N.C. Attorney General Josh Stein has told HCA Healthcare that he’s heard enough.
Now, he wants answers.
“The delivery of health care is truly a life-or-death issue,” Stein said in a statement issued late Tuesday as his office made public a letter addressed to Greg Lowe, president of the North Carolina division of HCA Healthcare.
“This is why my office took so seriously our responsibility to protect Western North Carolinians as we negotiated with HCA over its purchase of Mission. I am deeply concerned about what I’ve been hearing about HCA – and I want answers.”
Stein intervened a little more than a year ago in the negotiations between nonprofit Mission Health and for-profit HCA Healthcare, hammering out 15 distinct promises for which the Nashville, Tenn.-based health care giant is now accountable as part of its agreement to acquire Mission, the largest hospital operator in Western North Carolina.
Stein’s letter to Lowe focuses on four key issues raised during town hall meetings in communities served by Mission. The meetings were conducted between Jan. 28 and Feb. 13 by the independent monitor that Stein insisted be hired to ensure that HCA complies with its obligations.
Those meetings were attended by about 600 people in all, many of them HCA/Mission patients and employees feeling distraught and helpless as well as elected officials and other members of the community.
Three of Stein’s concerns – quality of care, sexual assault nurse examiner staffing and charity care – fall under some of the promises that HCA made, Stein submits. A fourth issue relates to patient billing.
Quality of care
With raised voices and some tears shed, many of HCA’s critics brought up numerous concerns about the impact of staffing cuts at Mission hospitals at the recent meetings, especially with regard to nursing and nursing support.
In addition, 30 written complaints have been filed with the attorney general’s office since Jan. 1, Stein said, and some of them are “harrowing.”
Stein, who is providing HCA with copies of the complaints, wants responses.
In addition, the attorney general said, he is sharing complaints with regulators at the N.C. Department of Health and Human Services who investigate quality-of-care concerns.
Under the asset purchase agreement that HCA signed as part of its deal, the corporation is required to provide many defined services such as “general medicine services” at the Asheville facility until 2029, Stein wrote.
“Widespread quality-of-care issues at Mission facilities would raise real questions about whether HCA is providing the services that it guaranteed,” he said.
Sexual assault nurse examiner staffing
At the independent monitor’s meeting in Franklin, a staff member of REACH, a regional nonprofit that assists victims of rape and other sexual abuse, said the emergency room at Angel Medical Center has not been staffed with a trained and certified nurse able to work with rape kits, resulting in the transporting of traumatized victims to Asheville and then having them face what she said were onerous bills.
In his letter, Stein cites a section of the purchase agreement signed by HCA that says it “shall not discontinue” any “emergency services” or “acute medicine services” at the Franklin hospital.
The support of sexual assault nurse examiners, commonly called SANE nurses, is “time-sensitive and of critical importance,” Stein wrote, asking for a response from HCA by March 4.
In nearly two full pages of his five-page letter, Stein dives deeply into concerns about a charity care policy that HCA had touted as being superior to what nonprofit Mission Health had adopted.
Stein is skeptical of that claim.
HCA’s charity care policy “is not transparent about what services are covered,” he wrote, and the hospital system’s decision to focus on emergent care “appears inconsistent” with the asset purchase agreement.
Led by N.C. Sen. Terry Van Duyn, D-Buncombe, a group of elected officials told the independent monitor’s Asheville meeting on Feb. 10 that patients were being “billed for services that they thought would be covered and now cannot afford,” with some of them facing the wrath of collection agencies.
Stein is now asking HCA for nine specific items pertaining to charity care by March 11, including the dollar value of all write-offs or write-downs of patient bills provided under Mission Health System Inc.’s ownership and under HCA’s ownership and the overall percentage increase or decrease in charges for medical services since the effective date of the merger.
In a Feb. 10 story in Carolina Public Press, dozens of employees at the Connestee Falls residential community in Transylvania County complained about surprise “outpatient” bills being tacked onto copays for Mission-affiliated primary care office visits when they had never set foot in one of Mission’s hospitals or had seen a specialist.
News coverage and growing complaints from the wider community ultimately led HCA to establish a phone line to address the concerns, but without announcing any rollback of the surprise fee.
“We ask that Mission provide our office with all disclosures that it made to customers about this outpatient fee,” Stein told HCA’s Lowe, with a submission deadline of March 11.
Rocio Borghini, the human resources manager at Connestee Falls who raised concerns about the surprise billing on behalf of dozens of employees, doesn’t expect HCA’s response to Stein to be lengthy.
“They’ve already admitted that they didn’t provide disclosure,” she said.
But, she said, her company’s employees “finally may get some answers from HCA.”
When asked late Tuesday about the overall content of the attorney general’s letter, Van Duyn praised Stein for asking the right questions.
“He’s asking for real information about staffing and quality of care at the hospital, and those are the issues that HCA needs to address.”
With Stein’s insistence on the hiring of an independent monitor, Van Duyn said, “we had a platform to raise these issues.”
Attorney general’s letter
Following is the text of Stein’s letter to HCA:
Stein Letter to HCA 02252020 (PDF)