By , originally published by Carolina Public Press. Carolina Public Press is an independent, in-depth and investigative nonprofit news service for North Carolina.
After more than a month of being criticized by patients and elected officials at a series of public meetings, HCA Healthcare is responding to allegations of inadequate staffing and poor service at the Mission Health facilities it acquired last year.
But even as the company speaks out, nurses from its Asheville hospitals rallied Sunday, with calls for a union to improve working conditions at the medical facilities the company acquired last year. Buncombe County Commission Chair Brownie Newman and Asheville Mayor Esther Manheimer issued a joint letter supporting the nurses’ efforts.
Tennessee-based HCA, a for-profit company, received permission from N.C. Attorney General Josh Stein last year to purchase Mission Health, an Asheville-based nonprofit that was the largest operator of hospitals in Western North Carolina.
But Stein placed a series of stipulations on the agreement for sustained services under the new ownership. Critics say the company is not holding up its end of the bargain.
HCA responds to critics
In a paid message published with Western North Carolina news media outlets, and in responses to questions posed by Carolina Public Press, Mission Health’s parent company has begun to answer its critics.
During seven public meetings conducted in late January and early February by Gibbins Advisors, the independent monitor hired to review HCA’s compliance with the promises it made as part of its acquisition of Mission, speakers complained about lengthy delays in assistance requested by both inpatients and visitors, largely at Mission’s Asheville campus, with nurses spread thin.
While praising the nursing staff at Mission as “professional and incredibly caring,” one such patient, Linda Goldberg, told CPP that she experienced 45-minute waits for bedside assistance during her four-night stay in the Asheville hospital last month.
Goldberg said nurses were “absolutely” overworked “to a huge degree.”
“You could see the forced smiles on the faces,” she said.
About the time Goldberg was in the hospital, a delegation of elected officials led by N.C. Sen. Terry Van Duyn, D-Buncombe, entered their own thoughts into the record at one of the independent monitor’s community meetings.
In a letter to HCA that Van Duyn read aloud, the group attributed much of the pressure felt by nurses to staff eliminations and reductions, specifically citing certified nurse assistants and unit secretaries.
Separately, N.C. Attorney General Stein has noted the receipt of 30 written complaints about quality of care filed with his office since Jan. 1.
“These complaints frequently raise concerns about the impact of staffing cuts, especially for nurses,” Stein said in a Feb. 25 letter to HCA.
“Some of the stories in these complaints are harrowing to read, and we are taking all of them seriously.”
Copies of the complaints were forwarded to HCA, with Stein asking for answers.
Now, HCA is starting to respond to these and other issues.
In a March 4 letter to Stein, Greg Lowe, president of HCA’s North Carolina Division, addressed concerns about the lack of a sexual assault nurse examiner at Angel Medical Center in Franklin, which CPP reported last week.
Lowe said cuts to these services at Angel and other rural hospitals occurred under Mission Health prior to its acquisition by HCA last year.
Although nonprofit groups that work with sexual assault survivors confirmed this timing, they and law enforcement disagreed with Lowe’s assertion that SANE nurses in Asheville were sufficient to serve the broader region.
Recruiting and retention
As HCA begins to respond to a wider array of service delivery issues, much of the corporation’s answer rests not on the elimination or reduction of staff but on an increase in patient volume at a time of intense competition in hiring.
“There have been no cuts to our bedside nursing positions,” HCA said in a statement provided to CPP last week.
“We are aggressively recruiting for RNs and nurse support positions such as certified nurse assistants, health unit coordinators, patient care technicians and a variety of other nurse support roles.”
In its statement, HCA did not respond directly to the specific allegations of staff cuts made by Van Duyn and other elected officials.
At the Asheville hospital, inpatient admissions and emergency room visits grew by more than 10 percent in 2019, HCA said, and it has already hired “hundreds of RNs, as well as other bedside caregivers and support team members” as a result.
Under HCA, Mission has also brought in approximately 300 traveling nurses who come and go as HCA successfully recruits new staff members, the corporation added.
But HCA is still trying to fill hundreds of positions.
As of March 6, 309 nursing jobs were available at Mission Health and affiliated medical offices, according to Mission’s website.
But while framing staffing in the context of a generally positive economy, Mission continues to offer few specifics about the size or scope of layoffs or changes in job descriptions that may have added to the burdens imposed on nurses.
At a Feb. 21 meeting at Mission convened by Lowe to address issues raised by Van Duyn and others, management did acknowledge the pressures being brought to bear on nurses, said state Rep. Brian Turner, D-Buncombe, who took part in the discussion and talked with CPP about the meeting.
“They did talk about how they were having difficulty finding good, qualified people. … Nurses were being tasked with additional duties to fill some of those gaps, which was leading to some of that pressure on nurses,” Turner said.
To help retain and recruit staff, Mission increased its minimum wage to $12.50 an hour last fall to better compete in a full-employment marketplace, HCA said, and more recently hiked the minimum to $15 an hour for nursing support positions.
“I question how competitive that $12.50 really is,” Turner said, comparing it to the starting salary at a fast-food chain.
Other sweeteners to boost retention and recruitment include a recent tuition reimbursement program worth up to $5,250 per year, double Mission Health’s prior program, according to HCA.
Charity care under HCA
In his paid newspaper message, HCA’s division president said the corporation provided “approximately $252 million in charity care, uninsured discounts and other financial assistance in our first full year of operation.”
According to Lowe, that sum represents about $100 million more under the new HCA policy than under nonprofit Mission’s charitable plan.
But in his letter to Lowe, Stein said HCA’s charity care policy “is not transparent about what services are covered,” and the hospital system’s decision to focus on emergent care “appears inconsistent” with the asset purchase agreement.
At the Feb. 10 meeting hosted by Gibbins Advisors, the elected officials who chastised staff cutbacks also expressed concern that HCA’s charity care policy no longer allows for preapproval of services.
As a result, they said, patients know whether services are covered by the charity policy only after they receive them, sometimes leading to financial hardships and bills being put out for collection.
At Lowe’s Feb. 21 meeting, the group again expressed concern over lack of preapproval.
According to Turner, Lowe told the gathering that returning to the prior Mission plan would result in a lower level of financial assistance than has been achieved in the first year of HCA’s ownership.
“He sort of defended the HCA policy in terms of generosity,” Turner said.
“He definitely leaned on the fact that it (the new policy) was approved by the attorney general’s office.”
In the end, both sides agreed to more discussions.
In HCA’s published message, Lowe addressed concerns about the company’s decision to close CarePartners’ Wheelchair and Seating Clinic, which has helped wheelchair users with seat fitting for comfort and health.
The matter was raised at the independent monitor’s Feb. 10 session, and an online petition has fought the closure.
“As we reconsidered this decision, we realized we may have moved quickly without having an alternative option readily available to patients,” Lowe wrote, and the clinic has continued to serve existing patients during a phase-out period.
Lowe said another community organization that he did not name has agreed to assume the clinic’s operations. More specifics on the handover will be released this week, Mission said.
As of Friday, the clinic was still serving existing clients.
HCA billing issues
In a Feb. 10 story from CPP, dozens of employees at the Connestee Falls residential community in Transylvania County complained about surprise “outpatient” bills being tacked onto copays for Mission-affiliated primary care visits, although those employees had never set foot in one of Mission’s hospitals.
“We ask that Mission provide our office with all disclosures that it made to customers about this outpatient fee,” the attorney general’s Feb. 25 letter to HCA said.
Rocio Borghini, the human resources manager at Connestee Falls who raised concerns about the surprise billing, told CPP that an HCA representative reached at the “833” number the company established to address the issue “stated that the fee was for a facility charge and it was going to remain as charged.”
The representative also said HCA had issued a notification of the new charge to its customers, but Borghini said none of her staff had received such a notice.
Information is due to Stein from HCA on the issue by March 11.
Mission Health nurses talk union
If all goes as expected, a vote on unionization by nurses at Mission Health’s Asheville hospital will occur sometime this spring, a group of nurses announced Saturday, followed by a public rally Sunday.
That vote will determine whether HCA must contend, on new terms, with a potentially growing class of critically needed workers who are armed with new rights.
Buncombe County Commission Chairman Newman, who coordinated with the rally organizers, told CPP that about 250-300 people turned out.
“This event was organized in just the last 24 hours,” he said Sunday afternoon, so he felt the number represented a solid turnout in light of the short time to plan the rally. Newman said several representatives of National Nurses United attended the event.
Newman addressed the crowd, as did Asheville Mayor Manheimer, City Council member Julie Mayfield and County Commissioner Jasmine Beach-Ferrara.
“They’re primarily motivated out of a concern for adequate working conditions at Mission,” Newman told CPP, and less out of a desire for compensation and benefits.
In Newman and Manheimer’s joint letter to the nurses, they promised to stand behind their efforts for a fair decision on unionization.
“We will be watching the voting process carefully and expect there to be a free and fair election at Mission Hospital,” they wrote.
“Nurses need to be able to make up their minds about the formation of a union without concern for workplace intimidation or retaliation. We expect the hospital to respect the right to hold this election without any delay or obstruction.”
Mayfield, who talked with CPP on Sunday just before the rally, said Mission’s nurses are “under pressure, under the gun and disrespected.” She said it’s important for elected officials to be visible in support of these workers.
Chad Patrick, HCA’s chief executive officer for Mission, in turn issued a letter to Mission employees late Sunday acknowledging the union organization effort.
Patrick said he was “discouraged” upon learning that some employees wanted to unionize, but acknowledged their right to do so. However, Patrick told employees that North Carolina employees will be given information from HCA that may prompt them to vote down a union.
When HCA employees voted to form a union at hospitals in Florida, “the hospitals could not share factual information regarding unions,” Patrick wrote.
“I strongly believe that if our team members in Florida had the benefit of hearing all of the facts, they would have made different decisions and would have noted ‘No.”