Why Villify Mission HCA? - TribPapers

Why Villify Mission HCA?

HCA's Galen College of Nursing is still under construction, but it is accepting applicantions for its ADN and BSN programs. Source: Galen College's website.

Asheville – Asheville City Council and the Buncombe County Commissioners have spared no snide remarks in expressing their disdain for Mission HCA, the for-profit owner of the former Mission Hospital. A strict adherent to the nation’s founding principles would argue it is the role of government to remove barriers to honest economic success. Yet, in the case of Mission, local governments, as well as Attorney General Josh Stein, have piled on to fight the hospital on various fronts.
Stein was recently in the news again, arguing that Mission HCA was taking advantage of its monopoly status to charge patients too much. A recent offering of a certificate of need to create 67 new acute-care beds in Buncombe County continues to elicit inflamed statements against Asheville’s hospital, largely on the grounds that it is a “for-profit corporation,” spoken with a certain, incriminatory intonation.

Costs –

National Nurses United, the union that organized at Mission soon after its purchase by HCA, published a study in 2020 that essentially condemned for-profit hospitals for having high charge-to-cost ratios. Entitled, “Fleecing Patients: Hospitals Charge Patients More than Four Times the Cost of Care,” the report states, “Of the 100 hospitals with the highest charges relative to their costs, for-profit corporations own or operate 95 of them. All of the top 100 hospitals are owned by hospital systems, as opposed to being independently operated community hospitals. The top system is HCA Healthcare, which owns 53 of these hospitals, including the hospital with the highest charge-to-cost ratio in the US.” [NOTE: The report’s use of CCR for charge-to-cost ratio is used throughout this article, although the industry typically reserves the acronym for the cost-to-charge ratio.]

HCA’s average CCR is 1,008.78%, which falls in sixth place. Capital Health, by way of comparison, has an average CCR of 1,443.98%. The report states that HCA owns six of the ten hospitals with the highest CCRs, and these six, incidentally, are all in Florida, where the study notes the overall CCRs are the highest in the nation. In fact, 40 Florida hospitals made the top 100. The average CCR among North Carolina’s 103 hospitals was 417.30%, which is amazingly close to the national average of 417.29%. Mission Health System’s CCR was 324.48%.

The report observes, “It is for-profit hospitals that tend to have the highest CCRs…The for-profit hospitals’ CCRs are 78% higher than nonprofit facilities’ average CCR, and 143% higher than governmental or public hospitals’ average CCR.” Elsewhere, the report complains that the CCRs for for-profit hospitals are also much higher than those of smaller community hospitals. This stands to reason, since government hospitals can offset billing costs with taxes; and university hospitals benefit from donations, endowments, and federal grants. Ironically, last year, the university hospital at UNC Chapel Hill and the community/university hybrid Wilson Medical Center were threatened with termination of Medicare funding over concerns for patient safety.

When it comes to comparing the CCRs of community hospitals and large hospital systems, information is lacking on the levels of service provided by each type of hospital. For example, it is likely the large hospital systems will have more state-of-the-art technology, more specialists, and a wider spectrum of advanced-care services—that is, offerings for which the smaller hospitals would have to outsource. It seems only reasonable that it should cost more to maintain advanced, precision apparatus and train and retain high-level expertise for the region.

What’s more, the increasing levels of administration associated with the advent of Obamacare have forced several small hospitals into mergers. According to EconoFact, actual statistics are not available, but insurance and billing services are estimated to comprise about 15% of healthcare costs, other administrative services account for another 15%, and about 25% of the medical labor force is believed to work in administration.

Charity spending fell abysmally short of nonprofit tax exemptions for many North Carolina hospitals in 2020. Even with COVID relief, many hospitals could only scrounge enough to "grow their balance sheets by hundreds of millions." Source: Johns Hopkins, "North Carolina Hospitals: Charity Care Case Report."
Charity spending fell abysmally short of nonprofit tax exemptions for many North Carolina hospitals in 2020. Even with COVID relief, many hospitals could only scrounge enough to “grow their balance sheets by hundreds of millions.” Source: Johns Hopkins, “North Carolina Hospitals: Charity Care Case Report.”

While smaller hospitals clearly cannot handle the administrative burden and practice medicine, the nurses’ union study views the rash of hospital mergers and acquisitions as spearheaded by corporate hospital systems desiring to absorb the competition so they can use their monopolistic powers to price gouge. More precisely, “Such markets allow hospitals and systems to gain negotiating power relative to health insurance companies over hospital charges and reimbursements.”

In free markets, that is, trade without government intervention, the price is always right. That’s because if it weren’t, the buyer would refuse to pay. In distorted markets, where the government, or in this case, insurance companies, intervene, things get hairier. One reason is that the consumer is insulated from charges by insurance companies, and, even though some reforms have been attempted and more are underway, there is very little transparency. Here, the problem is the same as that of wooing corporations to a jurisdiction with economic development incentives. Any politician will say the practice is crooked and unfair, and then add that they have to play the game to stay competitive. Following the logic, the problem would lie with “the system” and not with a particular hospital.

Also substantiating a counternarrative, “North Carolina Hospitals: Charity Care Case Report,” was prepared about a year ago by special request from State Treasurer Dale Folwell as a drill-down of a nationwide study by Johns Hopkins University. Among its findings were, “North Carolina’s largest nonprofit hospital systems reaped tax breaks worth more than an estimated $1.8 billion in 2019-2020. Across the majority of these systems, charity care spending did not exceed 60% of the value of their tax breaks. Fewer than 25 hospitals outstripped the value of their tax exemption with the amount of their charity care spending in North Carolina.

“Nonprofit status does not guarantee higher charity care spending than for-profit hospitals. In North Carolina, some nonprofits dedicated less than 0.5% of their total expenses to charity care. Their tax breaks are worth an estimated 5.9% of total expenses. For 25 nonprofits, charity care accounted for less than 2% of expenses.”Another example of supply-side contributions being overlooked in economic arguments was how Mission HCA’s generation of around $10 million in taxes for the city and county was overshadowed by the fact that it negotiated hefty tax breaks. The nonprofit hospitals the commissioners and city council would like to aid in gaining market share – whether on principle or as a non-naming exclusionary criterion – would pay no taxes.

This is not to say the “waste, fraud, and abuse” mantra from the era of fighting Obamacare is without merit. Horror stories of getting billed two or three times for a single procedure, receiving excessive treatments apparently designed to protect physicians from malpractice suits, receiving contraindicated treatments, mixing treatment plans with those of “the guy next door,” or being subjected to a Cadillac treatment when a Yugo version would be preferable, persist.

Care –

Knowing that anybody could wind up in the hospital at any moment, access to adequate care should be a community priority. Standing in the way of just about all hospitals across the country, however, is a shortage of healthcare workers. Almost all industries felt the “Big Quit,” or “Great Resignation,” as the government ordered people to stay home and shutter their businesses during the COVID shutdown. Healthcare workers, instead, were ordered to stay at work, where the risks of catching the beast ran high. Some workers opted to quit rather than expose themselves and their families, leaving those committed to helping to work longer hours in a profession where burn rates have always been high.

In addition, some hospitals gave employees an ultimatum to get vaccinated or quit. Mission HCA was not one of them. When then-SVP and CMO Dr. William Hathaway was grilled by Asheville City Councilman Parker Sloan about the decision, he merely replied that hospital workers follow best practices to avoid exposure to all sorts of health risks, and he trusted those would be adequate. Novant, one of the hospital systems competing with Mission for the certificate of need, fired 200 of its employees for failing to be vaccinated.

Meanwhile, COVID was amplifying the stressors that drive the burn rates, like long and unpredictable hours and trauma from experiencing death and suffering, while the workers and those in their personal and professional care often came down with the infection. As if the discomfort of stumbling around for back-to-back 12-hour shifts in gowns, goggles, and masks was not enough, COVID coincided with a spike in healthcare worker abuse. According to the American Hospital Association, (1) healthcare workers suffer more injuries from violence than employees in any other profession, and (2) since the pandemic, studies have found 44% of nurses to report experiencing job-related physical violence, and incidents are believed to be underreported.


To ascertain why local leaders deem Mission HCA’s 800 vacancies as a unique disqualifier is not easy in light of the scarcity of data in the public realm. Reporters covering statewide statistics have even commented on their inability to break down the available data among hospitals. An article in the Mountain Xpress from Asheville Watchdog, published earlier this year, reported a reduction, since 2019, of 223 physicians listed as working for Mission on Find a Doctor. Asheville Watchdog further reported over 100 of the doctors had left the state. Mission spokesperson Nancy Lindell, however, said a lot of those doctors no longer listed on Find a Doctor continue to work in affiliation with the Mission, and the number of doctors working in the hospital remains about the same. Whatever the count, it is easy enough to find doctors who left Mission in the early days of the HCA takeover, which coincided with the COVID shutdown.

Also in 2019, the Association of American Medical Colleges reported a shortage of 20,000 doctors in the country. In that year, an article published by the National Center for Biotechnology Information entitled “Physician Suicide: A Call to Action,” provided heartbreaking statistics about widespread wear and tear on physicians and how this trickles down to patients. Around the same time, Forbes also reported on the “epidemic” of “physician burnout.” Doctors have traditionally been under pressure to flawlessly provide diagnosis and prescriptions, around the clock, for every complex combination of afflictions. The Forbes report said, “Nearly half of all clinicians reported feelings of exhaustion, depression, depersonalization, and failure.” Physician burnout, according to the article, doubled the incidence of error and affected other healthcare workers as well.

The article continued, “While the reasons for physician burnout are complex and nuanced, the burden of menial tasks and increased documentation plays a big role, cutting into physicians’ quality time with patients—not to mention their nights and weekends. In fact, one study found that for every hour spent with patients, physicians spend an average of two hours on paperwork in electronic health record (EHR) systems, and this is even longer in specialties like general surgery, urology, and cardiology.”

This paperwork, by the way, isn’t contemporaneous, stream-of-consciousness jotting. The Forbes article reports, “The Centers for Medicare and Medicaid Services (CMS) release around 11,000 pages, or 58 new rules, each year containing new requirements and billing codes.” The article then editorializes about the burden of trying to keep up with the latest in clinical best practices and therapies, “while also deciphering thousands of pages of legalese to get paid for your hard work;” especially when overworked and burned out. The article explains that physicians would not despise EHR systems so much if they were designed to enhance patient care instead of fulfill empty regulatory requirements. The technology, it claims, wastes hours of professional labor trying to shoehorn data into a system inadequate and inappropriate for the field.


According to the University of North Carolina’s NC Nursecast, the shortage of registered nurses in North Carolina is expected to increase to 12,500 by 2033, and 10,000 of these vacancies are expected to occur in hospitals. To compensate for the nursing shortage, hospitals across the country have had to contract with or for travel nurses. These nurses, in turn, tend to get paid more than hospital hires, making recruitment and retention more difficult. Nationwide, the United States Bureau of Labor Statistics expects a total of 500,000 nurses to quit the profession this year, doubling the existing deficit.
An article in Carolina Nursing Quarterly, among many other sources, reported that, pre-pandemic, industry analysts had foreseen a perfect storm when baby boomers reaching the age of needing more medical attention would be met by a retiring nursing workforce. The pandemic only increased the number of sick people needing nurses who were stressed enough to take an early retirement.


Another critical staffing shortage in the healthcare field is that of training faculty. The American Association of Colleges of Nursing reported 80,000 applicants for nursing school were turned away in 2019 for lack of faculty, and vacancy rates have not recovered. As things stand, colleges are having to reduce their course offerings, and teachers are complaining about unsafe class sizes. What’s more, NC Health News reports the average age of nursing professors with a doctorate degree is 63, and persons without pensions would find it difficult to survive on the meager wages available.

NC Health News also reported that North Carolina will be second only to Pennsylvania in nursing shortages by 2026. The problem is already rather obvious in Buncombe County, where no CNA courses are offered by the Red Cross. A-B Tech’s webpage for its CNA program begins, “Call [the] Health Occupations Office to be placed on a call list to register for a CNA class. You will receive a call to register in the order your name appears on the call list.”

It is obvious Mission HCA is not responsible for the national trends. It is, however, fair to ask what they are doing to be part of the solution. Lindell can talk at length about the programs Mission HCA offers to provide more training and make it affordable. Some highlights are: the Asheville Campus of HCA’s Galen College of Nursing, is now taking applications for its BSN and ADN programs; another program pays students to train hands-on in the hospital and then assures graduates continued employment at Mission HCA; and the hospital system helps existing staff advance their careers by pre-paying for certifications and reimbursing tuition.