North Carolina Attorney General Josh Stein has investigated Mission Health since the start of the year, focusing on cancer care and whether the hospital system is honoring the purchase agreement his office approved in 2019 before HCA Healthcare bought the hospital system for $1.5 billion.
Stein, a Democratic candidate for governor, said in a recent phone interview with Asheville Watchdog that his office hears from Western North Carolina residents “on a variety of issues” and concerns related to Nashville-based HCA and Mission.
Those include a recent decision by a regional cancer care provider to pull back on some treatment at Mission facilities because of “system failures” that it said could potentially harm patients and the exit of all but one of the hospital’s medical oncologists. That doctor will leave at the end of November, The Watchdog reported Oct. 6.
“Based on those concerns, we’re looking into the practices of HCA and we want to make sure that they do live up to their commitments,” Stein said. “The fact that there are people in Western North Carolina who used to be able to get their cancer care done at Mission but no longer can is deeply troubling.”
Mission believes there are “broad and significant challenges that area oncology providers face in order to care for patients in Western North Carolina,” hospital spokesperson Nancy Lindell said via email. “Ignoring those challenges and attempting to vilify Mission Health is unproductive. We are meeting our commitment to provide oncology care to the community while working diligently to add additional oncologists to our team.”
Stein’s office has sent four letters to HCA this year and two to Gibbins Advisors, a Nashville-based firm hired by Dogwood Health Trust to monitor the purchase agreement. All were signed by Assistant Attorney General Llogan Walters of the North Carolina Department of Justice’s Consumer Protection Division or South Moore, Stein’s assistant general counsel.
But some question whether the letters, written after the attorney general announced his candidacy for governor, are merely a slap on the wrist.
Janet Thew of Flat Rock is frustrated by the lack of additional action.
“Stein’s February and June letters asked for lots of documentation and justification for loss of cancer services, but didn’t specify consequences for failure to comply,” Thew told The Watchdog in an email. “When will the AG take legal action to force HCA to fulfill its obligations to our communities? We have avoided Mission, choosing healthcare in Hendersonville, but I feel (the) takeover by HCA negatively affects healthcare for the region. Patients have to look elsewhere for care, thus burdening other providers. The AG must play hardball ASAP.”
Christine Aiken, a patient advocate who recently underwent cancer treatment, said she communicates with a local representative of Stein’s office regularly, sometimes three times a month if severe issues arise.
Aiken wrote four or five complaint letters this year to Stein’s office, she said. Those have resulted in minor improvements such as improved lighting and repairs to dilapidated floors and chairs on the third floor of Mission Cancer Center.
Aiken believes more needs to be done.
“We need more action,” she said. “HCA has basically thrown their hands up, and it’s hard now to even get any kind of a comment on my side from anybody at the corporate level.
When questioned whether the letters amount to a slap on the wrist for Mission and HCA, Stein said they are part of a “process by which we determine what is the status (of care) and does that status end up violating the agreement.”
Stein said his office takes people’s concerns very seriously, adding “That’s exactly why we’re investigating.”
Stein, the Democratic favorite for the 2024 governor’s race, was endorsed by outgoing Gov. Roy Cooper in early September. Stein campaigned Wednesday in Asheville, speaking to a packed house at Urban Orchard Cider. He briefly mentioned his investigation to the crowd.
Asked recently by The Watchdog how Stein would respond to those who say his letters are politically motivated, Stein spokesperson Nazneen Ahmed said only, “Protecting people’s health care is ongoing, long-term work that Attorney General Stein has made a priority at the Department of Justice and will continue to focus on.”
Health care is a winning policy area for Democrats more than for Republicans, Western Carolina University political scientist Chris Cooper said, noting action from an elected official’s office during a campaign season is not unprecedented.
“When people run for higher office, they run on their track record,” Cooper said, discussing Stein’s campaign, the letters to HCA leadership, and whether political motivation might be driving his investigation.
“As long as he’s not using his office or the resources of the office to formally campaign, then he can do this,” Cooper said. “And in some ways, this is what members of Congress do every day, right? They send letters. They make statements that may or may not be connected to legislation that they’re proposing, but they’re saying to the voters, ‘Look at me, I care about you.’”
The six letters
From February to September, Stein’s office sent the following correspondence to Lowe and Gibbins:
- A Feb. 20 letter to Lowe demanding answers and an explanation after Mission announced it would close the only pharmacy in its cancer center by March 4. Lowe responded in a March 6 letter, confirming the closure but noting Mission now offered “enhanced retail pharmacy services.”
- A May 11 letter to Lowe, which cited HCA’s sharp reduction in cancer services and expressed disbelief that the staff consisted of just one medical oncologist compared with the 14 at the time of the sale.
“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 stated. The letter also addressed alleged delays in new chemotherapy services and basic maintenance problems. Lowe responded in a May 22 letter that described the “headwinds” that Mission faced in recruiting and retaining oncologists.
- A June 20 letter to Lowe pushing back on his response. “To ensure compliance with the Purchase Agreement and avoid potential litigation, it is imperative that Mission Hospital restaff the medical oncology department immediately,” the letter stated.
- Another June 20 letter, this one to Gibbins, which stated Stein had “serious concerns about how closely Gibbins Advisors is monitoring HCA.” The letter detailed a number of concerns, including that as of June 16, Gibbins had not published a 2022 report on HCA’s compliance with the Purchase Agreement on its website. The letter criticized Gibbins’ periodic site visits to Mission, questioning the monitor’s practice of alerting the hospital beforehand of those visits.
Gibbins co-founder and managing director Ronald Winters responded in a July 12 letter, saying “(w)e were surprised and disappointed to receive your letter citing concerns, none of which had been expressed to us before receiving your letter. We have interacted with your office regularly, including two separate calls / meetings in May this year, and received no prior indication of concerns about our work.”
Gibbins would update its website, schedule meetings with the AG’s office and post them on its website and “(develop) other formats of public awareness in collaboration with Dogwood,” Winters wrote. Gibbins on Sept. 21 announced public meetings in six Western North Carolina counties served by Mission Health hospitals, including an Oct. 19 meeting in Buncombe.
Winters told The Watchdog on Wednesday that the omission of the 2022 Dogwood report to Gibbins’ website was an oversight that likely would have been corrected even if the attorney general’s letter had not mentioned it. The letter also prompted Gibbins to post a summary of an Aug. 31 meeting with the AG.
The attorney general’s June 20 letter played a role in Gibbins’ decision to host its upcoming community meetings, Winters said, adding that Gibbins is developing procedures “in coordination with Dogwood under which we intend to review and investigate relevant matters and request facility visits of HCA.”
- A July 25 letter to Gibbins, commending it for scheduling the public meetings. “We were also glad to see additions to your website,” Walters said, referring to the 2022 compliance report, and adding that the attorney general wanted to “explore the possibility of unscheduled site visits to HCA facilities. While we understand some of the practical limitations, we remain eager to explore the possibility of unscheduled site visits to HCA facilities and appreciate your willingness to engage with our office on that topic in upcoming meetings.”
- A Sept. 29 letter to Lowe asking what Mission knew about Messino Cancer Center’s decision to stop providing acute chemotherapy treatments for some patients because of what Messino said were systemic issues at the hospital.
The letter was the first this year to include a statement from Stein, which read:
“People in western North Carolina are worried and scared and frustrated because they can’t get the care they need at Mission. HCA agreed to provide cancer care in western North Carolina, and I will not stand by and let them fail cancer patients.”
The letter requested a number of pieces of information to be provided at “your earliest convenience,” including what the hospital planned to do in response and how many patients had been affected. It also addressed GenesisCare’s recent bankruptcy that led to the firing of local cancer surgeons.
Messino has practice privileges at Mission, and its work there is separate from Mission Health SECU Cancer Center. When asked earlier this year about Mission’s exodus of medical oncologists, Lindell, the Mission spokesperson, pointed to GenesisCare and Messino as partners in local cancer care.
15 commitments at time of sale
HCA Healthcare made 15 commitments in the purchase agreement, including promises to “keep material facilities open for at least 10 years” and “continue specified services for at least 10 years.” This includes oncology, specifically inpatient and outpatient cancer services, radiation therapy, surgery, chemotherapy, and infusion services, according to a list attached to the purchase agreement.
If HCA breaches the purchase agreement, Gibbins is supposed to inform Dogwood Health Trust, which holds responsibility for enforcing HCA’s compliance.
North Carolina law gives the attorney general’s office broad powers to investigate corporations or people doing business in the state and allows the office to pursue criminal or civil action if it finds alleged violations.
Stein told The Watchdog he has authority to address certain issues involving HCA and Mission, such as billing practices and transparency of charity care policies but he is powerless to deal with issues such as emergency department wait times or the cleanliness of rooms, Stein said, adding that is the responsibility of the North Carolina Department of Health and Human Services.
In early October, Stein’s office still awaited HCA to respond to its June 20 request for data on how long patients who are referred for cancer treatment must wait to get appointments and the number of appointments that have been canceled. On Oct. 3, The Watchdog asked Mission if it had sent this data to the attorney general’s office.
“We continue to be in direct communication with the Attorney General’s office regarding their letter to Mission,” Lindell said.
The next day Lowe sent a letter to Stein that showed Mission had already canceled 45 medical oncology appointments between January and June this year, compared with 60 for all of 2022, 51 for 2021, and 45 for 2020. The letter did not contain data on wait times for patients referred to Mission’s cancer treatment program.
“(M)uch of the data you requested in your June 20, 2023 letter is not information that Mission keeps in the ordinary course of its business,” Lowe wrote.
Stein told The Watchdog that his office still lacked information and data it had requested from HCA and Mission. He said he didn’t have a timeframe for the completion of his investigation.
“We are at times frustrated with HCA’s responses and believe they should be more forthcoming and quicker in getting us what we need to do our investigation,” Stein said.
HCA told the Stein’s office that it had “asked for a lot of information and their systems don’t always keep the information in the ways that we request it,” said Moore, the attorney general’s counsel. “They said that they are working to get us the information as quickly as they reasonably can.”
When asked why his office did not provide a specific deadline for its latest request, Stein said, “If they do not give us the information that we need quickly, we will certainly dial up our aggressiveness. ‘Earliest convenience’ means now.”
Stein said if his office didn’t believe Mission was justified in withholding data, “then we can make it a formal investigative demand, which is enforceable in court. Our hope is we don’t have to go there, and that they give us the information we need to determine what the situation actually is.”
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. To show your support for this vital public service go to avlwatchdog.org/donate.
very telling that he only started “investigating” this year.
Letter writing is not investigating. He’s relying on HCA to
freely divulge the extent of the problems there. It’s like asking the mob where they buried Jimmy Hoffa. WNC deserves better than this.
There are so many layers of problems that hurt the patients and staff at Mission that starts when you walk in and follows you back out. I think that a formal investigation is long overdue.
This is disappointing on so many levels. A few letters sent in campaign season. His office has received thousands of consumer complaints by now. They had received hundred 6 years ago when I spoke with someone in his office about the physical harm a family member of mine endured at Mission. Is there anyway to find out how much money HCA donates to political campaigns?
The other tragedy, is the damage this issue is going to do to the Democratic gubernatorial candidate. The NC Democratic party generally writes off Asheville assuming they will have our vote. It’s odd because I don’t think he can win without strong support from Asheville.
He thinks it’s enough to appeal to the “women’s right to choose” demographic. That’s his schtick. This deal stank to high heaven from the start and he rubber stamped it. It required his approval, but he then said he had no choice but to approve it. It doesn’t add up. Which is it? Takes some nerve to run for governor after decimating healthcare in an entire region of the state and then writing some dumb letters in an attempt to appease us.
He would be a better man if he had just said, I made a big mistake and it cannot be undone, you’re on your own, because that is the truth.
Michael Morgan, a former NC Supreme Court justice is also running for governor. He hasn’t gotten much attention because he entered the race after Stein when Stein had already raised $6 mil and had Gov Cooper’s endorsement. Consequently he’s not getting much attention. I very much resent when a candidate is pre-selected and the voter is supposed to rubber stamp.
Morgan will absolutely be getting my vote in the primary.
Stein has disappointed on the Mission fiasco as well as declining to press charges against Mark Meadows when he had the chance. I will of course vote for him in the general election if he is the Dem nominee but I won’t be completely happy about it.
Dale Folwell is the most qualified for NC Governor…he is admired as one of the top state treasurers in America! He is brilliant and has helped to save NC from the evils of democrat stupid spending.
If Dale gets through the Republican primary, he will have my vote for governor, no more Stein for me, thanks. If Stein was running for dog catcher, I’d vote for anyone else.
Can he win a primary against the rabid anti-semite crackpot Mark Robinson?
Mission Hospital is a real mess. My 87-year-old dad just spent two weeks there for a broken hip. The staff begged us to call, write and share our horrific experiences from sitting in an ER room with the floor covered in someone’s blood to having him languish a week in the hospital after being medically discharged to enter a Rehab. The staff is begging for someone to shine a light on what is happening here.
If you are on the YELP or Google platforms, share the experience there. Around 50 % of patients look at online review platforms, especially these, prior to getting elective care. It’s also a common place for prospective clinicians to look prior to seeking employment. Unfortunately, state and federal agencies don’t seem to correcting things for sufficiently for some HCA staff or patients.
Mr. Stein should not take the Democratic vote in the areas “serviced” by HCA/Mission for granted. While many of us would never vote Republican, I imagine people not voting would hurt. We each have our own scare stories of medical incompetence, filth, and lack of care at HCA/Mission so no point in rehashing. But does the AG have no power to force the Department of HHS to protect us? Where’s the accountability? It’s obvious that the bad guys are winning in all areas of our lives; it would just be comforting to see a public servant take them on, no matter the political timing.
“Earliest convenience means now,” so if a June request for data has not received a complete response from Mission — now is the time to bring action. Step One is surely insisting Mission hire back the 14 oncologists they are currently lacking. They might need to pay more. They might need sign-on bonuses. Whatever it takes, they need to do it — or Stein needs to bring legal action to enforce the agreement signed in 2019: there shall be no reduction in services.
It’s clear that Stein’s letters are just for show. He has no real intention of holding HCA accountable.
This is a travesty! Letter writing is not going to help the citizens of our community needing emergency, hospital or cancer care. Mission Hospital used to be an award-winning hospital be proud of. After personally needing life-saving care, along with my mom, I became an Ambassador for Mission. The community was involved and that is what’s lacking now.
So who does have the authority to get DHHS to take action to investigate complaints about HCA and Mission? Is it the Governor? How bad does a hospital have to get before someone somewhere does something?
Every local, state and federal representative we have should be calling for a state and federal investigation into the entire hospital. XDOne would be foolish to think this was contained only to the cancer center. But in the end HCA does not care, they care about 1 thing, and they are making plenty.
Charlotte, very good questions. Still no answers.
NCDHHS, NCMB, professional associations, state and federal agencies, and NC politicians, are you all ok with what’s happening in our state? A teenager regularly speeding to Asheville High School would probably get more consequences for behavior than a big healthcare institution with continual staffing, quality of care and billing problems, right? Why is that?
Stein’s investigation of Mark Meadow’s voting registration seemed a bit cursory. His original look into the HCA-Mission merger seemed to overlook conflicts of interest(at the very least), and now there’s this “letter writing campaign.” And Stein wants my vote! Where are the people of integrity who will run for office? I’m disappointed that the Governor would endorse him.
even by the questions Stein is asking in his silly letters illustrate that he is clueless as to what he is even “investigating.” What a charade. Is anyone from a legitimate hospital system advising him on what to look for because it is quite clear he is over his head or has his head in the sand.
Question for Watchdog: how likely is it mathematically that he can become governor without WNC?
Of course there are “headwinds” in recruiting. NO well qualified medical specialist would choose to work for HCA.. when they could work elsewhere.
reminder that people in large numbers have been complaining to him about HCA since 2019. not the best track record. there is something rotten in Denmark and he is not going to dig too deep as he was a key figure in this deal and needs to avoid the stench to promote his political aspirations. He unleashed this known failed hospital system to upend healthcare in WNC with no accountability to be had. Anyone waiting for HCA to do the right thing doesn’t know much about HCA. And because of that whole monopoly thing, HCA knows we don’t have much choice, especially in emergency medical situations and those who cannot travel out of the area for medical care.
Stein looked the other way until running for governor was on the table. He is part of the Raleigh group that would like Asheville to shut up and go away. Except for our votes. Now he’s interested. He’s not getting my vote.
It is increasingly evident that HCA acquired Mission for the purpose of milking it and does not give a damn about the quality–or lack of it–of the vital services that the people of this one-hospital community need. Stein or someone should sue to force HCA to transfer Mission to some other more capable and concerning entity. He should also open a criminal investigation of how a flourishing nonprofit hospital came to be sold to a corporation with a history of corruption amid nondisclosure provisions meant to conceal who was responsible and who benefitted personally.