By Christian Green, originally published by Carolina Public Press. Carolina Public Press is an independent, in-depth and investigative nonprofit news service for North Carolina.
When HCA Healthcare purchased Asheville-based nonprofit Mission Health, the Tennessee-based for-profit company promised to ensure everyone access to high-quality care health care in Western North Carolina.
Two years after the sale, nearly 100 physicians have left the HCA system, and several primary care clinics have closed.
In their exodus, doctors and other health professionals have joined nonprofit providers such as Pardee, Advent Health or Duke LifePoint, gone to work for local federally qualified health centers or created new independent practices rather than serve in a for-profit health system.
“Underneath all of the chaos that is our health care system, I think there is some excitement among providers,” said Ben Aiken, a primary care physician in Asheville who left HCA. “As we think more long term for the region, we can hopefully be a part of the change that we’ve wanted to see.”
While the changes opened a window of opportunity for more flexible primary care practices to develop, questions linger for patients who seek services at regional hospitals or who live in rural communities without adequate access to basic primary care services.
The approach to primary care
Before the sale, physicians at his clinic in Candler had a lot of concern, former Mission primary care practitioner Tim Plaut said.
“People started reading up, looking at HCA and looking at their patterns in previous purchases,” Plaut said. “And their pattern is to shut down primary care wherever they’re going and just assume other people are going to pick it up. They don’t want it. It’s not a big enough profit for them.”
Kate Rasche, who served as a family physician and medical director at the same Candler clinic as Plaut, said HCA alienated many primary care physicians.
“Mission honestly lost money on primary care before HCA came in,” Rasche said. “That’s why HCA has moved to cut costs and redo contracts, or just closed practices that weren’t performing financially.”
Even when whole clinics aren’t shuttered, Plaut said, HCA has cut back on services even though N.C. Attorney General Josh Stein stipulated that HCA could not make major cuts to services for at least 10 years.
“It’s all in the nuance,” Plaut said. “They say, ‘We’re not gonna cut services.’ Well in Candler, we had physical therapy. It was cut immediately. Did Mission still offer physical therapy? Yes. Was it drastically cut back? Yes, but it was still technically there.”
After just a few months, Rasche and Plaut’s clinic was among the very first to be closed after the sale.
Plaut said he asked leadership if there were plans to close the clinic and that he was initially assured HCA had no plans to cut primary care.
“Several weeks later they walked in and told us they were shutting it,” Plaut said, though he specified that he believed the decision came from higher up than the local leaders with whom he dealt.
“They told us we had 45 days,” Plaut said. “It was just a very corporate thing to do. And it didn’t take into account the literal thousands of lives that were affected.”
Though their clinic was not a moneymaker for Mission, both Plaut and Rasche said they believed Mission saw the value they provided to their roughly 5,000 primary care patients who would need to find a new provider.
Before the HCA sale, Aiken had been hired by Mission specifically to develop and pilot a direct primary care, or DPC, program, an emerging model of health care where clients pay a monthly fee directly to a network of physicians instead of paying per visit.
He said Mission was “trying to be innovative and push the envelope in what primary care could look like.”
After the sale, though, Aiken said the new leadership did not express that same support for the DPC experiment, saying HCA appreciated the model but that it was not a priority.
“Mission Health employs more than 100 primary care providers and has more than 20 primary care locations across Western North Carolina,” Mission Health spokesperson Nancy Lindell said in a statement.
“Primary care is also offered virtually. Our primary care locations continue to be available to the community for care needs, and we are recruiting as the needs of the community expand.”
New clinics fill the gaps
When HCA decided to close the direct primary care clinic in downtown Asheville, Aiken instead bought the practice so that it could continue independently as Lantern Health beginning in February 2020.
Rasche, who had previously worked with Aiken elsewhere and was already interested in the direct primary care model, joined Lantern soon after HCA shuttered her Candler clinic.
Some physicians view the direct primary care model as “concierge medicine” which caters itself to wealthier clients, Rasche said.
She and Aiken recognize that view but hope skeptics will see that the DPC approach, with its transparent pricing structure and a focus on payment for outcomes as opposed to fee-for-service, could represent a restructuring of an approach to health care.
For example, Aiken said, a typical primary care practice will average two or three interactions with a client in a given year.
“So far at our practice, we have somewhere between 10 and 14 touches with a client in a year,” Aiken said. “Those touches can be in person, they can be virtual, it could be just a text exchange. It’s a much more free-form model that results in more touches.”
Plaut opted for a different route after leaving HCA.
He is now the chief medical officer at the Asheville-based Appalachian Mountain Community Health Centers. AMCHC is a federally qualified health center, meaning it receives federal government support and offers a wide range of services on a sliding-scale fee basis to serve the most vulnerable populations in the community.
“The people who are working with us are here for the right reasons,” Plaut said. “They’re not going to make millions of dollars working for an FQHC, but they’re doing it for the right reasons and they’re proud of it.”
AMCHC was also originally created within the Mission Health system several years ago before becoming independent, though it did so before the sale to HCA.
Outside Asheville, other providers such as Pardee UNC Health Care and AdventHealth, which both operate hospitals in Henderson County, expanded their footprints and gained market share among the area residents who had to find new providers.
In 2018, before the sale, Mission held an estimated 49.5% market share in the 11 counties where it offers services, including hospitals in Mitchell, Buncombe, Transylvania, Macon, McDowell and Jackson counties, making it the clear leader, as the other 50% market share was divided among numerous other firms.
“Obviously, Advent and Pardee are taking this opportunity as a striking one to grow and absorb primary care practices,” Aiken said. “They are really kind of trying to position themselves as a more direct competitor, if you will, to Mission or HCA, and from the outside, it seems they are having some success in doing so.”
There is a similar story with Duke LifePoint, which primarily offers services to the west of Asheville and operates hospitals in nearby Haywood, Jackson and Swain counties.
LifePoint opened a new primary care office in the Candler area just after HCA announced it would close its clinic in the area. Plaut said several of his staff from the HCA Candler clinic moved to LifePoint and he interviewed with LifePoint to potentially head that new clinic before he decided to join AMCHC.
In Transylvania County, where more than a dozen local physicians have left HCA, Pardee has opened multiple new clinics within the past year, including a primary care office just across the street from HCA’s Transylvania Regional Hospital, where several of the physicians previously worked.
However, not all localities have seen new models filling in gaps. In Cashiers, several residents told Carolina Public Press that they have struggled to find health care in the region.
“There are no doctors here,” said Eleanor Blair, a professor of education at Western Carolina University in nearby Cullowhee. “I either go 30 minutes to Sylva or an hour and a half to Asheville,” referring to Duke Lifepoint’s hospital in Sylva and HCA’s in Asheville.
“I think the health care in this area is lacking,” said Ginger Dempsey, who currently drives 45 minutes to Brevard in Transylvania County to see a physician. “It’s not convenient, but I’ll be 89 in a few days, and I need to be able to see a doctor.”
Recently, Blue Ridge Health brought two physicians to a clinic located next to the HCA-owned Highlands-Cashiers Hospital.
Aiken of Lantern Health said he had been in contact with interested stakeholders in Cashiers and several other rural communities about potentially replicating the direct primary care model in these communities.
What shifting primary care means for regional hospitals
The full effect of the changing primary care landscape on the larger health care systems in the region is not yet known.
A solid network of primary care clinics also serves as the entry point to a referral network for a hospital system, Rasche explained.
“HCA has alienated a lot of primary care docs in the area,” Rashce said.
“When those doctors leave for competing systems and need to refer their patient to see a urologist or orthopedist, they are going to recommend within their own system. It will no longer be at Transylvania Regional Hospital or Highland-Cashiers, where they used to be.”
Jack Duncan of Brevard is one of those patients. He said his physician was one of those who made the move from TRH to Pardee.
“I’m happy to see Pardee come into the area,” Duncan said. “But I only live a mile from Transylvania Regional Hospital. Now if I’m recommended for surgery, I’ll have to go to Pardee Hospital in Hendersonville. It’s going to be a little bit harder.”
“That referral network is the financial lifeblood of those outlying regional hospitals,” Rasche said. “HCA is threatening the viability of those community hospitals, which means a great deal to the people who live there.”
As part of its purchase, HCA made 15 commitments required by the attorney general around retaining certain services to ease community fears around a reduction of services.
Mission Health’s independent monitor is responsible for reviewing data to determine whether HCA is in compliance with those 15 requirements.
Duncan said HCA’s promises at the time of the acquisition to abide by the stipulations weren’t convincing to him.
“When I look at the independent monitor … there’s a bunch of glad words to me,” Duncan said. “It says, ‘We’re committed to quality of care,’ but I don’t see ‘We will specifically do or not do this.’ Something is missing there.”
WLOS reported that Ronald Winters, co-founder of the firm which serves as HCA’s independent monitor, said while HCA has committed to maintaining specific services at hospitals, no specific metrics exist to gauge the level of service provided.
But gauging the level of service is exactly what Brevard City Council member Maureen Copelof wants.
Copelof, who serves as the council’s appointed community liaison for health care, said HCA has a history of moving into a community, then downsizing clinics and changing the services offered.
She wants access to specific numbers, such as the number of surgeries performed and number of MRI scans taken in a year, in order to monitor the data and ensure that TRH is used to the same degree as it was before the sale, she said.
“As long as physicians continue to refer (patients) to Transylvania Regional Hospital, and as long as the populace has confidence in the hospital, then a lot of those services could continue,” she said.
“But those two things have to happen. And that’s what we don’t know. That’s why checking the metrics is going to be so important.”
The Mission Health spokesperson said service usage data had been presented to the council at a public meeting in June but declined to say if raw 2021 service usage data would be publicly released. The presentation is not currently publicly available because, according to Brevard City Clerk Jill Murray, the meeting’s minutes have not yet been approved.
“The leadership of Transylvania Regional Hospital is very willing to speak with our patients and community members regarding their hospital care,” spokesperson Lindell said.