Editor’s Note: As 2022 comes to a close, Asheville Watchdog staffers take you back and inside their most memorable stories and news events of the year.

The document behind this story in March, that the North Carolina Attorney General’s Office had “great concerns” that the Mission-HCA deal was “rigged from the beginning,” was buried in an avalanche of more than 17,000 files Asheville Watchdog obtained under a public records request. 

But getting that memo wasn’t easy.

It took more than a year to obtain that one document, a year punctuated with repeated warnings to Attorney General Josh Stein from our friends at Duke University School of Law’s First Amendment Clinic, that Asheville Watchdog would sue him if the documents were not forthcoming.

excerpt from the memo

Here’s the background: In 2018 the board of directors of nonprofit Mission Health System stunned nearly everyone, including city and county leaders, by announcing that Asheville’s flagship hospital, five satellite hospitals in western North Carolina, and dozens of health clinics would be sold to the giant for-profit hospital chain HCA Healthcare, for $1.5 billion.

Under North Carolina law, the Attorney General is required to investigate the sale of a nonprofit corporation to a for-profit company to make sure that the public’s large investment in the nonprofit is preserved.

The investigation lasted months and in the end Stein, after demanding some changes to the sale agreement, said he would not block the deal.

Why did the Mission board decide to sell? Mission was by all appearances financially solid, with a strong reputation as one of the top 15 hospital systems in America. It also operated as a state-sanctioned monopoly, deemed so important to the people of western North Carolina that it was allowed to operate exempt from antitrust laws.

Nashville-based HCA, meanwhile, had a reputation for relentless cost-cutting, putting the interests of shareholders over the needs of patients, and leaving a trail of lawsuits and Medicare fraud settlements in its wake.

Perpetual Nondisclosure Agreements

No one involved in the deal — not the 20 members of the board, not Dr. Ronald Paulus, Mission’s CEO, or other the top leaders of the Mission system, not even the top officers of the Dogwood Health Trust that received the $1.5 billion sale proceeds — would answer questions from Asheville Watchdog.

A few who responded said they were prohibited from speaking by nondisclosure agreements that Mission’s lawyers drafted and they signed. And, they added, the NDAs were effective “in perpetuity.”

In short, there were details of the sale that the principals of Mission, HCA, and Dogwood Health wanted to keep secret forever.

A Mission spokesperson at the time flatly said the public — which for generations had supported Mission with tax dollars, donations, and countless volunteer hours — had no right to participate in, or even question, the decision.

‘That’s Confidential’

As a former business reporter and editor at The New York Times and Fortune magazine, I had a pretty good idea of how a billion-dollar business transaction normally unfolds. There was a lot that was abnormal about the Mission-HCA deal.  

Who else bid for Mission besides HCA? No one would say.

Were there even any other bidders? If so, who? Again, “that’s confidential.”

But the real impetus for the story came when I asked the Attorney General’s office some questions about its investigation.

“Much of what you ask is confidential,” one of Gen. Stein’s staffers told me.

Under North Carolina public records law General Statute 132, any person has the right to inspect, examine and get copies of documents or materials made or received by a government agency in North Carolina while conducting public business. There are exceptions, of course, but it’s up to the public agency to cite why a record is being withheld.

It was then, and still is, Asheville Watchdog’s contention that the Attorney General’s investigation into the Mission-HCA sale was public business, and thus subject to the public records law.

Surely in the course of its investigation, prior to his green-lighting of the sale, the AG would have determined if there was a competitive bidding process, which other hospital systems were invited to bid, and whether the citizens of Asheville and western North Carolina got the best possible deal. What’s so confidential about that?

Duke Law to the Rescue

The Duke Law First Amendment Clinic provides law students the opportunity to work directly with clients like Asheville Watchdog who 1) have First Amendment-related concerns or claims and 2) cannot afford the assistance of lawyers with specialized First Amendment expertise.

In what I assume was something like “Bring Your Grandparents to School Day,” the first- and second-year law students adopted the mostly retired Watchdogs and embraced our cause. Make that plural. They also meticulously steered us through Sally Kestin’s complex, year-long Equity Erased series.

When the Clinic’s informal entreaties to the AG’s office on our behalf yielded no action, Duke’s lawyers set a deadline. If the records weren’t sent by then, a lawsuit would be filed.

The first tranche of documents, some 7,000 of them, arrived in my email inbox shortly thereafter. It was followed a few weeks later by several thousand more. And then again, another batch. 

I was about midway through the mostly mundane and sometimes heavily redacted documents and emails — setting meeting schedules, telling colleagues of travel plans, and occasional discussions about public records requests from other media  — when I came upon an unsigned memo.

“We have great concerns about how HCA was selected to be the entity that purchased Mission,” the memo read.

“In the end,” the document stated, “an outside observer could conclude that HCA rose to the top among a limited number of bidders because the deck had been stacked in its favor from the beginning by Dr. Paulus and Mr. [Philip] Green.” Green, Paulus’s longtime friend and advisor, had an undisclosed prior business relationship with HCA, the memo revealed.

Philip D. Green, Mission’s strategic advisor

By cross-referencing with other documents, I determined that the memo was written by Special Deputy Attorney General Jennifer T. Harrod, who led the North Carolina Department of Justice investigation. The AG’s office confirmed it.

The memo revealed that the Mission board had given Paulus and Green the authority to identify and contact potential bidders, a critical role typically given by the board to an independent investment banker in deals of this size to ensure the best possible return. 

In the end, only two companies were invited to make a presentation to the Mission board: HCA, and nonprofit Novant. Novant’s bid was rejected immediately. (As we reported, Novant went on to buy a smaller hospital in eastern North Carolina for $5 billion. We also reported later that Mission’s former Chief Financial Officer said Novant’s offer was at least as good as HCA’s.)

Then-CEO Ronald A. Paulus of Mission Health

I had already discovered in earlier reporting that Paulus and Green solicited an offer from HCA long before asking permission from the board to begin a search for possible partners.

The Aftermath

Paulus collected a multimillion-dollar payout from Mission and joined HCA as a strategic advisor a few days after the deal closed. He has not responded to repeated requests to be interviewed by The Watchdog.

Now three years into its takeover of the Mission system, HCA is being sued for alleged anticompetitive practices and overcharging by the City of Asheville, Buncombe County, the City of Brevard, and six Asheville area residents. North Carolina Treasurer Dale Folwell has joined the Asheville-Buncombe lawsuit as well. Even Attorney General Stein, who said he had no power to stop the deal, weighed in against HCA in its bid to expand in Buncombe County.

The members of the Mission Health board that unanimously approved the sale, and the former Mission board members who now run the Dogwood Health Trust, all still refuse to speak with Asheville Watchdog, citing confidentiality.

And the Attorney General’s office still hasn’t provided all the public records we requested two years ago. Stay tuned. Maybe there’s another document out there that will turn into my favorite story of 2023.

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Peter H. Lewis is a former senior writer, editor, and columnist at The New York Times. Contact him at plewis@avlwatchdog.org   

16 replies on “Year in Review: ‘Rigged from the Beginning’”

  1. Keep pushing – we deserve to know why we ended up with such a terrible owner for our local hospital.

  2. “The members of the Mission Health board that unanimously approved the sale, and the former Mission board members who now run the Dogwood Health Trust, all still refuse to speak with Asheville Watchdog, citing confidentiality.”
    Can the reporter give the names of these members?

  3. Is Watchdog able to discern the names of the board member of Dogwood Trust? Can an audit of transactions involving the sale and the actual persons involved in the sale be discovered through subpoena?

  4. Have you asked the U.S. Attorney’s office for the Western District of NC whether there is an investigation into the various smoke columns emanating from this deal, and if not, why not? FYI, quite some time ago I sent them a copy of your earlier article with a request that they open an investigation. I have not had an answer.

  5. The stipulations that AG Stein insisted upon in the contract are illusory at best. There is no mention of quality of care and the “independent” monitor bit is just a ruse. HCA, who committed the biggest health care fraud in history (2003 US Department of Justice) waltzed in and quickly destroyed the quality of care for WNC. If AG Stein had to rely on Mission Hospital for his own medical care, perhaps he would have put more effort into protecting the citizens of WNC from a behemoth corporation with the worst reputation in the industry. Instead, we were thrown to the wolves with no remedy in sight for this disaster of a deal.

  6. It is still my contention that Mission got tired of having to deal with BCBSNC every couple or three years. Regardless, whatever the reason there is no excuse for all the secrecy that surrounds the mind boggling sale to HCA. I do know that after a 7 hour stay in their ER there is absolutely no regard for HIPPA at all.
    This sale was rotten from the beginning. The secrecy, to my way of thinking, is a big tell that something wasn’t right from the beginning. The fact that Dr Paulus ended up sitting fat and happy on the HCA board plus a fat load of cash stinks to high heaven. Everyone else who was connected to the underhanded sale should be named in the lawsuit. There is something rather stinky too about the NC Attorney General’s hesitancy to provide info to the Watchdog as well. It’s almost as though he’s trying to work both sides of the tracks. I hate to think that way but what else can one think when his office isn’t readily forthcoming?

  7. Thank you Peter Lewis. Something that affects the public to this degree involving a non profit should not be this secretive.

  8. HCA did indeed commit the largest Medicare fraud ever. Their CEO at the time was Rick Scott who resigned with tens of millions of dollars in bonus and stock options. He then became governor of Florida and is now a US Senator.

  9. The billion dollar question is what do we do about it now? Roughly 500,00 people in the Asheville Metropolitan Area rely wholly or in part on sub par care at Mission. The options are to seek care at Mission and hope for the best (good luck) or seek care elsewhere. Mission is the biggest money maker for HCA. Things are going swimmingly for them. They must contend with few Anti-trust lawsuits that will take years to litigate and no nothing to address the emergent patient safety issues. The unionized nurses have been telling us for years that patient lives are at risk. The horrifying medical negligence case (Smathers vs. HCA) will likely be the first in a series of patient atrocities to be told. They are also being accused of medicare fraud, yet again. Team Health, (hedge fund of the ER) is being sued for fraudulent billing. Whistleblowers need to step up and do the right thing.
    That was what ultimately exposed their corruption and greed in the 2003 criminal and civil fraud case. How does this end?

  10. the asheville watchdog IS ,far and away, the top journalistic paper of record for WNC. no one else does this type of deep dive reporting full of so much info my head spins from it!! i do not agree all of the time, but no one can question the thought,care,and professionalism of this dedicated group of mostly volunteers. my check is in the mail!! we must all support this type of journalism.

  11. Many thanks to Peter H. Lewis and the other volunteers who have followed this story from the beginning. Keep up the great work.

  12. Readers concerned should flood the Charlotte Office of the FBI with complaints regarding HCA/Mission. The USDOJ is the prosecutor, the Bureau does the investigations. The more information that accompanies a complaint, the better. Whistleblowers and former employees identities will be protected and their information used for leads.

  13. There is no doubt in my mind that the fix was in from the “get go”. The use of confidentiality agreements further substantiates that a shield was put in place to prevent anyone from knowing what happened. I, for one, feel that the state has also failed in this matter and that it was not powerless to pull back the curtain if it so chose. Legally I may be wrong, but it seems obvious that wrongdoing did occur and that action by the state was required and necessary.
    I am aware of a potentially significant misdiagnosis in the ER. I too was misdiagnosed in the ER. How long will this go on? WNC was thrown to the wolves on this one – Dogwood Trust or no.

  14. Thank you Peter Lewis for your dogged coverage and especially the point you make about the legal requirement for public disclosure when a community owned non-profit is sold to profit entity. Especially when involving a basic community service. Which leads to the question of how a board of a community owned hospital can legitimately sign a non-disclosure agreement. How is that accountable to the community they ostensibly represented?
    One angle that I have not heard discussed is the city council’s role in the sale.

  15. It seems the members of the Mission Board and administrators involved in this secret sale to a criminal organization (given the FL conviction under Rick Scott) should be publicly named. Will you please do so? Is there a reason this investigation doesn’t name them? Provide some kind of link to the information? I’ve had no success googling around myself. My husband was born here. We settled here full time some years ago, partly on the reputation of the good hospital, a necessity if one wants to age in place. Now, I fear the damage caused by these people who organized this giveaway to crooks in order to benefit themselves leads me to actively consider moving. And these NDAs–they don’t hold water in certain situations, right? The government, state and/or federal, needs to investigate these people and penalize them if they fail to provide testimony and information to get to the bottom of this and insist on accountability. I live in the shadow of HCA, and during what was a medical emergency last summer decided to take my chances of surviving at home rather than put myself in the hands of this broken place. Bless the nurses and doctors who do their best under impossible and unfair circumstances to take care of the community.

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