North Carolina's attorney general is demanding answers from HCA Healthcare after dozens of residents complained about rising bills and diminished quality at facilities the for-profit company bought last year.
When Nashville-based HCA bought six-hospital Mission Health, a former not-for-profit system based in Asheville, N.C., a little over a year ago, it agreed to a list of conditions, including keeping the hospitals open for 10 years. Attorney General Josh Stein questioned whether HCA is making good on its promises, and ordered the company to provide responses to questions about quality, charity care and billing by March 11.
"Widespread quality of care issues at Mission facilities would raise real questions about whether HCA is providing the services that it guaranteed," Stein wrote.
Stein's letter said his office has received 30 written complaints regarding Mission since Jan. 1. He asked HCA to respond to them.
Many residents complained about staffing cuts, especially nurses, and argue the cuts have reduced the quality and safety of patient care. Stein's letter noted that the flagship Asheville hospital's grade from the Leapfrog Group went from an "A" in spring 2018 to a "C" in fall 2019.
Stein also requested a wealth of information on HCA's charity care spending at Mission facilities. He noted that the charity care policy currently on Mission's website does not match the policy in the asset purchase agreement that allowed HCA's Mission acquisition to take place. That's because the policy on the website says it only covers emergent care. Stein also said it's not easy for physicians or patients to learn how the policy will be applied in their cases.
In an open letter to community members, Greg Lowe, president of HCA's North Carolina Division, wrote that HCA's more favorable patient financial assistance polices resulted in about $100 million more in charity care, uninsured discounts and other financial assistance in the first year of its ownership of Mission than would have been provided under Mission's previous policy.
Lowe wrote that Mission selected HCA as a partner because it offered financial stability.
"The promises we agreed to at the time of the sale were critical to this decision, and our mutual commitment to them is unwavering," he said.
Lowe's letter also countered patients' complaints about staffing, writing that HCA has hired hundreds of registered nurses, physicians, advanced practice providers and other caregivers to respond to increased admissions and emergency department visits.
Stein also directed HCA to respond by March 4 to complaints that Mission's Angel Medical Center no longer has a sexual assault nurse examiner on staff, which he indicated would also violate the purchase agreement. In a response dated March 4, Lowe said HCA provides the same services for sexual assault survivors that were available prior to its Mission purchase. Lowe wrote that HCA has not eliminated any of the health system's 11 trained sexual assault nurse examiners. He said those nurses are based in Asheville but are available to patients at Angel Medical Center 24/7.
In addition to several complaints about overbilling and double billing, several patients described in their letters being charged hospital facility fees at outpatient Mission clinics following HCA's purchase that didn't exist prior to the deal.
One patient, Jesse Urban, complained about an additional charge on his bill for a routine, outpatient procedure delivered at a family practice clinic that is considered part of a Mission hospital, Highlands-Cashiers Hospital in Highlands, N.C. In a response letter, the hospital's CEO said before HCA bought the hospital, Mission considered that clinic a physician's office when it billed commercial insurers. Beginning Aug. 1, 2019, HCA classified the clinic as a hospital outpatient site, which carries an additional facility fee.
Another patient, Sandra Westney of Brevard, wrote that it wasn't just that clinic. She said new facility fees are turning what used to be $50 co-pays for commercially insured patients into bills of several hundred dollars and "creating a health crisis for the people of NC."
"They have essentially removed doctors office visits from the reach of the general population," she wrote. "This act in my opinion is ethically and morally WRONG."
At a public hearing in Brevard, people complained that a skilled-nursing facility called the Transitional Care Unit at Transylvania Regional Hospital had been closed.
Ron Winters, principal and co-founder of consulting firm Gibbins Advisors, the independent monitor appointed to keep tabs on HCA's compliance with the purchase agreement, said HCA told him the same services were still being provided outside of the physical unit, but that the company had nevertheless agreed to reopen that unit.
Residents also complained about the closure of a wheelchair clinic called the CarePartners Wheelchair and Seating Clinic in Asheville. One resident, Jay Leavitt, said the closest similar facility is in Charlotte, but few patients can afford transportation there, himself included.
Jane Sutton, of Old Fort, N.C., wrote in an email that the closure is having devastating effects. She said traveling to the nearest comparable facility would take an entire day for many who can't drive. On top of that, being properly fitted for a wheelchair and receiving the wheelchair requires multiple visits, she said.
"HCA's decision is discriminating against people with disabilities," Sutton wrote.
Lowe conceded in his letter that HCA may have moved too quickly on that closure without having an alternative for patients. He said the clinic continues to serve patients with the highest needs, and that another community provider has agreed to assume operations of the clinic.
Casey Lance said she was laid off from her job in November 2019 in Transylvania Regional Hospital's scheduling department when the department was closed. At the time, she said HCA was requiring that self-pay patients cover a portion of their bill prior to the procedure date or their appointments were rescheduled.
In the event HCA is not in compliance with its agreement, Winters said Dogwood Health Trust, the not-for-profit organization formed using net proceeds from the $1.5 billion deal, and Stein, could compel the company to make changes.
Gibbins Advisors is currently paid by ANC Healthcare, which holds the proceeds of the sale. In a few months, that money will transfer to Dogwood, at which point Dogwood will pay Gibbins for serving as its independent monitor. Winters said Gibbins has created a website, www.independentmonitormhs.com, where residents can follow the latest developments, but that ultimately his firm is responsible to ANC—eventually Dogwood—and the hospital advisory boards.
"It's not, I don't think, a responsibility to the public, except to the extent that it helps us to be effective in our work and our clients wish us to do that," he said.
HCA, which has 184 hospitals, surpassed or came in at the high end of its own expectations last year on revenue, non-GAAP earnings and capital spending. The company posted $51.3 billion in revenue last year, up 10% from $46.7 billion in 2018.
