by Andrew R. Jones, avlwatchdog.org
Before he left Mission Hospital in January 2023, Dr. Scott Joslin did what he could to stop the exodus of his friends and colleagues, including 49 of his more than 60 team members.
“I wish I’d had a finger in the dike,” said Joslin, who until his departure was director of Mission’s hospitalist group, physicians who provide care exclusively for patients who stay at the hospital. “I was standing with my arms tied behind my back trying to stop it with my forehead most days.”
Joslin is one of more than 130 doctors who signed a public letter in October decrying HCA Healthcare for “gutting” the local health care system and is the physician most cited — 17 times — in a lawsuit against HCA filed by Democratic gubernatorial candidate and N.C. Attorney General Josh Stein in December. The lawsuit alleged that HCA had not honored the commitments to care it made at the time of the purchase.
The for-profit company bought nonprofit Mission for $1.5 billion in 2019, immediately triggering waves of hospitalist departures, said Joslin, who joined the Asheville Veterans Affairs Medical Center a year ago after working at Mission for 23 years.
“I think you understand from talking to me how extremely painful this transition has been for me,” Joslin, 60, told Asheville Watchdog in an exclusive interview a week before his sworn affidavit in the Stein lawsuit became public record. “I never imagined that I would work anywhere other than with the group I was with at Mission. I had anticipated working out whatever years left I had as a physician there.”
In his interview and in the affidavit, Joslin described the personal and professional toll he says working at Mission exacted on physicians and patients. He had lost nearly 50 members of his team, he had worked seven days a week for two consecutive years, tenured members of hospital leadership were leaving for other organizations and, he said, HCA wasn’t listening to concerns raised by staff.
The Watchdog asked Mission Health spokesperson Nancy Lindell several questions about the departure of hospitalists at Mission Hospital in Asheville, including how many had left since 2018 and how many that hospital employed today, including those who are hired as contractors and those who are locum tenens, a medical industry term meaning temporary positions.
“As of today, Mission Health has approximately 20 more hospitalist providers serving on our medical staff than we did in February 2019,” Lindell said, referring not only to the Asheville campus but the Mission hospitals throughout Western North Carolina.
Joslin described an untenable professional situation at Mission.
“I was beginning to feel like I was on a sinking ship,” Joslin said. “I was trying to work my way out of the problem, and I finally realized, with feedback from my wife, that I was not going to be successful. If I continued down that road, it was going to cost me my own health.”
But the choice to leave, he said he’s realized, wasn’t on him.
“The fact that I’m not there anymore is not, I’ve come to understand, because I left Mission. It’s because Mission left me,” Joslin said.
Waves of departures
Joslin initially took a wait-and-see approach when he heard HCA was going to buy Mission, where he was head of the 60-physician hospitalist group.
Then he started losing team members.
“Three or four… of my members had before they joined us worked at facilities that were acquired by HCA,” Joslin said. “I guess the first red flag that went up was that they all gave notice that they were leaving in 90 days.”
Joslin said he urged them to give HCA a chance.
Their answer was definitive, Joslin said.
“We’re not going to work at an HCA facility again,” they told him.
A second wave of departures involved a group of hospitalists who had student loans the federal government was paying off because they had been practicing at a nonprofit hospital. Many were at least halfway through 10-year forgiveness programs, Joslin said, and were each still saddled with tens of thousands of dollars in debt.
Because Mission became a for-profit hospital under HCA, the loan forgiveness program would be no more. Eight doctors with loans stayed right until the sale went through, then left, Joslin said.
Four years later, despite high hopes that things would improve, Joslin himself gave notice. He started work at the VA in January. Twelve doctors from his team also have moved there, he said.
“The straw that broke the camel’s back for me was … when Chris Flanders, who was the director for the emergency department physicians, notified me that he was stepping down,” Joslin said.
The Watchdog reached out to Flanders for comment but he did not respond.
Around the same time, former chief of staff Dr. Michael Frisch also left, which Joslin said was “devastating for me.”
After Flanders, who was on the Mission board of directors – which unanimously approved the Mission sale — left, Joslin said, he never really regained his equilibrium.
‘An absolute red line’
Joslin’s departure is one of many since the sale, a trend that hasn’t stopped nearly five years later.
Some have gone to the VA, though that hospital’s spokesperson, Vance Janes, said he could not say how many.
“That isn’t something we track, and we do not have the manpower to review all the hires of hospitalists’ previous locations,” Janes said.
After breaking away from Mission, some doctors have become vocal about their experience there. They’ve signed letters, written editorials, and talked publicly, not only about their experience after the HCA takeover, but about what they think will happen if things don’t change.
Some, like Joslin, have become a significant part of Stein’s lawsuit, writing affidavits bolstering the attorney general’s argument that HCA broke promises to keep emergency and cancer care services fully functional.
In his eight-page affidavit, Joslin recounts bringing concerns to his supervisors about patients put at risk due to low staffing.
“That subsequently evolved into worsening problems with patients I had admitted from the ED that instead of being sent to a hold area or to the floor were actually returned to the ED’s waiting rooms,” Joslin wrote in his affidavit.
In his affidavit, he recounted seeing an 18-year-old stop breathing in an emergency waiting room, forcing their mother to find help. Another patient he admitted was disconnected from drips and returned without Joslin’s knowledge to the waiting room, where they lapsed into a coma.
“I am aware of numerous examples of patients with decompensated acute medical conditions who were returned to the waiting room,” Joslin wrote. “I brought those concerns formally to the chief medical officer [Dr. Anthony Spensieri] who concurred with me that this was an issue but did not take steps to prevent that from happening. I indicated that it was absolutely unacceptable for a patient that I had admitted to the hospital to be returned to the waiting room without further care pending bed availability. I was never notified about such cases. It was an absolute red line for me that this could not occur.”
The Watchdog reached out to Spensieri and Lindell with questions about this interaction.
Spensieri did not respond, and Lindell said, “Regarding the specific claims you referenced, we will respond as part of the normal legal process.”
Mission leadership’s unwillingness to listen to medical and nursing staff is frequently referenced in Stein’s lawsuit.
Nurses have felt so ignored that they’ve filed complaints with the North Carolina Department of Health and Human Services and The Joint Commission, the nation’s largest hospital accreditation organization, prompting inspections and surveys late last year.
Before the HCA purchase and the chaos caused by the COVID-19 pandemic shortly afterward, Joslin’s group was in charge of roughly 300 of the hospital’s nearly 800 beds each day, he said. The group saw about 40-70 new patients every 24 hours, about 95% of whom came from the emergency department.
The hospitalist group at Mission grew from nine physicians to more than 60 over the two decades Joslin worked there.
But when it started to bleed members as the HCA sale went through, Joslin said the hospitalist group recognized it had to replace the losses. The group went to HCA and suddenly were “faced with a contract where we were being paid less and needing to work more,” Joslin said.
Lindell did not respond to a question about what kind of contract Mission presented to the hospitalist group after some members started to leave and whether it would have required doctors to work more for less pay.
“That created challenges in being able to hire and retain new physicians,” Joslin said.
So the hospitalists went to TeamHealth, a medical staffing company owned by the Blackstone private equity firm that had provided service to numerous HCA hospitals. TeamHealth first brought in hospitalists to fill the gap left by exiting doctors and then helped supply temporary doctors when the shortages didn’t let up during the pandemic, Joslin said.
“In the early part of 2021, had we not been in partnership with TeamHealth, my group would have collapsed,” Joslin said. “TeamHealth totally came to bat for us and continued to do so throughout the time I was there.”
Despite TeamHealth’s aid, Joslin said, his and other departments continued to lose people quickly.
“There were a host of unforced errors that resulted in the emergency department staff being put under stresses that caused them to leave, that caused my members to leave, that caused most of our psychiatrists to leave, that imploded our hospice and palliative care service, that caused all of our otolaryngologists to resign from the medical staff, that put stress on the cardiology group, and the pulmonary and critical care group,” said Joslin.
A broken covenant
Joslin said he felt like HCA didn’t care that it was losing medical staff.
That attitude, he said, is born out in recent proposed revisions to Mission’s medical staff bylaws, which still apply to Joslin and many others who have left the hospital but still have practice privileges there.
One of those proposed revisions would have curbed doctors’ right to criticize HCA. The medical community rejected the proposed bylaws — which doctors say had issues even before the revisions — by a single vote last November.
Instead of tightening restrictions on doctors and creating high turnover rates — something the hospitalists group has been especially vulnerable to — Mission’s administration needs to take additional time to focus on nursing and medical staff morale, Joslin said.
“They can’t be treated as commodities that are disposable,” Joslin said. “Destroying the institutional memory of the hospital makes it harder to practice medicine effectively there, not better. There’s much more involved in the successful operation of the hospital than the bottom line and providing for the shareholders at HCA.”
He emphasized Mission’s woes are not the fault of doctors and nurses who, he said, are doing everything they possibly can to meet needs at the hospital.
But Joslin believes a once firm bond between Western North Carolina and Mission is broken, describing in his affidavit a previous “covenant” between the hospital and the community.
“[T]he community trusted we were doing everything we could to provide the best possible medical care for our patients at all times,” Joslin wrote in his affidavit. “That covenant eroded with the HCA transition. Now the community was in a position where they questioned what our motives were, what our priorities were, and were we really a facility that was set up, designed, and engineered to provide the best medical and surgical care in Western North Carolina, rather than being an entity that was only interested in providing profit for its shareholders.”
The community has “turned on the facility” and put doctors and nurses in a position where they want to provide the best care possible, but feel they can’t because of corporate constraints, Joslin wrote.
That’s why, Joslin said, so many have left.
“It’s hard to do sometimes, but you have to be able to adapt to the circumstances that you’re confronted with and you have to be able to look at yourself in the mirror as well,” Joslin told The Watchdog.
“And if you’re going to work in the morning, knowing that you’re not making the contribution that you have to be able to make to feel like you’re working in good conscience, then you have to go.”
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 firstname.lastname@example.org. To show your support for this vital public service please visit avlwatchdog.org/donate.