North Carolina Attorney General threatens HCA with litigation

LETTER SENT: In a June 20 letter to Greg Lowe, CEO of HCA’s North Carolina Division, the North Carolina Attorney General’s office cited HCA’s sharp reduction in cancer services, consisting of just one physician “where it once had as many as 14.” Photo by Jen Castillo

by Andrew R. Jones and Peter Lewis,

The North Carolina Department of Justice today expressed “serious concerns” about HCA Healthcare’s compliance with the commitments it made as a condition of acquiring Asheville’s nonprofit Mission Hospital system in 2019.

In a June 20 letter to Greg Lowe, CEO of HCA’s North Carolina Division, the North Carolina Attorney General’s office cited HCA’s sharp reduction in cancer services, consisting of just one physician “where it once had as many as 14.”

“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,” the letter to Lowe stated.

Mission needs to “restaff the medical oncology department immediately” or risk potential litigation, the letter stated.

Separately, the Attorney General’s office wrote to Gibbins Advisors — the independent monitor hired by Dogwood Health Trust to oversee HCA’s compliance with the terms of the sale — to say its performance was inadequate. It criticized the monitor for “serious shortcomings” in serving the interests of the citizens of Western North Carolina.

Asheville Watchdog’s requests for comment from officials of Dogwood Health Trust and Gibbins Advisors were not immediately answered Tuesday evening.

On Wednesday, Gibbins’ co-founder and managing director Ronald Winters issued a short statement to The Watchdog.

“We will discuss the letter with the Attorney General’s office shortly to clarify and correct the record on certain points,” the statement read. “We are receptive to the Attorney General’s requests to deepen community engagement and expand upon the outreach and conversations we have already conducted.  We continue to welcome collaboration with the Attorney General in fulfilling our role as Independent Monitor.”

“We also just received the letter from the Attorney General’s office today and will respond directly to their office in the timeframe provided,” HCA spokesperson Nancy Lindell said Tuesday when asked for comment on the letter.

North Carolina Attorney General Josh Stein’s “letter of non-objection” to the $1.5 billion sale of nonprofit Mission to for-profit HCA came only after he demanded greater consumer protections than were included in the terms unanimously approved by Mission’s board of directors.

Stein’s conditions included the hiring of an independent monitor to oversee HCA’s compliance with the agreement; enforceable commitments to maintain current levels of service at all six hospitals in the Mission system, not for the five years the Mission board agreed to in some cases, but for 10 years; and requiring HCA to adopt what he viewed as Mission’s more generous charity care obligations.

Stein — who is running for North Carolina governor as a Democrat — also got HCA and Mission to agree that the attorney general could enforce the terms of the contract.

‘These are serious shortcomings’

Dogwood Health Trust — the successor nonprofit trust created to receive the money from the sale — hired Gibbins Advisors of New York as the independent monitor to evaluate HCA’s ongoing compliance with terms of the purchase agreement. “An effective independent monitor was a critical condition of HCA’s acquisition of Mission Health,” the letter to Gibbins stated.

Dogwood’s top management at the time consisted almost entirely of former Mission board members, some of whom were on the Mission board at the time of the sale to HCA. Gibbins Advisors is paid by, and reports to, the Dogwood Trust. Gibbins Advisors soon moved its headquarters to Nashville, where HCA’s headquarters are located.

“It is our view that Gibbins Advisors is not adequately monitoring HCA, is not adequately responding to patient complaints, and is not holding regular quarterly meetings with our office and Dogwood Health Trust,” stated the AG’s letter addressed to Winters. “These are serious shortcomings, but they are also easy to remedy.”

Gibbins had not responded to multiple AG requests for information about “alleged violations,” the letter stated, noting that as of mid-June, the firm had not since summer 2021 listed “a single action taken by Gibbins Advisors” on a website dedicated to purchase agreement monitoring.

“We believe that the Independent Monitor should annually publish a written compliance report and take a more active role in enforcing the terms of the Purchase Agreement,” the letter stated.

It also reprimanded Gibbins for not consistently setting up quarterly meetings with the AG’s office, instead scheduling them “casually” or not at all.

“Moving forward, we request that you publish a schedule of each year’s quarterly meetings no later than January 1 of the calendar year in which the meetings are to take place,” the letter stated.

The Attorney General’s office also chided Gibbins for “inadequate” site visits to HCA’s North Carolina facilities, and for informing Mission in advance of its periodic inspections, saying, “unscheduled site visits would provide a more accurate understanding of HCA’s daily operations.”

‘It is inconceivable’

Referring to previous correspondence between Lowe and the AG’s office, the letter focusing on cancer services noted confirmation that “Mission’s oncology practice now includes only one physician, where it once had as many as fourteen.”

The Watchdog in April 2022 first reported on a depletion of doctors including medical oncologists. In May 2023 Mission confirmed two doctors had left medical oncology and AG spokeswoman Nazneed Ahmed told The Watchdog the DOJ was examining issues there.

The letter to Lowe asks him to produce several pieces of information, including:

  • The number of oncologists employed by the Mission Medical Oncology practice for each month since February 2019.
  • The name of every oncologist employed by the Mission Medical Oncology practice since January 31, 2019, and the dates of those oncologists’ first and last day employed by the practice.
  • New patient data, service days offered, canceled appointments, referrals to non-Mission oncology practices, wait times, and other data for five different services.
  • A detailed description of the additional steps HCA will take to restaff the Mission Medical Oncology practice, including plans for recruiting and retaining oncologists.

The letter to Lowe was not the first from the AG in 2023. Stein’s office in February sent a letter asking why the hospital decided to shutter a pharmacy in Mission Cancer Center, which advocates described as the most ideal way to get their medication.

Patients in Buncombe and surrounding counties have complained about Mission Cancer Center, according to the letter, which conveyed disbelief that only one medical oncologist could serve such a broad region.

“It is inconceivable that HCA could provide the hundreds of thousands of North Carolinians who reside within this expansive geographic area with the quality of care that they need and deserve using a single oncologist,” the letter stated.

It closed by noting the purchase agreement and promising to “closely monitor” oncology services at Mission: “We will not hesitate to enforce the Purchase Agreement and protect the public’s right to care under (the purchase agreement).”

The purchase agreement states that HCA “shall not discontinue the provision of the services” including “inpatient and outpatient cancer services, radiation therapy, surgery, chemotherapy, and infusion services.”

One of HCA’s four core commitments after the purchase — broken down into 15 separate priorities — was to “retain services and hospitals.”

According to the purchase agreement, if HCA did not comply with the commitments it made, Dogwood would be notified and could trigger a resolution process. Other disputes would involve the North Carolina Business Court “or an arbitration process administered by the American Arbitration Association,” according to the independent monitor’s summary of the purchase agreement.

Both letters were written by Assistant Attorney General Llogan Walters of the N.C. Department of Justice’s Consumer Protection Division.

In March 2022, Walters wrote to Lowe that the N.C. Department of Justice was “extremely concerned about the high price of health care in Western North Carolina.”

“For many services, Mission Health charges insurers prices far higher than the state-wide average price for the same service,” her letter read. “Unsurprisingly, these costs are passed onto consumers. For example, insurance premiums within Mission Health’s service area are 30% higher than premiums in nearby counties, and over 50% higher than premiums in the State’s other large metropolitan areas.”

(Editor’s note: This story was updated Wednesday, June 21, to include a statement from Gibbins’ co-founder and managing director Ronald Winters.)

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 Peter Lewis is a former senior writer, editor, and columnist at The New York Times. Email  To show your support for this vital public service go to


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6 thoughts on “North Carolina Attorney General threatens HCA with litigation

  1. Jt

    Stein owns this infuriating debacle for ever signing off on the HCA takeover. If he’d done his homework he would have known their abysmal track record and would have told them to go pound sand. Everything he does now is too little too late. Sending letters?? He needs to assess actual financial penalties at the least, and ideally looking for every possible loophole that would allow him to cancel the deal for noncompliance with contract stipulations.

    • indy499

      Stein playing games where he wants to look like he’s in charge but has his minion sign letters in case it blows up

  2. Curious

    “Dogwood’s top management at the time consisted almost entirely of former Mission board members, some of whom were on the Mission board at the time of the sale to HCA. ”
    Could Asheville Watchdog (or Mountain Xpress) please give the names of these community leaders who are the “top management” of Dogwood and were on the mission board at the time of the sale to HCA? Why are these community leaders not being held accountable for this debacle?

  3. indy499

    Odd that on this supposed big issue, Stein couldn’t take the time to sign the letter.

    Too busy running for governor (hint: won’t win) to do his job?

  4. Trent Bishop

    The HCA purchase of Mission was the largest theft of public property in NC history. HCA “paid” for the system, but it is simple reasoning that the citizens of WNC would be reimbursing HCA for that purchase and all future profits. Asinine.

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