By Barbara Durr and Sally Kestin, for Asheville Watchdog
Two prominent physician groups quit the Mission Health system in the first two weeks of the year, the latest in an exodus from the hospital since its sale three years ago to for-profit HCA Healthcare.
The seven doctors at Asheville Ear, Nose & Throat “decided to no longer provide medical or surgical care at Mission Hospital or Asheville Surgery Center,” as of Jan. 1, they wrote in a letter to their patients.
Also on Jan. 1, the 10 surgeons at Carolina Spine & Neurosurgery Center parted ways with Mission and joined UNC Health’s Margaret R. Pardee Memorial Hospital in Hendersonville. They retain privileges to practice at Mission.
HCA declined repeated requests for the number of doctors who have left the Mission system since it took over in February 2019 and refuses to say how many doctors are on staff today, other than that the number is “relatively the same.”
But Asheville Watchdog identified 223 doctors who appear to be no longer practicing there; their names were on the Mission Find a Doctor website as of August 2019 but had been removed as of February 2022.
Another 57 doctors still on the website are no longer listed as employed or affiliated with Mission.
Asheville Mayor Esther Manheimer, who was among a group of elected officials signing a scathing public letter in February 2020 over concerns about patient care and staffing at Mission, said of Asheville Watchdog’s analysis,“It seems unavoidable that Asheville, Buncombe County and Western North Carolina will see a deterioration in healthcare as a result of Mission-HCA hemorrhaging doctors.”
“It seems unavoidable that Asheville, Buncombe County and Western North Carolina will see a deterioration in healthcare as a result of Mission-HCA hemorrhaging doctors.”Asheville mayor Esther Manheimer
State Sen. Julie Mayfield said,“The loss of these doctors represents collectively hundreds of years of experience, long-standing relationships within and outside the hospital, and consistency of and confidence in care for patients.”
“These physicians were a key part of what made Mission a world-class hospital system that prioritized patient care,” Mayfield said, “and it is truly unfortunate that HCA chose from the start to prioritize its profit over its people.”
Nancy Lindell, director of public and media relations for HCA Healthcare’s North Carolina Division, which includes Mission Hospital, said in a statement to Asheville Watchdog, “Mission Health is grateful to our team members who provide quality care to our community every day … It is expected that the transition to HCA Healthcare, life events, effects of a global pandemic, and the increasing demand for healthcare services, etc., would lead to both some additions and departures.”
HCA refuses to give numbers
The 223 doctors no longer on Mission’s Find A Doctor site include 33 family medicine physicians, 25 surgeons, and 15 pediatricians or pediatric specialists. More than 100 doctors moved out of the state or region; others are listed as affiliated with hospitals in Hendersonville, the Charles George VA Medical Center in Asheville, or private practices, according to the North Carolina Medical Board and Internet searches.
Lindell said many of the doctors still in the region continue to practice at Mission and “are still part of our medical staff and hospital teams, making the number of physicians on medical staff relatively the same.”
Lindell said the Find a Doctor site does not include open positions or doctors in the process of being hired and is not meant as a tool “for tracking the medical staff.” Mission has an office dedicated to medical staffing, but Lindell declined to provide even basic information about the number of doctors at Mission before and after HCA took over.
Asheville Watchdog sent Lindell the names of the doctors who are no longer on Find A Doctor or listed as employed or affiliated with Mission. She declined to comment beyond her statement and reiterated, “We continue to have approximately the same number of providers on the medical staff to serve the needs of our community.”
Providers include others besides doctors, including nurse practitioners, physician assistants, psychologists and dentists.
In interviews, doctors who left Mission cited concerns about declining patient care, job burnout, and frustrations with HCA’s emphasis on profits. Five of the doctors said some of their patients needing hospitalization were asking to be treated at hospitals other than Mission.
One doctor who remained in the area and spoke to Asheville Watchdog on the condition of anonymity because he said he feared retribution from HCA said, “I get asked every day by a patient if I can treat them elsewhere than Mission.”
Dr. Martin Palmeri, an oncologist who left Mission in December 2019 to join Messino Cancer Centers, said the hospital system before HCA “was run primarily by doctors and nurses and now it’s being run by businessmen.”
“Bedside care is knowing what patients and families are suffering,” Palmeri said. “Patient suffering is off their (HCA management’s) radar.”
He said the hospital needs more doctors in leadership. “We need the right balance between bedside care and corporate benchmarks and revenue,” said Palmeri, who was recently elected president of the North Carolina Oncology Association.
Dr. Ben Aiken, a primary care physician employed by Mission until January 2020, said many patients are skeptical “that HCA has their best interests in mind as a for-profit company.”
Aiken, who piloted a subscription fee direct primary care practice under Mission’s former leadership, said Mission used to employ more primary care doctors even though that specialty is less profitable. HCA shuttered two primary care practices in 2020, in Biltmore Park and Candler, and sold Aiken’s pilot program, now called Lantern Health, to him.
“Primary care generally is not an emphasis in HCA,” Aiken said.
At least 30 primary care or family medicine doctors and 10 internists have left Mission’s employment, Asheville Watchdog found in its analysis of the Find A Doctor website.
Aiken said Mission long was able to recruit high-quality physicians to Asheville, considered a desirable place to live and practice. But he said, “The type of physicians that were attracted to Mission may not be attracted to HCA. The business approach is very different.”
“Exact same doctors,” then-CEO pledged
An emergency room doctor, who spoke on condition of anonymity, said Mission before HCA “could be choosy” about the doctors it brought on staff because so many wanted to work there. “Now they just fill the gaps.”
The doctor said that nurses in the emergency room are caring for more patients while management concentrates on meeting minimum standards and “metrics” such as how long a patient waits to be seen.
“When HCA came in, there were so many emails on metrics,” he said. “We’ve gone from providing amazing care to mediocre care.”
Aiken said he wants to see a high-quality hospital in Asheville but believes Pardee UNC Health and AdventHealth, both in Hendersonville, are likely to expand if skepticism about Mission continues.
Lindell said Mission patients “continue to receive outstanding care at our hospitals by our clinical teams and board-certified physicians.” She said Mission recently passed a state inspection with no deficiencies, and a national accreditation review measuring 1,600 points of care did not produce “a single finding that required corrective action or a repeat visit.”
She said hospitals nationwide are struggling to hire and retain doctors, a shortage exacerbated by the pandemic, but that the Mission system in western North Carolina “welcomed almost 60 new physicians to our staff in 2021.”
In May 2018, before the sale of the hospital system, Dr. Ronald A. Paulus, then president and chief executive officer of Mission Health, told a local business group that Mission Health under HCA would still have “the exact same people and exact same doctors and exact same nurses” and provide similar or even superior care.
Paulus received a multimillion-dollar payout from Mission and joined HCA as a strategic advisor just days after the sale was concluded.
Staffing is key concern
A common complaint among doctors, nurses and patients is that Mission under HCA has skimped on staffing, among the largest costs for hospitals. In 2018, the year before the sale, Mission Health System reported more than 12,000 staff. The website now lists 10,500. Lindell said some employees formerly included under Mission, such as those working in billing and “our supply chain team,” are now counted under different entities.
But doctors and other employees told Asheville Watchdog there are fewer people in direct patient care, including certified nursing assistants (CNAs), health unit secretaries and mental health professionals, as well as support positions such as housekeeping, dietary services, and the morgue.
A source of many complaints about care, patients told Asheville Watchdog, is Mission’s emergency room.
Dr. Mitchell Li, an emergency medical specialist and the founder of Take Back Medicine, an organization that raises awareness about the dangers of the corporatization of medicine, told Asheville Watchdog that such staffing companies often replace ER physicians with nurse practitioners and physician assistants, a practice he observed first-hand while a resident at a Detroit area hospital staffed by TeamHealth. Li did not work at Mission or HCA.
“HCA and corporate ER staffing groups figure [they] can get away with a minimum of physicians,” said Li, who now operates a private, direct primary care practice serving Asheville, Black Mountain and nearby communities.
Asked whether emergency room doctors have been replaced with lesser trained staff such as nurse practitioners, Lindell said, “Most hospitals throughout the nation contract with ER provider groups … We also augment their care with other staff in addition to these ER physicians when further care providers are needed.”
Patients in “excruciating pain”
In interviews, doctors said staffing turnover and reductions have affected nurse-to-patient ratios and quality of care at Mission.
Palmeri said he was “horrified” to find on more than one occasion his patients at Mission in “excruciating pain” because nurses responsible for seven to eight patients each could not administer pain medications on time.
Dr. Ken Zamkoff, a retired hematologist in Asheville, said, “When a patient is lying in a bed, it’s not just the doctor, it’s the whole team that cares for the patient. If you don’t have nurses, CNAs, and the whole ancillary staff, you can’t do it properly. When you decimate the team, the patient suffers.”
Another former Mission doctor, who still has privileges there, said the reduced staffing places a burden on those still practicing at Mission and leads to an “erosion in quality.”
Before HCA, he said the staff included many longtime employees who had worked together for years, but “now there’s no consistency.”
Vote of no confidence
In their letter to patients, the doctors at Asheville Ear, Nose & Throat did not specify a reason for their departure from Mission but said, “All of our doctors will continue to provide medical and surgical care for our patients at both Pardee Hospital and Park Ridge Hospital (now known as AdventHealth Hendersonville). We also now offer outpatient surgical care at Western Carolina Surgery Center.”
The surgeons at Carolina Spine & Neurosurgery Center declined requests for comment. Phil Bridges, spokesman for UNC Health, confirmed that the doctors have affiliated with UNC Pardee, and said current and new patients can expect a seamless transition.
Some doctors have cited pay and management issues in their decisions to depart Mission, including attempts by HCA to cut some physicians’ compensation by as much as 25 percent, according to interviews and published reports. Lindell said that Mission Health compensates physicians in accordance with fair market rules.
But HCA’s approach to healthcare has led many to depart.
Palmeri, the oncologist, said he concluded that HCA’s approach to cancer treatment was, in his opinion, “focused on return on investment.”
“There’s a lot of aspects of oncology that are not that profitable,” Palmeri said, such as cancer care in small communities.” He said he saw “HCA pulling away from that.”
Palmeri said he wanted to ensure access to cancer care throughout the region. His practice, Messino Cancer Centers, has six locations, including Asheville. “I grew up here in Western North Carolina. It was critical for me to do that for our community,” he said.
Lindell said that Mission Health recently partnered with the Susan Cannon Cancer Institute of HCA Healthcare, known for its research, to expand its services across Western North Carolina.
The doctor who asked not to be named, and who said patients ask every day about alternatives to Mission, told Asheville Watchdog he left after being asked to take a salary cut, and seeing that “the patient experience was declining.”
“Concern for the community” at Mission, he said, “turned into care for the shareholder.”
A hematologist, who was on the medical staff at Mission and requested anonymity, said that the Mission oncologists last year were increasingly hearing from patients that they were “resistant to going to Mission.”
In June, the oncology team, troubled by quality of care and other concerns, took a no confidence vote in HCA management, he told Asheville Watchdog. “We brought up the issues again and again,” the doctor said, but little changed. Shortly after, he said he concluded that Mission “was more business oriented, not patient oriented,” and left.
Asked about the no confidence vote, Lindell said, “We have full confidence in our management team. We regularly gather feedback from physicians, nurses, patients and the community … The feedback raised at these meetings has been addressed.”
But two current oncology providers, who asked not to be named, told Asheville Watchdog that patient care concerns continue. They said nurse-to-patient ratios remain inadequate to provide needed care for the sickest patients, including providing pain medications on time; there are too few certified nurses for chemo treatments, which forces delays in administering the needed drugs; and there are too few CNAs.
While some patients may be seeking care elsewhere, Lindell said, “We continue to see patients choosing to come to our hospitals.”
Doctors have also left HCA-owned hospitals in other states for similar reasons. In Rochester, N.H., for example, 12 of the 14 primary care doctors at Frisbie Memorial left within 15 months after HCA acquired the local nonprofit community hospital in 2020. Some of them cited a lack of support for medical staff and a focus on profits rather than patients.
Top doctor departs
Mission’s highest-ranking doctor, Chief Medical Officer Dr. William Hathaway, announced on Jan. 6 that he, too, was leaving to become chief executive at MAHEC, the Mountain Area Health Education Center in Asheville, where he has been chairman of the board.
Hathaway told Asheville Watchdog that “my acceptance of the job was purely in relation to the retirement” of MAHEC’s CEO, Dr. Jeff Heck, which was announced last summer. Hathaway started as chief medical officer under nonprofit Mission and was the most senior of the previous Mission leaders under HCA.
In an interview with Asheville Watchdog, Hathaway acknowledged that his departure created an additional strain on the hospital. At the time, the Mission system was experiencing record COVID-19 cases and admissions, staffing shortages, a pending lawsuit over alleged price gouging, and an untold number of patient complaints.
But Hathaway, a cardiologist and third-generation physician, said he was excited to start at MAHEC, an organization he described as having a tremendous reputation. “It’s all about care for the patients,” he said.
HCA profits soar
North Carolina Attorney General Josh Stein reviewed and approved the sale of Mission to HCA, requiring 15 conditions, of which the most significant are restrictions on closing or selling facilities, continuing to provide certain services, and continuing Mission Hospital’s charity care policy. Separately, HCA made certain capital expenditure commitments.
Quality of care and staffing levels were not among the 15 stipulations added by Stein.Stein, however, is “extremely concerned about healthcare in western North Carolina,” said Laura Brewer, Stein’s deputy chief of staff.
“Healthcare facilities must be adequately staffed to ensure patients get the treatment they need,” Brewer said. “While the pandemic has exacerbated healthcare shortages all over the nation, reports of acute shortages at HCA are concerning.”
She added that the Attorney General will “continue to ask questions about HCA’s policies and commitments.”
An independent monitor, Gibbins Advisors, is responsible for ensuring HCA lives up to the Mission asset purchase agreement and the additional 15 conditions.
In April, Ronald Winters, a principal at Gibbins Advisors, said in a virtual public forum that Gibbins would examine the issue of physician departures. “To the extent those departures impact services at hospitals, that’s certainly something we’re going to look at and inquire about,” Winters said.
Winters told Asheville Watchdog last month that the evaluation is ongoing but declined further comment.
Mission has become a valuable asset in the portfolio of HCA, the largest hospital corporation in the nation. In January, the company reported a near doubling of profits during the full pandemic year of 2021, from $3.75 billion in 2020 to $6.96 billion in 2021.
Just months after the consummation of the sale of Mission Health, HCA raised prices across the Mission system by an average of 10 percent. By the end of the first year, net patient revenue increased $548 million compared to the 12-month period before the sale, Greg Lowe, president of the North Carolina Division of HCA Healthcare, wrote in a letter to Attorney General Stein on April 30, 2020. The letter was obtained by Asheville Watchdog under a public records request.
With annual net patient revenue exceeding $1 billion, Mission Hospital ranked No. 2 among more than 180 HCA hospitals in both 2020 and 2021, according to the consulting firm Definitive Healthcare.
“Healthcare should be the least transactional business in the world,” said the doctor who was asked to take a salary cut, but HCA’s “approach is very transactional.”
He said the upshot at Mission, where he said collegiality and community commitment were once hallmarks, is “the pride is gone. It’s just sad.”
Peter H. Lewis contributed to this report.
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Barbara Durr is a former correspondent for The Financial Times of London. Contact her at firstname.lastname@example.org. Sally Kestin is a Pulitzer Prize-winning investigative reporter. Email email@example.com. Peter H. Lewis is a former senior writer and editor at The New York Times. Email firstname.lastname@example.org.