PART 2: Restoring Better Healthcare in WNC | An Asheville Watchdog Forum

What Can We Do to Restore Better Healthcare in WNC? The nonprofit investigative news outlet the Asheville Watchdog posed that question in a Jan. 23 public forum at A-B Tech. 

In this episode, Watchdog editor Peter Lewis moderates a panel with Drs. R. Bruce Kelly and Clay Ballantine, Brevard Mayor Maureen Copelof, nurse and patient advocate Karen Sanders and Democratic State Senator Julie Mayfield of Asheville.

The opening comments at the forum from the same panelists are featured in a separate episode of this podcast.

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Transcript

Peter Lewis: We're going to get to the Q& A in just a second, but Dr. Susan Mimms, who's the CEO of Dogwood Health which is the successor trust that was formed with the 1. 5 billion from the sale of Mission Hospital has issued a statement. I'd like to read it:

Dogwood Health is committed to dramatically improving the health and being of all people in the communities across western North Carolina.

Over the past four years, Dogwood has granted over 250 million to community based organizations that work tirelessly to improve the health and lives of WNC residents by addressing issues including access to behavioral health, substance use prevention and treatment, the integration of health care and supportive services, the availability of safe and affordable housing, access to quality lifelong education and economic stability, job creation, wealth generation and more for those who are under resourced, and now we get to it. Our community's distress regarding the quality and accessibility of health care services at Mission HCA is of great concern to Dogwood. However, our role in monitoring HCA is constrained by the legal parameters of the Asset Purchase Agreement, APA, otherwise the contract that Mission Board signed with HCA.

While our organization alone cannot provide immediate solutions to the question posed to the panelists in this forum, we want to reiterate that Dogwood remains fully committed to working with all parties to find resolutions that will benefit the people of our region. In collaboration with others, Dogwood will work to continue to discuss multitude of options aligning our work with our community's common goals.

And she goes on to mention that the independent monitor hired by Dogwood will be holding informational sessions upcoming February 27th in Marion and February 28th in Burnsville. And, as always, we continue to encourage the community to share quality of care concerns with government agencies like NC Department of Health and Human Services and Centers for Medicare and Medicare Services.

The information is on the flyers that are outside that Dogwood delivered to us today. That's the statement from Dogwood Health. And now I would like to turn around and ask the question that came up most often that Watchdog solicited questions from all of the people who registered to attend.

Number one question, how do we get rid of HCA? Who would like to tackle that one? Someone with military experience.

Brevard Mayor Maureen Copelof: We continue to keep the pressure on HCA. We continue to document, we continue to look for every single aspect, multi faceted approach. We continue with the lawsuits, we continue, as Julie said, we build the coalition. That's what you do, is you build your strength. You bring in every asset you can.

We've brought in the physicians, we've brought in the nurses, we've brought in the faith community. We have brought in the elected officials, and I would call on every elected official in Western North Carolina to step up and join us in this effort. But and we take our, we also look for our media.

We've got to keep it in the spotlight. We don't let up. We consistently and totally and persistently move forward. It might be inch by inch. It might be little victory after little victory. I actually got two victories with HCA. They had closed a clinic that we forced them to open as a violation of the asset purchase agreement.

And they had closed our Oh, the the care unit you go to after a surgery and you don't go home. What's it called? Ah, yeah. Transitional care unit. Yeah, they had closed it. See, I am not a medical person, but we got it back open. You don't give up and we keep. Making sure that Sam Hazen at HCA realizes that North Carolina is never going to accept the corporate culture and the degradation of our medical services that they have brought into our community.

And eventually they're going to give up and sell.

Peter Lewis: Clay, I was going to ask you about certificates of public authority and certificate of need. What can you tell us about those?

Dr. Clay Ballantine: I'll just, I did want to say one other thing about the, about how you get rid of them. You got to hit them with the money, where their money is. And that's really what it's going to take and the way to do it is you force them to staff up. We all support the nurses and I guarantee you the nurses are going to be leaning on getting Staff ratios brought back up, bringing back the ward secretaries, the to answer the phones, to get medical assistance, to get cleaning personnel, pharmacy, lab, all that stuff.

They're going to push for increased staffing to support them because they're the ones I'm talking about who have borne a lot of the brunt as those things have been curtailed. So if we force them to bring the staff up in that setting, then that will be a good thing. And depending on. What happens with the some of the actual immediate jeopardies are based on low staffing ratios and just not enough people there to take care of the problems.

Force them through CMS and those actions to start chewing away. They're taking 1. 3 billion dollars in net patient receipts out of here every year. So it's going to take a lot of staffing them back up. And even then, they may still say, Oh, we got plenty of money, we're still net and positive. But hitting them in the money is also part of what you're talking about, which is you hit them with the public relations over and over again.

Their stock did drop when the AG filed suit. It didn't stay down there for too long, but it did drop some, and I didn't look to see if it stopped again when When CMS came out with the immediate jeopardy stuff, I suspect, watch what happens with that. But it's all about forcing them to staff up and trying to hit them in the bottom line one way or another.

Through lawsuits and fines or through forcing them to get additional personnel. That's just my take on that. The if I could say, I'll just start off about the CON, the certificates of need. So these are the, this is the patchwork of these little monopoly zones all over North Carolina. And inside each one, there's either competition or it's a monopoly.

When Mission bought St. Joseph's, it did away with the monopoly here. And and there was the Certificate of Public Advantage was put in place to stop Mission from abusing that. The first thing Paulus does when he gets here is he gets rid of the COPA agreement, which was the, which kept a cap on things.

And then you'll notice that as soon as that thing was gone, boom, the sales talk started. It's the Certificate of Need is a structure that's run by DHHS, and it's a it's been repealed in a bunch of states. North Carolina has some of the most complicated Certificate of Need regulations, and really trying to get at to either getting an exemption in the certificate of need for our area because it's a monopoly or trying to get some kind of monopoly control.

Something like that is a good start. So I hope Julie, she knows more about this than I do. 

NC State Senator Julie Mayfield: But somehow creating more competition here is also gets at Clay's point about getting to the bottom line. And so that, finding that path legislatively I have a lot of people come and say why don't you just get rid of CON?

Remember, I am not in charge of the legislature. One of a hundred and seventy, and they don't listen to me all the time. I don't understand. But but that's really hard. There are a lot of entrenched interests that like CON. There are a lot of people that would love to get rid of it. But it's not an easy legislative ask.

But as Clay said, there are Some paths through DHHS that we've identified that we are exploring and will be pursuing that would also, that would help to bring competition to the region and of course and I'll just say this to you so you can be on the lookout for it, there was the 67 bed, there is the 67 bed certificate of need that's currently under litigation, it was awarded to ADVENT, HCA, challenge that I, my understanding is we're expecting a decision from the judge probably in February on that case.

Dr. Clay Ballantine: That'll be some big news when we get that need protections that are out there, the hospitals like these, every place they've got 'em because it provides a monopoly or a controlled competitive environment. You can't build a hospital bed, a nursing home bed, an MR scanner MRI scanner. You can't put in a surgery center unless you go through those certificate of need permitting process.

DHHS oversees that. One of the great ironies of this whole thing to me is that DHHS has purview over this monopoly that's created here for these 15 or 18 counties. And, at the same time, Mission is price gouging. The state Medicaid funds that are under DHHS control. We pay 50 percent more for stuff here than anybody else in the state of North Carolina does.

And it's amazing that they can't get this, get all the way around the circle to figure this out. And say, hey, maybe we need a little competition. And on the competition front, Advent could probably go for a bigger hospital here. Novant is interested. I know UNC and Duke have been interested.

And the non profit, I think it's Atrium out of Charlotte would be interested. If this had, if we had a bidding war here for Mission Hospital, we'd have even more money for Dogwood to spend, and we could get rid of HCA. The trick is, how do you get them to sell a cash cow? 

Brevard Mayor Maureen Copelof: And I just want to say that, the antitrust lawsuit that we filed is directly about this monopoly.

They have 80 percent of the market in my county. That's outrageous. In the whole area. It's everywhere. But and the remedy, obviously that has resulted in. two to three times the cost for procedures at HCA versus other hospitals around this state. And so we are paying too much for lower quality.

And the remedy that we're asking for, of course, one of the remedies, is that the courts basically direct them. to stop these monopolistic practices. We need these lawsuits to continue and we need to, really be keeping the pressure on in the court of law because monopolies don't help the people at all.

Peter Lewis: As Karen mentioned in her comments, one of the most striking things about going into Mission Hospital these days is the overworked nurses. They're short staffed. The nurse to patient ratios are way out of whack from what they used to do. Is there a way to force statewide new regulations on nurse to patient ratios?

Karen Sanders: Can you hear me? No. What happens with nurse patient ratios in a normal hospital is So let me just back up. Hospitals here at Mission, Transylvania, whatever, we've had nurse patient ratios of 1 RN to 4 to 5 patients on a med surg unit, and maybe 1 to 5 or 6 on the night shift, and 1 to 2, 1 RN to 2 patients in critical care, and maybe 1 to 3 or 4 in step down.

And as when you are at Mission Hospital, you might see a nurse, if you're lucky, You have a person coming into your room that might be a traveler, and the CNAs all get taken away so that God only knows what the RN to patient ratio is. There are no laws in our state mandating nurse patient ratios.

There are in California and Massachusetts. As you can imagine having nurse patient ratios, hospitals don't like that means a lot more expense. So right now we don't have any legislation about that. 

Peter Lewis: How strong is the hospital lobby here in North Carolina? 

Karen Sanders: It's very strong. We have a very strong lobby.

And we do have about 140, 000 nurses in this state. However, they don't have a bigger voice as hospitals do because they, hospitals have a whole lot of money for, For pitching that. But anyway I guess we just have to keep advocating and advocating for that. 

Peter Lewis: Dr. Kelly, are we in a worst case scenario right now? What is the worst case scenario and are we in it right now?

Dr. R. Bruce Kelly: I think I think nine immediate jeopardies is pretty bad. As everybody said, the staff are doing everything they can. I would sure to think it's not going to get any worse and that the combination of the attorney general's lawsuit DHHS and CMS their response to the immediate jeopardies.

I think a lot of the work that's being done in the community with watchdog and hopefully the growing coalition that we are building. And more will force HCA to begin to make some changes. As one of the, very articulate nurses pointed out at the Attorney General's press conference, this is a manufactured crisis.

It doesn't have to be this way. They're making plenty of money, and they could make choices that would bring this healthcare system back to at least something closer than it became. We we know that at the annual HCA shareholders meeting this past summer, there was a resolution put forward to make patient safety and quality of care a focus for the company.

Only 19 percent of the shareholders voted for it. So I think that If there was any question that the quality of our health care is being publicly traded, that, that has clearly been answered. We have ten years of Medicare data five years before the sale five years after. It shows a decline in all of the Medicare metrics.

In 2022 patient satisfaction was a two star. Whereas prior to the sale, admission was consistently four or five stars all the way around. I would certainly hope that we have maybe hit bottom. A lot's going to depend on HCA's response to these recent changes. The landscape has changed.

And they're going to have an opportunity to, if not change their stripes, at least be more responsive to the needs that they say they're here to serve. 

NC State Senator Julie Mayfield: Yeah, if I can add a couple things to that. Number one, you can all be shareholders of HCA. You can buy one share, you can buy five, you can buy ten, you can buy a lot if you want.

But, my view is having our voices in that conversation, even if they are small, is important. I would encourage all of you who can, go buy a share. That gives you access to the earnings calls, that gives you access to the shareholder, the annual shareholder meetings. Which is next week? The earnings call is next week.

The earnings call is next week, sorry. Shareholder meeting April 25th. If you would like to be even more involved in being an active shareholder, come talk to me afterwards. In, in terms of are we at, I can't remember how you, are we in the worst case scenario? We are not. The worst case scenario would be that HCA is not able to do what they, will be required to do and staff up to address these immediate jeopardies.

And even if they get, a couple of extensions on the 23 days, the worst case scenario is CMS pulls our Medicare and Medicaid funding for the hospital. That is the worst case scenario. I about as soon as we knew about this, I was on the phone to the governor's office, on the phone to DHHS saying, you need to understand what an amazing, an incredible disaster that would be for our region.

As, as bad as things have, are at the hospital, closing this hospital would be ten times worse. The Canton Mill closure, nothing compared to this. tropical storm Fred, nothing compared to this. And so I have said to them, if you if there is even a hint that is going to happen, we need to be in major planning mode for what's going to happen.

I have been told that is unlikely. So I just want to be clear that it is unlikely that CMS would close our hospital because of the role it plays in the region. But what that also could mean is that the efforts at compliance would, could be stretched out over months and that would be, again, a place where we would be incredibly vigilant in making sure that progress continues to be made, and DHHS would be there as well but that's, yeah, I, we're not quite in the worst case scenario yet, I think.

Peter Lewis: No. We're right at the end of our allotted time at 8 o'clock, but if you guys don't mind, I have a couple more questions for the panel. Is that okay? First a news flash. We got a press release today from Mission Hospital. They have been named one of the 50 top hospitals in the United States by health grades.

Repeating the award that they got last year makes you wonder what immediate jeopardy plays a role in that. Okay. Clay is this something that can be solved? Soon? Years? Are we doomed to live with this for a long time? I

Dr. Clay Ballantine: don't know if we're doomed to live with this for a long time.

There's one wild card sitting out there. There's a court case in the state supreme court about trying to to declare the CON process is in is unconstitutional. And smart people tell me. Mark, that these arguments have been tried before and it failed in front of the Supreme Court. But some guy wants to do cheap procedures for 1, 600 out on the coast somewhere where the hospital charges 6, 000 and he can't get a certificate of need so he's taking this all the way up through the I think they're eye procedures or something like that, and he's taking it all the way up to the state Supreme Court.

They're supposed to hear that argument in February. And it could be that they issue a a decree that is, that says the CON process is no longer valid here. The state of North Carolina just, I'm sorry, the state of South Carolina just in July completely repealed all their CON laws. They didn't even protect their academic medical centers from outside competition.

And it hasn't turned into the Wild West yet, but there are definitely, there will be an upsetting of the landscape. If the two likely scenar the two most likely scenarios are one, something happens and mission changes some of their stuff and is able to get a little bit better and we have to live with them for a longer period of time.

Or, the best way to get this is to get them to sell. If we can get them to where they sell this system. And it's this continued pressure and it's getting everybody to continue to pump your stories of outcomes and problems for Mission Hospital into these regulatory agencies so that it becomes a nightmare for them to continue doing business here.

The public relations black eye, and I know that there are systems like Novant that are lined up and ready to to stroke a check to get in a bid, to put in a bid for mission if they get the chance. So it's possible that it could happen quickly and certainly with all these regulatory storms that are going on right now, it's possible that HCA may actually say, this is too much.

We've got too many lawsuits. We're just going to back out of this market and go invest our money someplace else. 

Peter Lewis: Lawsuits don't seem to have stopped them in the past. 

Dr. Clay Ballantine: When you got a 1. 3 billion dollar annual margin off of this healthcare system, you can buy a lot of lawyers. 

Peter Lewis: After North Carolina, 1. 3 billion? 

Dr. Clay Ballantine: That was, 1. 3 billion was the it was the data, it was net patient revenue for the Mission Hospital system. Out of 183 

Peter Lewis: hospitals that HCA operates, Mission Hospital in Asheville ranks number two. of net patient revenue. Number one has twice as many beds, so they're making money. It sounds like it at least.

Dr. R. Bruce Kelly: As we said, it's a manufactured crisis. It does not have to be this way. And we do hope that we can continue to build a community coalition to join with us to continue to advocate for change. If I could just take a minute Julie mentioned that we did come up with a some goals that, that we have as a group that's only been meeting for a few months.

So this is very early, and we've drafted these in terms of what we think are necessary to regain what we have lost, and we've also crafted them in a general way so that hopefully anyone who cares and wants the same thing we do can get on board. And there are eight. of these. The first is that we want leadership, hospital leadership, that is committed to the greatest good for our community and region, from the top down, embodies and demonstrates servant leadership, is guided by ethical principles, and embraces transparent decision making, prioritizes quality of care and patient experience over profit and decision making, ensures staffing and resources for all services.

to perform at their maximum ability, engages physician and nursing leadership and shared collaborative decision making, fosters a supportive, respectful workplace free of intimidation and fear of retribution and provides funding to ensure adequate care for marginalized and low income residents. So this is something that, we will stand by we anticipate, it will be adopted adapted as others come on board, but that, these eight principles are what, we feel are the foundation for what it is that we all want to see.

Peter Lewis: Julie, one more time, what can people do?

NC State Senator Julie Mayfield: Number one thing you can do is continue to share your stories. about your experiences at the hospital. And you can do that, again, directly to the regulatory agencies, and there's, there are forms outside that tell you how to do that. If you want to take an easier path, and send an email to me at my legislative email address.

I will immediately turn around and send it to DHHS, the Attorney General's Office, and the Independent Monitor in one fell swoop. I can cover all of them. That's number one. Number two would be to sign up to, Join our coalition and stay in touch, stay in tune, stay informed with what we're doing, with the efforts that we're putting forward.

We will be providing opportunities for you to, be part of the be part of the dialogue. We will need letters to the editor. We will need all sorts of things going forward, and we will need your voices. So again, I will point you to John Nicolay, who's right here, and to Missy Harris, and you can sign up at that table over there. Anything else I've forgotten?

Dr. Clay Ballantine: It's coming up. It's gotten overwhelmed with these other things, but this contract negotiation with the nurses is coming up and they basically what the nurses are probably gonna ask for is a lot of the stuff that we need back. And so when it comes up and it's time, there will be probably ways that you can express your support for the nurses as they negotiate with HCA.

They are, like I said, they've borne the brunt of it, and they have, they're organized, and they are going to be trying to push, probably, HCA to do a lot of the things that we really need to try to restore some of the quality in the facility. If you can support the nurses in some way or another, as their union goes to bat against HCA, please do it.

Peter Lewis: Bruce?

Dr. R. Bruce Kelly: Just one last thing. We're not naive. We don't anticipate that, HCA really cares much what, any of us think, it's their shareholders that they're responsive to so we are not naive, but what we do have are we have our relationships, and we have our voices, and we have our stories, and the hope is that we can continue to collect those, grow those, And that they, they are the power that we have.

As Julie said, we really encourage everyone to continue to build on those as much as possible. 

Peter Lewis: On behalf of all the watchdogs, I want to thank the panelists for their passion and their willingness to be here and talk to us all. And to thank all of you for coming out on a rainy night for this public forum.

Stay tuned, read the watchdog this is not a story that we're going to stop covering any time soon. The big guy back there wearing the mask is Andrew Jones, our mission hospital reporter. There he is. 

So again, thank you all very much for the evening.