Buncombe County has proposed to join N.C. Attorney General Josh Stein’s lawsuit against HCA Healthcare and Mission Health, seeking millions of dollars in damages for what it describes as excessive wait times and extra work for its emergency services crews when they transport patients to the hospital.
Buncombe filed a motion to intervene in Stein’s case April 3, alleging that, in effect, the hospital has relied on EMS to provide care because it has inadequately staffed its emergency department, leading to overcrowding. It seeks more than $3 million in damages from HCA and Mission.
“We owe it to the taxpayers to try to recoup that money, anything we could do to send a message to HCA to comply with their asset purchase agreement,” County Attorney Michael Frue told Asheville Watchdog. “They need to comply with that. And not only that, they need to bring their services up to standard as is set out in the AG’s complaint and our complaint. They owe it to the community to provide the best service possible and not to cut corners.”
In its filing in Buncombe County Superior Court and N.C. Business Court, the county cited Stein’s statement in his December lawsuit that “HCA has co-opted paramedics as employees of its own but stuck the taxpayers with the bill.”
Mission Health spokesperson Nancy Lindell responded to the county’s action, saying, “We’ve received the motion, and we will continue to defend the lawsuit vigorously.”
“The safety of our community members is a priority, and it is important that we ensure that our Buncombe County EMS will be able to provide their services effectively and not have extended wait times at the HCA emergency department,” said Buncombe County Commissioner Terri Wells. “We must hold HCA accountable.”
Commissioners were briefed on the possibility of joining Stein’s lawsuit before he filed it in December, Frue said.
“Defendants (HCA and affiliated entities managing Mission) intentionally understaffed the Mission ER so that Buncombe County’s EMS crews often experienced excessive wait times to transfer patients to the Mission ER, requiring EMS personnel to attend to emergency room patients long after arriving at the Mission ER,” Buncombe’s intervention complaint states. “Defendants continued to shirk their responsibility to emergency care patients at the expense of the County.”
EMS workers not only have spent hours with patients waiting to be admitted, according to the complaint, but they also have performed housekeeping duties, carried out orderly services and continued to treat patients — things they would not have had to do absent significant delays and a crowded emergency department.
“Overcrowding exists because the management of HCA refuses to staff and equip the Mission ER adequately,” Buncombe’s complaint states. “Overcrowding is enhanced by management admission policies which ensure the emergency department will be crowded but which enhance profits.”
Citing data from its own emergency medical services records, the county said EMS crews’ average wait time at the Mission ER increased from approximately 9 minutes and 41 seconds in the first quarter of 2020 to 17 minutes and 41 seconds in the third quarter of 2023. HCA purchased Mission in 2019.
“Concurrently, ‘90th percentile times’ — the time in which 90% of EMS-to-ER patient transfers occur — increased from approximately 16 minutes to over 32 minutes,” Buncombe’s complaint states. “These 90th percentile times far exceed the 20-minute national standard reported by the National Emergency Medical Services Information System.”
The Citizen Times first reported these extensive wait times in a July 2023 investigation. In 2018, 4.4% of “wall times” — periods in which an EMS crew stands against a hospital wall with a patient who is waiting to be admitted — “exceeded 20 minutes for Buncombe County ― that year a total of four patients waited on the wall for more than an hour,” the Citizen Times reported. “In the second quarter of 2023, 24% of wall times exceeded 20 minutes in the county. During that time, 104 patients waited on the wall for more than an hour.”
Buncombe alleged in its motion that these “substantial increases” in EMS wait times happened even though the county and EMS employees have been demanding better emergency department conditions since 2019. EMS crews over the years have spent hours waiting to return to their vehicles because rooms were not available at Mission or because rooms were not clean yet, according to the county’s complaint.
According to Buncombe’s complaint, the county previously demanded HCA reimburse it for “expenses and damages incurred as a result of its actions.”
Buncombe did not “receive the courtesy of a reply,” the complaint states.
Stein, a Democratic gubernatorial candidate, investigated Mission Hospital throughout 2023 and announced Dec. 14 that his office was suing HCA and the hospital’s management, contending they had violated the asset purchase agreement regarding cancer care and emergency services at Mission Hospital. That agreement was signed when Nashville-based HCA bought Mission Health for $1.5 billion.
HCA countered in February that it never committed to providing quality health care and that the asset purchase agreement — the legal document governing the sale — is “silent as to the quantity or quality of services required” at Mission.
Stein’s office declined to comment.
On April 1, Stein moved to file an amended complaint, a new version of his lawsuit containing arguments based on events that occurred at Mission since December, including immediate jeopardy sanctions levied by the U.S. Centers for Medicare & Medicaid Services against HCA and Mission after a recent investigation found numerous deficiencies in care and HCA’s management of the hospital.
In February, The Watchdog was the first to report on CMS’ findings, contained in a 384-page agency report, that detailed significant delays and lapses of care in the emergency department and other areas. The report detailed how some patients had to wait with EMS for hours until receiving treatment.
“In July 2023, EMS waited over two hours with a patient who needed an appendectomy,” Stein’s proposed amended complaint states. “In October 2023, EMS waited almost two hours to hand off a patient presenting with stroke symptoms. Even then, EMS handed off the patient to the ICU; the emergency department never accepted the patient.”
The July 2023 incident — involving a 41-year-old woman referred to by CMS as Patient #12 — was detailed in the 384-page report made public in February. Her experience was one of at least 15 recounted in the report, which showed exactly what incidents violated federal standards of care.
Stein’s amended complaint also cites the death of a 66-year-old man who came into the emergency department with chest pain, did not get immediate treatment and died hours later, a case detailed in CMS’ report. CMS found that the hospital had violated the federal Emergency Medical Treatment & Labor Act by delaying triage and medical screening for the man.
Many nurses interviewed in the CMS report said lack of staff was to blame for these and other incidents.
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.
It’s great that Buncombe County is getting onboard with this lawsuit. Make HCA feel as unwelcome as possible. They’ll eventually get the message… one would hope anyway. Why Paulus, Green -and HCA- haven’t been indited by a grand jury for HCA’s fraudulent “purchase” of Mission we can only be left to wonder.