What has changed and why?

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The new North Tower at Mission Hospital will be opening soon with a new emergency department and added patient rooms with smart technology.  (Photo: ANGELI WRIGHT/ASHEVILLE CITIZEN TIMES)

Dr. Josh Short calls it a “double whammy.”

Now an emergency room physician at Haywood Regional Medical Center, Short left a job within the Mission Health system about two years ago. He has watched from nearby as the six-hospital system experiences growing pains after being purchased by for-profit hospital giant HCA Healthcare in February 2019.

As a health care professional, Short said the changes made in Mission Health — which also operates numerous outpatient clinics — have started to impact his work and that he’s concerned about the challenges his former colleagues face.

But it’s recently become a personal issue, too.

“My son, my wife, myself, my aunt, ages 6 to 83, all go to one of the clinics that was closed,” he said. “Even as a physician, I haven’t been able to find doctors’ appointments for (all) of us.

“My son was the first pediatric patient at the Candler clinic that’s closing. Flu season’s starting in the middle of a pandemic. He doesn’t have a doctor now.”

Short said this is par for the course for HCA’s treatment of the Western North Carolina health system. Since the national health care conglomerate acquired Mission Health, patients and employees alike have criticized a plethora of changes. These range from frustrations over rural services being moved to the flagship in Asheville to complaints from registered nurses who call low staffing levels dangerous.

Tim Gary, CEO of Crux Strategies in Nashville and a member of the firm’s health care and government relations practices, said consolidating rural services is a typical move for HCA and that these types of changes are generally determined by market need.

“HCA is a good provider … but they’re also obviously professionally managed,” Gary said. “They have a lot of data at their fingertips and they will make pretty tough business decisions based upon the information that’s available to them.” 

Mission spokeswoman Nancy Lindell did not answer a question from the Citizen Times about what additional consolidations or cuts might be made in the future.

But she provided information about additions made under HCA’s management, which include more than $200 million in capital investments and funding toward higher wages and student loan relief for employees. She also said more new technologies and services will be announced in the coming year.

Consolidations and complaints

Nashville-based conglomerate HCA purchased Mission Health for $1.5 billion in a deal approved by state attorney general Josh Stein. Prior to its execution, Stein negotiated 15 commitments to hold HCA to terms of the deal, which included a requirement that certain services continue to be offered at Mission’s rural hospitals for at least 10 years.

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North Carolina Attorney General Josh Stein announces that he does not object to HCA’s purchase of Mission Health in a press conference at the Murphy-Oakley Recreation Center on Jan. 16, 2019.  (Photo: Angeli Wright/[email protected])

That hasn’t stopped the system from making changes to rural and suburban services, though. Most recently, Mission announced offices in Biltmore Park and Candler will stop offering primary care services. Lindell said these services will be “consolidated to our other primary care locations.”

More: Mission Health to stop primary care services in Biltmore Park, Candler

When his family got their notifications that the Candler clinic would be closing in six weeks, Short said Mission included a list of other doctors “which was largely not helpful because none of them are around here.”

He said there are about 4,000 patients at each of these primary care offices who have effectively been let loose.

“There’s almost 8,000 patients that have six weeks to find a new physician,” said Short. “Many of them are (insured through) Medicare and Medicaid, which local physicians aren’t accepting. On average, it takes several months to get an appointment with a new doctor. These patients also will not be able to get a flu shot from their primary care physician in the middle of a pandemic which disproportionately affects the elderly, who are most at risk because they have the most difficulty getting transportation to other places to get flu shots and the care they need.”

Mission also recently centralized chemotherapy services from Mission Medical Oncology locations in Franklin, Brevard, Marion and Spruce Pine to the Asheville clinic. Though an independent provider offers coverage in these areas, the move drew complaints from officials.

In January, Cashiers-area residents complained that the local clinic did not have a full-time doctor — Mission has since hired a new one — and said they sensed lower staffing levels negatively impacting quality of care.

Employees at Mission Hospital in Asheville also have complained of low staffing. This came as registered nurses unionized at Mission Hospital, in an effort ending with a landslide vote Sept. 17.

In response to staffing complaints, Mission spokespersons accused the union, National Nurses United, of stoking anxieties as part of a campaign “aimed at undermining the hospital’s reputation in the community.”

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Mission nurses gathered to call for an increase in staffing August 5, 2020 in Asheville. (Photo: Angela Wilhelm/[email protected])

HCA also closed the CarePartners Wheelchair and Seating Clinic last December. Lindell said the clinic had been grant funded and, because HCA cannot accept grants, it was transitioned from CarePartners to MountainCare “without any disruption in service to patients.”

In addition to complaints about service changes, some patients have criticized Mission’s new charity care system, though chief medical officer Dr. William Hathaway said previously HCA’s charity care setup is more standard for both for-profit and not-for-profit hospital systems across the country.

Lindell said Mission Health provided about $100 million more in their first full year under HCA’s policy in charity care, uninsured discounts and other financial assistance, a total of about $252 million in the first full year of HCA operation.

Mission Health additions under HCA

Mission also has boasted additions to its system since the acquisition as well as plans for more.

Under terms of the sale agreement, HCA agreed to build a 120-bed inpatient behavioral health hospital in Asheville, complete the Mission Hospital North Tower, build a replacement hospital for Angel Medical Center in Franklin and invest $232 million into Mission’s existing facilities.

So far, HCA has dedicated more than $200 million in capital investments and completed the North Tower and its expanded emergency department, according to Lindell.

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Dr. Joseph Buell, the chief of general surgery at Mission Hospital, talks to Mission Possible students about the Da Vinci Xi robotic surgical system as they try it out at Mission Hospital on July 23, 2019. The arms of the surgical system, right, are moved by controls in the console. The system, which is currently in use for some surgeries at Mission, allows surgeons to perform procedures in a much less invasive way causing less pain and allowing a patient to heal more quickly after surgery. Mission Possible is a summer program through Mission Health for students in Buncombe County that are interested in possibly pursuing careers in healthcare.  (Photo: ANGELI WRIGHT/ASHEVILLE CITIZEN TIMES)

The capital investments also supported:

  • Land for building a new Angel Medical Center facility in Franklin. 
  • Land for a new 120-bed behavioral health facility in Asheville.
  • State-of-the-art technology, including two da Vinci Xi robots, an upgraded Mako Robot, an O-arm surgical imaging system and six StealthStations.
  • Upgrades in imaging equipment, including new MRI and CT machines, and several new Mammography Units.
  • Investments in sister facilities to expand surgical and imaging capabilities throughout Western North Carolina.

Lindell said the health system also has “invested in (its) team” through a student loan repayment program, increasing minimum wage across Mission Health from $11 to $12.50 per hour and implementing “a new career ladder for hospital-based patient care technicians” with the minimum hourly rate increased to $13 per hour.

Mission Health employed about 12,000 people across Western North Carolina at the time it was acquired by HCA and Lindell said the same is true today, though there are almost 600 open positions in the system.

“We continually evaluate our services and operations to effectively meet the needs of our organization and community,” she said. “During these evaluations, we have identified areas where we have needed to hire additional staff and where consolidations have also been necessary.”

‘Medicine as a business’

Joe Lupica, of Newpoint Healthcare Advisors,  questioned some of the complaints angled at HCA. He said it’s common to hear gripes about low staffing during a unionizing campaign, but that it’s not typical for medical staff cuts to come as part of an acquisition.

More: Answer Man: HCA changing Mission Hospital culture? Cutting hours?

Based in Phoenix, Arizona, Lupica is a consultant to independent hospitals and health systems, advising on mergers, acquisitions, affiliations and other structures designed to enhance finances and operations. 

He said cuts following a health system acquisition stem from changes in the market — such as the appearance of a competing provider — and tend to occur when a service is unneeded.

“The question is whether services like this are still being provided in the community, because community need and demand is always the first question that a … hospital system has to ask,”  he said. “It’s not just a matter of doing the right thing, it’s also a business question.”

A sign at Hospital Corporation of America’s headquarters in Nashville, Tennessee, is shown in this 2013 photo. (Photo: The Tennessean)

Gary, on the other hand, said HCA is prone to making cuts to rural services.

Without being familiar with the Mission Health system sale, Gary wagered a guess that HCA was “consolidating services in Asheville and using the other facilities as really feeders to feed patient flow to that big facility.”

“That’s straight out of their playbook,” he said. … “I’m not saying that’s a bad thing, but part of the play to improve profitability is often to scale down services in local communities, use those facilities as, essentially, intake points through the ER and other clinics and then feed the higher acuity patients to a centralized facility that then they can staff up and deal with the more specialized cases.”

Gary advises clients on restructuring financial systems, mergers, acquisitions and financial revitalization. He has worked with rural hospitals on the other side of HCA deals.

He said it’s less profitable to offer services in rural areas that are available at a centralized hub because that requires a system to double up on expensive equipment and staff. Instead, he said, a system might offer basic services at the smaller hospitals and refer patients who need higher levels of care to the larger flagship.

“You’ll often see, for example, a rural hospital that has been the facility in a small county essentially convert over to an emergency department and health clinics, primary care physicians clinics, that sort of thing so that folks can … go see the doctor,” Gary said. “They can get their routine services, their flu shots, all of that. If they have an emergency, there’s an ER to go to. And then everything else, as far as the longer stay hospital beds, that sort of thing, gets moved to a centralized facility.”

Gary said HCA tends to look at several factors when it acquires a hospital or health system including:

  • Reducing the cost of management at a facility.
  • Reducing supply and inventory costs through purchasing power.
  • How a facility fits in with others in the area.

“You’ll see a different approach, more of a ‘medicine as a business’ approach than you will often see in locally-owned, standalone or small systems because it’s viewed as a business versus just purely a community service,” he said.

The impacts of Mission changes

Franklin Mayor Bob Scott has regularly voiced concerns about cuts to rural health care services. He took issue with Mission’s decision-making prior to the HCA deal, in particular when the system discontinued labor and delivery services at Angel Medical Center in 2017.

“After that everything just sort of went downhill and it’s been going downhill ever since,” he said.

Scott said things “absolutely” have gotten worse since HCA acquired the system and, while the care offered at Angel Medical is great, Franklin has access to fewer and fewer services as they slowly get moved to Asheville. He also said he’s received complaints about the way HCA does billing.

Mission Health has sent a “letter of intent” to HCA Healthcare to start sale proceedings. (Photo: Citizen-Times file photo)

“I feel very, very strongly that a community is only as strong and viable as its health care,” he said. … “You have got to have health care. And I don’t think that this is necessarily just here in Western North Carolina. I think that there’s a problem nationwide about rural health care.”

Short, who has friends still working in the Mission system, said some changes have been “devastating” for staff. As offices close, employees who have been with Mission for years are required to go through an application process for a new placement in the system. And Short said new positions don’t really exist.

“It’s not like they’re consolidating, they just let people go and they don’t have other jobs for them to fill,” he said.

An employee at one of Mission’s Buncombe County offices that recently stopped primary care services spoke to the Citizen Times on the condition of anonymity. They, too, said cuts have increased under HCA and that this re-application process even applies to veteran staff members.

“Everybody has to reapply for any positions that are open within Mission,” the employee said. “You have to reapply and go through the hiring process to get those positions. … And we don’t know if that potentially means that you’re up for pay cuts.”

With primary care offices closing, Short said he’s expecting Haywood Regional’s emergency room to see a dramatic influx of patients who don’t have a doctor with whom his staff can coordinate long term treatment.

Absent an emergency, he said it will take time for patients to get new basic care, noting that this comes amid a pandemic with flu season on the horizon.

Some patients have immediate care needs unrelated to the pandemic. Another patient at the Candler primary care office, Geoff Noblitt, said the news of primary care services ending came without warning a couple of days after he’d had neck fusion surgery.

“I saw it on Facebook and had to confirm it with my doctor,” he said.

Now, Noblitt said he’ll have to find a new doctor to aid him in pain management and other recovery issues following his surgery. He said he’s disappointed to lose a provider he’s gotten to know through several years.

Noblitt hopes he’ll be able to obtain care through a family member’s physician, but he said some patients won’t be so lucky.

“The closing of this office with no notice to the community, the staff that works there or the patients they serve show that HCA cares nothing about their patients or the community,” said Noblitt. “The little people get crushed under big corporate greed again. It’s messed up.”

He said he thought selling the “this gigantic private company” would offer Mission more resources and enable them to better serve the community.

“And all they’ve done since is under serve the community and take away resources,” he said. … “It looks like it’s an increasingly bad deal for our area.”


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