HCA-Mission's independent monitor got an earful. What happens now?

In recent weeks, the firm hired to ensure HCA Healthcare met the terms of its purchase of Mission Hospital met with Western North Carolinians.

From Cashiers to Marion, residents spoke up. They asked questions. A few highlighted improvements they’ve seen under HCA. The overwhelming majority, however, described negative and troubling health care experiences since HCA took over in February 2019.

Patients discussed uncomfortable delays during hospital stays. Others bemoaned inconsistent billing practices and charity care policies. One Mission-employed nurse wept while lamenting her hospital’s staffing ratios.  

The public broached a litany of other issues, from translator service changes to wheelchair clinic cuts to physician disenfranchisement to a lack of rural doctors.

“Certain themes were consistent across meetings while some were unique to a specific facility,” Ron Winters, founder of Gibbins Advisors, told The Citizen Times.

After seven meetings, questions linger for those invested in the region’s largest health care system: Who holds HCA accountable? What role, if any, does the attorney general play? And ultimately, what comes next?

What is the monitor's role? 

While Winters welcomed all public input, the community meetings in January and early February were ostensibly focused on the Asset Purchasing Agreement.

Before HCA bought Mission, HCA promised to uphold 15 commitments outlined in the agreement. Some of the guarantees include maintaining charity care, rural hospitals and building a new behavioral health hospital. Each commitment can be read here.

In October, state Attorney General Josh Stein approved Gibbins Advisors to monitor the $1.5 billion hospital sale. The appointment of a monitor was another condition of the transaction.

“As I mentioned in each meeting, I recognize that community members may be frustrated that the scope of our work is not to resolve the individual issues they spoke about,” Winters said. “That said, it was important to hear directly from the communities because it provided context and insight around key issues.”

Most of the issues raised at the public meetings — around staffing levels, wait times, early discharges, and service cuts — fall outside the agreement. Still, Winters said his firm logged all feedback, both from the meetings and online, and will share this information with the "seller group" on a monthly basis. 

Ultimately, the seller group is responsible for making sure HCA complies with the 15 commitments spelled out in the purchasing agreement. 

Who is the seller?

It's not a simple answer. The seller is a holding corporation, a temporary entity, called ANC Healthcare (ANC stands for Asheville North Carolina). At some point in mid-2020, the seller will becomeDogwood Health Trust.

“At some point” remains the most specific timetable as financial remnants from the former nonprofit entity Mission Health must be settled before Dogwood Health takes over.

A third of Dogwood Health Trust’s board of directors previously served on the Mission Health board of directors. Dogwood's leadership vows to protect the 15 commitments, be it through dialogue or litigation. 

"We remain optimistic that HCA will fulfill those commitments to provide much needed health care throughout the region," reads a statement provided to the Citizen Times by Dogwood Health Trust spokeswoman Erica Allison. "If discussions with HCA regarding compliance concerns were to result in an outcome that is unacceptable to the Seller Representative, it can take legal action against HCA."

The Dogwood statement admits the organization's "scope is limited to enforcing compliance as defined in the APA." 

Related coverage:

• 'We have no doctor here': Rural residents voice concerns at HCA compliance meeting
• 'Critically understaffed': Asheville crowd vents frustrations with Mission Health and HCA

The role of hospital advisory boards

Near the end of April, HCA will deliver its own purchase agreement compliance report to six advisory boards representing the region's six Mission hospitals.

In addition to receiving HCA's report, the advisory boards consent to any modifications HCA may wish to make to the purchase agreement. Winters said his firm is unaware of any HCA considerations to alter its 15 commitments. 

On each local advisory board sit four HCA appointees and four appointees selected by hospital boards at the time of the HCA-Mission sale.

What can Attorney General Josh Stein do?

If Stein finds the seller — ANC now or Dogwood later — fails to properly enforce compliance, his department can step in on behalf of the public to demand HCA make changes to meet the purchasing agreement.  

"Attorney General Stein is committed to ensuring that HCA complies with the agreement he negotiated," wrote Laura Brewer, NC Department of Justice communication director in an email to the Citizen Times. 

"If people are seeing anything that concerns them, please urge them to contact our office at 1-877-5-NOSCAM or www.ncdoj.gov/complaint," Brewer said. "Our office will look into these complaints and take action if appropriate."

Issues outside HCA's 15 commitments 

Most of the client complaints Karen Sanders hears do not apply to the HCA-Mission purchasing agreement. 

Sanders, of South Asheville, is an independent patient and registered nurse advocate who helps people traverse America’s bureaucratic, often befuddling health care systems. Her current caseload of patients across Western North Carolina sits at 60. Within the past year, Sanders said the number of complaints she’s received from patients at Mission hospitals have “escalated 100%.”

"I'm extremely concerned about the poor quality of care we're hearing about at the hospital,” said Sanders, who cited delays in patient care as the most common new issue she hears.

As a result of the seven public meetings, Sanders said she would like to see greater oversight of Mission hospitals.

Mission Health representatives say they've been listening to the worries of Sanders and others.

“We recognize that this past year has been a time of enormous transition for our organization, and that we have sometimes created confusion by not communicating about changes in a clear and timely way,” said Mission Health spokeswoman Nancy Lindell. “We have been making progress addressing staffing needs, funding new technological investments and investing in our clinical services. There is more work to be done.”

Who oversees hospitals?

A combination of state, federal and private agencies regulate and accredit hospitals.

The Joint Commission is a nonprofit that grants the accreditation health care organizations like Mission Health need to receive third-party payments like Medicaid and Medicare. Without this accreditation, a hospital would likely face bankruptcy.

The Joint Commission assesses compliance with its standards through extensive hospital visits, called surveys. Surveys typically take place every three years, though more frequent surprise visits occur. According to the website QualityCheck, the Joint Commission last conducted a full hospital survey of Asheville's Mission Hospital in April 2018. The Joint Commission conducted several more recent department specific surveys. All six Mission hospitals remain accredited by the Joint Commission.

At the federal level, the Centers for Medicare and Medicaid Services, called CMS, sets hospital regulations.

At the state level, the NC Division of Health Service Regulation lists its own codes. 

Sanders encouraged Western North Carolina residents reach out to these agencies to voice any hospital concerns that arise.

Have feedback to give? Here are seven ways to make your voice heard. 

Brian Gordon is the education and social issues reporter for The Asheville Citizen Times. He can be reached at bgordon@citizentimes.com, at 828-232-5851, or on Twitter at @briansamuel92. 

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