paulus to start looking for potential partners. It appears HCA had an inside track from the beginning. Mission’s directors invited only a few companies to make proposals and quickly dismissed other suitors besides HCA. They invited only one other bidder to make a formal presentation and speedily rejected that bid, which came from a nonprofit, it was later disclosed.
The board chose HCA, despite the fact that in 2017, HCA paid more than $200 million to settle lawsuits related to its purchase of a nonprofit hospital in Kansas City and that in 2003 HCA paid the government more than $1.7 billion in restitution, fines and penalties to settle fraud cases.
By contrast, New Hanover County Commissioners recently sold their publicly owned regional hospital to Novant, a non-profit associated with the UNC Health and UNC School of Medicine, after ample opportunity for public comment, for approximately $2 billion.
Fourth, and most outrageous, is the way HCA has systematically dismantled one of the nation’s premier regional health care systems. Western North Carolinians have long relied on Mission for advanced, high-quality health care. But for decades, Mission has also been an economic engine, making the area attractive to retirees and digital nomads and providing a hub for peripheral health related businesses.
“This is a four-level problem, “Dr. Clay Ballantine told an audience of about 350 people who attended an Asheville Watchdog sponsored event titled “HCA-Mission at Five Years: What Can We Do to Restore Better Healthcare in WNC?”
“You’ve got Mission Hospital,” Ballantine said. “You got satellite hospitals, but you’ve also got all these primary care and subspecialty practices that are under Mission’s purview and they are throughout the region. And then at the fourth level is patient services like rehab, low-cost pharmacies, and medical equipment that people need. HCA has impacted every single level of this system.”
As of 2022, Ballantine said, 3,500 Mission employees had left, including at least 200 doctors. HCA has gutted staff, failed to provide adequate supplies and shutdown laboratory facilities, Ballantine said. World class cancer and cardiology departments have been devastated. The situation is so bad, N.C. Attorney General Josh Stein is suing HCA and Mission for violating its asset purchase agreement regarding cancer care and emergency services. In its response, HCA insists the agreement is “silent as to the quantity or quality of services required.”
And even though HCA pledged to maintain the same level of charity care that had been in place before it purchased Mission, Asheville Watchdog reported that a draft report of a study by a Wake Forest professor of law and public health found that “genuine charity care has diminished in systematic and extensive ways … with unfortunate effects on access to health care in western North Carolina.”
It was multiple complaints from Mission nurses to the NC Department of Health and Human Services about policies, staffing levels, and quality of care that finally resulted in the inspection that brought about the CMS order to fix problems or lose Medicare and Medicaid funding. Those nurses’ persistent advocacy on behalf of their patients brings hope for improvement.
State Sen. Julie Mayfield, D-Buncombe, organized a Feb. 6 news conference to allow Mission nurses, local elected leaders and other advocates to respond to the CMS finding. Mayfield and others voiced their outrage over the decline in care. In her opening remarks, Mayfield said, “If HCA is unable or unwilling to put the health and safety of our people first, then it’s time to find a company that will. Let me be clear, this community will not stop our advocacy and we will not quiet our voices until Mission Hospital once again provides world class care and the public’s trust and confidence in our hospital has been restored.”
While it may be possible for HCA to accomplish such a reversal, it should be remembered that HCA’s first obligation is to its stockholders, who are likely pretty satisfied. Net income attributable to HCA Healthcare in the fourth quarter of 2023 totaled $1.607 billion, or $5.93 per share.
Improvement adequate to meet an acceptable level of care shouldn’t be tolerable when we know a much higher standard has been and can be provided by Mission Hospital. Whatever it takes, our voices should not go quiet until that standard has been achieved again.
Joy Franklin is a journalist and writer who served as editorial page editor of the Asheville Citizen-Times for 10 years. Prior to that she served as executive editor of the Times-News in Hendersonville, N.C. Franklin writes for Carolina Commentary.