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A.G. Josh Stein's Asheville Roundtable on Hospital Consolidation Pivots to HCA Concerns

Updated: May 18, 2022

AG Josh Stein invited local leaders, healthcare advocates, health care providers, and elected officials to a round table in Asheville recently. The purpose was to discuss hospital consolidation, its impacts to healthcare price and quality, what other states are doing to address it, and how North Carolina might handle the situation. AG Stein along with N.C. Sen. Julie Mayfield and others are developing legislation which would provide greater oversight and legal standing for transactions such as the purchase of Mission Health System by HCA. SEARCH leaders Jon Ward, Susan Larson and Victoria Hicks attended.

This meeting was an invited gathering of physicians, other health care professionals, local elected officials, health care advocates, and others to discuss the persistent problems resulting from the way in which the sale of the Mission Health System to HCA was carried out. The goal was to clarify those problems and suggest changes to state laws that regulate these processes so that a future sale of a health system can produce a more positive result.

Gen. Stein began the meeting with the message that Medicaid Expansion is essential to easing the strain on rural hospitals and should be passed. He thanked the organizers and attendees and then expressed his views about the process of the sale, its review, and the outcomes that have damaged healthcare in Western North Carolina. He discussed the nature of the pre-review process, the problems with it, and what it should be. While state law grants the authority to review the process to the Attorney General, it limits the review in ways that prevent consideration of many elements of the process that should be considered. These would include evidence of the fairness of the process and the quality of the resulting care.

The Attorney General then opened the meeting to general discussion:

  • Mark Warner, an executive for Blue Cross Blue Shield NC, spoke, noting that statewide we have experienced a loss of choice in health care and an increase in costs. He noted that increased costs result in increased insurance premiums.

  • Dr. Martin Palmieri, an oncologist with the Messino group, discussed the effects of physician consolidation from his perspective. He shared his personal experience of not renewing an unsatisfactory contract with Mission, and, with his partners deciding to leave Mission and develop an independent practice.

  • Palmieri also stated that HCA declared that they “owned” the patients in physician practices and would not allow departing physicians to communicate with them about their departure or plans for their practices. It was said that the deck was stacked against physicians.

  • A surgeon lamented the fact that physican groups such as his had decided not to leave Mission. One recent group he mentioned was Asheville ENT.

  • The past board chair of the WNC Medical Society discussed the impacts of restrictive covenants in causing physicians to leave the area..

  • A neurologist spoke, saying that Mission did not provide trained nurses on the neurology ward.

  • Charity care was mentioned several times. While HCA said that they would have a charity care plan, the one they developed required patients to pre-pay and then be reimbursed if they qualified. This is an unworkable approach for medically indigent patients.

  • A nurse, representing the nurses’ union, talked about the effects of short staffing (as many as 9 patients per nurse) on patient care and hospital operations at Mission Hospital. She said it diminished the quality of care.

  • The Mayor of Brevard said that the hospital system needs to present metrics on performance to the community so that leaders and the public can understand the situation. When she asked for this data from Mission, she was told that it was proprietary. For example, she could not get from HCA the number of doctors who had resigned from Transylvania County Hospital staff. She had to ask outside channels to get the number which was about 19.

  • Victoria Hicks from the Health Equity Coalition stated that the laws regarding hospital acquisitions are broken and that the sale of Mission to HCA was a “failed transaction.” She emphasized the importance of making decisions through an equity lens. She stated that people affected by these decisions need a seat at the table when they are made. She then presented a list of changes that should be made to improve access and the quality of care.

  • Esther Mannheimer, the Mayor of Asheville, stated that the community must be at the table in these transactions and must be able to understand what is happening. She said the buyer of a system must be present and accountable.

  • A Commissioner from Macon County discussed staffing issues at their regional hospital and their significant problems with drugs and mental health. He also described a local effort to set up a mental health unit and the way HCA blocked it. Gen. Stein asked to talk with him after the meeting. The Commissioner also made the general statement that people have lost faith in their institutions because they are not being supported by them.

  • Rep. John Ager questioned the fact that the option to bid was not made public and HCA rose to the top in a field of one. He cited the sale of New Hanover as a process that was conducted in an above-board manner.

  • Emergency room physician Dr. Mitchell Li spoke about the short shrift that ER doctors and hospitalists get. They are contract employees working without benefits and reporting their income on 1099s.

  • Susan Larson of SEARCH talked of how happy we had been when AG Stein announced the changes to the APA he’d made, but how disappointed we are by the reality that essential services, such as surgery, are only minimally maintained.

AG Stein made closing remarks, saying that he hopes with the help of Sen. Mayfield and others to pass a bill that will allow the AG to intervene more forcefully in future reviews. He cited Tennessee as an example where such a law exists. He noted the need for public participation prior to the sale as well as post transaction monitoring. The meeting adjourned after about 1.15 hours.


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