“You have to make money, you have to cover expenses, but for the bottom line to be profit over patient care, I just don’t think is right,” said Mission Hospital Pediatric ICU Nurse Amy Waters, RN.
Some Mission Hospital staff say it's not just doctors forced out or clinics closing that’s affecting patient care, as News 13 previously reported.
News 13's Investigative Team is looking into care standards and cost two years after Hospital Corporation of America (HCA) took over Mission Health. HCA reported $3.75 billion in systemwide 2020 profits, attributing the increase to solid cost management and highly acute inpatient volumes. While some health reviews give Mission Hospital in Asheville high marks, News 13 talks with nurses and doctors who cut financial ties, saying patient care at Mission Hospital isn't what it should be.
NURSES SOUND THE ALARM
Signals of support and concern surrounded Mission Hospital in early 2021. Ambulance drivers sounded sirens for the 1,600 unionizing nurses, taking to street corners to raise issues.
“Our duty as nurses are to be patient advocates above all else,” said one Mission Hospital nurse.
Nurses recently demanded HCA do more to put patients first.
“When you take care of more patients than you can physically take care of, obviously the care suffers,” said ICU nurse Waters.
Waters said she sees the impact on her young patients.
We’ve noticed a massive turnover in housekeeping, the cafeteria, the workers that bring food to the patients. I have to often clean the room and empty the trash. So, that's time that I should be spending with my patient and their family.
Waters also raised concerns with staffing care ratios.
“In the adult medical surgical floors, those nurses are taking seven patients, sometimes eight in the adult ICU’s the nurses are taking three ventilated patients, COVID patients that are very sick and require a lot of care,” Waters said.
HOSPITAL STAFFING AND RATINGS
Staffing isn’t public record and North Carolina has no mandated ratios. We asked Mission Health for hospital staffing levels before the purchase by HCA and currently to compare. The hospital wouldn’t provide numbers and denied our request for an interview.
In a statement, HCA points to the nationwide nursing shortage. Mission Hospital held a 200 RN's in 90 days recruitment effort in 2020. The VP of Human Resources explained in December, Mission has hired over 162 RN’s and have filled openings with traveling nurses.
“So if we don’t have kind of our incumbents, our team members that are here, we do bring in travelers because we do want to make sure that our communities are cared for,” said Nyema Sayed, Mission Hospital vice president of Human Resources.
When News 13 asked, HCA also wouldn’t provide how many traveling nurses are temporarily in full-time nursing positions at Mission. A Mission Health, HCA spokesperson said Asheville's Mission Hospital has hired 40 new physicians and more than 55 other advanced providers, but have nursing support openings for 50 Certified Nursing Assistants and Patient Care Technicians. When News 13 checked openings posted at Mission there were more than 300 posted.
The hospital offers the following incentives for recruiting employees: student loan repayment, tuition reimbursement/assistance programs, paid personal leave, 401K and insurance. Mission Health also has a minimum wage of $12.50 per hour. According to their statement, Mission partners “with local schools, offer on the job training and clinical rotations along with partnering with our local Chamber and Workforce Development Board.”
According to HCA's statement they, “continue to provide quality care to the communities they serve”, pointing to Healthgrades, which scores hospitals on patient outcomes from Medicare. Healthgrades rated Mission Hospital the best 50 hospitals for the last three years, with a 77- just above the national average. The Leapfrog’s Hospital Safety Survey in the fall of 2020 gave Mission an “A” with high scores in preventing errors, qualified nurses and effective leadership. Attorney General Josh Stein raised concern when Mission scored a “C” in 2019’s fall and “B”s in the last two spring ratings.
PHYSICIANS CUT FINANCIAL TIES
Those ratings mean little to doctors at Messino Cancer Center in Asheville.
“Hospitals often define quality in terms of ER through-put time, catheter related infections and a lot of times for cancer patients that doesn’t define quality,” said Dr. Martin Palmeri, a partner at Messino Cancer Center.
The group of 150 employees was among the first to cut financial ties with HCA in late 2019.
“When I think this transition occurred, you all of a sudden had a very different corporate philosophy," Dr. Palmeri said. "Now I can’t really speak to what that corporate philosophy is, but it was palpable that something was changing and in that particular setting everyone has to ask themselves, what’s best for my patients?"
Messino doctors still have a clinical partnership with Mission. Dr. Palmeri says he's found that less corporate oversight and a new tie to the American Oncology Network made it easier to get a newly approved FDA treatment.
“They were able to build me a regimen templet with safety protocols; they were able to procure the drug,” said Dr. Palmeri.
The process unfolded within 48 hours and Dr. Palmeri’s patient had the medication within a week.
“Compared to institutions that are not necessarily purely cancer focused. In my experience it would have taken weeks to get that to work out,” said Dr. Palmeri.
Then, there's prices.
“Hospital-based costs are rising dramatically and practice-based costs are either stagnant or going down,” said Dr. Palmeri.
Messino’s own area rate study found a savings for insurers and patients.
“This transition should lower costs by about 30% compared to sort of hospital-based costs,” said Dr. Palmeri.
In a 2020 response to North Carolina Attorney General Josh Stein, HCA reported a 10% charge increase in October of 2019, compared with Mission's previous average annual 6.8% increases prior to the sale of the hospital. When News 13 asked Mission about rate increases for patients in 2020, in Mission's statement, they stated they expect to release more on their finances in an upcoming Community Impact Report.
HCA in 2019 provided over $261 million in financial assistance for Charity Care, over $42 million more than Mission during the 12 months prior to the sale.
Continuing Charity Care is one of the 15 commitments HCA agreed to with the sale and they must maintain. Both an Independent Monitor and North Carolina's Attorney General are watching regularly to ensure HCA maintains the standards laid out in those 15 commitments listed below. News 13 reached out to the Independent Monitor, Gibbins Advisors, LLC which heard complaints in town hall meetings a year ago and Attorney General Stein.
Patients who were reluctant to speak on camera because of future care raised these issues with News 13: An emergency patient in November witnessed and reported areas not cleaned between patients and a lack of routine restroom cleaning. A recent inpatient told us of long waits for their IV changes and no nursing assistants. In December, staff who didn’t want to quit called Mission “unbearable and unsafe,” understaffed and overwhelmed. Both told News 13 their scope of accountability is limited to the 15 specific commitments, but AG Stein encouraged those with concerns to report them. “So that if HCA needs to be held accountable it will be,“ said Stein.
Here are the 15 commitments.
News 13 questioned the Attorney General and the Independent Monitor if either could hold MIssion accountable for consumer complaints or staffing levels, which prompted the following response from AG Stein:
Most of the commitments had to do with maintaining the hospitals in western (North Carolina) and in outlying counties and an assurance they would continue to provide a level of charity care.
Unionizing nurses hope they can further patient protections as part of upcoming negotiations.
“If we can get the hospital to agree to certain staffing levels and then we hold them accountable to those levels, patient care will improve,” said nurse Waters.
The negotiations are underway with the nurses union and will continue through early summer.
North Carolina’s Division of Health Service Regulation surveys hospitals and investigates complaints on behalf of CMS. News 13 is looking into those complaints.
If you’ve got a complaint about services at Mission Hospital, they tell News 13 you can reach out to Mission’s Quality and Safety Team at 828-213-1210
You can find Healthgrades ratings for Mission Hospital HERE
You can find Leapfrog's Hospital Safety ratings for Mission Hospital HERE.
You can find CMS's ratings for Mission Hospital HERE.
Just this week, HCA Healthcare also announced that, " it has been recognized for the 11th time by Ethisphere, a global leader in defining and advancing the standards of ethical business practices, as one of the 2021 World’s Most Ethical Companies." HCA Healthcare is one of only seven honorees in the Healthcare Providers category.
We are honored to again be recognized as a World’s Most Ethical Company and owe it all to our incredible colleagues, especially those working on the front lines,” said Sam Hazen, chief executive officer of HCA Healthcare. “This acknowledgement underscores that, even when faced with a threat to public health and safety like that of a pandemic, we are committed to doing what’s right for our people, our patients, our communities and other stakeholders.
INDEPENDENT MONITOR, GIBBINS ADVISORS, LLC
“As Independent Monitor our scope is generally limited to 15 specific commitments by HCA," said Ronald Winters, principal of Gibbins Advisors, LLC, the independent monitor of Mission Health. "While we regularly revisit the Asset Purchase Agreement to confirm our interpretation, aspects such as staffing levels, patient safety conditions and cleanliness are not specifically outlined as obligations in the APA or under the scope of the Independent Monitor and may alternately be in the purview of healthcare regulators to ensure standards are met. As part of our work, we do consider and evaluate whether such issues may indirectly impact compliance with HCA’s commitments but to date we have not found HCA has breached its obligations."
“Any individual with concerns around HCA’s compliance may submit information to us at our website or by email (email@example.com). We evaluate each submission to determine whether the issues raised fall under the scope of the Independent Monitor, and we will speak to the individuals submitting comments if they request or if it helps inform our work. We provide HCA with an anonymized log of comments we receive from the public, so that HCA is kept apprised of concerns,” added Winters.
For a link to Independent Monitor click HERE.
ATTORNEY GENERAL JOSH STEIN
The North Carolina Attorney General’s office continues to offer Consumer Protections. You can file a complaint with them and they’ll work to resolve it. AG Stein’s office responds on average to 20,000 consumer complaints each year. If they find a pattern of illegal business practices, they can enforce the law on behalf of all North Carolina consumers. The AG’s office can’t represent consumers in a private legal case, but they may be able to help if you didn’t get what you paid for.
In a News 13 investigation in 2020, the Attorney General submitted a number of questions on behalf of Mission patients who were incorrectly billed and charged for services. You can find that letter and the questions asked HERE.
Here’s the response the Attorney General received from HCA, which includes some of the information shared in this story.
While Mission Hospital and HCA would not agree to an interview, they provided News 13 with the following statement to some of the questions News 13 raised. They're detailed below:
The topics of greatest interest are the Leapfrog report, Mission’s scores recently improved to an “A” from a “C” in fall 2019, what changes occurred to accomplish that?
Mission Response: "Despite the extra effort required from the Mission Hospital team during the COVID pandemic, the team did not waiver in their commitment to providing exceptional patient safety and quality. The 2020 Survey Improvements included: Bar Code Medication Administration (BCMA) and Nursing Workforce Quality, along with Process and Outcome Metrics contributing to the improved performance."
What does the Magnet Designation mean to a facility like Mission?
Mission Response: "Mission Hospital’s journey to Magnet designation began in September of 2015, continued through the transition to HCA Healthcare, and culminated in a final site visit in September of 2020. The Magnet Model provides a framework for nurse engagement, a voice in practice, and processes for measuring and improving the quality and delivery of care. Magnet designation is the international gold standard for nursing excellence; less than 10 percent of U.S. hospitals have achieved Magnet recognition and Mission Hospital is the only one in Western North Carolina."
Staff tell us ratios even in department not dealing with Covid patients are stressed and support personnel CNA’s or PCT’s, clerical have been eliminated, housekeeping is also short, are these concerns seen nationwide, unique to Mission? What are the hospital’s recruitment efforts to increase staffing, improve care?
Mission Response: "While the nation as a whole is experiencing a national nursing shortage, Mission Hospital recently held a 200 RNs in 90 days campaign; while that effort was successful, we are still actively recruiting RNs and RN support positions. . Also, over the course of the year we have recruited 40 new physicians and more than 55 other advanced providers. Currently there are almost 50 open positions for CNA/PCT positions at Mission Hospital. We are committed to providing our employees with the support they need. At Mission Health, HCA Healthcare, we offer an array of medical, dental, and vision packages. Some of our unique benefits we offer include: Student Loan Repayment, Tuition Reimbursement/Assistance Programs, Paid Personal Leave, 401k, Insurance. Mission Health also has a minimum wage of $12.50 per hour. We additionally partner with local schools, offer on the job training and clinical rotations along with partnering with our local Chamber and Work Force Development Board."
If patients don’t have a good experience, notice conditions needing to be addressed where should they reach out, who should they alert?
Mission Response: "Mission Health continues to provide quality care to the communities we serve, exemplified by our recent recognition as a Top 50 Cardiovascular Hospital - the 15th time Mission has received this honor. Mission Hospital also received a Grade A in the fall of 2020 Leapfrog Hospital Safety Grade and has a 5-star rating from CMS, the highest rating offered. Additionally, our nursing team was honored in November with Magnet recognition as a reflection of its nursing professionalism, teamwork and superiority in patient care. The American Nurses Credentialing Center’s Magnet Recognition Program distinguishes organizations that meet rigorous standards for nursing excellence - a recognition given to fewer than 10% of hospitals in the United States. We are proud of our dedicated hospital teams that are facing the many challenges of this pandemic, including an ongoing nationwide nursing shortage, and the exceptional care they have provided to our patients. Our quality and safety team is always available if anyone has a concern at 828-213-1210."
In a letter to the AG, Greg Lowe mentioned that costs had increased 10- percent in the first 12 months since HCA assumed control, while Mission previously had increased costs primarily 6-percent. Were there additional increases in 2020, why were those needed?
Mission Response: "In the letter you are referencing, the data mentions that Mission’s charges for the four years prior to its sale AVERAGED 6.8 percent. Just as those earlier charge increases fluctuated given market drivers, so likely will ours. Please stay tuned for the Community Impact Report, which will be released later this year and may answer some of your additional questions."
Additional information provided by a Mission Hospital spokesperson:
Beginning March 20, 2020 with our first COVID-19 patient, Mission Health has seen hundreds of patients infected with this terrible virus. Every team member at Mission Health has been provided with appropriate PPE in accordance with CDC guidelines. Mission was very fortunate, as part of HCA Healthcare, to avoid pandemic-related furloughs and layoffs thanks to HCA Healthcare’s pandemic pay programs.
In the last several months we have been recognized for many elements of outstanding patient care including:
Magnet Designation, Leapfrog Grade A, CMS 5-star, HealthGrades Top 50 Hospital, Society of Thoracic Surgeons 3 Star, Top 50 Cardio Hospital for the 15th time, Baby-friendly designation
Investments in the community, provided by Mission Hospital:
- Invested $280 million in capital funding to support the delivery of care through state-of-the-art technology.
- Purchased land for new 120 bed Behavioral Health Hospital
- Purchased new MAMA helicopter
- Purchased land for building our new Angel Medical Center facility
- Purchased minimally invasive, state-of-the-art technology to enhance the caliber of services provided to our patients, including two da Vinci Xi robots, an upgraded Mako Robot, an O-arm surgical imaging system and six Stealth Stations
- Upgrades in imaging equipment, including new MRI and CT machines, and new Mammography Units
- Investments in our sister facilities to expand surgical and imaging capabilities throughout Western North Carolina
This is the second of three segments investigating what's changed with Mission Health since HCA took over. The next piece airs Thursday, Feb. 25, at 6 p.m.