Staff reductions contributed to Mission’s soaring profits after HCA sale, draft report says

by Andrew R. Jones, avlwatchdog.org

Mission Hospital’s patient care profits have skyrocketed since its purchase by HCA Healthcare in 2019, largely because of cost-cutting measures that have led to significantly lower staffing levels than at hospitals across the state and nation, according to public data.

A 12-page working draft report out of Wake Forest University titled “Mission Hospital’s Financial Performance Under HCA” collates information from federal data, HCA’s own projections and other studies to show how the Asheville hospital has prospered since the $1.5 billion purchase five years ago.

In 2019, Mission’s profits from patient care were just under $20 million, according to the draft report. By 2021, it made $221 million, ”which was eight times its profits the year prior to purchase (2018), and almost six times its four-year pre-purchase average,” the draft report stated.

Patient care profits represent a portion of the overall profits of the hospital, which include returns on investments. Mission’s overall profits in 2019 were $170 million. By 2021, they had risen to $273 million before dropping in 2022 to $156 million, according to the draft report.

Patient care profit, according to the draft report, appears to be directly related to a much smaller full-time staff. After the sale, costs went down, prices for services went up, and Mission saw a significant decrease in employees who care for patients, the report concludes.

Mission’s staffing rate per occupied bed dropped from 6.0 in 2018 to 4.7 in 2019. In 2020, that rate stayed steady at 4.7. But in 2021, it dropped to 3.7, according to the draft report.

“(P)rior HCA, Mission’s overall staffing levels were above state and national averages, but, under HCA, staffing levels immediately dropped by almost a quarter,” the draft report stated. Then, two years later, staffing dropped further, to a level that is roughly a third less than state and national levels,” the draft report stated.

Projections laid out in Mission’s own certificate of need application to bring 67 more hospital beds to the Asheville hospital show HCA expects to continue its financial trajectory. The company projected that its profits for acute care services would increase an additional 75% from 2021-26.

“These findings should give lawmakers here and elsewhere pause about the decision North Carolina made in 2016 to terminate antitrust oversight of the Asheville hospital market,” Mark Hall, the draft report’s author, told Asheville Watchdog, referring to the certificate of public advantage. “Without those financial guardrails, this track record shows that other background regulatory and market controls exert much less restraint on how a for-profit company manages a hospital that has a dominant market position.”

Mission has faced significant scrutiny recently after state and federal investigators found the Asheville hospital had violated care standards in more than 15 incidents between April 2022 and November 2023. Following investigators’ findings, the U.S. Centers for Medicare & Medicaid Services notified HCA and Mission that the hospital would be placed in immediate jeopardy until conditions threatening patients were amended.

The immediate jeopardy status, the most severe sanction a hospital can face, was removed in March, but because of numerous deficiencies, Mission remains at risk of losing U.S. Centers for Medicare & Medicaid funding.

The incidents included the deaths of four patients, and according to a 384-page N.C. Department of Health and Human Services and CMS investigation report, staffing issues played a part in each of those cases.

The findings are part of a larger report Hall is working on, set to be published later this year.

“This writing was funded by a group that is funding litigation against Mission Health. It is not an impartial ‘study,’ and it does not justify comment or response,” HCA and Mission Health spokesperson Nancy Lindell said when asked for comment on the draft report. She did not respond to several questions for more detail about hospital profits, staffing and Mission board members’ internal discussions when approving the HCA sale.

Hall, a member of the National Academy of Medicine, is a leading scholar on health care law, public policy and bioethics, and the author or editor of 20 books. He recently wrote other draft reports that said HCA has significantly decreased charity care for lower-income Mission patients since its purchase of the hospital and that showed the discrepancy between Leapfrog and Healthcare ratings for quality at the hospital and the recent federal finding of immediate jeopardy.

He is an independent academic researcher whose work is funded through an Arnold Ventures grant to Wake Forest University.

Arnold Ventures is a philanthropic group headquartered in Houston “working to improve the lives of all Americans by pursuing evidence-based solutions to our nation’s most pressing problems. We fund research to better understand the root causes of broken systems that limit opportunity and create injustice,” according to its website.

Arnold Ventures is helping to fund Fairmark Partners — a group pursuing antitrust lawsuits against “hospital behemoths in Wisconsin, Connecticut, and North Carolina,” according to the group’s website. Attorneys at Fairmark are representing plaintiffs in a Western North Carolina antitrust lawsuit against HCA and Mission Hospital.

Profitability spikes far above peers

Much of the draft report compares Mission with a set of 11 other hospitals in North Carolina and South Carolina that were used by N.C. Attorney General Josh Stein’s office, state regulators and Mission when evaluating the proposed sale to HCA. All parties agreed that these hospitals were valid comparisons, based on their size, scope of service, market and location, according to the draft report.

While Mission and the 11 other hospitals followed relatively similar fiscal paths from 2011-19, Mission’s veered dramatically after the sale.

Mission’s patient care and overall profit margins first plummeted in 2020 then spiked far above its peers in 2021, according to the draft report.

“HCA Mission went from a loss level at the bottom of the peer range in 2020 to a very large patient-care profit margin of 17% in 2021,” the draft report stated. “Mission’s profit margin exceeded any other peer comparison hospital and was much higher than the peer average, which was essentially zero. … Despite the instability caused by the COVID-19 pandemic, over HCA’s first four years of ownership, Mission went from the lower end of patient-care profitability to the top of the range among these peer hospitals.”

The draft report looks at two ways all hospitals boost profits: increased prices and reduced costs.

It found that prices did go up for patients, which the draft report said, is common: “(A)lmost all hospitals maintain list prices with a markup that is surprisingly or shockingly high.”

Few patients actually pay the full amounts for their care, the draft report explained, but for some, list prices are the basis for negotiating discounted payments. Being billed these amounts also can harm patients’ credit.

Mission has steadily increased its list prices since 2011, according to the draft report. After HCA bought the hospital, prices shot up more quickly and were much higher than the average list prices of the 11 peer hospitals, according to the draft report.

“Under HCA … Mission’s annual markup increases doubled, averaging 33 percentage points a year (or 30 points disregarding the 2019 transition year),” the draft report stated. “These accelerated price increases propelled HCA to the top of this peer range within just two years, which is especially notable considering that, over this same time, the average for peer comparison hospitals remained essentially level.”

Even though these price markups have been significant, they don’t fully explain Mission’s significant profit margins, according to the draft report.

Two things have played a role in those profits. One is how much it charges patients for care, or “cost-control,” according to the draft report.

“Mission’s Medicare profitability has skyrocketed under HCA,” the report stated. “Prior to HCA, Mission Hospital on average lost 4 percent each year on Medicare patients. Within three years after HCA’s acquisition, however, it was making almost a 15 percent profit on Medicare patients, and in 2022 continued to make 6 percent (with a three-year average of 10 percent). That remarkable increase pushed Mission from below the peer hospital average to near the top of the peer range, with only one hospital making more (Cape Fear at 13%).”

But Mission’s profits have benefited the most from deep cuts to hospital staff, according to the draft report.

“Following HCA’s acquisition … staffing plummeted in just a single year, from above the peer average to the bottom of the range, and staffing has remained at a level that is 30 percent below the peer group average,” the draft report stated.

The draft report relies on data from a State Employees International Union analysis published in 2022 to show Mission’s staffing of full-time equivalent employees per occupied hospital bed was lower than the state and national averages between the most recent years for which data was available: 2019-21.

Before 2019, that rate at Mission was higher than the state and national averages.

Though staffing data can be measured in various ways, the draft report says, each of those
points to a consistent conclusion: “Sharply reduced staffing for patient care under HCA explains a large component of the hospital’s markedly increased profitability under HCA. … HCA’s reported data provides only limited insight, but … much of its total expenses are concentrated in labor costs, and … the very large majority of labor costs are devoted to patient care rather than administration.”

This seems to contradict what board members were told as they considered approval of the HCA sale, according to the draft report, namely that improved financial performance would primarily happen “through purchasing power and back-office efficiencies.”

Data HCA and Mission submitted to NCDHHS in 2022 as part of its “certificate of need” application to add 67 more beds to the Asheville hospital suggest that such cost savings probably won’t be Mission’s main profit driver through 2026, according to the draft report.

Should Mission continue to boost profits through staff losses as it has since 2019, that trajectory would align with what nurses and doctors say they have experienced over the past five years after the sale and continue to experience today.

In a lawsuit filed against HCA and Mission last December, N.C. Attorney General Josh Stein, the Democratic candidate for governor, argued that the hospital company reduced staff and resources in emergency department and cancer care services, leading to patient harm and violating two of 15 commitments it made to keep services open and running for 10 years after the 2019 sale.

HCA countered Stein early this year in N.C. Business Court, saying it had never made a commitment to provide quality care.

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. The Watchdog’s reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/donate.