The decision to sell nonprofit Mission Health to for-profit HCA Healthcare was made behind closed doors, without public review, and, contrary to promises made by Mission’s leadership at the time of the 2019 sale, did not lead to lasting improvements at Mission Hospital, according to the final two installments of an academic study of the merger.

Though HCA made improvements to the western North Carolina health care system, according to the Wake Forest University report, many were already planned or required by then-Attorney General Josh Stein as part of the terms of the sale.

“[I]t is difficult to point to any concrete lasting improvements that HCA has brought to Mission Hospital,” the report states. “It is telling that, even under the most favorable viewpoints, there is no credible voice openly claiming that Asheville and western North Carolina are actually better off now with HCA at the helm of Mission.”

Other states could give their attorneys general more power over sales and strengthen or modify certificate-of-need laws that are supposed to regulate health care facility competition, according to the report, which was written by professor Mark Hall, a leading scholar on health care law, public policy, and bioethics.

They could consider requiring promises of quality of care in sale agreements or push for public review of mergers instead of letting the decision be made behind closed boardroom doors, the report states.

Read Asheville Watchdog’s coverage of Hall’s work:

Asked if Mission or HCA wanted to comment on the final installments of the report, Mission Health spokesperson Nancy Lindell said, “I do not have any comment for you on this.” Lindell has previously criticized the study because it is financed by a group that is also partially funding a law firm representing plaintiffs in a case against HCA.

At the time of the sale, Stein demanded 15 conditions be added to the deal’s asset purchase agreement (APA), several of which required HCA and Mission to maintain levels of service for 10 years following the sale. But the APA did not contain stipulations about quality of care. 

Stein sued HCA and Mission in late 2023, alleging they violated the APA  regarding cancer care and emergency services at Mission Hospital. HCA countered that it never committed to provide quality care, noting the APA is “silent as to the quantity or quality of services required” at Mission Hospital. 

Proposed legislation in the General Assembly has called for better regulation of hospital sales and more oversight power for the attorney general and a longer list of items to vet for the attorney general’s office during such a review process, the report notes. And though that bill may undergo significant alteration, it could garner bipartisan support, it added.

Since the sale, there has been an exodus of hundreds of doctors and nurses and the deal has sparked significant backlash. A group of doctors, health care advocates and politicians recently launched an effort to search for a new non-profit buyer for Mission.

Shortly after Stein’s suit, the federal Centers for Medicare & Medicaid Services found Mission Hospital to be in immediate jeopardy, the toughest sanction a hospital can face, related to multiple deficiencies in care. The federal government eventually lifted the sanction.   

A previous installment of Hall’s study, as well as extensive reporting from Asheville Watchdog since 2020, found that Mission Health board members, who voted unanimously to approve the sale, were blindsided by HCA’s decision to aggressively cut patient care staff in order to save money. 

The decision to sell the non-profit system to the largest for-profit hospital owner in the U.S. was based on the belief HCA would create efficiency while maintaining quality and would establish a massive health foundation, Dogwood Health Trust, to improve health and well-being throughout western North Carolina.

“[T]his study’s extensive interviews with former leaders at Mission uncovered virtually no one who felt that the sale was the right thing to do, knowing what we know now,” the report says. “Still, several leaders genuinely feel that the decision made was the right one at the time, based on what was known then.”

An examination of potential positive outcomes

The report also examines potential positive outcomes from the sale and tries to determine if the backlash against HCA and Mission is justified.

While Hall’s study describes many negative consequences of the sale, it says some of the harshest public criticism that has been leveled at HCA and Mission may be overstated.

“On balance, there are various bases on which to conclude that the picture that HCA’s harshest critics paint, or even that this study’s Executive Summary shows, is not as bad as it’s made out to be,” the report says. “There are some positive aspects to Mission’s conversion to a for-profit hospital, and to HCA’s substantial resources. Also, the problems that have arisen at Mission are not unique to it or to HCA.”

Dogwood, according to the report, could be seen as such a positive. A charitable foundation now valued close to $2 billion, Dogwood was created to improve health, social justice and community welfare in western North Carolina. The report issues a caveat, however, noting that Dogwood’s long-term impact may become clearer in coming years. 

Since the sale, HCA built several new facilities including a new behavioral health facility and a new emergency department. All five regional Mission hospitals remain open as well, part of the 10-year commitment HCA made to Stein’s office. The report notes that staffing has dropped in some of these hospitals. 

HCA’s position as the largest hospital chain in the U.S. makes it more able to respond to crises with money and resources, according to the report. It cites Mission’s performance during two significant crises in the past five years: the COVID-19 pandemic and Tropical Storm Helene.

“HCA Mission appeared able to access critical supplies and equipment early in the [COVID-19] crisis more quickly or effectively than some or many other hospitals,” the report says. “More recently, when hurricane Helene devastated the region, shutting down the water supply for weeks or months, HCA Mission was able to maintain or restore operations by bringing in 20 tanker trucks of water a day, along with fuel, food, and other essentials.”

But Mission has suffered supply shortages as well, the report notes. 

Hall conducted extensive interviews with unidentified sources in direct care and management, according to the report, and some said HCA was using its “superior data analytics and supply-chain management more to reduce costs than to ensure superior performance.”

In a section titled “Unduly Critical Reactions?” Hall notes that Mission was also criticized before the HCA purchase, and some current criticism may be born out of idealism.

“Many people tend to base their impressions on the level of performance they feel should be expected rather than a more realistic level that reflects the true difficulties that all hospitals face in current and changing economic, political, and public health spheres,” the report says. “In brief, as one former leader put it, the tendency is to measure Mission ‘against what is perfect, but not what is possible’ considering various realities.”

Final installments are part of 178-page study

The entries on positive aspects of the sale and regulatory paths forward are the last pieces of Hall’s eight-part, 178-page study titled “Lessons Learned from HCA’s purchase of Mission Hospital in Asheville, North Carolina.”

Previous installments reported that HCA significantly decreased charity care at Mission and examined the discrepancy between Leapfrog and Healthgrades quality ratings at the hospital and the finding of immediate jeopardy. Another preliminary installment published in late April showed Mission was making serious cutbacks in bedside nursing staff as its profits soared in 2021.

Mission has proven a unique case study, Hall told The Watchdog. 

“I cannot think of another instance where the sale of a hospital has generated this much controversy, and so I have to think that the experience in Asheville is rare,” he said. “I believe the main reason that’s the case is that HCA has rarely, if ever, taken over a hospital with the quality and stature that Mission Hospital previously had, and so Mission had a lot more to lose in being brought to HCA’s standard operating level than most of its other hospitals, many of which were struggling to stay afloat when HCA assumed control.” 

Despite the uniqueness of what has happened to Mission, laws and policies to prevent what happened in Asheville are applicable nationwide, Hall said.

“The North Carolina regulatory environment is fairly standard, and so reforms that might be (or might have been) helpful here could also be considered in other states,” he told The Watchdog. “One especially important feature of the North Carolina regulatory setting is the state’s decision in 2015 to terminate its financial oversight of Mission Hospital, despite having permitted Mission to acquire monopoly status on condition of subjecting itself to this oversight. Given what has transpired, that history raises the question of whether the state should revisit reimposing monopoly oversight.”

Hall’s work is funded through an Arnold Ventures grant to Wake Forest. 

Arnold Ventures is a philanthropic group headquartered in Houston “working to improve the lives of all Americans by pursuing evidence-based solutions to our nation’s most pressing problems,” according to its website. “We fund research to better understand the root causes of broken systems that limit opportunity and create injustice.”

Arnold Ventures is helping fund Fairmark Partners — a group pursuing antitrust lawsuits against “hospital behemoths in Wisconsin, Connecticut, and North Carolina,” according to the group’s website. Fairmark attorneys are representing plaintiffs in a western North Carolina antitrust lawsuit against HCA and Mission Hospital.

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s local reporting is made possible by donations from the community.  To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.

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