The North Carolina Department of Justice today expressed “serious concerns” about HCA Healthcare’s compliance with the commitments it made as a condition of acquiring Asheville’s nonprofit Mission Hospital system in 2019.

In a June 20 letter to Greg Lowe, CEO of HCA’s North Carolina Division, the North Carolina Attorney General’s office cited HCA’s sharp reduction in cancer services, consisting of just one physician “where it once had as many as 14.”

“This is an exceptionally high number of vacant positions, and it represents either a breach of the Purchase Agreement or a serious risk of a breach,” the letter to Lowe stated.

Mission needs to “restaff the medical oncology department immediately” or risk potential litigation, the letter stated.

Separately, the Attorney General’s office wrote to Gibbins Advisors — the independent monitor hired by Dogwood Health Trust to oversee HCA’s compliance with the terms of the sale — to say its performance was inadequate. It criticized the monitor for “serious shortcomings” in serving the interests of the citizens of western North Carolina.

Asheville Watchdog’s requests for comment from officials of Dogwood Health Trust and Gibbins Advisors were not immediately answered Tuesday evening.

On Wednesday, Gibbins’ co-founder and managing director Ronald Winters issued a short statement to The Watchdog.

“We will discuss the letter with the Attorney General’s office shortly to clarify and correct the record on certain points,” the statement read. “We are receptive to the Attorney General’s requests to deepen community engagement and expand upon the outreach and conversations we have already conducted.  We continue to welcome collaboration with the Attorney General in fulfilling our role as Independent Monitor.”

“We also just received the letter from the Attorney General’s office today and will respond directly to their office in the timeframe provided,” HCA spokesperson Nancy Lindell said Tuesday when asked for comment on the letter.

North Carolina Attorney General Josh Stein’s “letter of non-objection” to the $1.5 billion sale of nonprofit Mission to for-profit HCA came only after he demanded greater consumer protections than were included in the terms unanimously approved by Mission’s board of directors.

Stein’s conditions included the hiring of an independent monitor to oversee HCA’s compliance with the agreement; enforceable commitments to maintain current levels of service at all six hospitals in the Mission system, not for the five years the Mission board agreed to in some cases, but for 10 years; and requiring HCA to adopt what he viewed as Mission’s more generous charity care obligations. 

Stein — who is running for North Carolina governor as a Democrat — also got HCA and Mission to agree that the attorney general could enforce the terms of the contract.

“These are serious shortcomings”

Dogwood Health Trust — the successor nonprofit trust created to receive the money from the sale — hired Gibbins Advisors of New York as the independent monitor to evaluate HCA’s ongoing compliance with terms of the purchase agreement. “An effective independent monitor was a critical condition of HCA’s acquisition of Mission Health,” the letter to Gibbins stated.

Dogwood’s top management at the time consisted almost entirely of former Mission board members, some of whom were on the Mission board at the time of the sale to HCA. Gibbins Advisors is paid by, and reports to, the Dogwood Trust. Gibbins Advisors soon moved its headquarters to Nashville, where HCA’s headquarters are located.

“It is our view that Gibbins Advisors is not adequately monitoring HCA, is not adequately responding to patient complaints, and is not holding regular quarterly meetings with our office and Dogwood Health Trust,” stated the AG’s letter addressed to Winters. “These are serious shortcomings, but they are also easy to remedy.”

Gibbins had not responded to multiple AG requests for information about “alleged violations,” the letter stated, noting that as of mid-June, the firm had not since summer 2021 listed “a single action taken by Gibbins Advisors” on a website dedicated to purchase agreement monitoring.

“We believe that the Independent Monitor should annually publish a written compliance report and take a more active role in enforcing the terms of the Purchase Agreement,” the letter stated.

It also reprimanded Gibbins for not consistently setting up quarterly meetings with the AG’s office, instead scheduling them “casually” or not at all. 

“Moving forward, we request that you publish a schedule of each year’s quarterly meetings no later than January 1 of the calendar year in which the meetings are to take place,” the letter stated. 

The Attorney General’s office also chided Gibbins for “inadequate” site visits to HCA’s North Carolina facilities, and for informing Mission in advance of its periodic inspections, saying, “unscheduled site visits would provide a more accurate understanding of HCA’s daily operations.”

“It is inconceivable”

Referring to previous correspondence between Lowe and the AG’s office, the letter focusing on cancer services noted confirmation that “Mission’s oncology practice now includes only one physician, where it once had as many as fourteen.”

The Watchdog in April 2022 first reported on a depletion of doctors including medical oncologists. In May 2023 Mission confirmed two doctors had left medical oncology and AG spokeswoman Nazneed Ahmed told The Watchdog the DOJ was examining issues there.

The letter to Lowe asks him to produce several pieces of information, including:

  • The number of oncologists employed by the Mission Medical Oncology practice for each month since February 2019.
  • The name of every oncologist employed by the Mission Medical Oncology practice since January 31, 2019, and the dates of those oncologists’ first and last day employed by the practice.  
  • New patient data, service days offered, canceled appointments, referrals to non-Mission oncology practices, wait times, and other data for five different services.
  • A detailed description of the additional steps HCA will take to restaff the Mission Medical Oncology practice, including plans for recruiting and retaining oncologists.

The letter to Lowe was not the first from the AG in 2023. Stein’s office in February sent a letter asking why the hospital decided to shutter a pharmacy in Mission Cancer Center, which advocates described as the most ideal way to get their medication.

Patients in Buncombe and surrounding counties have complained about Mission Cancer Center, according to the letter, which conveyed disbelief that only one medical oncologist could serve such a broad region.

“It is inconceivable that HCA could provide the hundreds of thousands of North Carolinians who reside within this expansive geographic area with the quality of care that they need and deserve using a single oncologist,” the letter stated.

It closed by noting the purchase agreement and promising to “closely monitor” oncology services at Mission: “We will not hesitate to enforce the Purchase Agreement and protect the public’s right to care under (the purchase agreement).”

The purchase agreement states that HCA “shall not discontinue the provision of the services” including “inpatient and outpatient cancer services, radiation therapy, surgery, chemotherapy, and infusion services.” 

One of HCA’s four core commitments after the purchase — broken down into 15 separate priorities — was to “retain services and hospitals.”

According to the purchase agreement, if HCA did not comply with the commitments it made, Dogwood would be notified and could trigger a resolution process. Other disputes would involve the North Carolina Business Court “or an arbitration process administered by the American Arbitration Association,” according to the independent monitor’s summary of the purchase agreement.

Both letters were written by Assistant Attorney General Llogan Walters of the NC Department of Justice’s Consumer Protection Division. 

In March 2022, Walters wrote to Lowe that the North Carolina Department of Justice was “extremely concerned about the high price of health care in western North Carolina.”

“For many services, Mission Health charges insurers prices far higher than the state-wide average price for the same service,” her letter read. “Unsurprisingly, these costs are passed onto consumers. For example, insurance premiums within Mission Health’s service area are 30% higher than premiums in nearby counties, and over 50% higher than premiums in the State’s other large metropolitan areas.”

(Editor’s note: This story was updated Wednesday, June 21, to include a statement from Gibbins’ co-founder and managing director Ronald Winters.)

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 Peter Lewis is a former senior writer, editor, and columnist at The New York Times. Email   

32 replies on “North Carolina AG threatens HCA with litigation”

  1. We need to find a way to force a replacement of the monitoring company because of its obvious failures and conflict of interest

  2. Someone needs to come and look at how EVS techs are being treated.We bust out butts every day here and some get recognition while others don’t get nothing if you are not in there click then u are just a employee that doesn’t get the recognition like they should for the hard work they do and the favoritism in this department is ridiculous. Some of us believe if you are not their color then u just get ignored and expected to more than anyone else and pay suxs they have contractors coming in here making more than the employees that have been here for awhile and staff they can’t keep employees here especially on 2nd shift because of the manager and supervisor.2nd shift can’t keep staff because of these two and you can’t go to HR because they want do nothing they say they will but they never do.we all believe The people that own HCA should come here and help us EVS employees thank u plz do not use my name or email because I can’t afford to lose my job. Some of us employees would just like a change in how we are treated here by others

  3. Thank you for your commitment to bringing the issues to the attention of WNC residents. As patient advocates, we are doing our part to protect patients and raise the alarm as HCA continues to put profits over people. We recognize the AG and DOJ are both committed to protecting the citizens of WNC, and can only hope HCA will do the right thing, instead of sidestepping actionable items such as these. Christine Aiken, Advocacy Allies

  4. Finally maybe your reporting will put a fire under those who should be not only monitoring, but forcing Mission to live up to the agreements signed. When I first moved here in 2019 my experience with Mission was first class….after the change, year by year service/attitude went downhill. I now have left Mission use or the use of their providers and drive to either Advent Health or Haywood Regional Medical Center for all medical needs. As an older Senior it a big challenge to have to travel long distances to access a doctor or medical facility not affiliated with Mission.

  5. Thank you for your much needed attention to issues affecting Asheville and Western NC residents. Your topics and articles are timely, important, and well written. I am an avid supporter (and subscriber.) I know of no other source providing the coverage you do. Well done!
    Abigail Doggett Bordeaux
    downtown resident

  6. I feel another 12 part series from the AVL watchdog coming up on HCA. I also know that the series will infuriate us as to just how badly HCA is screwing WNC over. This sale was a mistake from the beginning, and it is a shame that we all knew it, but local and state leaders let this sale happen anyway.

    1. No sir. The blame rests solely on the the shoulders of Ron Paulus and the Mission Bd. I knew that Board and saw they were having the wool pulled over their eyes. That’s what happens when you staff your board with friends or only wealthy people — not individuals who know this field. ‘Suckers, all of us. We did not demand better. Ron Paulus, and the people who put him in the position to do this, have damaged this area irreparably. Please take Board stewardship seriously.

  7. Hmmm…HCA’s 15 commitments includes a box “other commitments”… seems as though this may be the loophole that allows HCA for dismissing ALL their commitments aside from their commitment to profit and shareholders… perhaps that box should populate a much larger space… this is really just a silly game of politics … Gibbins, dogwood trust , all the wolves in wolves clothing… wtf AG going for seat of governor when you didntbuave the due diligence from the beginning.

  8. I think the last paragraph of this article should be read over and over and over. just let it sink in.

  9. OK Folks, Listen up, Cynthia McFadden on NBC just released a report on HCA hospitals forcing patients into hospice. And Yes NC HCA hospitals are included. This is happening at Mission. I have receipts. Forced and coerced premature death for financial gain. Is this what happened to some of the cancer patients? Is Josh Stein going to write a letter about this? Watchdog, we need you all over this one. Everyone off the pickleball court and get on it.

      1. Thanks for that link, Peter. Every potential HCA patient and their family needs to be informed of that very troubling pattern. I wonder if The Watchdog could do a follow up article.

  10. The wheelchair clinic serves all of WNC and beyond. It was looked at closely as a loss of service. Creatively, rather than “close it” the Dogwood Trust provided funds for it under the Mountain Care nonprofit (which was also split out of CarePartners after HCA purchased them in the merger). They are now no longer finding it and it’s closure is pending. Huge, massive loss for this area and beyond. On paper it looks like they weren’t the culprits for closing it. There are many fingers like this with in our community.

  11. Easily predictable before the deal was ever made. HCA is nothing if not a predatory capitalist organization. ‘For-profit healthcare’ is a clear contradiction in terms and should be outlawed.

    1. Exactly. That’s the crux of the situation, just as with so many other issues in our community and country. Retrofitting is beyond costly.

  12. Josh Stein threatening HCA with litigation… That’s hilarious, HCA has more lawyers than doctors or nurses and more money than the entire coffers of NC. They don’t give a hoot about litigation. Mission is the 2nd most profitable hospital in their portfolio. They will milk it forever. Too little too late Mr. AG.

  13. Too little too late is exactly right. Where was nothing but a politician Josh Stein when he was susposed to be watching over the horrible sale to HCA in the first place. He let us down then and no amount of letter writing now will correct that. Remember this next year when he runs for governor.
    John Davis

  14. Gibbins’ founder last worked as Managing Partner for a firm that had HCA as a client. In his bio, he touts the Mission contract as his biggest personal responsibility, yet communication/accountability seem to be lacking. Considering the history of this transaction from day one, the whole arrangement just doesn’t smell right, does it? I hope Watchdog keeps shining light on this murky scene.

  15. Vote. Teach your kids to read and write. Teach them how to tell the difference between truth and fiction. Vote. Speak up when someone defends for-profit involvement in health care. Persist. Shout when they ignore you. Vote. Name the people profiting. Publish their photographs. Refuse to let them hide behind anonymity. I would say “vote” again, but this is all part of the devolution of our democracy that we’re witnessing on an accelerating basis, and it might very well be too late to bring about the level of change we need with the passive act of voting. In other words, it might be time for something much stronger…and uglier. Still: vote…

  16. On March 22 last year I wrote to the U.S. Attorney’s office in Asheville to request a grand jury investigation of the sale of Mission Hospital to HCA. I haven’t had an answer, nor have there been any outward appearances that any authority over than North Carolina’s attorney general is concerned about what has become a disaster for the public and a windfall for HCA. I think the Watchdog should ask the Justice Department about its apparent unconcern. The DOJ is the only appropriate entity to look into this scandal because North Carolina does not allow investigative grand juries for any issue other than drug crimes.

  17. If it weren’t for Messino Cancer Center utilizing some cancer services at Mission the Mission cancer center would soon dry up. I spent 7 nights on the cancer floor and was treated with kindness, and attentiveness, great employees…But that does not change the fact that it is a travesty that our wonderful well run hospital system was handed to the piranhas by an under-the-table deal, which will continue to have issues long into the future. Let’s dream and maybe we could find more breaches in the Purchase Agreement and let it return to the people who care about employees and patient care. Thank you Watchdog, please continue to stay on the trail of the improprieties of HCA.

  18. maybe josh stein ought to be sued for allowing this dumpster fire to happen in the first place while he sits back and watches it burn, as he tries to put the fire out with a few letters, in order to polish up his run for governor. NC politics sure are something.

  19. just an observation as someone who has been a cancer patient of mission health. have the “inspectors” not taken into consideration all of the outlying cancer centers under the mission umbrella? I do KNOW the importance of holding health care and insurance companies accountable, I just wonder if this will cause more damage for those of us who have been well-treated by the excellent oncology doctors that mission does still employ and I KNOW it’s not only one since I have spoken with at least 3 or 4 of them in the past year. ???

  20. This sounds like a public health emergency, not just a matter with “serious concerns.” How many people are going without cancer care now? What have their outcomes been? If a medical institution’s oversight is this bad, people should be arrested and serve jail time. We couldn’t get the Sacklers, but maybe we can get this bunch. It’s time to treat this as criminal behavior. This is outrageous.

  21. I would say forcing people into DNRs and hospice against their will is a public health emergency as well. Where are the feds, state and CMS in all of this? Don’t assume that these patients are at the end of life either. What is going on there will shock the conscience of anyone, except for HCA and the doctors doing HCA’s dirty work.

  22. I wonder if they know the one remaining oncologist is leaving at the end of the year? The radiation group in the cancer center is wonderful but now that the pharmacy is closed the rest of the building is just empty. It is so sad. My family received great care in this building several years ago and now there is hardly anyone left.

  23. The former Mission Oncology group was so pressured by HCA to revise their contract (in HCA’s favor) that they had a building shell outfitted and about 120 employees joined Messino Cancer Center. For me it was the same great people at a new address. Although a bit further to get to, I still had my trusted Oncologist, so there was complete continuity.

  24. I think it’s also important to note that there are no metrics included in the HCA purchase agreement by which to measure HCA’s compliance. Not a single number. The article quotes the purchase agreement saying “HCA ‘shall not discontinue the provision of the services’ including ‘inpatient and outpatient cancer services, radiation therapy, surgery, chemotherapy, and infusion services.'” Does “discontinue” meant no cancer doctors left at all? Can you technically consider the service discontinued if there is still one oncologist left out of what was previously a department of 14? The fact that no one questioned the terms of this agreement before the sale is insane to me. And it’s also insane to me that up until 2020, not one single elected official in North Carolina (including Josh Stein!!!!) had a negative thing to say about the sale, and Mission Health executives publicly patted themselves on the back about it while sliding into cushy jobs at Dogwood, paid for by funds that came from the profit from the sale. Thank you AVL Watchdog for continuing to report on this.

  25. Gibbins cannot address quality of care concerns because that was not part of the deal. They have already said that. Fact check me please. That should have been the reddest of red flags to know this deal was one sided. They can only monitor services, but not the quality of services apparently. Quality of care issues are under the authority of state and federal government as in NCDHHS, the former leader of such who is now chosen to run the CDC. CMS is the other agency responsible for care complaints. Anybody seen them milling about the hospital lately? Stein can threaten to enforce the contract for “services” all he wants, but its nothing but a dog and pony show.

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