Mission Health System has not only faced an exodus of doctors since for-profit HCA Healthcare purchased Asheville’s nonprofit hospital system in 2019, but it has also struggled to recruit physicians.
Five of six medical oncologists hired since 2020 have left or are about to depart, leaving Mission Cancer Center with just one. The staffing level at the department has generated “serious concerns” and a threat of litigation from the state attorney general.
HCA North Carolina Division President Greg Lowe wrote in a May 22 letter to the state attorney general’s office that Mission was advertising and recruiting for three open doctor positions in oncology but was encountering “headwinds in hiring and retaining oncologists.”
That difficulty surprised Martin Palmeri, an oncologist at Messino Cancer Centers in Asheville and president of the North Carolina Oncology Association
“Regarding HCA’s statements, that they can’t hire doctors, is a bit perplexing to me,” Palmeri said. “They have tremendous financial resources and a national footprint.”
After Messino Cancer Centers broke away from the hospital following the HCA purchase and opened its independent practice in January 2020, Mission reviewed 131 oncology physician applications, Lowe told assistant attorney general Llogan Walters in the letter. Forty candidates came to Asheville for interviews and six were hired.
The progress was temporary.
“Unfortunately, five of the six oncologists hired since 2020 have recently left Mission Medical Oncology or are scheduled to leave soon to pursue other opportunities, including some who have decided to stop practicing medicine,” Lowe said, adding that the hospital is still trying to recruit and retain oncologists.
The Watchdog reported in May that only one oncologist would be left after the departure of two others.
“Mission remains deeply committed to caring for patients throughout Western North Carolina through our comprehensive cancer program,” Mission spokesperson Nancy Lindell said when asked about the exchange between the AG’s office and Lowe, emphasizing that the hospital “work(s) very closely” with local groups, including Messino.
The hospital posted three job openings online in May — two for general oncology and one for breast oncology.
“Mission offers competitive salary and benefits for its oncology positions, but we have found that many physicians are reticent to enter a practice that competes against Messino Cancer Center, a larger, more established group of oncologists in the market.” Lowe’s letter said.
Lowe’s letter was in response to a May 11 letter from the assistant attorney general that cited HCA’s sharp reduction in cancer services, consisting of just one medical oncologist “where it once had as many as 14.” The letter demanded an explanation for why the hospital had not replaced physicians “in a way that keeps pace with departures.”
Walters’ letter also said the attorney general’s office had received patient concerns about the potential discontinuation of chemotherapy infusion services and “poor maintenance of the hospital facility,” including faulty treatment chairs, spotty lighting, insufficient privacy curtains and floors in disrepair. Walters told HCA to provide steps it planned to take to make sure its facilities were fully staffed.
Lowe said there was no plan to discontinue chemotherapy services and said HCA was “not aware of facility-related complaints.” He invited Walters to visit the cancer center.
Concerns over depleted oncology services prompted a stern reminder from the attorney general’s office last week that HCA needs to stay compliant with commitments it made, which include maintaining the cancer center, as a condition of its $1.5 billion purchase of the Mission Hospital system or face potential litigation.
“This is an exceptionally high number of vacant positions, and it represents either a breach of the Purchase Agreement or a serious risk of a breach,” Walters said in a June 20 letter to Lowe.
In a separate letter issued on the same day, the attorney general’s office criticized Gibbins Advisors — the independent monitor hired by Dogwood Health Trust to oversee HCA’s compliance with the sale’s terms — for “serious shortcomings” in serving the interests of the residents of Western North Carolina.
Mission, in response to the attorney general and to The Watchdog’s reporting in May, noted GenesisCare and Messino oncologists still use Mission admitting privileges — agreements between doctors and a hospital that allow them to admit patients to the hospital and provide services there.
Since 2020, Messino has hired two oncologists, one palliative care doctor and one neurologist with expertise in neuro oncology, Palmeri said.
Two doctors have left Messino – founder Michael Messino, who retired, and another because a spouse was transferred. There have been “no unexpected exits of any doctors,” Palmeri said.
“Retaining doctors is not hard,” Palmeri said. “Recruiting doctors who have top-tier credentials who will be a good match for our practice and the region is very hard.”
Palmeiri said he has researched why oncologists and hematologists leave a practice as part of his affiliation with the North Carolina Oncology Association, American Society of Clinical Oncology, and American Society of Hematology.
Here are the top two reasons why doctors leave, he said:
- Lack of autonomy in the practice of medicine
- Lack of colleagues who can be entrusted to manage patients during a physician’s absence, who are easy to work with and who can mentor early career physicians.
“I do know that hospitals who employ oncologists are seeing rising dissatisfaction among their cancer doctors because of the points I cited above,” Palmeri added.
‘There’s a shortage of oncologists’
“Here’s the real problem. There aren’t that many oncologists in the country so there’s a shortage of oncologists,” Messino said.
When he was with the group and it was still affiliated with HCA-owned Mission, they encountered some trouble hiring, Messino said. The oncology group didn’t have trouble hiring before the 2019 purchase, he noted.
“I think [it became] more difficult for us just because of the reputation of HCA,” Messino said.
After it ended its professional services agreement with Mission, things changed, Messino said.
A consultant had recommended Mission find some way to “work something out” with the Messino group, he said.
But HCA had other plans, he said.
“Their whole goal was not to work with us but to compete with us,” Messino said. That’s when, in 2020, Lowe announced Mission was going to hire 14 oncologists, he said.
Lindell and Lowe did not respond to a question about whether Lowe made this announcement. Lindell instead deferred to her statement about Mission’s dedication to patient care.
“I was at that meeting,” Messino said. “I chuckled. I wish I would have spoken up.”
It’s difficult to find that many people with that level of professional skill, he said.
Messino is well aware of the AG’s concerns about the practice area he once helmed at Mission.
“I think the AG is doing [its] job, which is to make sure that things are fair and correct,” Messino said.
“I wish they would have been a little more involved when [Attorney General] Josh Stein was reviewing [the HCA purchase] because a lot of these issues were out there and just didn’t get addressed. I think the AG’s office is starting to say, ‘Look, you’ve not kept your promise about the outreach hospitals. There are programs that are closing down. You’ve lost staff in the hospital. Those were things that weren’t supposed to happen.’”
A scramble to replace doctors
About 200 doctors have exited Mission since the purchase, according to The Watchdog’s reporting in 2022. That has caused not only staffing shortages but a scramble to replace doctors, even if they don’t live in the area, Palmeri said.
“Hiring as many doctors as you can as quickly as possible just to fill the holes in your program can be dangerous, and often an organization cannot maintain the same quality oversight,” Palmeri said, speaking generally about a challenge facing hospitals. “You bring in even one bad doctor into your practice, it can derail your efforts to build a high-quality successful program. Even worse, these doctors are now practicing subpar care in the community.”
Palmeri said he has seen scenarios where hospitals chose to employ large numbers of locum tenens oncologists — substitute physicians who generally have no practice of their own and move from area to area as needed — to fill their ranks.
In his experience, Palmeri said, temp doctors like these do not have up-to-date practice standards.
“In several cases [they] have delivered outdated inferior care to patients,” Palmeri said.
Lindell did not answer a question about whether locum tenens physicians work at Mission Cancer Center, and if so, how many.
Regardless of the systemic issues described by the AG’s office, Messino said patients need to be sure they trust their physicians and ask advice about where to get the best health care possible.
“I told somebody one day I said ‘If you’re going to have a … procedure, sit down with your surgeon and say ‘Where do you think I should go? Where are you most comfortable?’ And that’s what you do,” Messino said. “If your doctor is very comfortable that you’re going to get the right procedure done there, then you go there and get it done. If they’re not, they’re going to refer you somewhere else.”
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 go to avlwatchdog.org/donate.