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House Oversight Official Calls For Probe of HCA Over Fraud, Staffing Allegations

The chairman of the U.S. House Ways and Means Committee’s oversight subcommittee is calling for an investigation into Nashville, Tenn.-based HCA Healthcare over reports of alleged fraud and staffing issues at its facilities.

“Recent reports of systematic, unnecessary inpatient admissions intended to raise more-profitable reimbursement rates, in addition to severe understaffing issues, raise disturbing questions about HCA’s corporate policies and practices,” Rep. Bill Pascrell, Democrat of New Jersey, wrote in a letter Sept. 13 to Health and Human Services HHS Secretary Xavier Becerra.

Pascrell asked Becerra to investigate whether HCA, a 182-hospital system that owns and operates Asheville’s Mission Hospital, five other hospitals in western North Carolina, and many other healthcare facilities in the area, is improperly admitting patients to hospitals when patients do not require inpatient care. 

Pascrell cited a report by the Service Employees International Union that HCA may have billed Medicare as much as $1.8 billion in unnecessary admissions from 2008 to 2019. 

“I am especially alarmed by these findings given HCA’s history of health care fraud settlements with both federal and state authorities,” Pascrell wrote. “This includes a settlement for $1.7 billion in the early 2000s that resolved multiple criminal counts and civil fraud allegations — at the time the largest health care fraud in U.S. history — as well as other health fraud settlements involving HCA in subsequent years.”

Pascrell asked HHS to investigate HCA’s joint venture with EmCare, which provides emergency physician staffing in many of HCA’s hospitals. 

“There have also been allegations that HCA sets corporate admission targets and routinely threatens retaliation against staff if those targets are not met,” Pascrell wrote. “HCA’s long-standing joint venture with EmCare, a subsidiary of private-equity-owned Envision Healthcare, may play an essential role in the setting and/or implementation of these admission targets.” 

Pascrell also wrote to HCA Healthcare CEO Sam Hazen, requesting details about incentives for physicians related to patient admissions, a description of data collected related to physician performance, and a description of the company’s internal review processes. 

“We are reviewing Congressman Pascrell’s letter and will respond to his requests for information,” HCA said in a statement to Becker’s Hospital Review. “The issues raised in the letter appear to be similar to ones we addressed previously and publicly. HCA Healthcare operates more than 180 hospitals in a variety of communities throughout the country. Our hospitals are staffed by physicians, clinicians and nurses who work tirelessly to ensure our patients receive medically necessary care in the appropriate clinical setting.” — Peter H. Lewis

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North Carolina Is Ranked Dead Last for Workers

Third Year in a Row

For the third year in a row, North Carolina ranks as the worst state in the nation for protecting and supporting working families, and in particular meeting the needs of working women, according to an annual study by Oxfam, the international anti-poverty organization.

The study, called the Best and Worst States to Work in America 2022, tracks 26 policies across all 50 states plus the District of Columbia and Puerto Rico. It puts North Carolina at 52, or the worst place to work. The state, the study found, has a minimum wage stuck at the federal level of $7.25 an hour — unchanged since 2009; has no mandate for paid leave; no accommodations for pregnancy; and no sexual harassment protections.

The study examines policies that “can determine whether workers are safe at work, can afford food for a family, or whether they have a voice in the workplace.” Oregon was ranked number 1 for its worker-friendly policies.

For women, the study focused on the federal minimum tipped wage of just $2.13 an hour, unchanged in over three decades, because women are 69 percent of all tipped wage earners. Of those, 36 percent are mothers, half of whom are single mothers, according to the report.

The report said that “to have a sub-minimum tipped wage traps many women, especially single moms, in cyclical poverty.”  It noted that according to the National Women’s Law Center, poverty rates are nearly 30 percent higher in states that maintain a sub-minimum tipped wage compared to those which have ended the policy altogether.

Asheville-based Just Economics, which studies wages and cost of living in western North Carolina, reported the living wage rate for Asheville metro area is $17.70 per hour (with or without health insurance). It noted that in Buncombe County, “the disparity between wages and housing costs is a major factor in the local economy and our living wage rate continues to be tied to the cost of housing.” 

RentCafe, which calculates housing costs, puts the average rent in Asheville at $1,640 and average home price at $459,418, both out of reach for any minimum wage earner. It calculates that the “cost of living in Asheville, NC is 8 percent higher than the state average and 4 percent higher than the national average.”

According to Living Cost, a global crowd-sourced database that calculates costs of living worldwide, Asheville is the second-most expensive city in North Carolina after Chapel Hill, and in the top 3 percent of the most expensive cities in the world. — Barbara Durr

NC Elections Workers Threatened, Harassed

With just over two months to go before the 2022 elections, North Carolina election officials are reporting what has become commonplace in their jobs: harassment, intimidation and even death threats.

“We have had emails or correspondence that wish us a painful death, “ Karen Brinson Bell, the executive director of the State Board of Elections, said recently on the podcast Tying It Together. “We’ve had racist phone calls.”

In the last year, 43 of North Carolina’s 100 county elections directors have retired or left.

“It’s not what you signed up for,” Brinson Bell said. “Every day, we are still dealing with the 2020 election. It’s making it very difficult to prepare for this year’s election.”

Elections offices are being flooded with public records requests, many aiming to prove fraud or conspiracy theories in the 2020 election, Brinson Bell said in the podcast. In the six months leading up to that election, the State Board of Elections received 48 records requests. In 2021, that number jumped to 229, and Brinson Bell expects as many as 500 this year.

“It’s taking our attention and our energy,” she said.

Tensions have risen in Buncombe County, said elections Director Corrine Duncan. But “we’ve been lucky,” she told Asheville Watchdog. “We haven’t had any instances of harassment.”

Buncombe needs hundreds of temporary poll workers this year. Duncan said she fears some long-time poll workers may not return because of the contentious environment.  She said she is even having difficulty filling her four open permanent posts.

The elections office is coordinating with local law enforcement to ensure safety at polling places. “We are taking reasonable precautions,” Duncan said. “We’ve always taken it seriously” because “we are talking about the right to vote.” 

One change that could improve the next election is stricter rules for election observers, who are appointed by political parties. Proposed by the state elections board, the rules would prohibit the kinds of bad behavior that was documented in a statewide poll of North Carolina elections officials after the May primaries. 

Observers questioned poll workers carrying out their duties, repeatedly entered and exited the polling place, attempted to interfere with voters submitting their ballots, asked to photograph voters forms with confidential information, followed poll workers to their cars, and filmed them after polls closed, the election officials reported   

The rules on disruptive conduct must be approved by the board’s Rules Review Commission.  – Barbara Durr

Update: Cawthorn Files Overdue Campaign Report

Cawthorn celebrated his birthday with longtime friend Blake Harp, whose consulting firm is owed $183,991.35 from the campaign // Credit: Cawthorn’s Instagram account

Congressman Madison Cawthorn on Monday filed his overdue final campaign financial report as required by federal election law, although — to borrow the cliche — a day late and a dollar short.  Make that 32 days late and some $304,566.02 short.

Earlier this month, the 27-year-old Republican had been scolded by the Federal Elections Commission for failing to file the report, which details the campaign’s income and outgo.  In Cawthorn’s case, there is considerably more of the latter, leaving him in a deep financial hole and under continuing scrutiny by the FEC for possible violations of the law.  

The report covered the second quarter of the year, from April 27 through June 30.  This was a critical period for Cawthorn because it covered the run-up to the May 17 Republican Party primary election — which he lost — and the weeks after when the financial damage could be tallied.  

In addition to anodyne campaign costs, much of the spending repeated a pattern from prior reports: staff lunches at the Hendersonville Chick-fil-A, Papa’s & Beer and Moe’s BBQ, as well as cigars at the Casablanca Tobacconist.

Cawthorn, who became a right-wing wunderkind during his term, raised $4,095,533 — a record for any Western North Carolina candidate and among the highest in the Congress.  But he spent $4,199,759, leaving him in a hole some $104,225 deep.  

The report showed that much of the money he spent wasn’t actually his to spend.  It was money from donors who intended for it to be used in a general election campaign in the presumption that he’d win the GOP nomination.  He didn’t, losing to state Sen. Chuck Edwards.  So he had to repay all those folks, some $265,071.  

The report shows that Cawthorn chipped in $207,858 of his own money to partially cover those refunds, as the law requires.  He also raised $87,168 from new donors.  This is a pittance in comparison to prior quarters, but it came during a time when Cawthorn was in the news for some controversial behavior (suffice it to say this entailed sex, drugs and explicit videos).  

Notably, although the re-election campaign was in a tail-spin in the closing weeks, Cawthorn still paid some buddies for working on his campaign, all of whom were also collecting federal paychecks as members of Cawthorn’s congressional staff.  For example, he paid his district director, Harold Weathermann, $5,008. He paid $5,600 to his cousin and traveling companion, Stephen L. Smith, who also worked in the congressional office as a scheduler and ADA consultant.  

But it appears one longtime friend, Blake Harp, the congressman’s chief of staff, is among those being stiffed by the campaign. Outside his job with  Congress, Harp moonlights as managing partner of a Texas consulting firm called EMP Strategies, which profited handsomely from campaign spending in the earlier reports.  But the final report lists EMP Strategies as a creditor in the amount of $183,991.35.  Cawthorn also is in debt $33,844 to another Texas consulting firm, Harris Media specializing in helping arch-conservative politicians, recently among them Rand Paul, Ted Cruz and Benjamin Netanyahu.  

Unlike with over-paying donors, Cawthorn can settle that debt for fractions of the total, or even walk away from it altogether without federal penalty.  

Harp apparently wasn’t too upset about holding that debt.  He joined Cawthorn on August 1, the congressman’s birthday, as they donned commando gear and staged a mock raid to assassinate a mannequin while it was sleeping – as shown in photos posted on Cawthorn’s Instagram account. – Tom Fiedler

Mission Memo

From Mountain Maladies Facebook page

AdventHealth H’ville Named a “Best Hospital in America”

AdventHealth Hendersonville is designated one of the “Best Hospitals in America” in a new ranking from Money (formerly Money magazine) and The Leapfrog Group. No other hospital in western North Carolina made the list.

Out of more than 6,000 hospitals nationwide, only 148 hospitals were given the “best hospital” designation, based on criteria including quality, safe care, a reputation for excellent patient experiences, adequate staffing, and an ethical approach to treatment.

Five other hospitals in North Carolina earned the “best” designation, including Rex Hospital in Raleigh, WakeMed Cary Hospital in Cary, Watauga Medical Center in Boone, Wake Forest Baptist Health Wilkes Medical Center in North Wilkesboro, and Wake Forest Baptist Health Davie Medical Center in Bermuda Run.

To qualify for the list, eligible hospitals were required to carry an “A” letter grade on the Leapfrog Hospital Safety Grade assessment for Fall 2021. Mission Hospital in Asheville received an “A” grade in that rating, but Pardee UNC Health Care in Hendersonville received a “B.” AdventHealth Hendersonville, Pardee, and Mission all received “A” grades in the Spring 2022 scoring.

Hospitals were also required to meet a qualitative assessment of excellence. They were disqualified if they exceeded national mortality rates for heart attacks, heart failure, pneumonia, chronic obstructive pulmonary disease or coronary bypass surgery.

Leapfrog applied additional criteria related to safe medication ordering practices (to prevent medication errors), intensive care unit staffing, the response to “never events” (medical errors that are so serious they should never happen to patients, like operating on the wrong body part, leaving instruments inside the body after surgery, or a transfusion of the wrong type of blood), and performance related to certain high-risk surgeries including heart surgeries, bariatric surgery, hip replacements and lung cancer surgeries. — Peter Lewis

New Nursing School To Open in Asheville

Photo credit: Galen College of Nursing

Asheville is getting a new nursing school. HCA-owned Galen College of Nursing said this week it plans to open a new campus in Biltmore Park on Sept. 29, expanding the number of nurses being trained in western North Carolina during a nationwide nursing shortage.

HCA — the Nashville-based corporation that owns Mission Hospital in Asheville and five other hospitals in western North Carolina — said the new nursing school, located 30 Town Square Boulevard in Biltmore Park, will be a “state of the art” 16,900-square foot facility for classroom and patient simulation training.

Admissions for the fall quarter are now open, HCA said. HCA did not say what the expected enrollment or faculty size of the new campus is expected to be, but it said the addition of the Asheville-area campus will increase total enrollment across its 13 campuses to about 10,000 students this fall, for an average of about 750 per campus.

At present the Mission Health system has nearly 450 unfilled positions open for registered nurses (RNs), roughly equivalent to the total number of nurses graduated each year from all western North Carolina nursing schools combined. Mission Health recently awarded grants to three local nursing schools to add an instructor; in general, each instructor can train 10 students.

HCA-Galen’s Asheville campus will initially offer three degree options, including a two-year Associate Degree in Nursing (ADN), a three-year Bachelor of Science in Nursing (BSN), and a Licensed Practical Nurse to Associate Degree in Nursing Bridge Option (LPN to ADN Bridge). Galen also offers online programs. Admissions appointments can be scheduled by calling (877) 223-7040 or going online to galencollege.edu.

Based on tuition and fees at other Galen campuses, the new Asheville school is likely to be more expensive than other area nursing schools, with tuition and fees of as much as $20,000 a year, not counting living expenses and books.

A two-year associate degree at A-B Tech in Asheville costs about $4,000 a year, not counting living expenses, according to the A-B Tech website. Costs at Western Carolina University’s nursing school in Biltmore Park are approximately $5,000 a year, not counting living expenses, according to WCU’s website.

The opening of an HCA-owned nursing school in Asheville is not expected to reduce opportunities for graduates of other local nursing school programs, given the soaring demand for nurses and related healthcare jobs locally and nationwide. — Peter Lewis

City of Brevard Sues HCA, Citing ‘Skyrocketing’ Costs

[This story appeared first in Brevard Newsbeat, and is republished here with permission.]

By DAN DeWITT, Brevard Newsbeat

BREVARD — The city of Brevard filed a federal class-action antitrust lawsuit Friday that says HCA Healthcare Inc.’s monopoly in Western North Carolina has caused skyrocketing medical costs and “dramatically worsened facility conditions and patient service.”

The arguments in the suit mirror those in a class-action claim filed last August in Buncombe County Superior Court on behalf of six local residents. But the city’s lawsuit, the document says, focuses on the burdens HCA’s “unlawful restraint of trade and monopolization” has placed on self-insured entities such as Brevard. The suit was filed in US District Court in Asheville rather than Superior Court, said City Attorney Mack McKeller, because it relies on federal antitrust laws.

Mission Health, which owns Mission Hospital in Asheville as well as smaller facilities throughout Western North Carolina, acquired Transylvania Regional Hospital in 2012.

Mission Health was purchased for $1.5 billion in 2019 by HCA, which the suit calls “the world’s largest for-profit hospital chain.”

The Mission system dominates the market for inpatient care throughout the region, the lawsuit says, and holds a 79 percent market share in Transylvania County. 

The claim, like the one filed in August, provides a window on the prices charged throughout the system and at its Asheville flagship, Mission Hospital — prices HCA has failed to disclose in violation of a 2021 federal rule requiring healthcare pricing transparency, the suit said.

“Were HCA to comply and reveal to consumers and regulators the true prices that it charges, the public would know that HCA’s prices in the relevant markets are by far the highest in North Carolina,” the complaint says.

Citing a private database, it says “Mission Hospital-Asheville (has) charged commercial insurers 305% above the Medicare price” for inpatient services compared to a statewide average of 211 percent more than Medicare.

One of several examples listed in the suit was the cost of a shoulder arthroscopy: “The Mission-Asheville price for this procedure was $2,419 — nearly three times the statewide average of $897.”

Though the 2021 suit also documents the resulting higher prices of private medical insurance in the region, the city’s action addresses direct costs to self-insured entities, which can include cities, counties and some large private companies, McKeller said.

Though Brevard has paid “significantly more” for employee medical care in recent years, he said, it has not established the amount of these increases that can be attributed to HCA’s practices.

Once the city’s burden is tallied, however, the suit seeks a three-fold reimbursement of this amount, as well as an end to the conditions that allow HCA to charge “artificially inflated supracompetitive prices.”

“If HCA has increased the amount we have to pay because of monopolistic practices, the damages will be tripled as a way of punishing it for being a monopoly,” McKeller said.

One of the two law firms representing the city is Berger Montague, which has offices in several major cities and “is one of the nation’s most experienced and successful complex litigation firms,” a city press release said.

The claim also requests a reimbursement of legal fees, but McKeller said that even if the city loses the suit “we are not liable to the attorneys to pay them anything.”

The City Council agreed to go forward with the suit in a closed session about two months ago, McKeller said.

Nancy Lindell, Mission Health’s media relations director, said in an email the company had not been served with the suit and would “respond appropriately through the legal process.” But she did push back on the suit’s contention that it had neglected care at Transylvania Regional, where the company has invested more than $14 million in equipment and “infrastructure projects,” she wrote.

HCA has also recently added five primary care doctors locally and “renovated the primary care practices,” she wrote.

Mayor Maureen Copelof, who is the city’s designated liaison with HCA and, in the past, a harsh critic of its management of Transylvania Regional, said in the press release that the city has a responsibility to ensure quality healthcare for its residents.

“Over the past few years, our community has repeatedly expressed concerns over the degradation of health services, the difficulty in obtaining services, and the high cost of these services,” she said in the release. “Our attempts to address these concerns directly with HCA have been rebuffed.” 

In a recent interview she praised HCA Chief Executive Officer Sam Hazan for traveling to Brevard to meet with her and former members of the hospital board. She also said the meeting had left her cautiously optimistic the company will be more responsive to residents’ concerns.

On Friday, she said the suit shouldn’t derail that progress.

“There’s really two separate sides to this,” she said. The issues raised in the lawsuit are “completely different from the disconnect that exists between the community and HCA on delivering health services.”

[This story was updated to include a response from HCA Healthcare’s North Carolina division.]


Dan DeWitt is publisher of Brevard Newsbeat, which provides in-depth local reporting about Transylvania County, politics, environment, and land use. DeWitt is a longtime reporter and local columnist, Tampa Bay Times, formerly the St. Petersburg Times. Email: brevardnewsbeat@gmail.com.

All ‘A’s for local hospitals

Mission Hospital employees Erin Young (left ) and Lindsey Regner celebrate LeapFrog “A” safety grade // Mission photo

HCA-owned Mission Hospital in Asheville, Pardee UNC Health Care in Hendersonville, and AdventHealth Hendersonville all earned “A” grades in the Spring 2022 national hospital safety ratings by the nonprofit LeapFrog Group. Grades are updated twice annually, in the fall and spring, and for AdventHealth it was the 12th straight “A” grade.

Pardee’s score improved from a “B” in Fall 2021. Mission repeated its “A” score from Fall 2021, after getting a “B” in Spring 2021.

Mission Hospital McDowell in Marion also earned an “A” grade in the Spring 2022 ratings, but Haywood Regional Medical Center in Clyde, Rutherford Regional Medical Center in Rutherfordton, and Harris Regional Hospital in Sylva all collected “B” grades.

The Leapfrog Group assigns an “A,” “B,” “C,” “D,” or “F” grade to all general hospitals across the country. The grade uses more than 30 measures of safety data including rates of preventable errors, injuries and infections, while also accounting for whether hospitals have systems in place to protect patients from harm.

Nationwide, 33 percent of nearly 3,000 general hospitals achieved “A” ratings. North Carolina ranked first among all states for the percentage of A-rated hospitals, with 59.8 percent of all general hospitals earning the top grade. — Peter H. Lewis

Cawthorn Pulls a Fast One In Buncombe County Plea Deal

Rep. Madison Cawthorn (R-NC11)

Congressman Madison Cawthorn was able to dodge a serious speeding charge in Buncombe County by making a pre-trial plea deal with District Attorney Todd Williams just days before the State of Georgia alerted Williams’s office that Cawthorn’s license had been suspended as the result of a 2019 conviction for speeding and driving with an expired tag, Williams told Asheville Watchdog.

Meanwhile, Cawthorn was a no-show in Polk County court on Monday to face the second of three charges he’s collected in recent months for speeding and other alleged driving violations.

Last month Cawthorn, through a lawyer, pleaded guilty to a reduced speeding charge in Buncombe County after striking a plea deal with Williams and paying a fine. Cawthorn had been ticketed for driving 89 miles per hour in a 65 m.p.h. zone near Swannanoa in October. In return for the guilty plea, Williams agreed to reduce the charge to traveling just 74 miles per hour, a lesser infraction that allowed Cawthorn to keep his license without going to trial as scheduled on March 4.

But had he been aware of Cawthorn’s conviction in the December 2019 case in Clayton County, Georgia, Williams told Asheville Watchdog, he would not have agreed to offer the 26-year-old congressman the plea deal. The more serious charge could have resulted in Cawthorn facing up to 20 days in jail and fines up to $200. 

Although the Georgia speeding citation occurred in December 2019, it wasn’t settled until August 2021 when the conviction was entered and Cawthorn’s license was revoked. But, according to Williams, the State of Georgia didn’t report the revocation to North Carolina until February, after the pre-trial deal had already been reached with Williams’ office.

Williams said that when he learned of the Georgia revocation he inquired about reopening the case. But, he said, because Cawthorn had already paid the fine, the case was closed. Williams said the plea deal took advantage of what he called a “legal fiction” in North Carolina law where the driver can blame a faulty speedometer and receive leniency.

In the Polk County case, Cawthorn was ticketed in January for driving 87 miles per hour in a 70 m.p.h. zone, and ordered to face the charge in court April 18. But his lawyer, Gabrielle Valentine, appeared on Cawthorn’s behalf and successfully asked that the case be postponed until June 2. 

Valentine offered no reason for the requested delay and commented later that it was “routine.” Cawthorn’s press secretary, Luke Ball, did not respond to Asheville Watchdog’s request for an explanation of the delay and whether Cawthorn planned to contest the charge. 

The postponement means the case will not be heard until after the May 17 primary election, where the incumbent Cawthorn faces seven challengers in the Republican race to represent western North Carolina in Congress.

Cawthorn still faces a third court date for a charge on March 3 near Shelby in Cleveland County. That alleged violation occurred shortly after North Carolina had been notified that Cawthorn’s license had been revoked for speeding in Georgia. The state trooper stopped the congressman for swerving across the highway centerline, but charged him only with driving with the revoked license. That case is scheduled to be heard May 6, just days before the May 17 GOP primary.

The Cleveland County charge is a misdemeanor criminal offense that could result in a jail sentence of up to 20 days, as well as a fine of up to $200. — Tom Fiedler