It is unclear how long inspectors from the North Carolina Department of Health and Human Services will be at Mission Hospital. // Watchdog photo by Starr Sariego

So, what can we do?

That’s the question we at Asheville Watchdog hear most often about the apparent decline of the once-proud Mission Health System, the result of nearly five years of profit-oriented management by the giant Hospital Corporation of America, or HCA.

Every day in the Mission Emergency Room is scary like Halloween, doctors and patients tell us. Patients are parked in hallways for hours without food, water, or attention. Drug addicts puke in the waiting rooms.

For every story we hear about all the excellent doctors and caring nurses who remain at Mission, we also hear about the neglect, trash, and micromanagement that drives beloved long-time caregivers to walk away.

People tell The Watchdog that they’re now afraid to go to Mission when they get sick or need surgery. Simply referring their patients to Mission, one doctor tells us, makes them feel that they’re violating the Hippocratic Oath to Do No Harm. Nurses tell us that HCA’s profit-focused management model regularly puts patients at serious risk.

Prices for healthcare are up. Quality of care is down (although HCA-Mission disputes this). This is the exact opposite of what we were told would happen five years ago when Mission’s leadership announced plans to sell out to America’s biggest for-profit hospital chain.

“They’re not going to be more efficient at the cost of quality,” Mission board member Tom Oreck said after voting for the sale. “The quality of care is going to improve at the same time that they’re able to find ways to lower the cost of operation.”

Okay, that was then. Now, our neighbors are asking us if ambulances really have to take you to Mission. (Answer: Yes, depending on where you live.) Some doctors confess, off the record, that when they or their family members need consequential healthcare, they consider going elsewhere. They praise the skill and dedication of the doctors and nurses at Mission, but say the system is broken.

Does anyone think this is acceptable?

We deserve better. We deserve the kind of healthcare Mission used to provide, before HCA, when the hospital was considered one of the top health systems in the United States, a magnet for some of the finest physicians in the country, and a source of community pride.

But how do we change things? Is there anything we can do?

The Watchdog has documented the troubling details surrounding the sale in 2019: The secrecy, the backroom deals, the “rigged” bidding process, the exodus of long-time physicians and nurses. We’ve told often-heartbreaking stories about the degradation since HCA took over, from patients, family members, doctors, nurses, and other caregivers throughout our community.

Contrary to the promises made at the time, the sale of Mission to HCA turned out not to be in the best interests of the citizens of western North Carolina — despite the creation of the nonprofit Dogwood Health Trust from the proceeds of the sale.

Dogwood pours millions of dollars a year into western North Carolina to address the social determinants of health — poverty, racism, hunger, education, housing, and the like.

But Dogwood is prohibited by charter from competing with HCA. It can’t do what the former Mission Hospital did so well: treat, comfort, and provide compassionate care for people who are sick or injured or ailing.

Do the benefits of Dogwood offset the detriments of HCA? It’s hard to say they do.

“Kind of Hopeless”

Again: What can we do?

We’ve spoken to health care policy experts, government officials, hospital administrators, the attorney general, and the independent monitor responsible for overseeing HCA compliance with terms of the deal. The answer comes back:

Not much. Sorry. It is what it is. Done deal. You can’t unscramble the egg.

“It’s kind of hopeless,” one healthcare policy expert told me last week.

Even if that’s true, the answer is unacceptable. So let’s think this through:

First, there’s no evidence that HCA itself misled the Mission board about anything, which might have been grounds for reversal. 

Reputable financial experts concluded that $1.5 billion was a fair price — not the best price possible, given the astonishing lack of competitive bidding, but fair. Again, no do-over.

But the deal approved by the Mission board was so lopsided in favor of HCA, according to Attorney General Josh Stein, that he demanded 15 conditions be added to the purchase agreement. The stipulations were an attempt to preserve the value of the community’s long investment in the nonprofit hospital it created and sustained — and to protect the public from HCA’s pursuit of profits through elimination of unprofitable services.

North Carolina Attorney General Josh Stein // Watchdog photo by Peter Lewis

The absence of “quality of care” requirements in the Asset Purchase Agreement and in the added conditions turned out to be a crucial omission.

Citing “serious issues and concerns” with Mission’s deal with HCA, Stein even demanded that the Mission board vote again. But once again, even knowing Stein’s concerns, the board voted unanimously to sell to HCA.

Was the Mission board bamboozled? Was it sold down the river by its own executives? Did it consider a partnership instead of a sale, to keep local control? Why didn’t the Mission board issue a Request For Proposals, opening the process to more qualified potential buyers besides HCA?

We might never know. Mission required everyone involved in the deal to sign nondisclosure agreements that are, according to Mission’s lawyers, effective “in perpetuity.”

That means there are aspects to the deal that some people want to keep secret, forever. Even from the community that started and supported the hospital for more than a century.

If it turns out that there’s a hidden key to reopen the deal, the former Mission board members and hospital executives haven’t told us where it is.

What Are the Options?

Can anyone or any entity force HCA to sell Mission — either back to Dogwood Health Trust or to another health care system like Novant or Duke?

Force? Highly unlikely. HCA is a Fortune 100 company with a battle-hardened internal legal department that’s probably larger than the North Carolina Department of Justice.

Persuade? Maybe. All it takes is money. If the offer were big enough, HCA executives would have a fiduciary responsibility to consider it.

But someone would have to make HCA an offer so extravagant that it would more than offset the dollars HCA sucks out of the region to send to its investors elsewhere. Why would HCA give up a virtual monopoly that has made Asheville’s Mission Hospital the No. 2 generator of net patient revenue in the entire 183-hospital HCA chain?

Dr. Robert Kline, a former member of Mission Hospital’s board of directors before the hospital’s sale to HCA read a letter criticizing Mission Hospital at a public meeting hosted by Gibbins Advisors, the independent monitor hired by Dogwood Health Trust to oversee HCA’s compliance with the terms of the sale. // Watchdog photo by Starr Sariego

Watchdog investigative reporter Andrew R. Jones asked an HCA-Mission spokeswoman this month, “Can anyone or any entity change the HCA Healthcare / Mission Health asset purchase agreement at this point? Can the APA be changed at any point over the next six years (the remainder of the agreement) to be more specific in scope, as some community members seem to want?”

“No, we will continue to meet our mutually agreed upon commitments,” HCA Healthcare North Carolina Division public and media relations director Nancy Lindell responded. “HCA Healthcare has gone above and beyond our commitments to deliver exceptional care to the communities we are proud to serve.”

Jones posed the same question last week to the North Carolina Department of Justice, which issued a “letter of non-objection” to allow the deal to proceed in 2019.

The answer from Nazneen Ahmed of the Attorney General’s Office was:

“Section 13.14 (p. 145) of the attached [Asset Purchase Agreement] outlines how the APA might be amended, but the agreement is between HCA and Dogwood Health Trust, so they would be the responsible parties. Our office only has authority to reject a specific proposed change if the change was to one of the sections identified in Section 13.14(b).”

In other words, the Dogwood Health Trust — the successor foundation formed with the money from the Mission sale — and HCA both would have to agree to add amendments to hold HCA accountable for quality of health standards.

Since HCA contends that Mission is already providing “exceptional” quality of care, there appear to be only two chances of HCA agreeing to such amendments: slim, and fat.

What is Dogwood’s Role?

Asked if Dogwood Health Trust has considered pressing HCA to address the quality-of-care concerns of the people of the region, Dr. Susan Mims, Dogwood’s chief executive, referred to the series of public meetings being held by Gibbins Advisors, the independent monitor Dogwood hired to monitor HCA’s compliance with terms of the sale.

Dr. Susan Mims, Dogwood Health Trust chief executive officer

“Dogwood shares the community’s desire for everyone in Western North Carolina to have access to high quality healthcare,” Mims said in a statement to Asheville Watchdog. “We appreciate community members taking time to be present and share their concerns at these meetings and we encourage them to continue to do so. Unfortunately, we do not have the ability to unilaterally amend the contract to include quality of care.”

“What we can do,” Mims continued, “is continue to encourage dialogue about concerns and to enforce the APA as currently written. While some of the issues raised are concerns that the Independent Monitor is currently investigating, some stories and personal experiences shared in recent meetings offer new information. Where they pertain to the commitments outlined in the APA, we are encouraging the Independent Monitor to look into these areas of potential noncompliance.”

Mims’s statement concluded: “For issues pertaining to quality of care, we ask people to continue to share their stories with the Independent Monitor and with the governing bodies like NC DHHS Division of Health Service Regulation, the Joint Commission, and CMS who can address issues that fall outside the agreement but warrant further investigation.” 

Gibbins has held meetings this month for Transylvania Regional Hospital in Brevard and for Mission Hospital in Asheville. At the Oct. 19 Mission meeting in Asheville, fifty local physicians, including a former Mission chief of staff, signed a letter condemning HCA’s profit-driven management of Mission, saying it had “gutted the heart and soul of our community healthcare system.”

The third and fourth Gibbins meetings are Nov. 1 in Franklin, to discuss Angel Medical Center, and Nov. 2 in Cashiers, to discuss Highlands-Cashiers Hospital.

Meetings for Mission Hospital McDowell and Blue Ridge Regional Hospital will be held next year.

Could Dogwood offer to buy Mission back from HCA?

The Asset Purchase Agreement gives Dogwood the right of first refusal in the event that HCA eventually offers Mission Health for sale. But HCA is not offering.

The total assets from the sale were slightly less than $1.5 billion. That was several years ago. Dogwood’s assets are now over $2 billion.

But I’d guess that Dogwood isn’t keen to liquidate itself to buy Mission from HCA. That’s partly because Dogwood was created by the same people who voted to sell Mission to HCA in the first place.

And who knows how HCA would value Mission today, knowing the rich revenue stream it yields? $2 billion? $4 billion? More?

Could Dogwood pony up a big chunk of money to jumpstart a community effort to buy back Mission, part of a leveraged buyout?

Maybe, but who would step up to take on such a huge debt? And who would be willing to lend it?

And then there’s this issue: Who would run a newly independent Mission if a local coalition takes it over? Hospital management is nothing you’d want a group of amateurs to handle.

Okay, what about another hospital system, like, say, Novant? 

Remember, nonprofit Novant was the only company besides HCA invited to make a formal offer to the Mission board, and it was rejected — despite Novant’s pledge to match or beat any offer from HCA and to maintain staffing levels for three years.

Shortly after it was jilted by Mission, Novant paid $5.1 billion to buy a smaller and less profitable hospital in Wilmington. So it had the money, and it had the motivation. Does it still?

What about UNC Health? Duke? Atrium Health? AdventHealth? How about Ballad Health, based just across the border in Johnson City, Tenn.?

Of this group, Atrium — then known as Carolinas HealthCare System — was the only other healthcare company that the Mission board seriously considered. But Carolinas was rejected quickly and not even invited to make a presentation to the board, the records show.

One wonders if any of these, or any other healthcare systems nationwide, might be interested if HCA were to sell.

But be careful: In a recent MIT Sloan Management Review “Nursing Satisfaction Index” survey at 146 hospital systems nationwide, Ballad Health ranked dead last in workload and satisfaction. That was even worse than HCA, which ranked near the bottom, at 134.

Monopoly Money

What about asking the North Carolina Department of Health and Human Services to permit an alternative acute care hospital to be built in Asheville?

Don’t hold your breath.

In North Carolina, a state-approved Certificate of Need (CON) is required to open a new healthcare facility. “I don’t like the hospital I’ve already got” is not a compelling argument. A Certificate of Public Desire doesn’t exist.

And consider the bitter ongoing fight between HCA and AdventHealth over permission to build a new, freestanding emergency facility in West Asheville. Twice HCA has been approved to build the new emergency facility, and twice AdventHealth has appealed to block HCA.

Last year AdventHealth won state approval to build a new, 67-bed hospital in Enka/Candler. HCA-Mission filed a challenge to block AdventHealth, arguing instead that residents would be better served if HCA-Mission can add 67 beds to its Biltmore Avenue campus in Asheville.

Cynics might note that HCA can’t staff the beds it already has, suggesting that its desire to add more beds is as much an attempt to block competitors from entering the market as it is to relieve overcrowding in Mission’s emergency department.

And why wouldn’t HCA fight competition? In buying the Mission Health system in 2019, HCA acquired an unregulated monopoly for healthcare in western North Carolina. In other words, it bought a license to make money.

From 1995 to 2015, the North Carolina state legislature allowed Mission to merge with other local hospitals, like St. Joseph’s in Asheville, under a Certificate of Public Advantage.

The idea was that the state would allow Mission to grow strong, as a monopoly, to serve otherwise underserved western North Carolina, while shielding it from normal antitrust regulations. In return the state would oversee and supervise Mission to prevent abuses and to make sure it operated in the public interest.

Ronald Paulus, former president and CEO of Mission Health System.

Under then-CEO Ronald Paulus, in 2015 Mission successfully lobbied the legislature to rescind the COPA, creating a regulatory void that greatly increased Mission’s value, and its attractiveness to HCA.

Soon after the COPA was rescinded, Paulus and his longtime advisor, Philip Green, solicited proposals from HCA to either partner with Mission or buy it outright. That was before the full Mission board authorized Paulus to explore a possible sale.

When Mission handed itself to HCA, the result was exactly what the original COPA was intended to prevent: a monopoly that almost immediately raised prices and exerted pressure on doctors and insurance companies, with little obligation to operate for the public benefit. Instead, HCA’s prime obligation as a for-profit company is to put the interests of its shareholders first.

So, HCA has a sweet deal here. Why would it sell? 

The Watchdog has found no evidence that HCA has done anything illegal. It’s merely taking advantage of the deal it was offered by Paulus and the Mission board of directors.

Paulus cashed out and went to work for HCA within days of the handover.

Does that make you mad? Join the club.

Protest? Boycott? Complain? Sue?

But once again, what can people do with their anger? Protest?

U.S. Sen. Rick Scott (R-FL), former CEO of HCA Healthcare

Sure. But HCA has been unpopular since it was shamed by the federal government with what was at the time the biggest-ever fine for Medicare fraud, $1.7 billion. The HCA CEO at the time, Rick Scott, is now a United States Senator from Florida. HCA has paid hundreds of millions more in fines and settlements since then.

If HCA shrugs off billion-dollar and multimillion-dollar fines, a protest by a few dozen people in a remote corner of North Carolina is background noise.

Will it do any good to complain to state and federal agencies that monitor hospital performance?

Maybe. The federal Centers for Medicare & Medicaid Services (CMS) and the independent Joint Commission on Accreditation of Healthcare Organizations (JCAHO) set standards for patient safety and quality of care, and both investigate complaints and concerns about healthcare organizations that might not be meeting those standards.

Losing CMS and/or JCAHO certification is the nightmare for any hospital. Besides the reputational damage, being stripped of CMS or JCAHO accreditation could lead to fines, penalties, lawsuits, and loss of funding from government programs like Medicare and Medicaid.

That’s especially important in western North Carolina, where people are older, poorer, and sicker than other parts of the state.

The goal of the CMS and JCAHO standards is to make hospitals safer, not to force them out of business. 

Boycott Mission?

Certainly, if you have the luxury of driving to Hendersonville to go to UNC Health Pardee or AdventHealth when you’re sick or need elective surgery. But let’s say your doctor suspects you are having a heart attack or stroke, where every minute counts. Mission is 15 minutes away. Pardee and Advent are 45 minutes away. Which will you choose?

A boycott by doctors is another matter. When doctors at Messino Cancer Centers said they would no longer send patients to Mission because of safety concerns, you can bet it got the attention of HCA leaders in Nashville.

Pressure from local government officials?

Mission did not consult the city of Asheville or Buncombe County before announcing the sale to HCA, and HCA has shrugged off public criticism from state senators, state representatives, the state treasurer, county commissioners, and various mayors. 

“HCA has chosen to make its money by reducing charity care, eliminating medical and unit administrative staff to the detriment of patient care and safety, and sacrificing entire physician groups . . . by demanding significant reductions in pay,” local officials wrote to Gibbins Advisors, the independent monitor hired by Dogwood, just one year after the sale. “That wasn’t the deal we were told about and it wasn’t the deal we made as a community.”

The letter was signed by State Sen. Terry Van Duyn and state Reps. John Ager, Susan Fisher, and Brian Turner, as well as Buncombe County Commission Brownie Newman and Asheville Mayor Esther Manheimer.

Since then at least 15 Transylvania Regional Hospital doctors have quit, and two prominent members of the hospital’s board of trustees resigned in protest, saying they feared for the hospital’s future under HCA management.

Brevard Mayor Maureen Copelof met with HCA CEO Sam Hazen asking if HCA would sell the hospital back to the community. Hazen said no.

Angry letters?

The attorney general has written a bunch already.

Could Stein void the asset purchase agreement if he finds that HCA violated any of the 15 stipulations he set as a condition of the sale?

Nope. To be clear, the independent monitor this month said that HCA remains in full compliance with all the conditions. And if the attorney general does eventually find that HCA is in violation of something, the remedy will be to enforce compliance, not to void the sale.

What about all those lawsuits against HCA and Mission, alleging anticompetitive and predatory behavior?

Plaintiffs have been lining up in court since HCA raised prices 10% across the board. Along with a class action filed by local citizens against HCA-Mission, the City of Asheville, Buncombe County, the City of Brevard, and Madison County have sued HCA-Mission on antitrust grounds.

“The Asheville City Council and the Buncombe County Board of Commissioners felt it was necessary to take this step to bring an end to predatory practices that limit HCA Healthcare’s competition and clearly result in overpriced and limited choices in people’s healthcare,” Asheville Mayor Manheimer said last year.

If they win, can the court make HCA go away?

No. The lawsuits seek monetary damages from HCA, and changes in its behavior. But a change of ownership is not on the table.

Hopeless? Maybe Not

There might not be a way to pry Mission out of HCA’s clutches, but that doesn’t mean things are “kind of hopeless,” as my healthcare policy expert told me. 

If we band together as a community, we can pressure HCA to prove that quality of care is more important than profits.

One way to start is to ask the 22 members of the former Mission board of directors who supported this deal, along with the former Mission executives who pushed the sale, to come forward and go on the record:

Are you happy with the way the sale to HCA turned out?

If not, are you willing to demand publicly that HCA restore Mission to its former reputation as one of the country’s top healthcare systems? 

Our community deserves better.

Here are the former Mission Health board members who served while the sale to HCA was being discussed and voted. I invite all of them to contact me. For secure (encrypted) email, use

Mission directors during the time of sale:

  • John Robert Ball, MD, JD (chairman) 
  • Janice W. Brumit (past chair)
  • Daniel A Casse, joined board 1/1/2018
  • Suzanne S. DeFerie, joined board 1/1/2018
  • Bridget A. Eckerd 
  • Kristy Elliott, joined board 1/1/2018
  • Winston Leon Elliston, MD 
  • Paul “Chris” Christopher Flanders, MD
  • John William Garrett, MD (vice-chairman)
  • William S Hickman
  • Lynn Kieffer
  • Thomas A. Maher 
  • Robert M. Moore Jr., left board 12/31/17
  • Thomas Allen Oreck 
  • Peggy (Margaret E.) O’Kane, left board 12/31/2017
  • Anne Ponder
  • Kenneth G  Racht
  • Jeffrey “Jed” E. Rankin
  • Robert C. Roberts, left board 12/31/2017
  • Robby Russell
  • Lavoy Spooner Jr., joined board 1/1/2018
  • Wyatt S. Stevens

Senior leadership

  • Ronald A. Paulus, President and CEO. (Paulus is now President and CEO of Maribel Health in Santa Monica, Calif.)
  • Charles F. Ayscue, SVP and CFO, departed Jan 2018
  • Ann Y. Young, General Counsel

I’ll let you know what I hear from them.

This column was updated to include a statement from Dogwood Health Trust’s chief executive officer, Dr. Susan Mims, and to correct a reference to Janice Brumit. Brumit, the founding chair of the Dogwood Health Trust, stepped down last year.

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Peter H. Lewis is The Watchdog’s executive editor and a former senior writer and editor at The New York Times. Contact him at

Asheville Watchdog is a volunteer-run news team producing important local journalism as a community service. If you value our work, please consider becoming a supporter.

69 replies on “Opinion: Is there anything we can do about Mission and HCA?”

  1. Can the nurses strike yet or is their some prohibition in their union contract about that? Can you give us the skinny on that? It’s going to take a multi-pronged approach for this David vs. Goliath hellscape.
    Thanks Watchdog for all your coverage.

    1. The nurses will begin meetings for negotiations of a new contract in January. The current contract expires in July 2024.
      Depending on negotiations with HCA will determine if they strike. Is it possible they will strike? It all depends on HCA.

      1. Some of the nurses are incompetent. Recovery nurses. Let me go into respiratory distress and done nothing.

        1. Agreed. There are nurses there that should not have a license. Inept and dangerous without proper training for the departments they are working in. The Board of Nursing is a joke.

    1. Because they do not care!!!!! The laws which protect health care predators from providing a reasonable standard of care, and shield them of even material financial consequences of the laws (which is one thing which made the Mission cash cow so attractive to these blood suckers–good luck getting an attorney for medical malpractice in NC because of the absurdly low caps on damages). We MUST hold toes to the fire anyone running for public office, for AG, anywhere which might impact our ability to demand a reasonable standard of care and enforce it to earn our vote. Be they D or R, it has to be the hill they will die on for our votes before we all die on the hill of Paulus’ backroom deal and Rick Scott’s monstrous creation.

  2. In reply to the section “Hopeless? Maybe not”, I can only respond to what end? You’ve done a tremendous job researching the problems but they appear to be no avenues of redress. Thank you for your efforts.

  3. JCAHO and CMS are probably your best organizations for logging complaints.
    Their role’s are to ensure quality services in this setting.
    Any complaints should be documented and certified then sent to both respectively.
    The result with enough follow up etc. could result in suspension of $$$s.
    Another tactic would be to support another CON in the area.

  4. I hear your concerns about profits generated by HCAs business model. But I don’t see much in your editorial about the actual quality of care. Surely there must be objective measures that we can use to document a decline in the quality of patient care. Have mortality rates increased, for example. Otherwise, this all sounds like subjective supposition and anger that a company generates profits from Healthcare services.

    1. You left off Jill Hoggard Green in the Mission leadership list. She was COO for Mission Health.

    2. Are you kidding?? The problems with substandard care have been thoroughly documented in stories across all local media. THIS story is about community response possibilities.

    3. Getting those metrics would be interesting. I also wonder how much decline they’ve seen in patient numbers. Although so many people are moving here; the new residents are likely to go there without knowing about Mission’s decline/reputation. I don’t interpret the anger as being due to profits but rather that there are considerable profits and yet quality has gone down to the point that reputable doctors and practices are either leaving or speaking up, and the sentiment that HCA has not lived up to what it said it would do. One of the things I found most disturbing was the reported concern with clean surgical instruments.

      1. Yes. More than sufficient revenues to provide the same level of quality care as before the purchase, but they choose to suck it out of us and send it elsewhere. I’ve followed along, and they’re very, very good at playing the metrics to their advantage. And some care issues which are not as easy to apply metrics to are part of the equation of excellent care better patient outcomes, and work conditions for the doctors and nurses.

  5. Thank you for finally naming the members of the Mission board who approved the sale to HCA. Will public shaming of these civic leaders ensue? A series of full-page ads in local media calling them to account?

    1. agreed! Anne Ponder was chancellor of UNCA at one point, I believe. And I notice so many on the board had only been there since the year before the sale. How calculated was this before the actual vote took place?

  6. ““No, we will continue to meet our mutually agreed upon commitments,” HCA Healthcare North Carolina Division public and media relations director Nancy Lindell responded. “HCA Healthcare has gone above and beyond our commitments to deliver exceptional care to the communities we are proud to serve.”
    As Malcolm X once said, “You can put a shoe in the oven but that doesn’t make it a biscuit.” Saying they deliver exceptional care doesn’t make it so.

    1. Pete, thanks for a terrific synopsis of the issues.
      It feels like a breath of fresh air after all of our overwrought huffing and puffing…though it is disheartening.
      There have been rumblings over the years to get rid of the certificate of need requirements, which currently prevent competition. This situation is exactly the reason the CoN should be done away with…let Pardee or Novant come in, so that people could vote with their feet.
      I would encourage all to contact their legislators about this.
      Wonderful job, Watchdog!

      1. The huffing and puffing is what’s drawing attention to these extreme and urgent problems. We need to keep the volume high. I just spent some time with a former NC Hospital Association executive who was there (as an observer) while Paulus sold us out, and says it was obviously going to be another already known to be expected horrible HCA takeover. Our outcome was predicted by health care administrators as it took place. It’s how HCA, and other corporate owned hospital takeovers, roll. And, she seemed to feel getting the CON out of the way, though a slow solution, was key and definitely on the radar and under consideration. Other big hospitals, not just Advent and Pardee, are known to be circling this rapidly growing area, are well aware of our situation with HCA, and without the CON, will be competing to pounce on the area with a real hospital, a real competitor. So write our legislators indeed. Not just those who represent us regionally. Everyone. Flood them with the informed witnesses and victims and employees of this disgraceful corporation, and make their re election contingent on ridding us of the CON, and let someone else build a real hospital and let the HCA corporate chips fall where they may. I’m exhausted trying to navigate my senior years dodging all things HCA.

  7. As you said, the actions of physicians abandoning Mission is impactful. More such actions – or at least the threat of them by active physicians – may produce the most meaningful results as HCA cannot make money without doctors. Fear of reprisal stands in the way, though, so physicians would need to speak as a group with one voice in order to exercise the necessary leverage. That will take persuasive efforts from within the ranks, but it can be done if the will exists.
    As journalists, it seems to me that your reporting would be most effective if you can describe in detail more specific examples of poor-quality care. As you know, large numbers of compelling personal stories and photographs shared with the public have greater impact than general descriptions and statistics.

    1. I agree this should come next. The Facebook (private) group Mission Maladies is a terrifying romp through the horror stories experienced by those on the receiving end, and (usually) anonymous (to the group) nurses and doctors trusting the group admins to provide their inside information without publicly naming them. A former oncologist at Mission has a lawsuit headed by attorney Cate Edwards in Raleigh because they have effectively succeeding in blackballing him and his ability to attain employment anywhere. HCA apparently will mow down anyone, anywhere, anyhow who stands in the way of their singular goal of maximizing profits. If a driver caused serious injury or death of another through actions which could reasonably be expected to lead to those outcomes, they’d be held legally, financially, and criminally responsible. Why not these corporate execs?

  8. It appears pretty hopeless in the end. Those with serious health issues should move to somewhere that actually has a hospital they would go to. Retirees beware.

  9. My husband has been to Mission for procedures 5 times in 1 and half years. From the time he goes in to the time we leave the care has been excellent. There are problems with staffing sure but this is nationwide.
    I am sure HCA could improve many things but this constant criticism of the hospital is wearing down the staff. No one wants to constantly hear where they work is bad. I am beginning to think you enjoying the sensationalism.

    1. Having been staff there I would say the opposite is true. We need the community to know what is going on in the hospital. The care is good because these people are giving everything. You can be working people to the bone behind the scenes and they can still show up and give everything to the patients they are there to care for. What you need to worry about is when people quit fighting and talking about this. Then you will see HCA get away with even more.

    2. I’m glad you’re husband received good care. Until the day comes that you don’t you will never understand the harm that many patients and families have endured. Consider yourself lucky and please don’t minimize the suffering of others.

  10. Certainly there is a medical ethics committee within that hospital. Are they turning a blind eye? Can you find out the members of that committee? There are some doctors within who are choosing the side of HCA for their own interests.

    1. There used to be a medical ethics committee. No clue today. But anyone who has watched HCA take on and destroy anyone who speaks against their brutal operations knows taking a public stand may be career ending, and they have families to feed, medical school student loans to repay. The moral harm being done to the fine staff who struggle upstream against these corporate overlords (a description used by a specialist I was referred to regarding HCA) is so wrong.

  11. Terrific, local reporting. A brutal, ongoing story, but thanks to your thorough coverage and direct-to-reader tone you help create the sense that we are not each out here by ourselves tilting at windmills but that we belong to an informed and caring community. Thank you, again.

  12. The best antidote would be to seek a replacement system to compete with HCA. A tall order, I’m sure but maybe if things get much worse, inducements from local governments could be used as persuaders. Gee, the board doesn’t want to re-vote on the deal? Could the piles of money they each got be the reason? Always follow the money. Great investigation.

    1. Who gets to vote on the membership of the board of Dogwood Trust? How about sending in informed, qualified, and capable people to run for board seats and try to undo this mess?

  13. Thank you once again AVL Watchdog for excellent reporting on a very serious problem in our region. I remember when Mission was something to be proud of. No more. Now I feel disgust when I drive by. Sad to say it, but in our house, we have started going elsewhere for care, even though Mission is a lot closer. In fact, this may be more and more prevalent as a doctor recently told me they’re sending patients elsewhere, and no longer sending to Mission. Until there’s a better way the community can apply pressure, we’ll speak with our dollars.

  14. “Hopeless” is what HCA wants us to believe. We owe it to ourselves and to all of the residents of WNC to do what we can to change things, to the best of our abilities.
    Sherry Luft

  15. Thank you Watchdog. I was a nurse at Mission but eventually had to leave because the moral outrage of what I endured in that hospital became to much. I now drive 30 minutes away to be a nurse outside of my own community.

    This is important. Please keep the pressure on!

  16. Great job, Peter Lewis and Watchdog staff, with this great article about HCA. As an RN Patient Advocate, I receive multiple complaints each week about the quality of care at HCA. This past weekend a patient and family member called to report that the room was filthy and trashcans have never been emptied, and the nursing staff were understaffed and were not appropriately medicating a patient with narcotics for exquisite pain. She also stated they only had one Certified Nursing Assistant for the entire 40 bed unit for the last two days. Also, the physical therapist scheduled to work with the patient did not show up one day because they were short staffed, and breakfast comes at 10:00am because there are not enough staff to deliver meals on time. And her quote, “I have lived here for 50 years. Mission Hospital used to be a hospital with great care. Do the HCA hospital administrators have a mother or father here to get this level of care? I don’t think they have a conscience.” I encourage my patients to document the details of their hospital stay in a daily journal and then when they are discharged, we will together contact the NC Division of Health Service Regulation Complaint and Healthcare Investigations Section or Joint Commission and make a formal complaint. Also, I tell my patients to please go to, type in their zip code, and look up patient satisfaction scores, which show today, that Mission Hospital has a patient satisfaction score of 2 stars on a 5 star scale. Patient Satisfaction scores are an excellent quality of care measure. I also refer your readers to your excellent Watchdog article by Barbara Durr, on April 28, 2023, entitled, “Ratings Company Says Asheville’s Mission Is the Best Hospital in North Carolina. We Seek a Second Opinion,” where LeapFrog gave Mission Hospital a grade “A” for “Safety,” in the spring, 2023. This article cites a New England Journal of Medicine article that states Healthgrades and LeapFrop hospital rating companies, are paid by the hospitals that rate them. And, here we are with a patient satisfaction score of 2 stars on a 5 start scale today at Mission Hospital. Lastly, I tell all of my patients to always have an advocate with them at Mission Hospital who can speak up on behalf of the patient and ask questions and demand answers when they are in the hospital. An advocate can be a friend, family member, neighbor, or a professional. As a community, we need to hold hands together and continuously demand high quality healthcare for patients and families at Mission Hospital. As Winston Churchill says, “Never, never, never give in.” As a community, we will never give in on demanding high quality care at HCA Mission Hospital.

    1. If you go to Mission you have to take your own nurse your own doctor, a lawyer, your own clean sheets and blankets, paper towels are essential because they never have any. Handwashing is not a priority there. Bring a mop and a broom and cleaning supplies to clean your own room and some trash bags. And your own first aid kit would help because they are always out of supplies and your own food if you want to eat. Your google machine because you’ll have to properly diagnose yourself too. If you need a bath you won’t get one, so bring some wipes because they are always in short supply. Your phone, because you may need to call 911 because nobody answers the call bells. This is not hyperbole. Better yet, save yourself the trouble and don’t ever go there.

      1. I’m sorry for the moral harm to the fine staff, but I am more concerned about harm to the patients. The staff can get up and leave, even if with financial hardships, repercussions and retaliation, I get that. They can get out alive. However, most patients cannot just get up and leave, especially when very ill. HCA will mow down its own patients for profit.

  17. Thanks for this in-depth reporting to address the question on everyone’s minds. I personally know at least one doctor who left Mission and now works at AdventHealth, and says “the difference is night and day”. If Mission can’t recruit/keep staff, perhaps they’ll have to change something.

  18. I don’t think Halloween is the best analogy. It’s a living nightmare, a horrow show if you will, not a festive holiday for kids and candy.

  19. I’m very grateful to the Watchdog for providing us with real investigative journalism. Ironic, because this kind of journalism is a fundamental pillar of democracy, but if there truly is no remedy for this horrific situation, to those worried about losing our democracy – forget it, it’s gone. The underlying story here is of the utter corruption of elected officials by corporate campaign money, dark money, and lobbyists who have written (or rewritten) all the laws in recent years that have made this possible. The fact that board members of a public institution vital to the health and safety of citizens are legally allowed to sign permanent NDAs is an outrage. Injured patients can’t sue after three years, even though it may take them that long to (hopefully) recover from the treatment at Mission and who remain dependent for care at Mission because they have a monopoly, as was the case with my spouse. The corporate executives like, now U.S. Senator Rick Scott, who pay no price for their chicanery, in fact are rewarded for it. The list is long. The Watchdog should definitely get statements from our senators and congress people on HCA and what they intend to do about it. I’d like to see them all condemned to surgery there.

  20. What is see missing and not accounted for in information gathering is the community members, like me, who fear “having” to go to that hospital for an emergency or for surgery. It feels like we are a community without even an adequate hospital and that seems unsafe. Unbelievable there is not adequate accountability for this mess. Thanks for the role you’ve taken on.

  21. It’s not hopeless but it is a long fight that will cost. There
    is enough money in AVL to fund a serious publicity campaign to shame former board members and Dogwood. But, political will and leadership are necessary. HCA business practises are alleged in one pending Buncombe County suit as violations of NC anti trust statutes.

    This is a regional and national problem not one we evaluate on whether I got care meeting my expectations. Who will put up significant dollars and call citizens together to bust the medical industrial monopoly?

  22. Yes, great article — thank you, Watchdog. Important that the Board members who sold to HCA were listed by name. Any way to find out if they personally profited? I have long suspected that was the case. Bad people do bad things.

  23. After reading the commemts/responses to this article, it appears, to me, almost all of the respondents must be sitting in the same echo chamber. The US Census Bureau in 2020, says Asheville’s population is 93,776 people, and that’s just Asheville. When approximately 26 individuals jump onto the HCA pile (26 / 93776 = 0.028%) that is not what I call proof of any sizable sentiment.

  24. Have not read the full article, but paused at “local acute care.” 3 years ago a specialist I used in the Mission System opined that they guessed HCA wanted to turn Mission into a Trauma Center. Hello. So let’s watch what happens.

  25. Watchdog, are you implying that the latest move from Josh Stein, (his investigative demand letter) is an empty gesture?

  26. My experience with Mission Hospital has been negative ever since it became a for -profit institution. One of the reasons my husband and I moved to Asheville was because of its excellent reputation for health care. I do not believe that hospitals in general, should EVER be for-profit, and I believe our experience with Mission proves my point. To be fair, I would have to say that private practice healthcare has also declined. It is virtually impossible to schedule an appt. to see a doctor anymore, within a reasonable period of time, and the cost of dental care and drugs is out of sight. I do not believe that our representatives in Congress have a clue as to the severity of this crisis.

  27. There was a documentary about whisky making in Islay on 60 minutes several years ago. Zero crime on the island because of fear of ostracization. At a minimum, the administrators/spokespeople that subject sick people to the criminal ER experience at Mission and/or obfuscate should be named, recognized and shunned.

  28. Sorry I still don’t understand the paragraph about alternative facilities. “In North Carolina, a state-approved Certificate of Need (CON) is required to open a new healthcare facility. “I don’t like the hospital I’ve already got” is not a compelling argument. A Certificate of Public Desire doesn’t exist.” It would seem that our state legislators could get around this if they wished. Are they being paid off by HCA too? Please explain. Competition would solve this problem.

  29. This piece struck me as more of a rant than an article.

    Throwing it all against the wall in case some sticks is rarely effective argument.

    Mr. Lewis could spend a few minutes studying for profit and not for profit hospitals and discover:

    1. America’s best are a mix of both
    2. Prices paid by patients/insurers are not different
    3. The only meaningful difference is for profit hospitals dispurse profits to shareholders, whereas non-profits distribute any proceeds to their cause

  30. Why does HCA need a brand new building in West Asheville when all they need to do is staff the already brand new wings of the emergency department that were built, and then never opened due to staffing issues, of the already standing building. The fact that we still debate this five years later proves we are never going to get out from underneath HCA blood sucking ways. No one in a position of authority or power actually cares….why, why is that? Well, I among everyone else, have my theories. You know democracy is failing when the people speak, and we get crickets in return. I wish the entire hospital staff would walk out. People will die, you might say? Well, people area already dying. And the staff are the ones that has to live with it. Not HCA. We need radical action to see radical change from these blood suckers.

    1. I wish they would evacuate all patients safely to a real hospital and padlock that place until further notice. That’s the only solution at this point. People are being harmed and dying there unnecessarily, the doctors and nurses know it, everybody there knows it, that’s why they staff complains so much about their own “moral injury.” They know they are hurting people.

  31. Terrific reporting and thought provoking possible solutions. The public naming of the people who helped destroy Mission’s quality of care is a good start. Letting the federal Centers for Medicare & Medicaid Services (CMS) and the independent Joint Commission on Accreditation of Healthcare Organizations (JCAHO) know about each and every failure, every conflict of interest, every loss of yet another qualified nurse, physician or staff member is worth the time and effort it will take.

    I’m already boycotting Mission for Advent. The stink that is arising from the sale to HCA is intensifying. Greed and profit making have no place in healthcare – none. Remorseless deal makers like Scott and Paulus (languishing on a beach in Santa Monica) while Asheville’s quality of healthcare is destroyed will certainly bring out the voters. It ain’t over, not by a long shot.

  32. When something smells this bad, there is surely something rotten somewhere. When I urged District Attorney Todd Williams to investigate, he explained that North Carolina law does not allow investigative grand juries except for narcotics issues. (This is why nobody but the Feds and the Election Commission have ever cleaned anything up here.) I wrote to the U.S. attorney asking for a grand jury investigation. I received no reply. To everybody who cares, I suggest that you write the U.S. attorney for the western district of North Carolina, make the same request, and send a copy to the Watchdog. I also think that one of the local governments that are so concerned should ask for a U.S. Senate investigation, although the prospects would be dim considering who the North Carolina senators are.

    1. And the NC senators are indeed a problem. Elections have consequences. But, we can remedy this problem since neither seem inclined to work for our protection interests. I think writing to the US Attorney for the western district of NC is a great idea. Yes, I can google, but, do you have contact information? Is anyone knowledgeable enough of the potential legal issues (outside the narrow confines of compliance with the toothless purchase agreement) to know what elements of this nightmare we might focus on for an investigation which fall within the purview of that US attorney for the district?

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