By Mark Tosczak
ASHEVILLE — Bill O’Connell is one of thousands of retirees who have chosen western North Carolina to retire.
He and others have been drawn by the area’s natural beauty, opportunities to volunteer and other amenities that helped put the mountain city on Forbes’ list of best places to retire for several years.
For O’Connell and others, though, one of the most important draws is Mission Health, the six-hospital, $1.8 billion nonprofit health system that is, at least by some measures, one of the best hospital systems in the nation. It has also been consistently profitable.
So when Mission announced in March that it planned to sell itself to HCA Healthcare Inc., the nation’s largest for-profit hospital operator, O’Connell and many others were surprised.
“It comes as rather a jolt,” O’Connell said, “… that the Mission leadership had determined it was going to sell itself to, of all things, the largest proprietary hospital chain in the United States.”
A big enough jolt, in fact, that O’Connell has turned the focus of a small think tank he’s founded, Communities for Older Adult Health, to the transaction and the possible foundation it would birth.
The group is planning an Aug. 3 forum for leaders from across the region to discuss that foundation.
Residents raising concerns
If the sale is completed, perhaps later this year, an estimated $1 to 2 billion in proceeds would fund the just-created Dogwood Health Trust, a foundation that would use the money to tackle some of the social determinants of health, which contribute to some of the poor health outcomes in the 18 counties that Mission Health serves.
Social determinants of health are interrelated social, economic and environmental forces that have a major influence on health. Some of these include access to transportation, poor quality housing, job insecurity, hunger and the like. Researchers estimate that social and environmental factors are twice as important as health care services when it comes to determining risk of premature death.
Though Mission leaders have waged an aggressive public relations campaign to sell the benefits of the deal, O’Connell and some other western N.C. residents aren’t fully sold on it.
They wonder how the Dogwood Health Trust will be set up and run, who will be involved and how it will gather input from 18 counties. Some worry about the foundation’s ability to effectively police the terms of the HCA acquisition in coming years. The foundation created when HCA bought a large health system in Kansas City, Mo., fought a years-long legal battle against the company to enforce the terms of HCA’s purchase. That litigation was settled in early 2017.
Others are raising concerns about what HCA ownership might mean for rural hospitals, especially those already smarting from the loss last year of local labor and delivery services.
In the coming weeks, as Mission and HCA complete their negotiations and settle on a final price, these residents are hoping N.C. Attorney General Josh Stein will step in to make sure their concerns are heard.
Petitioning for a voice
Susan Spruill of Spruce Pine, northeast of Asheville in Mitchell County, views her local hospital — Blue Ridge Regional Hospital — as property of the community. It’s been part of the Mission system since 1998, but it was built in the 1950s in part with donations from community residents.
WHEN: Aug. 3, 10 a.m. to 1 p.m. Registration opens at 9 a.m.
WHERE: UNC-Asheville’s Reuter Center, Room 102
“As soon as you say for-profit and health care, it just, you know, raises the hair on the back of my neck,” Spruill said.
“If you’re doing for profit, any place that has no profit … you’re going to want to minimize that,” Spruill says. “And that means minimizing the outlying rural hospitals.”
Small rural hospitals across the country have struggled to survive in recent years. The demographics in many parts of rural America — with high rates of Medicare and Medicaid patients and low rates of employer-paid insurance — mean lower revenues for these hospitals. These small facilities, at least on their own, don’t have the same cost efficiencies and negotiating clout that bigger urban and suburban hospitals can muster.
Spruill, along with a small group of loosely organized community members that have dubbed themselves Plan B, launched a petition on Change.org that calls on Stein to either return Blue Ridge to local, community ownership or ensure the proceeds from its sales are funneled into a foundation focused just on the communities that Blue Ridge serves.
Mission Health CEO Ron Paulus said in an interview with North Carolina Health News that it wasn’t feasible for small rural hospitals, like Blue Ridge, to operate independently. And HCA has sought to reassure those concerned about how it might handle Mission’s rural facilities.
In an ad that ran in the July 8 Asheville Citizen-Times, the company said it understands local concerns and is committed to the health care needs of rural communities.
As of Sunday, the Plan B petition had attracted 897 signatures, though there’s no way of knowing if they’re all from residents of Avery, Mitchell and Yancey counties, or even all from western North Carolina.
“Our goal is not to stop any kind of agreement between mission and HCA, if that’s what’s best,” Spruill said. “It’s just to make sure that in the end of it, our community is best served by it.”
If the choice in her community, Spruill says, is between having a foundation taking on social determinants of health and having a hospital, “I’d rather have the hospital.”
Focusing on the foundation
Other people say that no matter how they might privately feel about the sale to HCA, they’re focused now on ensuring the Dogwood Health Trust is set up so that it truly benefits western North Carolina.
One of the main talking points in Mission’s PR campaign in favor of the sale has been the prospect of a foundation that could funnel as much a $100 million per year into western North Carolina.
But a loosely allied group of citizens is raising questions about who will run the foundation, how it will be structured and whether its leadership will be able to effectively take on social determinants of health.
“It needs to be thought through very carefully,” said Susan Larson, one of the leaders of Sustaining Essential and Rural Community Healthcare, a group formed last summer after labor and delivery services were closed at Blue Ridge Regional Hospital. “It’s not just a matter of choosing a board and going ahead and giving the money out.”
Among the concerns that Larson and others have raised about the Dogwood Trust: Will its board members have the knowledge and expertise to take on social determinants of health? And will the board draw members with enough diversity to speak to issues across western North Carolina, not just in Asheville and Buncombe County?
Forming a board
While those questions haven’t been answered, Mission has begun to take steps to do so. On July 16, the health system announced the creation of Dogwood Health Trust and said it had appointed Janice Brumit, a longtime community volunteer and Mission board member, as founding chair of the nonprofit.
Brumit said that in the coming months one of her tasks will be to recruit the inaugural board the foundation needs to take on social determinants of health.
“We are developing a criteria,” Brumit said. She says people will be able to apply to serve on the board, which will likely end up with 11 to 15 members. And, she said, the board is “certainly not going to be Asheville-centric in any way, shape, fashion or form.”
Those criteria should be posted around Aug. 1, she said.
O’Connell, from Communities for Older Adult Health, said that based on what he knows, the choice of Brumit to be the inaugural chair is a good one. “That’s a very positive step in terms of this individual,” he said.
But, he added, Mission still continues to talk at the community rather than with the community.
“Out in the community, one looks at this and still says, ‘Gee, nobody came by here recently, and had a conversation with me about what I think should be,”’ he said.
O’Connell and his group also want the attorney general to weigh in on the Mission sale to ensure the foundation is created in a way that can successfully address social determinants of health across 18 counties.
Communities for Older Adult Health is holding a forum Aug. 3 at UNC-Asheville’s Reuter Center to discuss what the foundation might mean for the region. Among the speakers will be Karl Stauber, CEO of Danville Regional Foundation, a hospital conversion foundation in Danville, Va., as well as N.C. Deputy Attorney General Jennifer Harrod.
The leader of an Asheville nonprofit focused on poverty as well as someone from Sustaining Essential and Rural Community Healthcare will also present.
O’Connell said had reached out to Brumit informally to invite her and was planning to follow up with a formal invitation. Brumit, in an interview with N.C. Health News on Thursday, said she had heard about the forum, but didn’t think she would attend.
“I think that it’s a little premature for us to get in front of anybody, because we’re still forming,” she said. “We’re still in the nascent stages.”